Evidence Based Practice &Toolkits: Evidence Based Practice &Toolkits: Implementation of Integrated Dual Implementation of Integrated Dual

Diagnosis Treatment (IDDT)Diagnosis Treatment (IDDT)

Karin Kalk, Project ManagerMarc Bono, PsyD, Trainer

California Institute for Mental Health(Adapted from Presentation by Neal Adams, MD, MPH)

Dual or Co-Occurring Dual or Co-Occurring Disorders - a DefinitionDisorders - a Definition

Mental illness and substance use disorder occurring together in one person substance use disorders are common in people

with severe mental illness mental illness is common in people with

substance use disorders

Dual disorders lead to worse outcomes and higher costs than single disorders

Co-Occurring DisordersCo-Occurring Disorders

High SA

Low MI

High SAHigh SA

High MIHigh MI

Low SA

Low MI

Low SA

High MI

Substance Abuse

Mental Illness

Worse OutcomesWorse Outcomes

Relapse of mental illness Treatment problems and hospitalization Violence, victimization, and suicidal behavior Homelessness and Incarceration Medical problems, HIV & Hepatitis risk

behaviors and infection Family problems Increase service use and cost

Integrated Dual Diagnosis Integrated Dual Diagnosis Treatment - a DefinitionTreatment - a Definition

Treatment of substance use disorder and mental illness together same team same location same time other characteristics to be described later

Emerging evidence based practice toolkits as a strategy for dissemination and

implementation Developed for use in Mental Health Systems

Philosophic UnderpinningsPhilosophic Underpinnings

Comprehensive Recovery-Oriented Person-Centered Individualized

InterventionsInterventions

Motivational interviewing Cognitive behavioral counseling Group Interventions Social skills training Self-help groups Working with families Housing, employment, Psychopharmacology

Advantages of IDDTAdvantages of IDDT

Comprehensive all aspects of treatment from screening to relapse

prevention

Substantial consensus of many experts that it is a useful approach.

It incorporates many of the currently accepted techniques of substance abuse treatment including motivational interviewing stages of treatment, family psycho-education pharmacological advances

IDDT Advantages contIDDT Advantages cont

Provides guidelines reduce the wide variability of clinical practices

Focuses attention on an important and very difficult population offers hope and assistance to stressed staff and

clients

Clinicians and administrators find it of immediate practical value

IDDT Advantages contIDDT Advantages cont

Virtually no practical alternative models parallel treatment in the substance abuse system

has generally not been found to be feasible in California, although work continues on trying to overcome these barriers

dual disorder adapted therapeutic community model is also supported by evidence but is not appropriate for all clients or those not willing to participate

Clinician Knowledge & SkillsClinician Knowledge & Skills

Knowledge about substances Knowledge and skills for stage-wise treatment

outreach, practical help motivational counseling substance abuse counseling skills training self help referral family work infectious disease prevention and treatment

Rehabilitation training skills

California IDDT Training & California IDDT Training & Evaluation GrantEvaluation Grant

California Department of Mental Health has been awarded a SAMHSA grant to provide training for and evaluation of the implementation of integrated dual diagnosis treatment in four counties (eight sites) throughout the state.

Neal Adams, MD, MPH, DMH Medical Director, PI: IDDT Toolkit Grant

SAMHSA ToolkitsSAMHSA Toolkits

Information about the EBP Individualized information for stakeholders,

including consumers, family members and practitioners, administrators and pubic mental health authorities

Implementation tips Basic curriculum Fidelity scales

Toolkit Issues: California GrantToolkit Issues: California Grant

3 general questions California project hopes to answer: Can the IDDT model be implemented with high

fidelity in a variety of California sites typical of public mental health programs serving persons with severe mental illness?

Is the Toolkit helpful? What else is important in making implementation work?

Will client outcomes in our programs correlate with the fidelity of implementation of the IDDT model?

CountiesCounties

Alameda Los Angeles Ventura Stanislaus

Organizational ChangeOrganizational Change

Changes at 5 levels health authority program leadership clinician/supervisor family consumer

Each level has its own training and TA needs

Tools for Design & EvaluationTools for Design & Evaluation

Fidelity Scale General Organizational Index Client Outcomes

Fidelity ScaleFidelity Scale

Defines the IDDT program and its elements Operationalizes the principles of IDDT

complex model cannot be tested component by component • would require hundreds of studies

fidelity scale based on expert consensus opinion “validated” fidelity scale should

• discriminate low from high fidelity programs• correlate with outcomes

……..…see detailed Fidelity Scale

Chart of Work FlowChart of Work Flow

Flow of Client from system entry to recovery A ‘bird’s eye view’ Over generalized

Clarify what IDDT elements apply when Eventually clinic will have its own chart of the

IDDT Work Flow

………..see separate Work Flow Chart.

General Organizational IndexGeneral Organizational Index

General Organizational Index (OI) Similar to fidelity scale

applies to all of the SAMHSA evidence-based practices

Measures adherence to organizational practices believed to further successful organizational change and

high quality treatment

……….see detailed General Organizational Index

GOI ItemsGOI Items

Program philosophy EBP commitment

Eligibility/Client identification standardized screening

Penetration % receiving EBP

Assessment standardized assessment

GOI Items GOI Items contcont

Individualized treatment plan Individualized treatment Training

EBP for all practioners

Supervision structured, weekly

Process monitoring EBP implementation

GOI Items GOI Items contcont

Outcome monitoring substance use for IDDT

Quality Assurance semi-annual review of EBP

Client choice regarding service provision

Outcome MeasuresOutcome Measures

Alcohol Use Scale (AUS-R) Measures alcohol use from abstinence – institutionalized

dependence

Drug Use Scale (DUS-R) Measures drug use from abstinence – institutionalized

dependence

Substance Abuse Treatment Scale (SATS) Assigns client to a level of treatment used in designing

appropriate interventions

Multnomah Community Abilities Scale (MCAS) 17 item validated level of functioning scale

Grant ActivitiesGrant Activities

Staff Training Monthly Education credits Syllabus

Implementation Activities Sequenced with training topics Development of multi-disciplinary team Selection of clients for project

Evaluation Initial, baseline fidelity evaluation – August Training on clinical evaluation tools – September Re-evaluation every six months

PerspectivePerspective

Developing a culture of learning, inquiry, quality and transformation multiple levels

• system

• administration

• clinicians

Organizational focus not evaluation of staff performance

3 year vision

On to the fidelity scale…On to the fidelity scale…

IDDT Fidelity ItemsIDDT Fidelity Items

Multidisciplinary teams Integration of dual diagnosis

specialist Stage-wise interventions Access to comprehensive

services Time unlimited service Outreach Motivational Interviewing Substance abuse

counseling

Group dual diagnosis treatment

Family psycho-education in dual diagnosis

Participation in alcohol and drug self help groups

Pharmacological treatment Interventions to promote

health Secondary interventions for

substance abuse treatment non-responders

Multidisciplinary TeamsMultidisciplinary Teams

All clients targeted for IDDT receive care from a multidisciplinary team (MDT).

An MDT consists of two or more of the following: a physician, a nurse, a case manager, or providers of ancillary rehabilitation services described in Item 3.

1 2 3 4 5

Traditional outpatient or brokered CM model; no team

Minimal implementation of Multidiscipline team(2 or three disciplines, low frequency of meeting, little integration)

Partial Implementationof Multi discipline team (all three criteria are better than in “2” or one criterion donevery well butothers not)

Nearly full Implementationof Multi-Discipline team (all three criteria met to Large degree)

Full implementation of Multi discipline team with Case managers, psychiatrist,nurses, residential staff,and vocational specialistswork collaboratively on mental health; treatmentteam meetings daily; highlyintegrated.

Integration of Dual Diagnosis Integration of Dual Diagnosis SpecialistSpecialist

A DD specialist with at least 2 years of experience Works collaboratively with treatment team Experience can be in a variety of settings, preferably

working with clients with a dual disorder

1 2 3 4 5

IDDT clients are referred to a separate substance abuse department within or outside the agency (e.g., referred to drug and alcohol staff)

A substance abuse specialist serves as a consultant to treatment team; does not attend meetings; is not involved in treatment Planning

A substance abuse or DD specialist is a fully integrated member of the treatment team; attends all team meetings; involved in treatment planning for IDDT clients; models IDDT skills and trains other staff in IDDT

A DD specialist is a fully integrated member of the treatment team; attends all team meetings; involved in treatment planning for IDDT clients; models IDDT skills and trains other staff in IDDT

The team consists of multiple DD specialists with 2 years experience, fully integrated. They attend all team meetings; are involved in treatment planning for IDDT clients; model IDDT skills and train other staff in IDDT

Stage-Wise InterventionsStage-Wise Interventions

All interventions (including ancillary rehabilitation services) are consistent with and determined by the client's stage of treatment or recovery.

Concept of stages of treatment (or stages of change) include: Engagement, Motivation, Action, Relapse Prevention

1 2 3 4 5

Program does not use stages of treatment at all

Minimal use of stages (no ratings, or not up to date, truncated or fuzzy stages, lack of interventions for each stage)

Moderate use of stages (at least one element well implemented but not all three); or some staff use and others do not

Consistent use of stages but at least one of the criteria not implemented fully

A full range of interventions is available for all four stages and each client has a written up-to-date rating of current stage in treatment plan and is consistently reflected in progress notes

Stages of Change &TreatmentStages of Change &Treatment

Precontemplation -- Engagement outreach, practical help, crisis intervention

Contemplation & Preparation -- Persuasion provide education, set goals, build awareness

Action -- Active Treatment substance abuse counseling, medications, skills

training, family and self-help groups Maintenance -- Relapse prevention

relapse prevention plan, skills training, expand recovery to other areas of life

Access to Comprehensive Access to Comprehensive ServicesServices

To address a range of needs of clients targeted for IDDT, agency offers the following 5 rehab services: Residential service Supported employment Family psychoeducation Illness management and recovery Assertive community tx (ACT) or intensive case

mgmt (ICM)

Access to Comprehensive Access to Comprehensive Services Services contcont

1 2 3 4 5

Access to related services identified in the client treatment plan

None of the charts reviewed showed consideration of need for related services such as employment, illness mgmt or intensivecase mgmt

Some mention of related services in individual treatment plan, but few related services were actually accessed by the clients

More related services identified in the treatment plan and they were usually actually accessed by the clients

Multiple related services identified. All related services were accessed, but not necessarily within 2 mos

Multiple related services identified. All related services identified in treatment plan were accessed within 2 months

Access to residential/housing services for DD clients-Housing specialist(s)-Wet-damp-dry housing

No housing specialist available in county or program; limited or inadequate wet, damp, dry housing for DD clients

Housing specialist(s) in county but not program; limited or inadequate wet, damp, dry housing for DD clients

Housing specialist(s) in program; limited or inadequate wet, damp, dry housing for DD clients

Housing specialist(s) in program; full range of wet, damp, dry housing for DD clients

Housing specialist(s) in program; full range of wet, damp, dry housing for DD clients; residential program affiliated with program

Time Unlimited ServiceTime Unlimited Service

Clients with DD are treated on a long-term basis with intensity modified according to need and degree of recovery.

The following services are available on a time-unlimited basis: Substance abuse counseling Residential service Supported employment Family psychoeducation Illness management and recovery ACT or ICM

Time Unlimited Service Time Unlimited Service contcont

Clients with DD are treated on a long-term basis with intensity modified according to need and degree of recovery.

Services available on a time-unlimited basis: Substance abuse counseling Residential service Supported employment Family psychoeducation Illness management and recovery ACT or ICM

1 2 3 4 5

Overall program has a time limit.

Program as a whole has no time limit but some of the services, such as particular groups are time limited.

Neither program nor individual services have time limits or utilization limits per se, but some services are only offered some of the time.

No time limits; services available at any time; but waiting lists exist.

No time limits; services available at any time; no waiting lists.

OutreachOutreach

For all IDDT clients, but especially those in the engagement stage, IDDT program provides assertive outreach

Characterized by some combination of meetings and practical assistance (e.g., housing assistance, medical care, crisis management, legal aid, etc.) in their natural living environments as a means of developing trust and a working alliance.

Other clients continue to receive outreach as needed.

Outreach Outreach contcont

1 2 3 4 5

Outreach:

In situ aid for housing, medical, court and legal

Outreach to engage clients initially and re-engage if stop attending

Program is passive in recruitment and re-engagement; almost never uses in situ outreach mechanisms.

Program makes initial attempts to engage but generally focuses efforts on most motivated clients; little or no in situ engagement

Program staff frequently attempt in situ OR engagement outreach, but not both.

Program staff frequently attempt BOTH in situ and engagement outreach (but it is not formally supported in policy, supervision and charting requirements).

Policy, supervision, and charting requirements encourage in situ and engagement outreach. Over half the charts show evidence it has occurred when appropriate (e.g. when attendance is poor or a client has dropped out or if a client has court appearances).

Motivational InterviewingMotivational Interviewing

All interactions with DD clients are based on motivational interviewing that includes: Expressing empathy Developing discrepancy between goals and

continued use Avoiding argumentation Rolling with resistance Instilling self-efficacy and hope

Motivational Interviewing Motivational Interviewing contcont

1 2 3 4 5

Motivational Interventions: Quantity Clinicians who treat IDDT clients use strategies.

≤20% of client charts reflect motivational interviewing approach (ie goals discrepancies, pay-off matrix);

21%- 40% of client charts reflect motivational interviewing approach (ie goals discrepancies, pay-off matrix);

41%- 60% of client charts reflect motivational interviewing approach (ie goals discrepancies, pay-off matrix)

61%- 79% of client charts reflect motivational interviewing approach (ie goals discrepancies, pay-off matrix)

>80% of client charts reflect motivational interviewing approach (ie goals discrepancies, pay-off matrix)

Motivational Interviewing Qualitative

No record of training on MI within past year

Training on MI within past year but not all staff have attended

Training for all staff on MI within past Year

Training for all staff on MI within past year and staff interviews reflect use of MI

Multiple trainings for all staff on MI within past year and staff interviews reflect use of MI

Substance Abuse CounselingSubstance Abuse Counseling

Clients who are in the action stage or relapse prevention stage receive substance abuse counseling aimed at: Teaching how to manage cues to use and consequences of

use Teaching relapse prevention strategies Teaching drug and alcohol refusal skills Problem-solving skills training to avoid high-risk situations Challenging clients’ beliefs about substance use; and Coping skills and social skills training to deal with symptoms

or negative mood states related to substance abuse

Substance Abuse Counseling Substance Abuse Counseling contcont

1 2 3 4 5

DDX counseling is not routinely provide

Mental Health or Substance Abuse Counseling is provided by referral in a parallel or sequential model

Mental Health or Substance Abuse Counseling is provide by the agency in specialized SA and or MH individual and/or group services

Mental Health and Substance Abuse Counseling is provide by the agency in specialized integrated individual and/or group services

Mental Health and Substance Abuse Counseling is provide by the agency in an integrated fashion throughout all aspects of programming as well as in specialized integrated individual and/or group

Group Dual Diagnosis Group Dual Diagnosis TreatmentTreatment

All clients targeted for IDDT are offered a group treatment specifically designed to address both mental health and substance abuse problems, and approximately two-thirds are engaged regularly (e.g., at least weekly) in some type of group treatment.

Groups could be family, persuasion, dual recovery, etc.

Group Dual Diagnosis Group Dual Diagnosis Treatment Treatment contcont

1 2 3 4 5

Group DD Treatment: DD clients are offered group treatment specifically designed to address both mental health and substance abuse problems

<20% of DD clients regularly attend a DD group

20% - 34% of DD clients regularly attend a DD group

35% - 49% of DD clients regularly attend a DD group

50% - 65% of DD clients regularly attend a DD group

>65% of DD clients regularly attend a DD group

Integrated group treatment for DD: DD clients are offered group treatment specifically designed to address both mental health and substance

abuse problems

No groups are offered

for DD clients

Groups are offered for only one of the two disorders

Separate groups are offered but not integration of the disorders in the groups

Separate groups for each disorder, but some integration occurs in the groups

Integrated groups where both disorders are the focus of treatment

Family Psychoeducation in Family Psychoeducation in Dual DiagnosisDual Diagnosis

Where available and if the client is willing, clinicians always attempt to involve family members (or long-term social network members) to give psychoeducation about DD and coping skills to reduce stress in the family, and to promote collaboration with the treatment team.

1 2 3 4 5

No identification of families or significant others for each client; or no outreach to families provided

Minimum outreach to families provided: Materials on DD offered or sent Consultation with families around treatment decisions

Moderate outreach: materials, consultation, some specific intervention, i.e. support group, coping skills training group.

Partial implementation of an evidence-based family intervention for DD. Reviewers will look for evidence program is using an explicit evidence-based model

Full implementation of an evidence-based family intervention for DD. Reviewers will look for evidence program is using an explicit evidence-based model.

Participation In Alcohol And Participation In Alcohol And Drug Self Help GroupsDrug Self Help Groups

Clinicians connect clients in the action stage or relapse prevention stage with substance abuse self-help programs in the community, such as: Alcoholics Anonymous (AA) Narcotics Anonymous (NA) Rational Recovery Double Trouble or Dual Recovery

Proactive Self Help Groups & Liaison Staff have a working knowledge of the Self Help Groups

they refer to Staff attend self help groups with clients Staff help clients to prepare and/or adjust to self help

groups

Participation In Alcohol And Participation In Alcohol And Drug Self Help Groups Drug Self Help Groups contcont

1 2 3 4 5

<20% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community

20% - 34% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community

35% - 49% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community

50% - 65% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community

>65% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community

No referral of dual-disorder clients in action or relapse prevention stages to self-help in community or at agency

Occasional referral of dual-disorder clients in action or relapse prevention stages to self-help in community or at agency

Routine referral but staff do not have a working knowledge of the self help programs

Routine referral and staff has a working knowledge of the self help programs

Routine referral and staff has a working knowledge of the self help programs and take proactive steps to assist clients in utilizing this resource including such things as mock groups or attending with the client

Pharmacological TreatmentPharmacological Treatment

Physicians or nurses prescribing medications are trained in DD treatment and work with the client and the IDDT team to increase medication adherence; decrease the use of potentially addictive medications such as

benzodiazepines; and offer medications such as clozapine, disulfiram, or naltrexone that

may help to reduce addictive behavior. Five specific indicators are considered - do prescribers:

1. Prescribe psychiatric medications despite active substance use2. Work closely with team/client 3. Focus on increasing adherence4. Avoid benzodiazepines and other addictive substances5. Use clozapine, naltrexone, disulfiram

Pharmacological Treatment Pharmacological Treatment contcont

1 2 3 4 5

All clients do not have ready access to psychiatric evaluation and treatment

Clients have access to psychiatric evaluation and treatment but medications may be withheld for those with concurrent substance abuse; OR prescription of medications with abuse potential (e.g.enzodiazepines) is not controlled

Clients have access to psychiatric evaluation and treatment, medications are not withheld, and medications with abuse potential are controlled; but prescribers have virtually no contact with treatment team and make no apparent efforts to Increaseadherence

Clients have access to psychiatric evaluation and treatment, medications are not withheld, and medications with abuse potential are controlled; and prescribers have extensive contact with the treatment team and make apparent efforts to increase adherence

In addition to criteria in #4, prescribers actively consider naltrexone, disulfiram, clozapine, & other medications having some evidence base for use with persons with dual disorders

Interventions to Promote Interventions to Promote HealthHealth

Efforts are made to promote health through encouraging clients to practice proper diet and exercise, find safe housing, and avoid high-risk behaviors and situations.

Intent is to directly reduce the negative consequences of substance abuse using methods other than substance use reduction itself

Typical negative consequences of substance abuse that are the focus of intervention include: physical effects social effects self-care and independent functioning, and use of substances in unsafe situations

Interventions to Promote Interventions to Promote Health Health contcont

1 2 3 4 5

No explicit programmatic support for promoting health or reducing negative consequences of DD

Program support for general health interventions such as diet and exercise but not for reducing the negative consequences of DD

Program support for general health interventions and for reducing negative consequences of DD but interventions not used consistently (as documented in charts, protocols, and staff interviews)

Program support for general health interventions and for reducing negative consequences of DD but only individually (no programmatic interventions such as trauma groups, smoking cessation groups, and needleexchange)

Program supports reduction of negative consequences of DD and interventions are used consistently including programmatic interventions such as trauma groups, smoking cessation groups, and needle exchange)

Secondary Interventions for SA Secondary Interventions for SA Treatment Non-respondersTreatment Non-responders

Secondary interventions are more intensive (and expensive) interventions that are reserved for people who do not respond to basic outpatient IDDT.

Program has a specific plan to identify treatment non-responders; evaluate them for secondary (i.e., more intensive)

interventions; and link them with appropriate secondary interventions.

Potential secondary interventions might include special medications that require monitoring; more intensive psychosocial interventions; or intensive monitoring, which is usually imposed by the legal

system.

Secondary Interventions for SA Secondary Interventions for SA Treatment Non-responders Treatment Non-responders contcont

1 2 3 4 5

Secondary interventions for non-responders. Diagnosis based (including trauma) Residential program Criminal-justice liaison Money management or payeeship Contingency management Outreach harm reduction approach for pre-contemplation clients Medications such as clozapine that require close monitoring Others if specified in tx plan

No formal way of identifying non-responders

Formal way of identifying non-responders but no specific interventions are in treatment plans for these clients

Formal way of identifying and one to or two interventions are specified in treatment plans for these clients

Formal way of identifying and three or four interventions are specified in treatment plans for these clients

Formal way of identifying and five or more interventions are specified in treatment plans for these clients

Knowing is not enough; we must apply.

Goethe