Services Integration Services Integration Richard N. Rosenthal, MD Richard N. Rosenthal, MD COCE Senior Fellow COCE Senior Fellow Professor of Clinical Psychiatry, Professor of Clinical Psychiatry, Columbia University Columbia University Chairman, Dept. Psychiatry, Chairman, Dept. Psychiatry, St. Luke’s Roosevelt Hospital Center, NY St. Luke’s Roosevelt Hospital Center, NY Co-Occurring Center for Excellence (COCE) COSIG Workgroup Presentation May 19, 2005
Transcript
Services IntegrationServices Integration
Richard N. Rosenthal, MDRichard N. Rosenthal, MDCOCE Senior FellowCOCE Senior Fellow
Professor of Clinical Psychiatry,Professor of Clinical Psychiatry,Columbia UniversityColumbia University
Chairman, Dept. Psychiatry,Chairman, Dept. Psychiatry,St. Luke’s Roosevelt Hospital Center, NYSt. Luke’s Roosevelt Hospital Center, NY
Co-Occurring Center for Excellence (COCE)
COSIG Workgroup Presentation May 19, 2005
Services IntegrationServices Integration
Services integration refers to both:Services integration refers to both: The process of merging previously The process of merging previously
separate clinical services into a seamless separate clinical services into a seamless and harmonious framework of practices at and harmonious framework of practices at the level of the individual the level of the individual
The delivery of integrated treatment for The delivery of integrated treatment for clients with co-occurring disorders (COD) clients with co-occurring disorders (COD) utilizing various techniquesutilizing various techniques
Services IntegrationServices Integration
Services integrationServices integration for COD can be defined as for COD can be defined as the process of providing of two or more the process of providing of two or more interrelated services to specific clients within a interrelated services to specific clients within a primary treatment relationship or service setting primary treatment relationship or service setting (CSAT, 2005). (CSAT, 2005).
Integration can range from single-provider efforts Integration can range from single-provider efforts to comprehensive program integration. to comprehensive program integration.
Complete services integration requires a Complete services integration requires a consideration of, and response to, the needs, consideration of, and response to, the needs, problems, and issues across services for problems, and issues across services for persons with co-occurring disorders (COD). persons with co-occurring disorders (COD).
Any process by which mental health and Any process by which mental health and substance abuse services are appropriately substance abuse services are appropriately integrated at the client level for an individual with integrated at the client level for an individual with COD. COD.
Integrated services can be provided by: Integrated services can be provided by: Individual or team in one or more settings that Individual or team in one or more settings that
collaborates in collective responsibility for a collaborates in collective responsibility for a client and assumes responsibility for client and assumes responsibility for integrated servicesintegrated services
Organized program with a structure specifically Organized program with a structure specifically designed to facilitate delivery of integrated designed to facilitate delivery of integrated services by all clinicians or teams to all clients services by all clinicians or teams to all clients
Services IntegrationServices Integration
Co-location of mental health and Co-location of mental health and substance abuse programs or substance abuse programs or clinicians may facilitate the provision clinicians may facilitate the provision of integrated services, but is neither of integrated services, but is neither necessary, nor sufficient for services necessary, nor sufficient for services integration. integration.
Services IntegrationServices Integration
Complete implementation merges previously Complete implementation merges previously separate medical and psychosocial services such separate medical and psychosocial services such as: as: medication management medication management case managementcase management rehabilitation servicesrehabilitation services addiction counselingaddiction counseling psychotherapypsychotherapy
into a set of harmonious, internally consistent into a set of harmonious, internally consistent clinical practices that appear seamless from the clinical practices that appear seamless from the client’s perspective. client’s perspective.
Who Provides Services Who Provides Services Integration?Integration?
Services Integration may include Services Integration may include integrated clinical treatment by an integrated clinical treatment by an individual treatment provider or clinical individual treatment provider or clinical team, or COD program development by team, or COD program development by a particular treatment program.a particular treatment program.
Processes at Different Levels Processes at Different Levels of Organizationof Organization
SYSTEMS
SERVICES
TREATMENTS
Programs
Licensure
Funding Regulatory
Education
States and States and Sub-State EntitiesSub-State Entities
Contrasting Systems Contrasting Systems IntegrationIntegration
Systems IntegrationSystems Integration facilitates an integrated facilitates an integrated response to client needs through the development response to client needs through the development of educational, fiscal, and regulatory of educational, fiscal, and regulatory infrastructures within States and sub-state entities infrastructures within States and sub-state entities that support integrated services for COD.that support integrated services for COD.
Systems integration = infrastructure integration, Systems integration = infrastructure integration, e.g., deals with e.g., deals with Clinician education Clinician education Licensure of clinicians and programsLicensure of clinicians and programs Service settingsService settings Funding sourcesFunding sources
Contrasting Systems Contrasting Systems IntegrationIntegration
Systems level above Services level Systems level above Services level Includes States and sub-state entities such as Includes States and sub-state entities such as
cities, counties, tribes and tribal organizations cities, counties, tribes and tribal organizations Processes connecting these entities with respect Processes connecting these entities with respect
to integration for COD are: to integration for COD are: Interagency cooperation, coordination, and Interagency cooperation, coordination, and
communication at the local and State levelscommunication at the local and State levels Negotiated fiscal co-responsibility Negotiated fiscal co-responsibility Shared certification and licensure Shared certification and licensure Workforce development including pre-service and Workforce development including pre-service and
continuing educationcontinuing education
Processes at Different Levels Processes at Different Levels of Organizationof Organization
Services IntegrationServices Integration: all relevant clinical : all relevant clinical processes that touch clients directly.processes that touch clients directly. Providers & practices: screening, assessment, Providers & practices: screening, assessment,
treatment, the programs they work in, and treatment, the programs they work in, and organizations and institutions that sustain them. organizations and institutions that sustain them.
Program IntegrationProgram Integration: services integration : services integration implemented by agency or institution to enable implemented by agency or institution to enable clinicians to provide integrated COD treatment. clinicians to provide integrated COD treatment. An integrated program is organized to provide An integrated program is organized to provide specific services to a particular group of clients specific services to a particular group of clients in a deliberate way.in a deliberate way.
Processes at Different Levels Processes at Different Levels of Organizationof Organization
Treatment IntegrationTreatment Integration, a component of integrated , a component of integrated services, is at the next level down, where the services, is at the next level down, where the provider acts with specific skills to achieve service provider acts with specific skills to achieve service goals. goals. Emphasis on the moment of provider/client Emphasis on the moment of provider/client
interaction.interaction. Integrated treatment is a Service Integration activity, Integrated treatment is a Service Integration activity,
like integrated screening or assessmentlike integrated screening or assessment Integrated treatment occurs Integrated treatment occurs
Across agencies Across agencies Within a program Within a program In an individual provider’s office (CSAT, 2005).In an individual provider’s office (CSAT, 2005).
Why Integrate Services?Why Integrate Services?
Strong literature base supports the need for the Strong literature base supports the need for the integration of services provided to COD clients integration of services provided to COD clients (CSAT, 2005). (CSAT, 2005).
Need is generally based on:Need is generally based on: High community rates of COD (Regier et al., 1990; High community rates of COD (Regier et al., 1990;
Kessler et al., 1994; Grant et al., 2004), Kessler et al., 1994; Grant et al., 2004), Negative impact of each untreated disorder on Negative impact of each untreated disorder on
recovery from the other (Rosenthal & Westreich, recovery from the other (Rosenthal & Westreich, 1999), 1999),
Most treatment settings unprepared to effectively Most treatment settings unprepared to effectively manage both substance use and mental disorders manage both substance use and mental disorders (SAMHSA, 2002).(SAMHSA, 2002).
Why Integrate Services?Why Integrate Services?
Most research evidence has focused on need Most research evidence has focused on need for, and effects of, services integration for for, and effects of, services integration for severe substance use and mental disorders severe substance use and mental disorders (e.g., Drake et al., 2001). (e.g., Drake et al., 2001).
Less work has been done investigating Less work has been done investigating services integration for those with severe services integration for those with severe addiction problems and less severe co-addiction problems and less severe co-occurring mental disorders, e.g., Quadrant IIIoccurring mental disorders, e.g., Quadrant III
How Do You Know?How Do You Know?
A “bottom-up” approach: A “bottom-up” approach: comprehensive client assessment comprehensive client assessment documents need for integrated services.documents need for integrated services.
Determining current diagnoses and Determining current diagnoses and corresponding impairments usually corresponding impairments usually sufficient to reveal need for additional sufficient to reveal need for additional core services within traditional provider core services within traditional provider settings. settings.
COD Treatment CapacityCOD Treatment Capacity
Current programs can be classified as having Current programs can be classified as having basic, intermediate, or advanced capacity for basic, intermediate, or advanced capacity for COD treatment, with the highest level being COD treatment, with the highest level being full integration of addiction, mental health, full integration of addiction, mental health, and related services (CSAT, 2005). and related services (CSAT, 2005).
There is a wide range of models that fall into There is a wide range of models that fall into the label of “integrated treatment” and the label of “integrated treatment” and “integrated programs” and the classification of “integrated programs” and the classification of these subtypes is an area of future work. these subtypes is an area of future work.
Role of IntegrationRole of Integration
Available research for the severely mentally ill Available research for the severely mentally ill in combination with documents based on in combination with documents based on consensus-based practices (SAMHSA 2005), consensus-based practices (SAMHSA 2005), support the principle that, provided that support the principle that, provided that proper attention is paid to severity and type of proper attention is paid to severity and type of disorder, services integration can play an disorder, services integration can play an important role in providing appropriate and important role in providing appropriate and effective treatment to persons with COD effective treatment to persons with COD (SAMHSA, 2002).(SAMHSA, 2002).
Optimal Design of Integrated Optimal Design of Integrated ServicesServices
Meets stage-specific needs of COD Meets stage-specific needs of COD clients clients
The treatment team The treatment team Coordinates all pertinent aspects of careCoordinates all pertinent aspects of care Ensures care is accessibleEnsures care is accessible Especially for clients with serious disordersEspecially for clients with serious disorders
Optimal Design of Integrated Optimal Design of Integrated ServicesServices
Involves a range of services Involves a range of services Provisions for integrating medication for addictions and Provisions for integrating medication for addictions and
mental illnessesmental illnesses Case management, including ACT or ICMCase management, including ACT or ICM Motivational interviewing Motivational interviewing Individual or group addiction counselingIndividual or group addiction counseling COD-adapted evidence-based therapies COD-adapted evidence-based therapies
Most services not initially designed for COD-Most services not initially designed for COD-specific service needs specific service needs
Integration usually requires new services Integration usually requires new services Advantage: strategy enables programs to build Advantage: strategy enables programs to build
on current knowledge, skills, and strengths on current knowledge, skills, and strengths while expanding gradually (SAMHSA, 2003a). while expanding gradually (SAMHSA, 2003a).
Approach allows facilities and providers to Approach allows facilities and providers to simplify and change licensing and certification simplify and change licensing and certification requirements for treating COD in the context of requirements for treating COD in the context of different licensing and certification standards. different licensing and certification standards.
Other COD Integration Other COD Integration StrategiesStrategies
Referral networks (no wrong door)Referral networks (no wrong door)Physical and temporal proximity Physical and temporal proximity
services provided by the same clinician or services provided by the same clinician or in the same settingin the same setting
Care coordination Care coordination services provided by a team of providers services provided by a team of providers
from different service arenas who take joint from different service arenas who take joint responsibility for the client. responsibility for the client.
Principles of Care That Principles of Care That Facilitate Services IntegrationFacilitate Services Integration
Consensus viewpoint: Consensus viewpoint: Respect for the individual Respect for the individual Engagement of the most difficult to reach Engagement of the most difficult to reach Belief in the human capacity for change Belief in the human capacity for change Provision of culturally competent services Provision of culturally competent services
(e.g., appropriate for age, sexuality, and (e.g., appropriate for age, sexuality, and gender, and reflective of community gender, and reflective of community diversity)diversity)
Recognition of the importance of community, Recognition of the importance of community, family, and peers to the recovery processfamily, and peers to the recovery process
Integration Success or FailureIntegration Success or Failure
Depends on:Depends on: Quality of leadership Quality of leadership Development of shared values Development of shared values Staff access to (and funds for) training Staff access to (and funds for) training Funding for treatment Funding for treatment Administrative support Administrative support Common assessment toolsCommon assessment tools Capacity for changes in licensure and certification Capacity for changes in licensure and certification Broad stakeholder involvementBroad stakeholder involvement
The systemic benefits can be demonstrated at The systemic benefits can be demonstrated at program, clinician, and client levels. program, clinician, and client levels.
Inadequate leadershipInadequate leadership Rigid, bureaucratic restraints Rigid, bureaucratic restraints Lack of trained staff Lack of trained staff Insufficient collegial support Insufficient collegial support Change-resistant culture Change-resistant culture Demoralized staff (Corrigan et al., 2001). Demoralized staff (Corrigan et al., 2001). ““Top-down” strategic decisions guided more by Top-down” strategic decisions guided more by
power structures, ingrained routines, and power structures, ingrained routines, and established resource configurations than by established resource configurations than by evidence or consensus (Rosenheck, 2001).evidence or consensus (Rosenheck, 2001).
Vital Steps to Transform Services, Vital Steps to Transform Services,
Including Services IntegrationIncluding Services Integration Develop effective leadership styles that prioritize Develop effective leadership styles that prioritize
organizational values: “no wrong door”, a organizational values: “no wrong door”, a recovery perspective, and adopting a multi-recovery perspective, and adopting a multi-problem viewpoint (CSAT, 2005).problem viewpoint (CSAT, 2005).
Remove barriers, e.g.: inadequate funding, Remove barriers, e.g.: inadequate funding, cohorted disciplines, antiquated program cohorted disciplines, antiquated program requirements, disparate meeting times, requirements, disparate meeting times, “standard” assessment forms without “standard” assessment forms without appropriate addiction and mental health appropriate addiction and mental health screening screening
Support and promote staff developmentSupport and promote staff development
Vital Steps to Transform Services, Vital Steps to Transform Services,
Including Services IntegrationIncluding Services Integration Allow staff to take appropriate ‘risks’, Allow staff to take appropriate ‘risks’,
such as: such as: Asking about substance history in MH Asking about substance history in MH
clients, mental health history in CD clients; clients, mental health history in CD clients; Challenging mental disorder diagnoses Challenging mental disorder diagnoses
given to clients who have long-term SUD; given to clients who have long-term SUD; Challenging use of addictive anti-anxiety or Challenging use of addictive anti-anxiety or
sleep medications.sleep medications.
Vital Steps to Transform Services, Vital Steps to Transform Services,
Including Services IntegrationIncluding Services Integration Establish new relationships, such as AA/NA Establish new relationships, such as AA/NA
for mental health staff; with psychiatrists and for mental health staff; with psychiatrists and other mental health clinicians for addictions other mental health clinicians for addictions treatment staff treatment staff
Encourage decisions that are driven by Encourage decisions that are driven by current scientific evidence or through current scientific evidence or through consensus derived by reasonable inquiry consensus derived by reasonable inquiry (Garvin & Roberto, 2001)(Garvin & Roberto, 2001)
Support and implement technology transfer Support and implement technology transfer as evidence-based practices are validatedas evidence-based practices are validated
Management and Fiscal Structures Management and Fiscal Structures That Impede Services IntegrationThat Impede Services Integration
Lack of funds for cross-trainingLack of funds for cross-training Lack of funds to support delivery of co-Lack of funds to support delivery of co-
occurring servicesoccurring services Lack of incentives for clinicians to cross-train Lack of incentives for clinicians to cross-train Outdated policies that do not support COD Outdated policies that do not support COD
treatment treatment Fiscal restraints that impede the treatment of Fiscal restraints that impede the treatment of
more severe disorders (SAMHSA, 2002).more severe disorders (SAMHSA, 2002).
Management and Fiscal Structures Management and Fiscal Structures That Facilitate Integrative ProcessThat Facilitate Integrative Process
1998). 1998). Investigate general regulatory guidelines for a Investigate general regulatory guidelines for a
service’s funding streamservice’s funding stream Generate specific guidelines and instructions for Generate specific guidelines and instructions for
providing and documenting appropriately providing and documenting appropriately matched integrated treatment within the context of matched integrated treatment within the context of the already funded service (Minkoff & Cline, 2004).the already funded service (Minkoff & Cline, 2004).
Outcomes Expected From Services Outcomes Expected From Services
Integration:Integration: Program LevelProgram Level Common values and principles developCommon values and principles develop
When mental health and substance abuse programs When mental health and substance abuse programs are administratively and locally unified, orare administratively and locally unified, or
When internal capacity to treat COD is increased When internal capacity to treat COD is increased (SAMHSA, 2003a, SAMHSA 2005).(SAMHSA, 2003a, SAMHSA 2005).
Multi-problem view of clients Multi-problem view of clients Clear description of treatment population Clear description of treatment population Specific program COD services and levels of Specific program COD services and levels of
care to be provided are identified.care to be provided are identified. Services that are to be coordinated with other Services that are to be coordinated with other
agencies are identified.agencies are identified.
Outcomes Expected From Services Outcomes Expected From Services
Integration:Integration: Practice LevelPractice Level Clinicians have been trained in: Clinicians have been trained in:
Case management Case management Psychopathology Psychopathology Integrated screening and assessmentIntegrated screening and assessment Generating an integrated treatment planGenerating an integrated treatment plan Treatment strategies for mental and substance use Treatment strategies for mental and substance use
disorders disorders Case management skills facilitate engagement into medical, Case management skills facilitate engagement into medical,
housing and vocational services (McLellan et al., 1998). housing and vocational services (McLellan et al., 1998). SUD treatment tailored for SMI clients, and stage-wise, SUD treatment tailored for SMI clients, and stage-wise,
motivational counseling offered in the context of an motivational counseling offered in the context of an alliance-building and supportive therapeutic relationship alliance-building and supportive therapeutic relationship (CSAT, 2005; Winston et al., 2004). (CSAT, 2005; Winston et al., 2004).
Outcomes Expected From Services Outcomes Expected From Services
servicesservices More likely to complete treatmentMore likely to complete treatment BetterBetter outcomes (McLellan et al., 1997).outcomes (McLellan et al., 1997).
With clinically, philosophically, and environmentally With clinically, philosophically, and environmentally integrated services, severe COD clientsintegrated services, severe COD clients Better engaged in treatment (Hellerstein et al., 1995) Better engaged in treatment (Hellerstein et al., 1995) Better outcomes, e.g., increased abstinence or Better outcomes, e.g., increased abstinence or
reduced psychotic symptoms (Barrowclough et al., reduced psychotic symptoms (Barrowclough et al., 2001; Drake et al., 1997, 2001; Jerrell and Ridgely, 2001; Drake et al., 1997, 2001; Jerrell and Ridgely, 1995).1995).
Citations: See NotesCitations: See Notes
IntegrationIntegration
A range of processes for combining different A range of processes for combining different types of services provided by different agencies types of services provided by different agencies or systems to deliver care to clients with complex or systems to deliver care to clients with complex problems. problems.
““Integration” may describe combining primary Integration” may describe combining primary health care and behavioral health care, health care and behavioral health care, incorporating behavioral health into criminal incorporating behavioral health into criminal justice settings, etc.. justice settings, etc..
Integration refers here to strategies for combining Integration refers here to strategies for combining mental health and substance abuse services to mental health and substance abuse services to address the needs of individuals with co-address the needs of individuals with co-occurring disorders.occurring disorders.
