Comprehensive, Continuous, Integrated, Systems of Care Model An Introduction to The CCISC Model Anne Arundel County Co-Occurring Change Agent Group

Introduction The CCISC Model Is a Model of Best Practice (Comprehensive Continuous Integrated Systems of Care) Is a Model of Best Practice Principles Of Treatment 2001 version was based on work of a consensus panel that led to a SAMSHA report in 1998 entitled: “Individuals with Co-occurring disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies, and Training Curricula” (Minkoff, 1998)

CCISC Model Developed by Kenneth Minkoff, MD, Clinical Assistant Professor of Psychiatry, Harvard Medical School

CCISC Model For the purpose of improving treatment capacity for individuals with co-occurring psychiatric and substance disorders. Key words are “treatment capacity” Co-occurring clients have historically been caught in gaps of treatment. We frequently lament the fact that they “fall through the cracks” The beginning of this model was in when Kenneth Minkoff chaired a consensus panel to establish guidelines for standards of care for indiciduals with co-occurring disorders for managed care. This was a huge undertaking and included input from virtually all professionals in the U.S. who were making strides in treating this population. The list of contributors included David Mee Lee, Kathleen Sciacca, Maryland’s own Fred Osher, Prochaska & DiClemente and numerous others

CCISC Model The latest version, complete with a “Train the Trainers Curriculum” was developed in collaboration with Christie A. Cline, MD, MBA, formerly of the New Mexico Department of Health Dr. Cline served in several capacities including Medical Director She was a clear and constructive voice at the SAMHSA Consensus hearings in

Basic Characteristics System Level Change System level change ix accomplished by implementing the model at the program level, the clinical practice level, and the clinician competency level Program Level = No wrong door Clinical practice level = learn and apply best practices – for example, psych meds and relapse Clinician competency level – training, motivational enhancement

Basic Characteristics Efficient Use of Existing Resources Does not require additional resources – other than planning, technical assistance, and training.

Basic Characteristics Incorporation of Best Practices CCISC is recognized by SAMHSA as a best practice and it utilizes evidence based on research and clinical consensus 1. Welcoming Motivational Enhancement

Welcoming!

Stages of Change Prochaska & DiClemente The Stages of Change model is key to understanding the process of recovery

Motivational Enhancement Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Support Self Efficacy

Basic Characteristics Integrated Treatment Philosophy Integrates the principles and perspective of both mental health and substance abuse professionals and utilizes a common language Parallel treatment Sequential Treatment

Principles of CCISC Model # 1 The co-occurrence of A Substance Abuse Disorder and Mental Illness is an expectation, not an exception. Research tells us this. Experience tells us this Clients may try to hide it based on their past experience Treatment programs must be proactive in fully diagnosing clients

Principle # 2 All Co-occurring Clients are not the same. Treatment must be individualized. One of the ways it must be individualized is locus of care. Where should the client be treat

Appropriate Level of Care Addiction or Mental Health Only Dual Diagnosis Capable Dual Diagnosis Enhanced

Four Quadrant Model misa Minor Mental Illness Mild or no Sub Abuse miSD Major Sub Dependence MIsa Major Mental Illness Mild Sub Abuse MISA

Locus of Care According to Four Quadrant Model

Principle # 3 Successful Treatment is based on empathic, hopeful, integrated and continuing relationships Welcoming and Motivational Enhancement are key to engaging and maintaining client in treatment Clients often present as train wrecks – tough to be hopeful Different disciplines are better at empathetically detaching from some presentations than others

Principle # 4 Case Management and clinical care must be properly balanced with: empathic detachment, opportunities for empowerment and choice, contracting, contingent learning. Empathic detachment - usually SA professionals find it easier to empathetically detach from SA related behaviors and MH professionals from MH issues Strength based treatment is the best practice and strength based assessment is an important skill Mental Health and Substance Abuse professionals are both used to contracting but often in different ways. Cooperation between disciplines is usually necessary to achieve optimum results Contingent learning is often a form of contracting and is crucial to advancing treatment goals

Principle # 5 When psychiatric and substance disorders coexist, both disorders should be considered primary. Diagnosed psychiatric illness receives the most clinically effective psychopharmacologic strategy available regardless of status of the co morbid substance disorder - special considerations apply to the use of potentially addictive medications that may have psychiatric indications such as benzo’s or stimulants

Principle # 6 Both serious mental illness and substance dependence disorders are primary biopsychosocial disorders that can be treated in the context of a “disease and recovery” model. Biopsychosocial is a term that expresses the dynamic and interactive nature of various aspects of disease and recovery. It is holistic. Substance Abuse Relapse Prevention has long recognized the biopsychosocial aspects of the process – frequently comparing chemical dependence to diabetes and other chronic diseases. The chronic nature of mental illness lends itself well to a “recovery” model. The recovery model implies that interventions are not only diagnosis specific, but also specific to phase of recovery and stage of change.

Phases of Recovery Acute Stabilization (Detoxification) Engagement/Motivational Enhancement Active Treatment/Prolonged Stabilization Rehabilitation/Recovery (Relapse Prevention) Stage of Change and Phase of Recovery should be harmonious with each other

Principle # 7 There is no one correct approach to individuals with co-occurring disorders. This fact dictates a good strength based assessment in order to determine effective approach and satisfactory outcomes

Principle # 8 Clinical outcomes for client with co-occurring disorders must also be individualized. What do you consider success. Needs to be decided for each individual client Often needs to be re-defined during treatment - different outcomes for different stages of treatment May include reduction in symptoms or use of substances, increases in level of functioning, increase in disease management skills, movement through Phases of Treatment or Levels of Change.