Breaking Down Barriers: Providing Integrated Care for Individuals with Severe Mental Illness and Substance Use Disorders Ken Bachrach, Ph.D. Debbie Innes-Gomberg, Ph.D. Monica Weil, Psy.D. Martin Hernandez, MSW

The Mental Health Services Act  Proposition 63 Passed November, 2004  Identifies 4 distinct age groups: Children Transition Age Youth16-25 Adults26-59 Older Adults60 +

MHSA Philosophy  Goal is to transform the mental health system  An inclusive planning process  Fund or expand programs that use proven service models  Assure accountability by collecting data on outcomes  Do whatever it takes to support clients to achieve recovery

Components of MHSA  Planning  Community Services and Supports FSP and Systems Development  Prevention and Early Intervention  Capital Facilities and Technology  Workforce, Education and Training  Innovation

Full Service Partnerships Adults Adults who are a severe mental illness and who are:  Homeless  In jail  Frequent users of psychiatric hospitals or ERs  In institutions (IMDs, State Hospitals)  Being cared for by families but in the absence of the family would be at risk of the above.

FSP Services Whatever it Takes  Individualized, comprehensive treatment and support focused on recovery  1:15 maximum staff to client ratio  Multi-disciplinary daily team meetings  24/7 availability for crises  Field-based service approach  Peer support services  Integrated COD services  Housing and employment assistance

Services Provided in Residential Drug and Alcohol Treatment Assessment & Treatment Planning Assessment & Treatment Planning Individual and Group Counseling Individual and Group Counseling Addiction and Recovery Services Addiction and Recovery Services Social Services Social Services Community Linkages Community Linkages Discharge Planning Discharge Planning

INTAKE Assess need for treatment and determine level of care Complete required forms Admit Patient Preliminary Treatment Plan within 24 hours COMPLETE ASSESSMENTS: ASI Psych Symptom Chklist Family/SO Nutritional Screening History & Physical Psychiatric INTEGRATED SUMMARY COMPLETE TREATMENT PLAN INITIAL CASE CONFERENCE TREATMENT PLAN UPDATE / PT PROGRESS REVIEW TREATMENT PLANNING PROCESS

Groups Educational (Addiction Education) Educational (Addiction Education) Psychoeducational (Relapse Prevention) Psychoeducational (Relapse Prevention) Process (Recovery Issues; Men’s / Women’s Group) Process (Recovery Issues; Men’s / Women’s Group)

Core Groups Addiction Education Addiction Education Family Education Family Education Relapse Prevention Relapse Prevention Self-Help Orientation Self-Help Orientation Recovery Issues Recovery Issues Multi-Family Group Multi-Family Group

Residential Electives Stress Management Stress Management Spirituality Group Spirituality Group Depression Management Depression Management Trauma Group (separate for men & women) Trauma Group (separate for men & women) Grief & Loss Grief & Loss Anger Management Anger Management Recreational Therapy / Leisure Education Recreational Therapy / Leisure Education

Residential Drug Treatment Recipients Often have a long history of substance abuse and documented severe and persistent psychiatric disorder Often have a long history of substance abuse and documented severe and persistent psychiatric disorder Often homeless or recently released from a psychiatric hospitalization Often homeless or recently released from a psychiatric hospitalization Unable to stop their substance use on an outpatient basis, but don’t meet criteria for a psychiatric hospitalization Unable to stop their substance use on an outpatient basis, but don’t meet criteria for a psychiatric hospitalization

Four-Quadrant Framework for COD Source: NASMHPD, NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002 Less severe mental disorder/ less severe substance abuse disorder More severe mental disorder/ less severe substance abuse disorder More severe mental disorder/ more severe substance abuse disorder Less severe mental disorder/ more severe substance abuse disorder High severity Low severity

Service Delivery for COD Consultation between systems Generally not eligible for public alcohol/drug or mental health services Low to Moderate Psychiatric Symptoms/Disorders And Low to Moderate Severity Substance Issues/Disorders Services provided in outpatient chemical dependency or mental health system LOW - LOW HIGH - LOW Collaboration between systems Eligible for public mental health services but not alcohol/drug services High Severity Psychiatric Symptoms/Disorders And Low to Moderate Severity Substance Issues/Disorders Services provided in outpatient and inpatient mental health system LOW - HIGH Collaboration between systems Eligible for public alcohol/drug services but not mental health services Low to Moderate Psychiatric Symptoms/Disorders And High Severity Substance Issues/Disorders Services provided in outpatient and inpatient chemical dependency system HIGH - HIGH Integration of services Eligible for public alcohol/drug and mental health services High Severity Psychiatric Symptoms/Disorders And High Severity Substance Issues/Disorders Services provided in specialized treatment programs with cross-trained staff or multidisciplinary teams Source: Ries, 2004

FSP & Concurrent Residential Drug Treatment  A model for integrated services  Provides a safe environment to address substance use and mental health symptoms and to create a joint treatment plan

The Pilot Study  Purpose – To identify promising practices supporting integrated services for clients with co-occurring disorders  What added value does the FSP team serve while an FSP client is in residential drug/alcohol treatment?  What are the unique roles of the FSP team and the residential team?  How do the teams work together best?

FSP Clinical Case Conferences  2 weeks after an adult FSP enrollee enters residential drug/alcohol treatment, a clinical case conference will be initiated by the FSP program or the Service Area District Chief.  Clinical case conferences continue every 30 days until the client is discharged from the residential program.

Clinical Case Conference  Review treatment plan- client stage of recovery and intervention strategies  Identify unique services provided by FSP team and residential treatment team.  Ensure services are not duplicated

Case Example #1  Mr. Vinnie Boom Botz  52 year old Hispanic male who has been diagnosed with Schizoaffective Disorder and alcohol dependence.  Long history of ETOH dependence  Patient suffers from head injury as a result of sustaining a beating while intoxicated and homeless.  Due to patient’s Organic Brain Disorder, frequent relapse on alcohol and other substances of abuse – patient required stabilization on the residential unit.

Vinnie, Continued Case consultation began immediately between FSP Case Manager, FSP clinician and residential clinician and counselor. Case consultation began immediately between FSP Case Manager, FSP clinician and residential clinician and counselor. DMH was consulted as well DMH was consulted as well As a result, patient was given a neuropsychological testing battery and reports were written to advocate for patient to receive SSI. As a result, patient was given a neuropsychological testing battery and reports were written to advocate for patient to receive SSI. Patient was approved for SSI. Patient was approved for SSI.

Vinnie, Cont. Patient is currently living in sober living Patient is currently living in sober living Patient attends community meetings Patient attends community meetings Patient continues with FSP case management and therapeutic services Patient continues with FSP case management and therapeutic services Patient’s SSI payments are administered by a third party as he is unable to manage his own finances. Patient’s SSI payments are administered by a third party as he is unable to manage his own finances. Patient is receiving dental and medical services Patient is receiving dental and medical services

Vinnie, Cont. Patient has a strong connection with residential unit and with treatment facility. Patient has a strong connection with residential unit and with treatment facility. Auditory and visual hallucinations remain, but have decreased in both quality and quantity Auditory and visual hallucinations remain, but have decreased in both quality and quantity He has been able to recognize that his hallucinations are not reality and respond more appropriately to them. He has been able to recognize that his hallucinations are not reality and respond more appropriately to them.

Case Example #2 Mr. Jimmy Rodz Mr. Jimmy Rodz 27 year old Hispanic male diagnosed with Psychotic Disorder NOS and Poly-substance abuse and Methamphetamine Dependence 27 year old Hispanic male diagnosed with Psychotic Disorder NOS and Poly-substance abuse and Methamphetamine Dependence Has short but extensive history of abusing drugs Has short but extensive history of abusing drugs Prior to age 18, client had been doing well, enrolled in college, and wanted to be a peace officer. Prior to age 18, client had been doing well, enrolled in college, and wanted to be a peace officer. Mother explained that she believes that the community they lived in (high drug use), possibly influenced his extensive drug use Mother explained that she believes that the community they lived in (high drug use), possibly influenced his extensive drug use

Jimmy Cont. Prior to FSP services, he was accepting sporadic mental health services due to client’s non-compliance with recommended treatment. Prior to FSP services, he was accepting sporadic mental health services due to client’s non-compliance with recommended treatment. Client had numerous psychiatric hospitalizations while he was under the influence or coming down from using. Client had numerous psychiatric hospitalizations while he was under the influence or coming down from using. When enrolled into FSP services, program also enrolled and placed in a residential drug treatment facility. When enrolled into FSP services, program also enrolled and placed in a residential drug treatment facility. Client responded well to the structured treatment and the Co- Occurring Disorder Treatment. Client responded well to the structured treatment and the Co- Occurring Disorder Treatment. FSP Program held weekly team meeting at which client’s case was discussed, and bi-monthly meetings with residential drug treatment program and FSP treatment team. FSP Program held weekly team meeting at which client’s case was discussed, and bi-monthly meetings with residential drug treatment program and FSP treatment team.

Jimmy Cont. Client graduated residential drug treatment and moved on to sober living. Client graduated residential drug treatment and moved on to sober living. He continues to received FSP services and has moved to independent living. He continues to received FSP services and has moved to independent living. Client has strong relationship with substance abuse support groups in the community. Client has strong relationship with substance abuse support groups in the community. Currently, client has full-time employment and is planning to enroll in college. Client continues to remain sober since entering FSP Program and Residential Drug Treatment. Currently, client has full-time employment and is planning to enroll in college. Client continues to remain sober since entering FSP Program and Residential Drug Treatment.

Lessons Learned  It is important to have available short-term residential drug treatment in the continuum of care for individuals with severe mental illness and severe substance abuse problems  Short-term residential drug treatment can provide the opportunity to conduct a thorough assessment of the individual’s psychiatric and psychosocial functioning when not using substances that is rarely possible on an outpatient basis.

Lessons Learned Mental health services can be initiated or continued in an environment where their effectiveness can be better evaluated, given the controlled environment of residential care Mental health services can be initiated or continued in an environment where their effectiveness can be better evaluated, given the controlled environment of residential care Mental health services can be coordinated during treatment and continued after leaving residential care in a seamless fashion Mental health services can be coordinated during treatment and continued after leaving residential care in a seamless fashion Frequent communication between AOD and DMH providers is critical to provide coordinated and integrated care. Frequent communication between AOD and DMH providers is critical to provide coordinated and integrated care.

Next Steps  Expand the number of AOD providers who can work with FSP programs  Continue to refine and improve communication and coordination of care  Evaluate the effectiveness of providing residential AOD services in improving outcomes