1. Complexities of Co-occurring Disorders STATE AGENCY PERSPECTIVE June 24, 2004 Renata J. Henry, M.Ed.

2. Mental Health Commissioners and Substance Abuse Directors would agree…  Need to improve services for people with co-occurring disorders.  Definition of co-occurring has broadened to include other disabilities, physical health, and infectious disease.  Best approach is an integrated system both across disciplines and systems

3. Several conceptual models…  Dual-Diagnosis Capable and Dual Diagnosis Enhanced – ASAM  Dual-Diagnosis Integrated Treatment – Drake  Co-Occurring Disorders Matrix – NASADAD/NASMHPD

4. Service Coordination

5. Service Coordination by Locus of Care

6. Barriers exist to truly integrated services and systems…..  Separate and uncoordinated State MH and SA systems  Little connection between providers and programs  Few staff bridges between programs  Categorical funding streams  Disparate insurance coverage

7. Barriers exist to truly integrated services and systems Cont…..  Differences in workforce  Limited research and evidence based practices  Lack of assessment and screening tools  Regulatory and licensing contradictions

8. In Delaware……  Integrated administrative structure  Commitment by leadership  No wrong door approach  Moving away from silo funding toward blended funding  Minimum standard for the system is dual diagnosis capable

9. Training effort with MH and SA staff…  Interagency Program Development for Integrated Treatment Services Across Systems.  Focus on co-occurring MH, SA, and HIV  MH, SA, Homeless, CJ, and HIV systems.  Addresses all four quadrants with emphasis on II, III, and IV  Model includes: screening, assessment, engagement, client readiness, phase and stage treatment, outcome measures and data collection.

10. Delaware’s System

11. Overcoming barriers…… Action needed at three levels:  Administration  Federal  Research

12. Administration….  Leadership at all levels is a necessary ingredient in the development and implementation of services  Establish the standard and sets expectations  Leadership brings the players together and initiates the dialogue.  Leadership takes responsibility for dissemination of tools and information to the field  Develop methods to overcome funding and regulatory barriers at various system levels

13. Federal……  Develop policies and methods that promote integration and collaboration.  Eliminate the funding barriers and develop a method to pay for co-occurring services.  Various agencies have to define their role in the development of a co-occurring infrastructure.  Earlier investigation of the barriers to adoption of new research.  Improve dissemination of co-occurring research  Connect service researchers to state systems

14. Research: What State Directors Want to Know….  What are the most effective models for this population? What combination of drugs, psychosocial interventions work?  Is integrated treatment cost effective?  What client, staff factors or other variables are associated with better outcomes from a fully integrated co-occurring team/site approach vs. lesser integrated models, e.g. consultation or collaboration?

15. Research: What State Directors Want to Know Cont….  What EBP’s work for the majority of this population? What portion of this specific population does an EBP work better for?  What skill sets/competencies does staff need to have for co-occurring services and what is the impact on client outcomes? Who should be providing what types of care?  Are there organizational prerequisites for integrated services to be successful? What SMHA/SSA actions create readiness to adopt co- occurring services?  Which elements of identified EBP’s must be implemented with fidelity to attain outcomes associated with the practices? Which can be modified without sacrificing outcomes? What should be modified with this population?

16. In conclusion…  Treatment of co-occurring disorders is an important issue for State Directors  States play a key role in developing, improving and maintaining an infrastructure in which co-occurring services are provided  Progress made, but barriers still remain: financing, workforce, special populations, and research  Partnerships between state agencies, federal agencies, and researchers is imperative in moving forward