Report on CoOccurring Disorders to California Mental Health Planning Council

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Report on Co-Occurring Disordersto
CaliforniaMental Health Planning Council
David Pating, MD
10.15.2009
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Overview

• Update MHSOAC
• Report on Co-occurring Disorders to MHSOAC
• Status COD treatment in California

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Mental Health Services Act

• Prop 63 passed 2004 by 54 electorate
• 1 assessment on incomes gt1M specifically to
  Transform Mental Health Care in California
• Priorities
• Client Family Centered
• Cultural Linguistically Competent
• Recovery Wellness Focused
• Community Partnership
• Integrated Service Experience
• (Co-Occurring Disorders 11/09)

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MHSOAC Staff and Officer

• Chair, Andrew Poat Vice Chair, Larry Poaster
• Committees
• Services Pating, Gould
• Finance Poaster
• Client Family Vega
• Cultural Linguistic Competency
• Evaluation Poaster, Van Horn

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MHSOAC Annual Priorities

• In April 2009, the MHSOAC committed to the
  following annual priorities
• To fund and execute all five MHSA programs
• Define Transformation and articulate its
  vision.
• Develop an integrated consistent approach to
  evaluate the results of the MHSA and facilitate
  the adoption of the best practices across the
  entire community-based mental health system.
• Adopt an approach for significantly reducing
  forms of mental health stigma and resulting
  discrimination towards those at risk and of
  living with mental illness and their families
• Further define the roles and responsibilities of
  the Commission (in light of AB5xxx)

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MHSOAC Current Priorities

• 1) Prudent Reserves MHSOAC continues to
  anticipate decreased revenue due to economic down
  turn from 1.6B (2008-9) to 900M in 2010.
  Fiscal discussions are underway to develop policy
  on maintenance and use of prudent reserves to
  smooth fiscal volatility.
• 2) Statewide PEI Projects Guidelines are
  expected in December 2009 to implement 3
  statewide projects Student Mental Health
  Initiative, Stigma and Discrimination Reduction,
  Suicide Prevention. Alternative funding
  mechanisms have emerged to create collaborative
  entities to administer these programs.
• 3) Complaint Processes DMH, in collaboration
  with MHSOAC is developing a comprehensive
  complaint review process that integrates county
  and state review.

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Report on Co-Occurring DisordersTransformin
g the Mental Health SystemThrough Integration
9.25.2008
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To Achieve the Promise

• To achieve the promise of community living for
  everyone, new service delivery patterns and
  incentives must ensure that every American has
  easy and continuous access to the most current
  treatments and best support services.
• -Presidents New Freedom Commission on
  Mental Health (2003)

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Health care for general, mental, and
substance-use problems and illnesses must be
delivered with an understanding of the inherent
interactions between the mind/brain and the rest
of the body. --The Institute of
Medicine, 2006
To Achieve the Promise
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OAC Workgroup On COD
Following 6 months of hearings, the OAC Workgroup
on Co-occurring Disorders Proposed in September
2008

• Recommendations to Improve
• Treatment for Co-Occurring Disorders
• Template for Integrating Services
• under the Mental Health Services Act

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Transforming Mental Health

• If we want people with co-occurring disorders to
  recover,
• we must promote systemic recovery.
• -COD Report, p.2

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Co-occurring Disorders Report Overview

• Statement of MHSA Tenets
• Whatever it Takes
• Integrated Services
• Key Findings
• Global Concerns
• Systemic Strengths
• Core Recommendation
• Promote COD Competency

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1. MHSA tenets include

• Effective services for people living with serious
  mental illnesses must include whatever it takes
  for recovery.
• Services must be integrated.

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Whatever it takes

• Refers, in part, to flexible funding.
• Flexible funding allows the use of funds for a
  wide array of clinical services and supports
  beyond what is normally allowed in categorical
  funding.

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Integrated Services

• Means mental health prevention and treatment are
  coordinated so that there is
• no wrong door to receiving care.
• Services should be concurrently delivered
• by a coordinated team of caregivers, often
  sharing single sites.

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2a. Global Concerns
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• Key Finding 1.
• Approximately one half of people with a mental
  illness or a substance abuse disorder, also have
  the other condition.
• These individuals have a co-occurring disorder
  (COD).

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Mental Substance Use Disorder

• Epidemiology

(Regier, Arch. Gen Psy, 1991)
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Comorbidity in Public Sector Treatment

• In public sector, 49 to 70 of the clients
• have co-occurring mental health
• and substance use disorders

National Survey on Drug Use and Health National
Findings 2004
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Mental Diagnosis by Service TypeSan Francisco
County 1998-2004
N224, recruited from MH and SA Svc Havassy, Am
J Psychiatry, 161 (1), 139-145.
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SUD Diagnosis by Service Type
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2a. Global Concerns
underserved

• Key Finding 2.
• Individuals with COD are among Californias most
  underserved.
• Up to 60 of individuals receiving treatment in
  our public sector mental health system have COD.
  Most do not receive integrated care.

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Treatment Status for COD Respondents In 2004
NSDUH Sample
National Survey on Drug Use and Health National
Findings 2004
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Utilization of Mental Health Services
All significantly different at p lt .001.
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Percentage of Participants Who Received SA
Services


Results of chi square tests. plt .05, p
.000
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2a. Global Concerns
disabling

• Key Finding 3
• COD is pervasive and disabling.
• Individuals with COD have more relapses,
  hospitalizations, depression suicide, violence,
  homelessness, arrests and incarcerations, HIV,
  trauma and school failure.

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Why Dual Diagnosis?

• Alcoholic or Substance Dependent
• with Mental Health Impairment
• 2-4 times more likely to seek treatment than any
  single disorder.
• (Grant, NIDA Monographs, 1997)

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2a. Global Concerns
expensive

• Key Finding 4
• Insufficient support for integrated COD
  treatment leads to a paucity of programs and
  skilled providers.
• Unable to access appropriate care, individuals
  with COD are disproportionately served in
  emergency rooms, jails, foster care and among the
  homeless at great financial and emotional cost.

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California Treatment System
COD
County DMH/ADP
Vet Adm
Untreated
University Schools
Non-Profit Outpatient
Recovery Homes
Hospitals
Jails/Court
Methadone Clinics
Insured
COD impact our Whole Treatment System
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Warning Hospital Closures
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Warning Jail Overcrowding

• 16 Arrests related to MH or SA
• In CA some counties, up to 50 incarcerations are
  meth-related.

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Warning Foster Care

• 70 of youth in juvenile detention, foster care
  or group homes abuse alcohol or drugs
• 60 have mental disorders.

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Warning Homelessness

• COMPARE
• Cost Homeless Care 61,000 annually
• Cost for Supportive Housing 16,000

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2b. Californias Strengths
COD

• DMH ADP Established the
• Co-Occurring Joint Action Council
• Developed COD State Action Plan
• Screen Tool, Universal Charts, Standards
• COD Best Practices in (16) Counties
• Multiple funding sources available.
• Effective model Peer Family Services

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2b. Effective National Models

• Improved Quality at Lower Cost!
• MHSA Supportive Housing
• MHSA Full-Service Partnerships
• California SACPA (Prop 36) AOD Diversion
• Bexar County (Texas) MH Diversion
• Allegheny County (Penn) MH Court
• California AOD SBIRT (San Diego)

Just what the doctor ordered
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Decision How do we Integrate Services?

• Californias Strengths
• DMH/ADP National BP

DMH ADP
Support Existing COD State Plan
Transformation Through MHSA
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Change in Two Sizes

• i I
• Little Big
• Integration

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Support COD State Plan

• Leverage MHSA funds, where possible, to implement
  components of COD Plan.
• Screening Tool
• Universal Charting
• Training and Technical Assistance
• Standards and Outcomes

DMH-ADP
Priority focus for Integrated Plans?
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In a Transformed System
Integration Means

• Involve the Whole Community
• Integrate the Whole System
• Treat the Whole Person

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To Transform a System

• The Science of Transformation
• Change Culture The Process of Transformation
  should Mirror its Goals.
• Effective Implementation Policy bodies must work
  through its intermediaries.
• Focus on Achievable Outcomes Measurable Progress
  should be rewarded
• Consultants, Ken Minkoff Chris Cline (SAMHSA)

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Unique MHSA Opportunities

• In a Transformed System of Integrated Care
• through the Mental Health Services Act
• Culture of Partnership Mental Health Services
  should be delivered in collaboration with
  non-mental health partnerships mirroring the
  partnership with clients and families.
• Support Systemic Integration Policy, Guidelines
  and Technical Assistance would consistently
  support whatever it takes for counties and
  agencies to comprehensively integrate services.
• Measure Whole-person Care The client
  experience
• of service continuity and meaningful care would
  be the
• hallmark of successful service integration.

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Towards Integrated Plans

• Mental Health Partnerships
• Explore means to enhance our Community Planning
  Process.
• System-wide Integration
• Review Integrated Plans for Continuity among
  MHSA Programs (CSS, PEI, INN, WET) and
  opportunities for flexible funding.
• Client-Centered Outcomes
• Explore measures of client-centered
  satisfaction and continuity of care.

Forward to Integrated Plan Discussion
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3. Recommendation

• The MHSOAC should promote
• Co-occurring Disorders Competency as
• a core value in implementation of the MHSA and
  this value should be reflected in the
  Commissions Annual Strategic Plan.

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Analysis

• By adopting co-occurring disorders competency as
  a core-value, the MHSOAC provides policy
  direction which facilitates the achievement of 10
  key goals necessary to improve the treatment of
  co-occurring disorders, as well as, transform the
  mental health system in California.

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Transformative Goals for the Mental Health
Services Act

• Goal 1 Create a Culturally Competent
  Integrated System of CareGoal 2 Establish
  Systemic PartnershipsGoal 3 Encourage DMH and
  ADP CollaborationGoal 4 Provide Ample Training
  and Technical AssistanceGoal 5 Close Gaps in
  the Continuum of CareGoal 6 Expand Peer-based
  Wellness Recovery ServicesGoal 7 Empower
  Families to Enhance RecoveryGoal 8 Effectively
  Treat TraumaGoal 9 Use Outcomes to Measure
  ProgressGoal 10 Provide Incentives to Promote
  Transformation

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In a Co-Occurring Disorders Competent System
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In a Co-occurring Disorders Competent System

• Integrated Care Mental Health Care in California
  will be provided through an integrated continuum
  of care.
• Partnerships Mental Health Care in California
  will reflect a public health perspective, which
  results in the development of collaborative
  partnerships.
• Collaboration DMH ADP will support COJACs
  state plan.
• Training MHSA Training Technical assistance
  will support ongoing workforce development and
  behavioral health competency.
• Comprehensive Continuum Services for mental
  illness and substance abuse will be comprehensive
  and promote seamless transition in and out of
  emergency services.

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In a Co-occurring Disorders Competent System

• Peer-Based Recovery Peers will be broadly
  involved in the continuum of care and provide
  peer-based wellness and recovery services.
• Strengthen Families Families will be engaged and
  assisted to support and sustain recovery.
• Trauma Awareness Competency to treat trauma will
  be promoted and valued in MHSA programs.
• Measure Progress Use evidence appropriate
  outcomes.
• Incentive Transformation Encourage growth of the
  mental health system towards greater integration
  and co-occurring competency.

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Next Steps for COD

• Recommendation Approved 11/08
• Services Committee to prioritize
• Patings recommendations
• Implement Screen Tool
• COD Standards of Care
• Offender-based Treatment

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Status of Co-occurring Disorders Collaboration in
California
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Current Status COD

• Minkoff Change Agents
• COJAC Screening Tool
• Administrative Office of Courts Inquiry
• COD Prevention and Early Intervention

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Look Ahead COD

• Integrated Primary Care Initiative
• Universal Chart
• MHSA Integrated Plans

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MHSA Prevention and Early Intervention Projects
Addressing Co-Occurring Disorders

• David Pating, MD
• October 2009

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Approved PEI Funds to Date

• 45 PEI Plans Approved 320,699,429
• October 2009 Commission Meeting will include
• Sacramento PEI Plan 1,600,000
• Ventura PEI Plan 5,250,583
• Will total 47 PEI Plans 327,550,012
• 22 Training, Technical Assistance Capacity
  Building (Info. No. 08-37) 8,7456,900
• 20 Annual Updates 84,786,707
• 2 Innovation Plan 479,549

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• San Diego County
• In 2002 they adopted the Comprehensive,
  Continuous, Integrated System of Care (CCISC)
  model to improve services for persons with
  co-occurring disorders. The model outlines 4
  quadrants (broad parameters) of responsibility of
  Alcohol and Drug Services (ADS) and Mental Health
  (MH) programs for persons with co-occurring
  disorders
• Quadrant III are persons identified
  (respectively) with high substance abuse
  issues/treatment issues low MH issues/treatment
  needs and are high-risk for SMI

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• San Diego County
• PEI Project Goals
• Screening, brief intervention and referrals for
  1800 people identified as Quadrant III
• Training for Staff and Law Enforcement
• Linkages to Providers, rehabilitation programs,
  detox, self-help groups, sober living homes,
  counseling, legal services etc.
• Collaboration with TAY and Older Adult programs,
  Teen Centers, Senior Centers, health care
  providers, community clinics and expanded
  collaboration with ADS providers/resources
• Annual outcome evaluation

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• San Diego County
• Embedded Mental health and Substance Abuse staff
  served in San Diego County Psychiatric Hospital
  Crisis Recover Unit
• 6,000 adults (25-59)
• 1,000 TAY (18-24)
• gt300 Older Adults (60)
• These individuals made almost 16,000 visits in
  FY2006-07

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• Riverside County
• Seeking Safety Program simultaneously helps
  people with a history of trauma and substance
  abuse issues
• Guiding Good Choices Program is a prevention
  program for the Native America (NA) Community
  9-14 years old. With the historical trauma in NA
  communities substance abuse is inextricably
  linked with depression, Bi-Polar Disorder and
  PTSD. Riverside County PEI plan page 143
• Riverside County PEI Plan has resources/collaborat
  ion or referrals available in virtually all of
  their programs

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• City of Berkeley coordinated system for
  screening for post-partum depression and
  peri-natal alcohol and other drug use
• San Francisco within Trauma and Recovery
  Services Project they are offering a
  comprehensive, culturally competent, co-occurring
  capable services for youth and families affected
  by violence and trauma
• Fresno had a co-occurring specific focus group
  and has a PEI project designed to address the
  trauma experienced by the children of substance
  abusing or gambling addicted fathers

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• Marin County
• Youth 15-21 have the highest prevalence (over
  60) of co-occurring substance abuse and mental
  health disorders
• Marin County integrating services for people with
  Co-Occurring disorders in PEI Programs
• Older Adults, Home Delivered Meals PEI Program
• Suicide Prevention Project
• Children and Youth PEI (co-occurring assessment
  with parents)
• Increased collaboration with Student Assistance
  Program and Department of Education
• TAY Prevention and Early Intervention Project
• Primary Care Integration Project

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• PEARLS
• Program to Encourage Active And Rewarding Lives
  for Seniors
• Evidenced Based Practice
• Reviewed by the Nations Registry of
  Evidence-based Programs and Practices of the
  Substance Abuse and Mental Health Services
  Administration
• A few Counties who are implementing PEARLS
• Imperial - San Diego
• Los Angeles - San Joaquin
• Merced - Riverside

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Examples MHSA PEI Projects Addressing
Co-Occurring Disorders

• Global MHSA PEI REVIEW
• A review of 28 of the 45 approved PEI plans found
  that 75 of the plans included some attention to
  or consideration for people with co-occurring
  disorders

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The Future of Co-Occurring Disorders

• The MHSOAC and its partners should support the
  transformation of mental health care by
  immediately investing in the integrated treatment
  of co-occurring disordersto act both politically
  and financially.
• The long-term dividends from investment in
  Co-occurring Disorders will reap major financial
  savings and improve overall mental health and
  social welfare far beyond meeting the challenge
  of co-occurring mental illness and substance
  abuse. -COD report, p 24

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Acknowledgements

• The MHSOAC Co-occurring Disorders (COD) Workgroup
  would like to thank the members of our
  predecessor COD Workgroup for their efforts in
  bringing this issue to the attention of
  Californians. The 2007 COD Workgroup included
  Gary Jaeger, Judge Steven Manley, Rod Shaner, and
  Rusty Selix.
• This report is the culmination of over eight
  months of work on the part of the 2008 COD
  Workgroup. The 2008 Workgroup was comprised of
  Workgroup Chair and MHSOAC Commissioner David
  Pating, Workgroup Co-Chair and Commissioner Beth
  Gould, Commissioner Larry Poaster, Commissioner
  Darlene Prettyman, Maureen Bauman, Delphine
  Brody, Nick Damian, Pia Escudero, Mary Hale,
  Patricia Harris, Joan Hirose, Sandra Marley,
  Alice Gleghorn, Rusty Selix, John Sheehe, Marvin
  Southard, Cheryl Trenwith, Henry van Oudheusden,
  and Dede Ranahan.
• We also thank our many presenters who took the
  time to travel to inform the Workgroup and the
  public about the latest issues in COD policy. The
  2008 presenters to the COD Workgroup included
  Delphine Brody, Alice Gleghorn, Kathy Jett, Gary
  Jaeger, Patricia Johnson, Sheree Kruckenberg,
  Stephen Mayberg, Dede Ranahan, Tom Renfree, Rusty
  Selix, Vicki Smith, Marvin Southard, Cheryl
  Trenwith, Alice Trujillo, and Renee Zito.
• The MHSOAC COD Workgroup would like to recognize
  the leadership and tenacity of David Pating,
  principal author, to bring this report to
  completion. His experience, dedication and
  boundless energy inspired us to complete this
  report.
• Thanks to Stuart Buttlaire, Richard Conklin and
  Sheri Whitt for their consultation during the
  writing of this report.
• Special thanks to MHSOAC staffers Matt Lieberman
  and Deborah Lee for their contributions to
  writing and editing this report. Thank you to
  Dede Ranahan and Dan Souza for writing
  contributions.
• MHSOAC COD Workgroup Co-Chairs, David Pating and
  Beth Gould

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