CCISC

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CCISC

• IMPLEMENTATION PRINCIPLES

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IMPLEMENTATION

• Top-down/Bottom-up Development
• Aligning the Parts of the System
• Inclusion, not Exclusion (programs and
  populations)
• Strategic Use of Leverage (Incentives, Contracts,
  Standards, Licensure, etc.)
• Outcomes and CQI (CO-FIT 100?)
• Model Programs
• Evaluation of Core Competencies (COMPASS? and
  CODECAT?)
• Action Planning
• Train-the-Trainers
• Backfilling

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12 STEPS OF IMPLEMENTATION

• 1. INTEGRATED SYSTEM PLANNING
• 2. CONSENSUS ON CCISC MODEL
• 3. CONSENSUS ON FUNDING PLAN

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12 STEPS OF IMPLEMENTATION

• 4. IDENTIFICATION OF PRIORITY POPULATIONS WITH 4
  QUAD MODEL
• 5. DDC/DDE PROGRAM STANDARDS
• 6. INTERSYSTEM CARE COORDINATION

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12 STEPS OF IMPLEMENTATION

• 7. PRACTICE GUIDELINES
• 8. IDENTIFICATION, WELCOMING, ACCESSIBILITY NO
  WRONG DOOR
• 9. SCOPE OF PRACTICE FOR INTEGRATED TREATMENT

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12 STEPS OF IMPLEMENTATION

• 10. DDC CLINICIAN COMPETENCIES
• 11. SYSTEM WIDE TRAINING PLAN

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12 STEPS OF IMPLEMENTATION

• 12. PLAN FOR COMPREHENSIVE PROGRAM ARRAY
• A. EVIDENCE-BASED BEST PRACTICE
• B. PEER DUAL RECOVERY SUPPORT
• C. RESIDENTIAL ARRAY WET, DAMP, DRY, MODIFIED TC
• D. CONTINUUM OF LEVELS OF CARE IN MANAGED CARE
  SYSTEM ASAM-2R, LOCUS 2.0

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Individuals with Co-occurring DisordersPRINCIPLE
S OF SUCCESSFUL TREATMENT
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Eight Principles of CCISC

• 1 Dual diagnosis is an expectation, not an
  exception. This expectation must be incorporated
  in a welcoming manner into all clinical contact.
  

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Eight Principles of CCISC

• Principal 1
• Clinical Implications
• every clinical encounter must treat individuals
  with COD with welcoming expectation, to
  facilitate screening, ID, assessment, and
  treatment engagement.
• All clinicians must develop empathetic, welcoming
  attitudes and skills to ID and engage these
  individuals.

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Eight Principles of CCISC

• Principal 1
• Program/System Implications
• Every program in the system must be designed to
  be welcoming to individuals with COD, and to
  maximize screening, identification, and reporting
  of COD.
• Every program must meet basic criteria for dual
  diagnosis (DDC), embodied in policies, procedures
  and documentation within the context of existing
  resources

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Eight Principles of CCISC

• 2 Treatment success derives from the
  implementation of an empathic, hopeful,
  continuous treatment relationship, which provides
  integrated treatment and coordination of care
  through the course of multiple treatment episodes.

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Eight Principals of CCISC

• Principal 2
• Clinical Implications
• Clinical practices should always reduce barriers
  to initial access. The goal of the initial
  encounter is to make a connection with
  integrated, continuous treatment ASAP.
• Clinicians who provide ongoing care need to
  develop competency in empathetic acceptance of
  individuals who may be non-adherent to treatment
  recommendations, and in maintaining treatment
  continuity at appropriate intensity.

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Eight Principals of CCISC

• Principal 2
• Clinical Implications
• When in doubt, facilitate access and maintain
  continuity since persons with COD are unlikely to
  benefit from treatment they never receive.
• Episodic interventions (including referral to
  addiction programs) are ideally planned within
  the context of continuous, integrated treatment
  relationships.

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Eight Principals of CCISC

• Principal 2
• System/Program Implications
• ID of programs responsible for providing
  integrated, continuous relationships to various
  subgroups at varying levels of intensity
  (individual, team, intensive team) is a system
  priority.
• Policies and procedures should support efforts to
  maintain integrated, continuity of care at the
  appropriate level of intensity.

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Eight Principals of CCISC

• 3 The Four Quadrant Model is a viable mechanism
  for categorizing individuals with co-occurring
  disorders for purpose of service planning and
  system responsibility.

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Eight Principles of CCISC

• Principal 3
• Clinical Implications
• Initial screening assessment processes should
  identify probable SPMI and probable
• addiction for purposes of initial tx
  assignment
• All clinicians should develop familiarity with
  clinical identification and welcoming of SPMI who
  are actively using substances

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Eight Principles of CCISC

• Principal 3
• Clinical Implications
• All clinicians should develop familiarity with
  diagnostic criteria for abuse vs. dependence, and
  ability to ID each disorder.

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Eight Principles of CCISC

• Principal 3
• System/Program Implications
• All programs should develop assessment tools that
  distinguish SPMI vs. non-SPMI, and
  abuse/dependence
• The system should establish a plan for assignment
  of subgroups for initial engagement and ongoing
  evaluation and treatment

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Eight Principles of CCISC

• 4 Within the context of the empathic, hopeful,
  continuous, integrated relationship, case
  management/care (based on level of impairment)
  and empathic detachment/confrontation (based on
  strengths and contingencies) are appropriately
  balanced at each point in time.

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Eight Principles of CCISC

• Principal 4
• Clinical Implications
• Clinicians will require consistent support from
  supervisors and peers to establish a stance of
  empathic detachment within which to negotiate
  the right balance between caretaking and
  expectation.
• There is no one correct place to draw the line
  for individuals with COD in general, or for any
  particular indefinitely. Finding the right
  balance between support and consequences for any
  individual may involve a process of learning for
  the clinicians involved in the tx.

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Eight Principles of CCISC

• Principal 4
• Clinical Implications
• Treatment planning needs to emphasize the value
  of contingent learning through a combination of
  continuity and consequences, and develop models
  for designing contingency based treatment
  interventions.

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Eight Principles of CCISC

• Principal 4
• Program/System Implications
• Programs within the system must each determine
  the balance between caretaking and expectation
  that best suits the mission of that program, and
  develop policies and procedures that are
  consistent with that balance.

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Eight Principles of CCISC

• Principal 4
• Program/System Implications
• Within a system of care, there needs to be a
  range of programs which provide this balance
  indifferent ways, such as a range of housing
  programs with different levels of support and
  different levels of expectation regarding
  substance use (e.g.- wet, damp, dry housing).

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Eight Principles of CCISC

• 5 When substance disorder and psychiatric
  disorder co-exist, each disorder should be
  considered primary, and integrated dual primary
  treatment is recommended, where each disorder
  receives appropriately intensive
  diagnosis-specific treatment.

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Eight Principles of CCISC

• Principal 5
• Clinical Implications
• All clinicians must develop comfort with
  educating consumers to continue medication even
  when using substances, and when participating in
  addiction recovery programs.
• Conversely, clinicians must emphasize the
  importance of continuing (and, if necessary)
  addiction recovery supports during periods of
  psychiatric crisis.

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Eight Principles of CCISC

• Principal 5
• Clinical Implications
• Clinicians need to develop competency in
  educational and skill development in
  interventions regarding substance use to
  accommodate individuals with psychiatric
  impairments.
• Scope of practice, job descriptions, clinical
  practices, competency expectations, and
  documentation requirements must reinforce
  adherence to stabilizing treatment regimes for
  both primary disorders.

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Eight Principles of CCISC

• Principal 5
• Program/System Implications
• All administrative policies and procedures,
  including MIS system and reporting requirement,
  should be designed to identify two primary
  disorders.
• All programs must be required to demonstrate the
  sequence of assessment, ID, treatment planning,
  and treatment intervention fro the second primary
  disorder.

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Eight Principles of CCISC

• 6 Both substance dependence and serious mental
  illness are examples of primary, chronic,
  biologic mental illnesses, which can be
  understood using a disease and recovery model,
  with parallel phases of recovery.

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Eight Principles of CCISC

• Principal 6
• Clinical Implications
• Clinical Assessment should routinely document
  phase of recovery and stage of change to support
  treatment matching.
• Clinicians should become familiar with the key
  differences in diagnosis-specific interventions
  that occur in different phases of recovery or
  stages of change.

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Eight Principles of CCISC

• Principal 6
• Clinical Implications
• Many stage-specific interventions are best
  conducted in groups a range of stage-specific
  treatment groups provides the best opportunity
  for treatment matching.

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Eight Principles of CCISC

• Principal 6
• Program/System Implications
• Programs within the system of care may provide
  integrated treatment with individuals matched
  according to stage of change, not just diagnosis.
  Consequently, for example, psychiatric housing
  programs may be wet, damp, or dry.

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Eight Principles of CCISC

• Principal 6
• Program/System Implications
• Program policies should adhere to standards
  requiring identification of stage of change in
  assessment, treatment planning, treatment
  interventions, and outcome measurement.

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Eight Principles of CCISC

• 7 There is no one type of dual diagnosis program
  or intervention. For each person, the correct
  treatment intervention must be individualized
  according to subtype of dual disorder and
  diagnosis, phase of recovery/treatment, level of
  functioning and/or disability associated with
  each disorder.

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PARALLELSPROCESS OF RECOVERY

• PHASE 1 Stabilization
• - Stabilization of active substance use or
  acute psychiatric symptoms
• PHASE 2 Engagement/ Motivational Enhancement
• - Engagement in treatment
• - Contemplation, Preparation, Persuasion
• PHASE 3 Prolonged Stabilization
• - Active treatment, Maintenance, Relapse
  Prevention
• PHASE 4 Recovery Rehabilitation
• - Continued sobriety and stability
• - One year - ongoing

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Eight Principles of CCISC

• Principal 7
• Clinical Implications
• The assessment process needs to support the
  gathering of information to facilitate treatment
  matching using this model.
• This model implies that Harm Reduction and
• Abstinence Orientation are not competing
  philosophies. Each is an appropriate intervention
  provided it is well matched to individual needs.

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Eight Principles of CCISC

• Principal 7
• Clinical Implications
• Level of impairment defines the extent and/or
  intensity of case management that is required
  external contingencies may define parameters for
  contracting and confrontation.
• Level of impairment defines the extent and/or
  intensity of case management that is required
  external contingencies may define parameters for
  contracting and confrontation.

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Eight Principles of CCISC

• Principal 7
• Program/System Implications
• Within a comprehensive system of care, there is
  no correct COD program. All programs participate
  in the treatment of COD, and each program is
  assigned a job, in terms of type of consumer,
  level of care, stage of change, etc.
• Some programs are responsible for the continuity
  of integrated treatment, others for episodic
  interventions at defined levels of care.

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Eight Principles of CCISC

• Principal 7
• Program/System Implications
• Clinicians must learn a template for identifying
  the role of each type of program within the
  system, both in terms of client referral and in
  terms of interface with other programs.

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Eight Principles of CCISC

• 8 In an integrated system, individualized
  treatment matching also requires multidimensional
  level of care assessment involving acuity,
  dangerousness, motivation, capacity for treatment
  adherence, and availability of continuing
  empathic treatment relationships and other
  recovery supports.

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CHANGING THE COUNTY

• A. SYSTEM LEVEL CHANGE
• B. PROGRAM
• C. CLINICAL PRACTICE
• D. CLINICIAN

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CHANGING THE COUNTY

• A. SYSTEM CHANGE
• 1. Empower structure to manage change
  (Leadership Committee)
• 2. Consensus building on principles (Charter)

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CHANGING THE COUNTY

• 3. Regulatory Change
• Licensure/certification
• Reimbursement/funding
• Program standards/practice guidelines
• Clinician competency/certification

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CHANGING THE COUNTY

• 4. Quality management/outcome evaluation
• Continuous Quality Improvement (CQI)
• Quality Assurance (QA)

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CHANGING THE COUNTY

• B. PROGRAM CHANGE
• 1.Structured plan for programmatic interface
• Formal interagency care coordination
• (administrative/clinical)
• Mechanisms for administrative and clinical
  dispute (atmosphere for problem solving)

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CHANGING THE COUNTY

• B. PROGRAM CHANGE
• 1.Structured plan for programmatic interface
• Vertical continuity/integration front door meets
  back door
• Continuity in SA treatment regardless of
  failures)
• MH emergency services also for SA, not just MH
• Psychopharmacology resources for SA programs
• MH support to SA system
• SA continuity of connection

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CHANGING THE COUNTY

• B. PROGRAM CHANGE
• 2. Comprehensive program array
• Horizontal integration (MH SA coordination)
• Vertical integration/managed care
• Move through levels of care with continuity
• Address front door/back door problem
• Where is intermediate level of care? (eg- 7-10
  day stepdown)

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CHANGING THE COUNTY

• B. PROGRAM CHANGE
• 2. Comprehensive program array
• Program Categories
• SA System (ASAM PPC2R)
• Dual Diagnosis Capable-CD (DDC-CD)
• Dual Diagnosis Enhanced-CD (DDE-CD)
• MH System (Minkoff)
• DDC-MH
• DDE-MH
• Peer Involvement/Cultural Competency

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CHANGING THE COUNTY

• B. PROGRAM COMPETENCIES
• 1.Clinical case management
• 2. Emergency services
• 3. Crisis stabilization
• 4. Detoxification
• 5. MH inpatient
• 6. MH partial hospitalization

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CHANGING THE COUNTY

• B. PROGRAM COMPETENCIES
• 7. SA day treatment/intensive outpatient (IOP)
• 8. SA residential treatment programs
• 9. MH residential treatment programs

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CHANGING THE COUNTY

• C. CLINICAL PRACTICE STANDARDS
• 1. Welcoming philosophy
• 2. No wrong door access
• 3. Screening assessment (e.g.- incentives for
  identification rather than kick out people with
  SA disorders)
• 4. Level of care assessment
• (e.g.- ASAM PPC2R LOCUS)

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CHANGING THE COUNTY

• C. CLINICAL PRACTICE STANDARDS
• 5. Continuity of care MH SA
• 6. Phase-specific treatment matching
• 7. Psychopharmacology guidelines
• Continuity, quality,etc.
• 8. Consistent treatment manuals (from inpatient
  to outpatient)

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CHANGING THE COUNTY

• C. CLINICAL PRACTICE STANDARDS
• 9. Outcome measures
• Utilization
• Reduction of Harm
• Abstinence/use
• Stage of Change/Stage of Recovery
• Build in both in assessment tool(s) to be used as
  outcome measures (QA)

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CHANGING THE COUNTY

• D. CLINICIAN STANDARDS
• 1. Competency/certification
• A. Required basic competencies
• (develop basic competencies in system)
• B. Place/train job descriptions (onsite
  supervision)
• C. Certifications for career ladders
• D. Advanced competencies for trainers and
  supervisors

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CHANGING THE COUNTY

• D. CLINICIAN STANDARDS
• Training
• A. Systemwide training plan
• B. Training program guidelines
• C. Train trainers for each site
• D. Curriculum guideline dissemination
• E. On-site case-based continuing training
• F. Experiential learning/staff exchange