Supporting Individuals with

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• Supporting Individuals with
• Intellectual and Mental Health Needs
• A framework for Inter Systems Collaboration
• Dr. Robert J. Fletcher
• Founder and CEO, NADD
• North Bay Regional Center
• March 8, 2012

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Outline of Presentation

• Barriers to Service Delivery
• At the National Level
• Working Together or Not
• Principles in Service Planning
• A Framework to Promote Cross System
• Collaboration

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Dual Diagnosis Policy Issues
The Typical Picture

• Individuals with MI and ID are among the most
  challenging persons served by both MH and ID
  Service Delivery Systems

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Dual Diagnosis Policy Issues

• The Typical Picture
• Failure to plan services
• Failure to fund flexible services
• Failure to obtain technical assistance

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Dual Diagnosis Policy Issues

• The Typical Picture
• Failure to provide adequate training and
  technology transfer
• Failure to share and assume joint responsibility
• Failure to articulate a policy

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Dual Diagnosis Policy Issues
The Typical Picture

• MH providers perceive that they do not have the
  skills to serve adults or children with a dual
  diagnosis
• DD providers do not understand the services that
  the MH sector offers
• MH providers do not understand the services that
  the DD sector offers

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Dual Diagnosis Policy Issues
People with MI and ID typically require

• Professional staff with specialized clinical
  experience
• Comprehensive service coordination
• Presence of consistent backup support
• Living requirements with fewer people

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Dual Diagnosis Policy Issues

• MH System
• Short term episodic treatment
• Focus on psychiatric needs
• Recovery model
• Local authority
• Medication Treatment
• Consumer/Client
• /Patient

• DD System
• Services/supports over lifetime
• Emphasis on direct support
• Self Determination
• State authority
• Behavioral Support (PBS)
• Self Advocate/ Consumer

Little Collaboration
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Dual Diagnosis Principles

• Co-occurring disorders should be treated as
  multiple primary disorders, in which each
  disorder receives specific and appropriate
  services.
• Collaboration of appropriate services and
  supports must occur as needs are identified.

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Dual Diagnosis Principles

• Service collaboration between systems is
  essential
• Services provided to the individual are
  consistent with what the person wants and what
  supports are needed

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Dual Diagnosis Principles

• Services are determined on the basis of
  comprehensive assessment of both MH and DD needs
  of each individual
• Services are based on individual needs and not
  solely on either MH or ID diagnosis

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Dual Diagnosis Principles

• Emphasize early identification and intervention
• Involve the person and family as full partners
• Coordinate at the system and service delivery
  level.

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Dual Diagnosis Principles

• The whole system must be designed to be welcoming
  and accessible to people with co-occurring
  disorders
• People with co-occurring disorders shall be
  supported in the least restrictive environment.

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Dual Diagnosis Principles

• People with co-occurring disorders and their
  significant others, when appropriate, shall be
  empowered to make treatment decisions.
• The system recognizes and values the long-term
  cost effectiveness of providing best practice
  services and supports for persons with
  co-occurring disorders.

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In 65 of states, policy is developed in
collaboration with other state agencies
Working Together or Not

• Relationships with Mental Health
• 55 Effective, very effective or extremely
  effective
• 45 Not or not very effective

• Relationships with Corrections
• 73 Not or not very effective
• 22 Effective
• 5 Very effective

NASDDDS, 2011
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Financial Operations
Working Together or Not

• Operational authorities
• State governments
• Local counties and municipalities
• Regional boards

• Medicaid and Medicare funding
• Medicaid covers 75 - 95 of costs for DD
  services, limited MH supports
• Some potential under Medicare

NASDDDS, 2011
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In general, . . .
Working Together or Not

• DD has primary responsibility for long term
  support
• in 70 of states

• MH has primary responsibility for psychiatric
  care
• in 78 of states

NASDDDS, 2011
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MH State Plan Services are available, But access
is frequently difficult..
Working Together or Not

• MH programs are
• Under funded
• Stretched to the limit
• Lack expertise to meet needs of people with ID /
  DD
• Unable to bill for necessary activities
• Include structural barriers

NASDDDS, 2011
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Emergency Support and Response in 13 States
Working Together or Not

• DD exclusively in 5 of 13 states (38)
• MH exclusively in 3 of 13 states (24)

• Mixed in 5 states (38)
• Usually MH but DD may support
• Usually DD but MH may support
• DD provides but MH contributes funding

NASDDDS, 2011
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Top Barriers in 2010
Working Together or Not

• Availability of funding, targeted flexible
  dollars
• Providers with sufficient expertise and interest
• Access to appropriate psychiatric treatment and
  related services
• Lack of trained staff MH and DD staff
• Effective and timely crisis supports

NASDDDS, 2011
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Effective Practice Elements
Working Together or Not

• Leadership
• Commitment
• Clear lines of authority
• Independence
• Protection
• Commitment to collaboration
• Focus on the Individual

The person-centered planning process must
determine what is important TO the person and
what is important FOR the person. - Michael Smull
NASDDDS, 2011
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Essential Elements..
Working Together or Not

• Training
• Coordination

• Effective Staff
• The right person
• The right match
• Build trust, dependability
• Focus on the System
• DD/MH interface

Its not a matter of showing up it is who shows
up. It must be someone with commitment and
interest in the individual. Someone who cares. -
David Petonyak
NASDDDS, 2011
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Effective Treatment
Working Together or Not

• Timely Access to
• Appropriate psychiatric treatment and medication
  management
• Positive Behavioral analysis and supports
• Effective treatment strategies such as
  dialectical behavior therapy, EMDR, etc.
• Community services, supports and resources
• Employment and meaningful opportunities to
  participate in community life
• Supports in home and with family

NASDDDS, 2011
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Top New Initiatives and Good Ideas
Working Together or Not

• Expanding Community Support Teams
• Developing new psychiatric practice standards
• Increasing DD expertise among MH
• Establishing Centers for Excellence for training,
  leadership and technical assistance
• Deinstitutionalization creates opportunities
• Developing capacities through university programs
• Cross-System Planning Formats
• Strengthening crisis supports

NASDDDS, 2011
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A Framework To Promote Cross Systems
Collaboration
Cross Systems Task Force/Committee
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Cross Systems Collaboration
Mission of a Dual Diagnosis Task
Force/Committee A Cross System Task Force is a
mechanism to draw attention to and make
recommendations about, policy and services for
individuals with ID and MH needs
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Cross Systems Collaboration

• Purpose/Function of A Dual Diagnosis Task
  Force/Committee
• Gather relevant data/formation
• Identify strengths in service delivery systems
• Identify challenges in service delivery system

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Cross Systems Collaboration

• Purpose/Function of A Dual Diagnosis Task
  Force/Committee
• Generate options for improvement in service
  delivery systems
• Promote cross systems education/training to
  enhance staff competencies
• Advocate for policy initiative that advance cross
  systems collaboration

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Cross Systems Collaboration

• Composition Of A Dual Diagnosis Task
  Force/Committee
• Representatives from Mental Health Departments
• Representatives from ID/DD Departments
• Representatives from provider agencies
• Family/consumer/advocate representatives

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Cross Systems Collaboration
Stakeholders from other than MH IDD systems
could be included as appropriate, perhaps on an
as needed basis. These include, but are not
limited to representatives from
Substance abuse Criminal Justice Health Department Social Services Education Early Intervention Child Welfare Coordinated Childrens Services
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Five Aspects Of A Coordinated Care System

• Collaboration
• Comprehensiveness
• Flexibility
• Continuity
• Leadership and Partnership

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Coordinated Care System

• Service Collaboration
• Policy level linkage
• Program level integrated
• Individual level person-centered coordination

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Coordinated Care System

• Comprehensiveness
• No One System Can Serve All People with MH/ID
• Mental Health Education
• MH/DD Social Services
• Child Family Substance Abuse
• Health Criminal Justice

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Coordinated Care System
Substance Abuse
Mental Health
Child Family Serv.
Criminal Justice
Vocational
PERSON
Health
Education
MR-DD
Housing
Social Serv.
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Coordinated Care System

• 3. Flexibility
• Flexible Enough to Modify Traditional Approaches
• Sufficient flexibility for
• increase time/resources in assessments
• cross training
• modification of traditional approaches

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Coordinated Care System

• 4. Continuity
• Keep an eye on
• changing needs
• changing systems
• propensity for behavioral problems
• need for long term treatment supports
• need to focus on multiple systems in different
  contexts over a life span

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Coordinated Care System

• 5. Leadership and Partnership
• Partnership across systems
• Need leadership to facilitate coordination
• Ensure accountability
• Political will

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Other Policy Recommendations

• Other Important Aspects of Policy Development
• Children and Adolescent Issues
• Cross Systems Training
• Cross Systems Crisis Intervention Service
• Consultation and Treatment
• Cross System Coordination State/Local Level

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• Children Adolescent Issues

• Train teachers, other professionals, and parents
  to recognize signs and symptoms of ED in children
  with ID
• Improve transitional planning from school to
  adult systems system operations

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• Training Issues

• Need Cross-Systems Training
• Mutual understanding of different culture,
  language and philosophy
• Acquire knowledge regarding how the other system
  operations
• - eligibility - funding
• - assessment - structure
• Learn how habititative/treatment strategies are
  different from one system to another

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Crises Intervention Service

• A Cross System Approach
• Provide short term crisis intervention with the
  goal of minimizing a need for hospitalization,
  crisis residential care or out-of-home placement
• Staff from crisis service interacts with all
  appropriate systems

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• Consultation Treatment Issues

• Bio-Psycho social model in assessment
• Rationale psychopharmacology
• Integrating mental health treatment with
  behavioral approaches
• Effective cross-systems transitional services
• Modifying individual and group therapy

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• Cross Systems Planning Coordination

• State and Local
• Planning and coordination at local level
• Planning and coordination at state level
• Planning and coordination between local and state
  level

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Treat Collaboration as Seriously as You Do Your
Budget
If you need expert assistance to forge
collaboration, get it!
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Service Planning and Policy

• Plan cross systems services strategically
• Design flexible service models that can change
  over time as individual needs change
• Obtain technical assistance
• Provide cross systems training to enhance agency
  and practitioner competencies
• Provide incentives for assuming and sharing
  responsibility

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Collaboration Strategies

• Identify and clearly state specific purposes for
  collaboration
• Allow time to consider all provisions, so that
  final decisions will be more fully supported
• Negotiate written agreements for organizational
  responsibilities, program design, fiscal
  arrangements, and established time frames

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Collaboration Means Sharing Resources and
Authority

• Make sure that each organization understands what
  it brings to the collaboration and reach a
  middle ground.

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ID/MI Discussion Matrix
State Regional County Staff Training Clinical Quality Advocacy/Other
How are you doing now?
How could you improve over the next year?
What plans can you make for the next 1-3 years?
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ID/MI Action Plan
Action to be Taken Resources Needed to Complete Action Date of Expected Completion Responsibility Person(s) Organization(s)
System Strategies
State
Regional
County
Staff Training
Clinical Quality
Advocacy/Other
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THANK YOU!

• For more information, please contact
• Dr. Robert J. Fletcher
• NADD
• 132 Fair Street, Kingston, NY 12401
• Telephone [phone]
• E-mail rfletcher_at_thenadd.org
• Web site www.thenadd.org