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V A.Co-occurring disorder addressed in discharge planning process

Element Details

Definition:

Programs that offer treatment to individuals with a co-occurring substance use disorder develop discharge plans that include an equivalent focus on needed follow-up services for both mental health and substance use disorders.

Source:

Discharge plans, memoranda of understanding.

Item Response Coding:

Coding of this item requires an understanding of the key elements considered in the documented discharge plan of individuals with co-occurring substance use disorders.

  • Mental Health Only Services = (SCORE-1): Not addressed. The discharge plans of individuals with co-occurring disorders routinely focus on mental health disorders only and do not address substance use disorders.

  • (SCORE-2): Variably addressed by individual clinicians. Within the program, the discharge plans of individuals with co-occurring disorders occasionally address both the substance use and mental health disorder, with the mental health disorder taking priority. The variability is typically due to individual clinician judgment or preference.

  • Dual Diagnosis Enhanced = (SCORE-3): Co-occurring disorder systematically addressed as secondary in planning process for offsite referral. Within the program, the discharge plans of individuals with co-occurring disorders routinely (at least 80 percent of the time) address both the substance use and mental health disorders, but the mental health disorder takes priority and is likely to continue to be managed within the program’s overall system of care or by the next mental health treatment provider. Follow-up substance use services are managed through an offsite linkage, and are often generically addressed (e.g., “remain abstinent”) as part of the discharge plan.

  • (SCORE-4): Some capacity (less than 80 percent of the time) to plan for integrated follow-up, i.e., equivalently address both substance use and mental health disorders as a priority. Discharge plans occasionally include appropriate follow-up services for both disorders equally. The variability is secondary to the judgment or expertise of the individual clinician.

  • Dual Diagnosis Enhanced = (SCORE-5): Both disorders seen as primary, with confirmed plans for onsite follow-up, or documented arrangements for offsite follow-up; at least 80 percent of the time. The discharge plans of individuals with co-occurring disorders routinely (at least 80 percent of the time) address both the substance use and mental health disorder. And: Both disorders are considered a priority, with equivalent emphasis placed on ensuring appropriate follow-up services for both disorders. The agency may have the capacity to continue management and support of both disorders in-house or have a formalized agreement with addiction agencies to provide the needed services. In the case of discharge from the agency (not just the mental health program), appropriate services are identified to address both disorders. Referrals are routinely made, confirmed, and documented in the discharge plan. The program has specific protocols that guide the discharge process.
Enhancing MHOS Programs

Since MHOS programs often do not list the co-existing substance use disorder or problem on the treatment plan, it may not be a subject for intentional discharge planning. In order to achieve DDC status, the MHOS program must make a more deliberate plan post-discharge and consider the potential interaction of the co-occurring disorders. DDC programs will conceptualize mental health disorders as primary, but will also underscore the importance of appropriate psychosocial and pharmacological treatments for substance use disorders and will make discharge plans accordingly. Collaborative relationships with addiction treatment providers are particularly important here, since successful linkage is predicated on a close relationship and clear protocol shared by providers. Programs that admit from and discharge back to wide geographic areas may not have these relationships with every provider, but every effort is made to formally arrange services prior to discharge. The discharge process, in considering both disorders, retains a largely clinician-driven rather than protocol-driven format.

Enhancing DDC Programs

DDE programs have an equivalent focus on discharge planning for mental health and substance use disorders. Treatment providers and interventions, medications and dose, recovery supports and relapse risks for both disorders are well described and routinely documented for all patients with co-occurring disorders. The DDE program takes a routine approach to this co-occurring informed discharge process, resulting in a systematic rather than clinician-driven discharge plan.

The Miracles detoxification program transfers men from their clinically-managed setting to an affiliated addiction outpatient treatment program that has a collaborative agreement with a local mental health clinic. Miracles staff schedules an initial appointment prior to discharge and arranges for a primary caregiver to accompany the patient on this visit. Upon discharge from detoxification services, a patient has already visited the outpatient program (which offers mental health and addiction treatment) and has met his counselor. This process has improved linkage to both programs and addresses both substance use and mental health problems equally.