I C.Coordination and collaboration with mental health services
- Element Details
Programs that transform themselves from ones that only provide services for substance use disorders into ones that can provide integrated services typically follow a pattern of staged advances in their service systems. The steps indicate the degree of communication and shared responsibility between providers who offer services for mental health and substance use disorders. The following terms are used to denote the stepwise advances and originate from SAMHSA’s Co-Occurring Measure (2007).
Minimal coordination, consultation, collaboration, and integration are not discrete points, but bands along a continuum of contact and coordination among service providers. “Minimal coordination” is the lowest band along the continuum, and integration the highest band. Please note that these bands refer to behavior, not to organizational structure or location. “Minimal coordination” may characterize provision of services by two persons in the same agency working in the same building; “integration” may exist even if providers are in separate agencies in separate buildings.
Minimal coordination: “Minimal coordination” treatment exists if a service provider meets any of the following: (1) is aware of the condition or treatment but has no contact with other providers, or (2) has referred a person with a co-occurring condition to another provider with no or negligible follow-up.
Consultation: Consultation is a relatively informal process for treating persons with co-occurring disorders, involving two or more service providers. Interaction between or among providers is informal, episodic, and limited. Consultation may involve transmission of medical/clinical information, or occasional exchange of information about the person’s status and progress. The threshold for “consultation” relative to “minimal coordination” is the occurrence of any interaction between providers after the initial referral, including active steps by the referring party to ensure that the referred person enters the recommended treatment service.
Collaboration: Collaboration is a more formal process of sharing responsibility for treating a person with co-occurring conditions, involving regular and planned communication, sharing of progress reports, or memoranda of agreement. In a collaborative relationship, different disorders are treated by different providers, the roles and responsibilities of the providers are clear, and the responsibilities of all providers include formal and planned communication with other providers. The threshold for “collaboration” relative to “consultation” is the existence of formal agreements and/or expectations for continuing contact between providers.
Integration: Integration requires the participation of substance abuse and mental health services providers in the development of a single treatment plan addressing both sets of conditions, and the continuing formal interaction and cooperation of these providers in the ongoing reassessment and treatment of the client. The threshold for “integration” relative to “collaboration” is the shared responsibility for the development and implementation of a treatment plan that addresses the co-occurring disorder. Although integrated services may often be provided within a single program in a single location, this is not a requirement for an integrated system. Integration might be provided by a single individual, if s/he is qualified to provide services that are intended to address both co-occurring conditions.
Interviews with agency director, program clinical leaders, and clinicians. Some documentation may also exist (e.g., a memorandum of understanding).
Item Response Coding:
Coding of this item requires an understanding of the service system and structure of the program, specifically with regard to the provision of mental health as well as addiction treatment services. An understanding of the SAMHSA terms defined above is also necessary. The DDCAT scoring directly corresponds to those definitions.
- Addiction Only Services = (SCORE-1): No document of formal coordination or collaboration. Meets the SAMHSA definition of Minimal Coordination.
- (SCORE-2): Vague, undocumented, or informal relationship with mental health agencies, or consulting with a staff member from that agency. Meets the SAMHSA definition of Consultation.
- Dual Diagnosis Capable = (SCORE-3): Formalized and documented collaboration or collaboration with mental health agency. Meets the SAMHSA definition of Collaboration.
- (SCORE-4): Formalized coordination and collaboration, and the availability of case management staff, or staff exchange programs (variably used). Meets the SAMHSA definition of Collaboration and has some informal components consistent with Integration. These programs have a system of care that meets the definition of collaboration and demonstrate an increased frequency of integrated elements. However, these elements are informal and not part of the defined program structure. Typical examples of activities that occur at this level would be informal staff exchange processes or case management on an as-needed basis to coordinate services.
- Dual Diagnosis Enhanced = (SCORE-5): Most services are integrated within the existing program, or routine use of case management staff or staff exchange programs. Meets the SAMHSA definition of Integration.
- Enhancing AOS Programs
AOS level programs either have no existing relationship or an informal one with the local mental health provider. Programs intending to achieve DDC status must develop more formalized procedures and protocols to coordinate services for persons with co-occurring disorders.
Staff at the North Shore Alcohol and Drug Treatment Center (NSADTC) often referred patients to the Lakeland Mental Health agency for psychiatric emergencies or for a medication evaluation if deemed appropriate. Psychiatric emergencies would occur one to two times per year, and would usually be dealt with by calling 911. A social worker at NSADTC who formerly worked at Lakeland was often asked to contact his former colleagues so that patients might be evaluated within a more expedient time frame.
To become DDC, NSADTC initiated a series of meetings with Lakeland and the agencies composed a memorandum of understanding (MOU) that addressed admission, transfer and referral procedures (a sample MOU outline may be downloaded). Monthly meetings between program coordinators and designated intake clinicians were also initiated to review the protocol and discuss plans for common patients.
An AOS program moves from a loose and clinician-driven consultation model to a more formalized and collaborative one in order to become DDC.
- Enhancing DDC Programs
Programs at the DDC level will need to develop more integrated services in order to score at the DDE level. Integration can be accomplished at the program level by providing all services “in house” so patients may obtain one-stop services. Integration can also be accomplished at the system level where programs are so closely connected either by common policies, electronic medical record systems, or other lines so that integration occurs across agencies. Coordination or consultation between programs is not sufficient for integration. Integration is characterized by mental health and addiction treatment provision by one or more providers that is seamless from the patient’s perspective. Integration within a program can exist for both outpatient and residential levels of care.