SAMHSA logo Report to Congress - Nov 2002








Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 4 - Evidence-Based practices for Co-Occurring Disorders - System Level Approaches


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System-Level Approaches

Systems of care for people with co-occurring disorders must be comprehensive and appear seamless to the clients. The systems of care that need to be integrated include the substance abuse and mental health systems, as well as the primary care, criminal justice, and social service systems.

The concept of integrating human services to improve outcomes for individuals and families with multiple and complex problems is not new. Called by such names as community integration, comprehensive services, community support systems, and continuum of care (Dennis et al., 1999), services integration has been an integral part of social service reform efforts (Miller, 1996).

More recently, researchers and policy makers have begun to make the important distinction between integrated services, designed to improve an individual's access and use of all needed services resources through such techniques as case management (Miller, 1996), and integrated systems, designed to change service delivery for a defined population, involving fundamental changes in the way agencies share information, resources, and clients (Dennis et al., 1999).

In particular, systems integration focuses on reducing barriers, and on coordinating and improving existing services at the program level, and on developing new programs to improve the availability, quality, and comprehensiveness of services (Miller, 1996). A report by the National Association of State Mental Health Program Directors (NASMHPD, 2000) underscores several key precepts that underlie the concept of systems integration:

Successful systems integration can occur only when a comparable emphasis is placed on integrated services (Agranoff 1991).

Systems integration does not necessarily require the creation of new services or agencies, nor does it require that existing agencies or services be combined.

Systems integration can be measured by both system-level and client-level outcomes.

Ultimately, systems integration is about improving peoples' lives.

Many findings about the process and outcomes of systems integration are a product of SAMHSA's Access to Community Care and Effective Services and Supports (ACCESS) program. ACCESS was designed to test promising approaches to service system integration for people with serious mental illnesses, including those with co-occurring substance abuse disorders, who are homeless or at imminent risk of homelessness. Begun in 1993, the 5-year demonstration program was an interdepartmental effort involving the U.S. Departments of Health and Human Services, Labor, Education, Veterans Affairs, Agriculture, and Housing and Urban Development.

Unlike earlier systems integration efforts, ACCESS included an extensive, cross-site evaluation of both system-level and client-level outcomes. Evaluation data reveal that systems integration is both possible and measurable, and that systems integration works best with a salaried coordinator, an interagency coordinating body, strategic planning, and adequate resources (Cocozza et al., 2000). Client-level outcomes included increases in stable housing and use of outpatient psychiatric services and decreases in substance use and criminal activity (Rosenheck, 1998; CMHS, online). The ACCESS evaluation also revealed that outreach and referrals to case management increase access to mental health and other important services for people with serious mental illnesses and/or co-occurring substance abuse disorders (CMHS, online).

Two other national demonstration projects focused on the development and implementation of systems integration strategies to better serve vulnerable populations: the Robert Wood Johnson Program on Chronic Mental Illness and the National Institute on Alcohol Abuse and Alcoholism Community Demonstration Grants Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals. Both included individuals with co-occurring disorders. Empirical data from each suggest that systems integration can improve access to services, client satisfaction, and selected client outcomes (Ridgely et al., 1996; Orwin et al., 1994; Goldman et al., 1990).

Despite growing evidence about the effectiveness of systems integration for people who have multiple, complex disorders, system-level problems remain a significant barrier to effective response for people with co-occurring substance abuse disorders and mental disorders (Osher, 1996). The need to address the problems created by the systemic schism between substance abuse and mental health services has been well documented (Osher, 1996; Minkoff, 2000; Ridgely et al., 1998; Drake et al., 1996). The ability to do so is complicated further by the multifaceted nature of how care for individuals with co-occurring substance abuse disorders and mental disorders is organized and financed.

A Conceptual Framework for System Development and Financing

A comprehensive, coordinated system of care for individuals with co-occurring substance abuse disorders and mental disorders and their families involves a process that evolves over time and begins with strong leadership and consensus among key stakeholders. It also requires flexible funding, the use of evidence-based practices, and a process for developing and monitoring outcomes (NASMHPD/NASADAD, 2000). SAMHSA constituents believe that the Agency should help States and communities develop coalitions and evidence-based approaches to integrating programs and systems (SAMHSA, 2002f).

In Financing and Marketing the New Conceptual Framework for Co-occurring Substance Abuse and Mental Disorders, the NASMHPD/NASADAD Joint Task Force on Co-occurring Disorders outlined a process for organizing and financing a comprehensive system of care as displayed in Table 4.1 (NASMHPD/NASADAD, 2000).

Table 4.1: Organizing and Financing a Comprehensive System of Care
for People with Co-Occurring Disorders

Key System Development Components

Financing Principles

Provide Leadership/Build Consensus

Define the Population/Plan to Purchase Together

Identify Resources

Secure Financing

Develop New Models/Train Staff

Purchase Effective Services

Decide on Outcomes

Purchase Performance

Evaluate Program

Evaluate and Improve

That report and others (e.g., Cocozza et al., 2000) include a wealth of information on how to convene key stakeholders and build consensus for change. This discussion focuses on three issues of specific concern to SAMHSA and its constituents in the development of a comprehensive system of care for people who have co-occurring disorders: resources/financing, staff training, and outcomes (SAMHSA, 2002f).

Identify Resources/Secure Financing

The availability of flexible funding, often from multiple sources, is a necessary tool if local mental health and substance abuse providers are to be successful in efforts to meet the needs of individuals whose disorders do not fall neatly into one or another categorical funding stream. This requires creativity, persistence, a fair amount of planning, and strategic thinking - the key elements of which include (NASMHPD/NASADAD, 2000):

Aligning financial incentives with expected outcomes to achieve goals. Financing mechanisms should produce performance, not just units of service. The capacity for local reallocation of funds from high-cost services to alternative programs is critical. For example, communities that reduce the use of higher cost inpatient care should be able to redirect the saved dollars to appropriate outpatient options for people with co-occurring disorders.

Reducing or eliminating statutory and regulatory barriers. Particularly reduce or eliminate those related to facility licensure and certification for the provision of services for people with co-occurring substance abuse disorders and mental disorders.

Combining funds at the local level. Maintaining separate funding streams at the Federal and/or State level will help ensure that both the mental health and substance abuse systems remain viable and able to complement one another, each retaining and refining its areas of expertise. Coordination of those funding streams, through "pooling" of funds, at the local level by community providers may permit the most effective way to respond to the unique needs of individuals with co-occurring disorders.

Many States depend almost exclusively on their SAPT Block Grant to support the provision of substance abuse services; in contrast, the CMHS Block Grant funding represents a small percentage of a State's mental health services budget. At the same time, the Federal-State Medicaid program funds a significantly larger amount of mental health treatment than substance abuse services. The continuation of the two separate Federal block grant funding streams places the burden of coordination on State and local mental health and substance abuse agencies. SAMHSA constituents who provided their views in the development of this report suggest that the existence of separate finding streams is perhaps the most significant impediment to integrated services for people with co-occurring substance abuse disorders and mental disorders (SAMHSA, 2002f). Ninety percent of respondents- representing both mental health and substance abuse constituencies - believe that some form of "pooled" funding is a key ingredient for success.

Other constituents recommend "blended" funding, that treats mental health services and substance abuse treatment and prevention dollars as indistinguishable from one another. Others in the field adamantly oppose co-mingling funds, suggesting that services for individuals with a single disorder may be shortchanged as a result.

Integrated services do not require blended funding to be successful. In the long-run, disagreements about blended funding may be more of a barrier to developing integrated services than the actual process of combining mental health and substance abuse funds. Indeed, as Drake, Essock et al. (2001) note:

Anecdotal evidence indicates that blending mental health and substance abuse funds appears to have been a relatively unsuccessful strategy, especially early in the course of system change. Fear of losing money to cover nontraditional populations often leads to prolonged disagreements, inability to develop consensus, and abandonment of other plans.

Many States and community providers have chosen yet another option for service funding: aggregated or "braided" funds. This mechanism enables them to create comprehensive systems of care for people with co-occurring disorders by drawing on distinct sources of funds that can be tracked and audited separately. A number of examples of this approach are found in Chapter 2 of this report.

Success stories such as those in Pennsylvania, Arizona and New York that are detailed earlier in this volume support the NASMHPD/NASADAD Task Force (2000) contention that significant improvements can be made within existing delivery systems and financing mechanisms to improve delivery of services to people with co-occurring substance abuse disorders and mental disorders. It is SAMHSA's responsibility to give States and localities the tools and knowledge to accomplish this goal - and accomplish it to the benefit of people with substance abuse and mental disorders.

Train Staff

A significant gap exists between what research shows to be effective for people with co-occurring disorders and what clinicians practice in the field. Both SAMHSA constituencies and the NASMHPD/NASADAD Task Force agree that staff in both the substance abuse and mental health systems must be trained to work with people with co-occurring disorders. In fact, no system can adequately care for people with co-occurring disorders in the absence of appropriate training at all levels of service delivery.

Clinical competence at all front doors of service. Mental health and substance abuse programs-and other social service programs, as well-should emphasize clinical competence that helps to create a seamless system of care for people with co-occurring disorders. A number of States (e.g., New York, New Mexico, Arizona) are moving toward the establishment of a required basic level of competency for mental health and substance abuse providers who are providing integrated services. These States and others are developing training curricula to help clinicians achieve and update these competencies. Still other States (e.g., Illinois) have created certification ladders and pathways - as well as financial incentives - to encourage clinicians to achieve higher levels of competence in the delivery of integrated co-occurring disorders treatment (CSAT, in press).

Train primary health care providers. Primary health care providers also would benefit from training in the assessment, diagnosis and treatment of substance abuse and mental disorders. Family practitioners, pediatricians, and emergency room staff may be able to help identify and engage individuals who are not in the formal treatment system.

Train future providers. Training future providers is equally important. Educational and training programs for physicians (including psychiatrists), psychologists, social workers, counselors, and other clinical staff will help produce a future work force better prepared to serve individuals with multiple disorders.

Train consumers, recovering persons, and family members. Consumers, recovering persons, and family members all play a critical role in ensuring that services are relevant and are achieving their desired outcomes. Training can better prepare them to support both service providers and service recipients in the development and implementation of programs.

Measure Outcomes

The bottom line of any system designed to address the needs of people with co-occurring substance abuse disorders and mental disorders is to provide quality, cost-effective, and results-driven treatment and prevention services that improve client outcomes. Therefore, focusing on improved outcomes is among the highest priorities for system change (NASMHPD/NASADAD, 2000).

However, outcome measures need to document actual changes in client functioning, not just process measures such as the number of client served (Yessian, 1995). Measures of improved client functioning for people with serious mental illnesses, including those with co-occurring substance abuse disorders, may include decreased psychiatric symptoms; decreased substance abuse; improvement in housing and community tenure; increased employment; improved social networks; decreased involvement with the criminal justice system; and improvement in perceived quality of life (NASMHPD/NASADAD, 2000).

The development of performance-based outcome measures specific to people with co-occurring disorders will allow those who contract for services to tie financial incentives to achievement of key outcome measures. Outcomes also may assess reduced costs to clients, their families, and society at large across such measures as decreased involvement with the criminal justice system, decreased use of inappropriate emergency room visits, and less frequent and shorter hospital stays (NASMHPD/NASADAD, 2000).

Collecting and using data related to program effectiveness can help initiate and sustain treatment programs and spark system change (The National Council and SAAS, 2002). For example, data on relapse rates can be an initial and powerful measure of program effectiveness. Programs can use such data to seek additional support for co-occurring disorders treatment. The inclusion of alcohol and drug testing data can be very helpful in assessing program effectiveness, and are widely used in the substance abuse treatment community.

SAMHSA constituents who participated in the development of Strategies for Developing Treatment Programs for People with Co-occurring Substance Abuse and Mental Disorders (The National Council and SAAS, 2002), stressed the importance of simple, realistic expectations about the utility of data as a measure of effectiveness, since existing information systems often capture only part of the story. For example, co-occurring disorders treatment programs might not be able to access data on rehospitalization contained within the State mental health data system. Likewise, confidentiality regulations intended to protect the privacy of individuals in substance abuse treatment might limit the amount of data available to a mental health provider. However, substance abuse and child welfare systems have been able to establish working relationships within the rules to collaborate with one another to serve both parents and their children (U.S. DHHS, 1999a). These models may prove useful for the mental health and substance abuse treatment fields.

Systems Integration in Practice

Many States and communities already have begun to implement innovative systems integration strategies, as highlighted in Chapter 2. The most recent NASMHPD/NASADAD Task Force report (2002) has profiled program activities and models implemented in Colorado, Illinois, Maine, Maryland, Ohio, Pennsylvania, Tennessee, Texas, and Virginia.

While approaches varied by State, important commonalities in their efforts can help guide other States interested in developing effective system-level strategies for addressing the needs of individuals with co-occurring disorders, among them (NASMHPD/NASADAD, 2002):

A shared vision and expectations concerning co-occurring disorders treatment that staff were encouraged, supported, and expected to follow.

A comprehensive service system - based on an integrated services model that has been tailored to respond to local needs - that is capable of responding to all or most of the needs of individuals with co-occurring mental and substance abuse disorders, including the presence of other concurrent health issues.

The State services staff expectation that individuals with co-occurring symptoms and disorders would be the rule rather than the exception among individuals needing services, coupled with the ability to screen and assess for related conditions, such as HIV/AIDS, a full range of physical and/or sexual abuse, brain disorders, physical disabilities, etc.

Cross trained staff taught to be culturally competent in both mental health and substance abuse disciplines, while continuing to work within their fields of expertise. Care delivered as part of a multidisciplinary team that featured shared responsibility for clients.

Client-centered services that engage individuals who are at various stages of acceptance and recovery.

Special Programs and Demonstrations of Systems Change

Federal, State, and local governments, as well as private funding sources, have supported a range of systems integration initiatives designed to improve the delivery of services for people with co-occurring disorders. Two such efforts are profiled here. A third, the Community Action Grants for Service System Change program, is highlighted in the final section of this chapter.

The Clinical Standards and Workforce Competencies Project

In 1995, SAMHSA's Center for Mental Health Services began a managed care initiative designed to identify systems-level best practices in behavioral healthcare - including issues affecting people with co-occurring substance abuse disorders and mental disorders - that could be integrated into the design of managed care structures.

A consensus panel of experts in co-occurring disorders, including researchers, providers, and consumers and family members, conducted a comprehensive review of the literature on the successful treatment of co-occurring disorders in managed care systems and developed both an annotated bibliography (CMHS, 1997) and a consensus report, Co-Occurring Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies, and Training Curricula (CMHS, 1998). The report highlights specific tools and supporting materials that could be adapted by systems of any size to initiate systems change in program standards, practice guidelines, and competencies with few, if any, additional resources. Many States and communities have applied these materials as part of systems integration initiatives, including five of the grantees supported by the SAMHSA Community Action Grants for Service System Change program described later in this chapter (Berreira et al., 2000; Minkoff, 2001).

Comprehensive Continuous Integrated System of Care (CCISC)

The Comprehensive Continuous Integrated System of Care (CCISC) is a model designed to join the mental health and substance abuse treatment systems (and other systems, potentially) in an effort to develop a comprehensive, integrated system of care for people with co-occurring disorders (Minkoff, 2001, 1991). This model includes work derived from the Clinical Standards and Workforce Competencies Project cited above (Minkoff, 2001; CMHS, 1998).

CCISC, identified by SAMHSA as an exemplary practice, is at various stages of implementation in no fewer than 15 State and regional systems (CSAT, in press), including Arizona, Maine, New Mexico, Oregon, and Florida. CCISC is applicable to systems of any size ranging from an entire State to a local service network or agency, and may be extended to include linkages with systems such as corrections and homelessness services. The CCISC model is based on two core principles:

(1) Integrated System Planning.

Because co-occurring disorders are an expectation in all parts of the service system and are associated with poorer outcomes and higher costs, the CCISC model requires that both funding and services be planned specifically based on those assumptions. As a consequence, all services programs are designed to be "co-occurring capable programs," meeting minimum standards of capacity. Some programs are designed to be "co-occurring enhanced"; e.g., they have the capacity to respond to co-occurring substance abuse disorders and mental disorders in inpatient psychiatry units.

Each program matches services to individuals with co-occurring disorders based on their treatment needs. For example, some programs provide continuity-of-care case management services for substance using individuals with serious mental illnesses. Other programs might include residential addiction programs for individuals with serious addiction and trauma disorders.

Although new resources are always needed, the CCISC helps identify how current resources can work more efficiently by designing programs to be co-occurring disorders capable from their inception. In addition, the CCISC encourages use of any best practice intervention or program for either mental illness or substance disorder, provided that the intervention is designed to be offered routinely in an integrated manner to individuals with co-occurring disorders.

(2) Integrated Treatment Philosophy.

The CCISC treatment philosophy is based on eight best practice treatment principles that reflect consensus among clinical experts (CMHS, 1998). These principles emphasize the need to acknowledge co-occurring disorders as an expectation, to consider both substance abuse and mental disorders as primary disorders, and to develop program structures and interventions that accommodate each individual's needs.

No one program or intervention is right for all people with co-occurring substance abuse disorders and mental disorders. For any individual at any point in time, interventions must be matched to the status of the individual - from diagnosis to phase of recovery and from needs/strengths/contingencies to level of care requirement (CMHS, 1998). Finally, the measure of success is based on an individual's treatment goals. At any point in time, success may be defined by acute stabilization of symptoms, movement through stages of change, skills development, or reduction in substance use.

Practice guidelines based on this model have been adopted by the State of Arizona and by the Illinois Behavioral Health Recovery Management project. Minkoff has developed a "12-Step Program for the Implementation of the CCISC," and Minkoff and Cline (2001, 2002) have developed a toolkit to facilitate this process, including tools to evaluate system fidelity, program capability, and clinician competency. These tools are beginning to be used and evaluated in systems change initiatives throughout the U.S. and Canada.


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