Experts Identify Problems, Examine Solutions (Part 2)

An Integrated System

Overcoming those barriers is possible, however. Renata Henry, M.Ed., Director of Delaware's Division of Substance Abuse and Mental Health, described her state's successful model for treating individuals with co-occurring conditions.

Ms. Henry began by adding to the list of barriers to integration.

State mental health and substance abuse systems are typically separate and uncoordinated, she explained. Funding streams usually require single diagnoses, so that individuals need a substance abuse-related diagnosis to get treatment from a substance abuse treatment program and a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition to get mental health treatment. The two workforces often have different educational backgrounds and treatment philosophies. And there's not a lot of research on evidence-based practices for treating co-occurring disorders.

Faced with such obstacles, Delaware took action. With the state's substance abuse and mental health divisions already integrated administratively, leaders committed to improving services for individuals with co-occurring conditions. They blended funding streams, and they developed a training program so that staff in the mental health, substance abuse, homelessness, criminal justice, and health care systems are able to treat people no matter what treatment "door" they enter.

More needs to happen to eliminate barriers, Ms. Henry said. Administrators need to establish standards, initiate dialogues, disseminate information and tools, and remove funding and regulatory barriers. The Federal Government should develop policies that encourage integration, eliminate funding barriers, and improve dissemination of research.

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What Works?

Researchers are already busy trying to determine what treatments work best. But conducting research on co-occurring conditions requires investigators to ask new questions and develop new ways of working, noted Constance Weisner, Dr.P.H., M.S.W., a professor of psychiatry at the University of California and an investigator in the Division of Research at Northern California Kaiser Permanente.

"We need to move away from the traditional paradigm of investigators setting the research agenda alone and move toward developing questions in collaboration with clinicians," she said, noting that health plan administrators, primary care providers, accrediting bodies, policymakers, and others should be involved. She described a cyclical process: a continuous loop of brainstorming questions, studying interventions, implementing findings, and using the results to identify new questions.

Researchers also need to put more emphasis on studying the elements that influence adoption of best practices, said Dr. Weisner. Although a lot of research shows that integrated treatment is effective, for instance, most clinical trials focus on homogeneous populations, which may not represent the demographics of a particular treatment center or service provider accurately.

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Incentives for Quality

Financing is one of the real-life factors that affect the treatment of co-occurring disorders.

"Over the last 5 years, national attention on the financing of services for co-occurring conditions has been growing," said Mady Chalk, Ph.D., Director of the Division of Services Improvement at SAMHSA's Center for Substance Abuse Treatment (CSAT). The Institute of Medicine's 2001 report on gaps in health care quality led to an increased focus on measuring quality and developing financial incentives, Dr. Chalk said. The Institute is now drafting a report specifically on substance abuse and mental health.

Constance Horgan, Sc.D., Director of the Schneider Center for Behavioral Health at Brandeis University, called for a clear and direct link between quality and financing of services for individuals with co-occurring conditions.

As an example, Dr. Horgan described the work of the Washington Circle, a group of researchers, substance abuse treatment providers, health care policy experts, and others convened by CSAT in 1998. The group developed a framework for performance measures across the continuum of care based in four core domains—prevention/education, recognition, treatment, and maintenance of treatment effects. To drive quality improvement in substance abuse treatment, the group has initially developed and tested measures that focus on the front end of treatment: identification, initiation, and engagement.

The National Committee for Quality Assurance, the U.S. Department of Veterans Affairs, and many public systems have adopted these measures or are considering doing so.

In one study of individuals who get health insurance through large employers, the group found that private sector health plans needed to improve significantly on ways to identify substance abusers, and to initiate and sustain treatment.

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