Expansion and Enhancement of Davidson County Dual Diagnosis Service Capabilities


Individuals with co-occurring disorders with access to intensive and long-term community-based outpatient services utilized fewer high cost services such as inpatient hospitalizations, emergency room visits, and incarcerations six and twelve months following enrollment to outpatient services.

  • From March 2002 to December 2003, 581 participants with Co-Occurring substance abuse and mental health disorders were enrolled in the IOP study at Foundations Associates.
  • IOP participants reported greater utilization of outpatient services six and twelve months after enrollment in the program. At the same time, participants reported reduced utilization of high-cost Inpatient hospitalizations, emergency room, and residential treatment services in the year following enrollment in the Foundations Associates Intensive Outpatient Program. Although the frequency of social interactions did not increase significantly, the quality of natural supports appeared to improve as satisfaction with family and social interactions increased at follow-up.
  • The majority of program participants who were actively using in the 30 days prior to enrollment in the program were no longer actively using alcohol or illegal drugs at six and twelve months. The frequency of substance use was also reduced regardless of the severity of mental health problems.
  • Quality of life and daily functioning improvements were reported by all program participants, including clients with greater impairments who received supplemental case management services.


The Expansion and Enhancement of Davidson County Dual Diagnosis Service Capabilities was a three year federally funded project to develop and implement less restrictive community-based outpatient services based on best practices services for individuals with Co-Occurring Disorders. Foundations Associates (FA) developed the outpatient services model based on FA’s successful integrated community-based residential treatment model. The already established residential program consistently demonstrated successful outcomes for this difficult to treat population. However, the expense of residential services and the magnitude of need for appropriate services that address Co-Occurring Disorders limited the impact of these unique services in the local Davidson County community. Expansion and Enhancement of Davidson County Dual Diagnosis Service Capabilities was developed by Foundations Associates (FA) in response to this growing need for less restrictive and resource intensive community-based services that provided adequate services for multiple and complicated problems associated with Co-Occurring substance abuse and mental health disorders. Key evaluation questions are based on the intended results of program activities including:

1) Did program services reach the intended audience? Integrated outpatient services targeted adults with co-occurring mental illness and substance abuse disorders who required access to public-funding resources for treatment services.
2) Did program participants have greater access to natural supports and lower cost professional resources?
3) Did increased access to cost efficient supports and resources reduce reliance on inappropriate and costly resources including inpatient hospitalizations, residential treatment, emergency room services, and criminal justice involvement?
4) Did participants reduce substance use and mental health problems, along with improved functioning and quality of life?

The purpose of this report is to provide an overview of the program and to describe the implementation of this model and actual services delivered. The baseline findings describe the targeted population and whether the project successfully enrolled and engaged these consumers in treatment services. In the Outcomes section, the intended impact of treatment services on individual consumers is described with findings across multiple functional domains. The discussion section summarizes these consumer outcomes and discusses the local community impact of FA’s unique integrated services. Finally, the conclusion reviews the relevance of these findings with respect to more recent developments.

Program Services

FA increased program capacity for front-end Intensive Outpatient Program (IOP) services and offered services to uninsured, homeless, and low-income individuals. IOP services were offered five days per week and three hours per day, including three separate daily groups, each one hour in length, designed to provide psychoeducation, addictions treatment, relapse prevention, therapy, and coping strategies. Case management and individual/group therapy consistent with ASAM PPC-2 Level II.1 criteria were provided over an additional six months following completion of more intensive IOP services.

Program Participants

From March 2002 through December 2003, 581 participants were enrolled in the IOP study. Study participants were 55% female and 36 years of age on average (36’9 years). The majority was White (64% or n=369) and minority participants were almost entirely Black or African American (35.6% of overall sample or n=207). The average grade completion was 12th grade, including 38% who did not complete high school. Half of participants reported an income totaling $200 from all sources in the last 30 days and 29% reported full or part-time employment. Although only 16.2% were literally homeless, only 20.1% were housed independently. A small percentage indicated overnight incarceration in the last 30 days (9%), however, 29.1% indicated at least moderate difficulty (moderate = 3 on a scale from 1 to 5 with higher indicating greater difficulty).

Of the overall baseline sample, alcohol use (50.1%) was reported less often than illegal drug use (64.7%), which included cocaine (44.8%) and followed by marijuana (27.7%). The majority were diagnosed with substance dependence (85%) and only 19% with substance abuse. The most common psychiatric diagnosis was Major Depression (34%) followed by Bipolar Disorder (21%), Schizophrenia (16%), and Anxiety or Panic Disorders (15%).


  • GPRA (Modified ASI items): drinking to intoxication, Total Income
  • Administrative Records: level of case management services, IOP services
  • Lehman Quality of Life (modified administration): Housing QOL, Overall Life QOL, Social Relationships, Social Interaction Objective, Financial Objective
  • Brief Symptom Inventory (BSI): Global Severity Index (GSI), Positive Symptom Total (PST), Positive Symptom Distress Index (PSDI), Somatization, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, Psychoticism.
  • 12-Item Short Form Health Survey (SF-12): Mental Component Summary (MCS), Physical Component Summary (PCS)
  • Co-Occurring & Functional Disorders Survey (COFD): The sum of six items from the COFD was used to create the summary variable, Total MH Problems, with values ranging from 6 (low reported severity of mental health problems) to 24 (high problem severity). An additional variable generated from the COFD, Difficulty Managing, was intended to capture severity of difficulty managing daily tasks such as household cleaning tasks, shopping, and taking care of children.


Following informed consent, each participant completed the baseline and follow-up interviews conducted six and twelve months after the baseline date.

Process Evaluation

Program participants were invited to participate in the evaluation study and enrolled following signed informed consent with 581 participants enrolled from March 2002 to December 2003.

Services Received

All program participants were enrolled in FA’s Intensive Outpatient Program (IOP) services. The median amount of IOP was 22 days and only 7% received fewer than four days of IOP. More than half also received case management services (56%), including 40% who received at least 10 days of case management services. Only 21 participants failed to engage in IOP and case management with fewer than 4 days of each. This relatively low percentage appears to indicate that the program successfully engaged participants in outpatient services.


The specific amount of participation was based on the individual client rather than an arbitrary standard dosage and mix of outpatient services. However, the general goal was to increase access and utilization of outpatient community-based services with a long-term perspective. The chronic nature of Co-occurring Disorders requires a longer-term perspective with sustainable services that do not overwhelm public funding resources or create overly restrictive treatment environments.

Utilization of outpatient services was reported by 49% of participants at the six-month follow-up while only 28% reported either inpatient hospitalization or emergency room services. These high-cost services included 21% inpatient and 13% emergency room.



Baseline characteristics for consumers who received fewer than nine days of IOP (lowest 25th percentile for the study group) were compared to those who received at least nine days of IOP. Initial descriptive analyses identified potential predictor variables based on chi square statistic for categorical variables and t-tests for continuous variables. All variables that approached statistical significance (p value at or below 0.10) were included in further analysis using binary logistic regression (see Table 1). Given the exploratory intent of this analysis, all potential predictor variables identified in the previous step were entered as a block in the regression analysis to explore the extent to which at least marginally significant variables predicted early IOP retention.

Of the categorical variables that were tested as potential baseline predictors of IOP participation, significant baseline predictors included drinking to intoxication and level of case management services. Continuous variables that were also tested included Housing QOL, Overall Life QOL, Social Interaction Objective, Financial Objective, GSI, PST, PSDI, IS, Dep, Anx, Phobia, Paranoia, Psychotic, Total MH Problems, Difficulty Managing, Social Relationships, and Total Income. There was also one categorical variable, Other Psychiatric Diagnosis, and one continuous variable, MCS, which were both marginally statistically significant but were excluded due to missing data.

The only significant predictor was additional access to case management services at Foundations Associates. Compared to participants who did not access case management services, those with at least minimal case management (4 to 22 units) were 1.879 times as likely to successfully engage in IOP services, and participants with 23 or more case management units were 3.188 times as likely to engage in IOP services beyond the initial 8 days. In this analysis, substance use, quality of life ratings, amount and adequacy of income, social interactions, level of mental health problems, and daily functioning did not predict IOP retention.


Outpatient services were intended to engage difficult to treat conditions and facilitate access to sustainable resources necessary to treat the chronic nature of co-occurring disorders. Access to outpatient services and natural resources was measured prior to program enrollment and again six and twelve months later to determine changes over time. Level of participation in the treatment program was also included in this estimate in order to improve the likelihood that changes over time were attributable to program services.

The amount and adequacy of financial resources increased significantly six months after program enrollment and improvements over pre-program measures were maintained at twelve months. Income from all sources (combined total wages, public assistance, retirement, disability, and any other sources) increased from $200 median income at baseline to $350 at six months and $419 at twelve months. Similarly, adequacy of finances to cover basic needs (food, shelter, clothing, etc.) increased from adequacy to pay for less than half of basic needs (2.2 average on 0 to 5 scale) to available finances covered majority of basic needs at follow-up (3.0 at six months and 3.3 at twelve months). Financial improvements were likely influenced by increased access to resources provided either directly or facilitated by program staff. However, income was also impacted by an increase in employment from 28.6% to 30.6% at six and 33.9% at twelve months.

Changes in social and family interactions were also an important indicator of access to natural support resources (see Figure 1). Ratings of satisfaction with family and social relationships increased over time even though the frequency of family and social interactions declined slightly. However, more frequent interactions may not always reflect improved natural supports as negative peer or family interactions may impede recovery and continued progress.


Utilization of high-cost non-outpatient services declined as measured by both follow-up interviews compared to baseline levels prior to participation in program services (Figure 2). Inpatient hospitalizations declined from 29% to 13% at six months and 10% at twelve months. Similarly, emergency room services and residential treatment declined after enrollment to the outpatient program at Foundations Associates (28% to 14% and 25% to 11% from baseline to 12-month respectively). Although criminal justice involvement as measured by recent arrests or incarcerations did not change over time, the percentage of participants who experienced recent legal problems declined from 41.8% at baseline to 20.5% at six months and 18.4% at twelve months. Outpatient services utilization increased over the same time period from 22% prior to program enrollment to 50% at six months and 36% at twelve months. However, access to outpatient services was not a useful predictor for high-cost service utilization.


Reduced substance use and mental health problems were the key long-term indicators of successful project outcomes. These key indicators were measured at each interview in order to measure change before (baseline) and after treatment program participation. The variable for substance use was coded to reflect any illegal drug use or alcohol use in the last 30 days. Program success was measured by substance use at follow-up for participants who reported substance use at baseline (before program participation).

The measure of mental health problems was based on six items that asked the respondent to indicate level of mental health problems in the last 30 days. Each item was measured on a 1(not at all) to 4 (extremely) scale for all six items (CA=.77) with scores ranging from 6 to 24. The six items rated how troubled or bothered in the last 30 days by Depression, Anxiety, Hallucinations, Concentration, Violent Behavior, or Suicidal Thoughts.

Substance Use

The percentage of participants who reported no substance use following active substance use before the program included 53% at six months and 58% at twelve months (see Figure 3). These outcomes represent the 406 participants who reported substance use at baseline and completed at least one follow-up interview. Across both follow-up interviews, 44.1% (n=179) reported no substance use, 33% (n=134) reported substance use at all available follow-up interviews, and the remaining 22.9% (n=93) indicated substance use in at least one follow-up with no substance use in the other follow-up.

Mental Health Problem Severity

Although mental health problems also improved at follow-up compared to baseline, participants who reported substance use consistently reported higher (worse) mental health problems than participants who did not report recent substance use. In figure 4, mental health problems were higher when substance use was reported in the same time period. In subsequent analyses, current level of mental health problems was a more significant predictor of current substance use than previous measures. For example, mental health problems at 12 months was a significant predictor of substance use at 12 months, while previous baseline and six month measures were not significant predictors of 12 month substance use.

Functioning and Quality of Life

The amount of difficulty with daily activities, Difficulty Managing, and overall quality of life ratings were also significant predictors of substance use. Greater difficulty with daily tasks at each interview was associated with substance use during the same interview time (Figure 5). As illustrated in Figure 6, overall quality of life ratings predicted substance use at each interview. This pattern across substance use and time was similar to the mental health problems measures. However, level of mental health problems was a stronger predictor of substance use.

Impact of Specific Program Services

As expected, participants who received case management services averaged more severe mental health problems and greater difficulty with daily activities as measured during the initial baseline interview. However, this initial greater level of severity was no longer apparent at either follow-up interview.


The project described was supported by Grant Number TI12720 from the Substance Abuse and Mental Health Services, Center for Substance Abuse Treatment. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Center for Substance Abuse Treatment.

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