SECTION III: Desirable System Characteristics

SECTION III Desirable System Characteristics An effective system of care for people with co-occurring disorders ? one that encourages and allows for consultation, collaboration, and integration ? will have several overarching characteristics in such key areas as philosophy, services, staffing, and funding. These qualities are described in this section, along with specific strategies for improving consultation, collaboration, and integration.

Overarching System Characteristics

An Ongoing Commitment. Any service system that can effectively care for people with co- occurring disorders must be built on a strong foundation of shared principles and values. There must be agreement among all key stakeholders ? including Federal, State, and community officials; policy makers; mental health, substance abuse treatment and primary health providers; consumers; and advocates? about the need for, and the value of, treatment systems working together to improve consumer outcomes. Whether such agreement is spelled out in a formal memorandum of understanding or is simply acknowledged to be the case, there should be ongoing and shared commitments to address the needs of this group. It should be clear to all parties that consultation, collaboration, and integration are not only allowed, but are encouraged and programmatically supported, depending on consumer needs. States will play a key role in defining and implementing these policy changes, in part because of their role to ensure appropriate treatment for the individual while also operating in the public interest.

Consumer-Centered. Because the underlying goal of working together is to improve consumer outcomes, any successful service system must be consumer- centered as well as culturally- competent. A consumer- centered system is one in which mental health and substance abuse consumers and their families are actively involved not only in treatment decisions, but also in program design, administration, and evaluation. The role of mental health consumers in advancing care for people with serious mental illnesses may be instructive in this regard, several meeting participants noted.

“No- Wrong Door.” Meeting participants were unanimous in their belief that services for people with co- occurring disorders must be available and accessible wherever, and whenever, the person enters a service system. Often called a “no-wrong door” approach, this ensures that an individual can be treated, or referred for treatment, whether he or she seeks help for a mental health problem, a substance abuse problem, or a general medical condition. This eliminates unnecessary duplication of services and reduces the likelihood that an individual will fall through the cracks of an uncoordinated system of care.

Comprehensive, Long- Term Care. In addition, because of the chronic and severe nature of many co- occurring conditions, treatment for such individuals must be comprehensive, longitudinal, and increased or decreased according to changing needs and consumer motivation.

Engagement. Because many individuals with co-occurring disorders are not currently receiving any treatment at all, a strong recommendation was made that providers focus on engaging those who are not currently in the mental health or substance abuse treatment systems. Special efforts should be made to reach out to children and adolescents at risk for developing mental health and substance abuse disorders, many of whom present in primary care settings or school- based clinics. In addition, individuals with co-occurring disorders are found in jails and prisons, in hospital emergency rooms, and living in shelters or on the streets. These sites constitute primary sources for case finding and service delivery.

Integrated Service Delivery. While service delivery for some individuals with co- occurring disorders should be integrated (i.e., those with the most severe disorders), service agencies or programs need not be. Because both the mental health and substance abuse systems have unique characteristics that will be important in an overall system of care, their efforts should be combined, but it may be neither practical nor desirable to merge the systems themselves. Regardless of the specific organizational structure of the mental health and substance abuse treatment systems in a particular community, however, the system must be experienced as seamless by the consumer. The use of common intake forms, used to facilitate a “no- wrong door” approach, is one example of an integrated service delivery technique.

Respect and Trust. A comprehensive service delivery system for people with co- occurring disorders will be as successful as the individuals who staff it allow. Their ability to work together begins with an appreciation for the skills and strengths of providers in both systems. Further, front- line staff must be able to trust one another and know that they are working together for the good of the consumer.

Cross-Training. Substance abuse and mental health staff must be oriented toward, and have a basic understanding of, each other?s disciplines in order to be effective with consumers who have co- occurring disorders. However, participants offered the caveat that cross- training alone does not make an individual an expert in the other field. Further, credentials in a specific area do not necessarily equal competence. In order to be effective, mental health and substance abuse staff must have enough knowledge to know what they don?t know and to seek appropriate advice from one another (see “specific strategies for consultation,” below). In addition, primary health care providers would also benefit from further training in mental health and substance abuse disorders.

Common Data, Assessment Tools, and Performance Indicators. Because one of the biggest barriers to coordinated care for people with co-occurring mental health and substance abuse disorders is lack of common assessment tools, meeting participants strongly recommended that such instruments either be developed specifically for this purpose or selected from among existing tools. The use of common instruments will help providers in both systems determine the primacy of an individual?s mental health and substance abuse disorders and plan effective treatment and follow- up care.

Movement of consumers between the mental health and substance abuse systems will be further enhanced by the collection of common data. Also, when both systems are using shared performance indicators to assess treatment of co-occurring disorders, consumers, family members, program planners, advocates and funders can better determine whether stated outcomes are being met.

?Flexible Funding Streams. Flexible funding is a necessary tool if local mental health and substance abuse providers are to meet the needs of individuals whose disorders don?t fall neatly into one or another categorical funding stream. Maintenance of separate funding streams at the Federal and/or State level may help to ensure that the mental health and substance abuse systems remain viable and able to complement one another, each retaining and refining their areas of expertise. In the final analysis, coordination of those funding streams at the local level by community providers may permit the most effective response to the unique needs of consumers with co-occurring disorders.

Specific Funding Mechanisms. To support a philosophy of consultation, collaboration, and integration, State and local planners may need to develop specific funding mechanisms that allow such partnership activities (e.g., special work groups or task forces) to be reimbursed.

Specific Strategies for Consultation ?For consultation to be effective, mental health, substance abuse and primary care providers will need to know what the other system expects of them. Meeting participants suggested the following general categories of knowledge exchange:

?From the mental health field, substance abuse providers need information about how to recognize the symptoms of mental illness and differentiate them from the symptoms of substance use/abuse; how to plan effective treatment interventions for mental illness that co- occurs with substance abuse disorders; how best to take advantage of consumer participation in treatment planning; and how to directly and immediately access the mental health services available to their clients.

?From the substance abuse field, mental health providers need information about how to assess and recognize patterns of substance use/abuse, particularly as they relate to mental health disorders; how to help consumers through the phases of substance abuse treatment (engagement, persuasion, treatment, and relapse prevention); how to plan effective treatment interventions for substance abuse that co- occurs with mental illness; and how best to use the self- help approach to recovery from substance abuse.

?From the primary health care sector, both the mental health and substance abuse systems need to know more about the medical consequences of co- occurring disorders and how to manage diseases that may result from, or co- occur with, mental health and substance abuse disorders.

?From the mental health and substance abuse fields, primary care practitioners need more information, education and training about how to recognize the symptoms of mental illness and substance abuse, especially as they relate to one another; and how to make appropriate referrals for mental health and substance abuse treatment, particularly for those individuals with co- occurring disorders.

In addition to knowledge about each other?s disciplines, substance abuse, mental health and primary care providers need to know how best to construct and use the consultation process. Providers should be trained to know whom they should ask for help, when they should seek it, and what types of assistance they can expect.

Specific Strategies for Collaboration Collaboration will be easier to achieve if the mental health and substance abuse systems have a joint vision that clarifies the importance of their efforts. A vision statement might refer to the need to improve consumer outcomes, to ensure the most appropriate services, and to use resources more effectively.

System planners can solidify their commitment to work together by signing a formal memorandum of understanding (MOU) that helps operationalize their joint vision. For example, parties to the agreement might spell out specific areas of collaboration, including the use of common data, assessment tools, and performance indicators.

An MOU or other formal agreement should specify how the key players will monitor their progress. Ongoing mechanisms for communication will be vital to this effort. These should include work groups of both administrative and front- line staff responsible for maintaining the spirit of collaboration and for ensuring that the needs of specific consumers are met. The absence of these players in the communication process severely diminishes the chances of implementing an effective program.

Participants were united in their belief that sharing resources at the local service delivery level is the best way to ensure that an individual consumer gets the specific services he or she needs. Joint fiscal support will help providers make the best use of limited resources and provide consumers with the most appropriate mix of services.

Specific Strategies for Service Integration One of the primary integrated service mechanisms through which providers can serve individuals with co- occurring disorders is the addition of substance abuse specialists to mental health crisis and treatment teams and the addition of mental health specialists to substance abuse crisis and treatment teams. Integrated treatment teams provide “one- stop shopping” for consumers, and they help providers in both systems to be more aware of, and more knowledgeable about, co- occurring disorders.

When mental health and substance abuse providers are part of the same treatment team, they can develop and monitor a joint treatment plan that serves the unique needs of each individual with co- occurring disorders. Joint treatment plans and services take into account the interactive nature of the individual?s specific diseases and are designed to provide appropriate support for recovery from both mental health and substance abuse disorders.

Additional funding specifically geared to people with co- occurring disorders may be identified at some future point. However, planners and providers may choose to use existing funds, including Federal and State monies, to leverage new resources. These might include, for example, housing funds tied to the provision of supportive services or foundation monies targeted to a specific population.

in Managed Care Contracts Meeting participants noted that there is a trend for many states to contract with managed care organizations for the provision of mental health and/or substance abuse services. Concern was expressed about the ability of managed care organizations to serve individuals with co- occurring disorders effectively. Because their needs are complex and long- term, such individuals are likely to be ill- served by the short- term treatment approaches that tend to be favored within the managed care environment. Mental health and substance abuse policy makers and funders can have a significant impact on the care of this group by reinforcing comprehensive and integrated models of care in managed care contracts that will cover people with co-occurring disorders throughout their recovery process.

Next Steps The group recognized that the type of system changes outlined in this dialogue will not happen overnight, and certainly cannot happen in a vacuum. They require a coordinated effort at all levels ? local, State, and Federal ? to have a significant impact. Recommendations for moving forward with these critical suggestions are highlighted in the final section.

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