SECTION II The Conceptual Framework Just as individuals with co-occurring disorders are unique, so too are the service systems through which they receive their care. The conceptual framework that meeting participants proposed, which is outlined in this section, provides a common set of reference points and allows policy makers, providers, and funders to plan services for individuals regardless of their specific diagnoses or the current structure of the health care delivery system in their State or community.
The New York Model James Stone, M.S.W., Commissioner of the New York State Office of Mental Health, presented a model his State uses to locate individuals with co-occurring mental health and substance abuse disorders on a continuum of care (see Figure 1). The underlying assumption of the New York model is the fact that people with co- occurring disorders vary in the severity of their mental health and substance abuse disorders, from less severe mental health and substance abuse disorders to more severe mental health and substance abuse disorders. Individuals for whom one or the other disorder is predominant fall between these two groups.
Further, the model is based on the fact that these differences in severity determine the service system location in which individuals receive their care, including the primary health care, mental health care, and alcohol and other drug treatment systems, as well as the criminal justice system, the homeless service system, and so on.
Participants chose to elaborate on the framework by expanding on these specific areas of concern. Most importantly, it was agreed that the framework could accommodate service coordination needs and (at some future point) funding sources quite well. Each of three areas?severity, primary locus of care, and service coordination ? is discussed below.
The Revised Framework The conceptual framework that meeting participants developed expands on the New York model and represents a new paradigm for considering both the needs of individuals with co- occurring substance abuse and mental health disorders and the system characteristics required to address these needs. Unique features of this approach include the following:
?The revised framework is based on symptom multiplicity and severity, not on specific diagnoses, and uses language familiar to both mental health and substance abuse providers. As such, it encompasses the full range of people who have co- occurring substance abuse and mental health disorders. In addition, it points to windows of opportunity within which providers can act to prevent exacerbation of symptom severity.
?The framework permits discussion of co- occurring disorders along several dimensions, including symptom multiplicity and severity, locus of care, and degree of service coordination. It permits a number of key decisions to flow from it, including the level of service coordination required and the best use of available resources.
?The framework accommodates different levels of service coordination rather than specifying discrete service interventions. It represents a flexible approach that can be adopted or adapted for use in any service setting.
?The framework identifies two levels of service coordination?consultation and collaboration?that do not require fully integrated services. It points to the fact that individuals can be appropriately served with interventions that do not require full service integration. This is important for those service settings in which integration is not feasible or desirable, and for those individuals whose needs can be addressed with a minimum amount of system change.
Co-occurring Disorders by Severity Regardless of specific diagnoses, meeting participants agreed that individuals with co- occurring disorders fall into one of four major categories based on the severity of their mental health and substance abuse disorders:
?Category I. Less severe mental disorder/less severe substance disorder.
?Category II. More severe mental disorder/less severe substance disorder.
?Category III. Less severe mental disorder/more severe substance disorder.
?Category IV. More severe mental disorder/more severe substance disorder.
This is a simplified categorization that permits further discussion. Individuals at various stages of recovery from mental health and substance abuse disorders may move back and forth among these categories during the course of their disease.
States need to be most concerned with individuals in categories I and IV, meeting participants agreed. While individuals in categories II and III may be receiving some level of care in the substance abuse and mental health systems, respectively, category I ? those individuals whose disorders are not severe enough to bring them to the attention of the mental health or substance abuse treatment systems at this time?is largely ignored. This group is of particular concern because it includes many children and adolescents at risk for developing more serious disease. Meeting participants agreed that providers may have the greatest impact in minimizing future disease by providing appropriate prevention and early intervention strategies for people in category I.
Members of category IV ? those with more severe mental health and substance abuse disorders?are more likely to be found in inappropriate settings (e.g., jails, homeless), to use the most resources, and to have the worst outcomes. This group includes those with severe, chronic disease who may be the most difficult to serve. Because those in category IV consume the bulk of a system?s resources, attention to people in this group may help reduce treatment costs and produce better consumer outcomes.
Using the revised framework, States can decide how best to direct their mental health and substance abuse efforts. For example, the framework encourages States to respond to the needs of those individuals who fall into category I by expanding their prevention and early intervention efforts. By the same token, States may choose to reduce expenses and improve outcomes associated with serving persons in category IV by diverting them from inappropriate and more costly treatment settings. In general, the framework supports State- directed efforts to work toward meaningful integration of services for these persons with the most severe mental health and substance abuse disorders.
Primary Locus of Care by Severity Based on the severity of their disorders, people with co- occurring mental health and substance abuse disorders currently tend to receive their care in the following settings (see Figure 3):
?Setting I. Primary health care settings, school- based clinics, community programs; no care.
?Setting II. Mental health system.
?Setting III. Substance abuse system.
?Setting IV. State hospitals, jails, prisons, forensic units, emergency rooms, homeless service programs, mental health and/or substance abuse system; no care.
As with categories of illness, the use of such clearly delineated settings is for ease of discussion. In reality, there is a great deal of overlap between and among these settings; individuals with different combinations of severity are served in all of the systems highlighted above. In addition, individuals may move back and forth throughout the system of care based on their level of recovery at any given time.
Service Coordination by Severity Based on the severity of their disorders and the location of their care, the following levels of coordination among the substance abuse, mental health and primary health care systems is recommended to address the needs of individuals with co-occurring mental health and substance abuse disorders (see Figure 4):
?Level I. Consultation. Those informal relationships among providers that ensure both mental illness and substance abuse problems are addressed, especially with regard to identification, engagement, prevention, and early intervention. An example of such consultation might include a telephone request for information or advice regarding the etiology and clinical course of depression in a person abusing alcohol or drugs.
?Levels II/III. Collaboration. Those more formal relationships among providers that ensure both mental illness and substance abuse problems are included in the treatment regimen. An example of such collaboration might include interagency staffing conferences where representatives of both substance abuse and mental health agencies specifically contribute to the design of a treatment program for individuals with co- occurring disorders and contribute to service delivery.
?Level IV. Integrated Services. Those relationships among mental health and substance abuse providers in which the contributions of professionals in both fields are merged into a single treatment setting and treatment regimen.
Putting the Pieces Together The revised framework has implications for funding strategies. For example, Dr. Pepper strongly recommended making better use of existing resources through coordinated or shared funding at the local service delivery level. This may be of particularly value for those individuals who fall in categories II and III. Reducing the use of inappropriate service settings (e.g. jails and prisons) for people in category IV would help save costs. Recognizing that a topic of such significance could not adequately be addressed within the scope of the current meeting, participants stressed that future attention be paid to the topic of funding opportunities.
Finally, the framework is a necessary, but not sufficient, piece of the puzzle. To accomplish system change for people with co-occurring mental health and substance abuse disorders, policy makers, funders, and providers must define an effective system of care and delineate what successful consultation, collaboration, and integration look like. These concepts are discussed in the next section.