Abstracts from COSIG
Abstracts from the COSIG State Grant Applications
Alaska
To improve the identification and treatment of individuals with co-occurring disorders throughout a diverse serve delivery system, Alaska has committed to addressing SAMHSA's goals of improved screening, assessment, treatment, and training, which will be accomplished through infrastructure development, focusing on staffing competency, credentialing, and licensure; financial planning and reimbursement; and information sharing and data collection. The work will be carried out in fulfillment of a State action plan for the integration of mental health and substance abuse services, developed in consultation with co-occurring disorders experts Dr. Kenneth Minkoff and Dr. Chris Cline. The conceptual model guiding the activities is based on eight clinical consensus best practice principles that promote an integrated clinical treatment philosophy applicable to the treatment of both mental health and substance disorders. The process will result in the development of an integrated planning and implementation structure; an organized strategic planning and quality improvement process; acceptance of a universal integrated screening process; implementation of a CQI program to monitor the provision of integrated treatment for individuals with co-occurring disorders; the elimination of barriers to integrated screening, assessment and treatment; establishment of an integrated management information system, Alaska Automated Information Management System; and a system-wide training plan to ensure the achievement of dual diagnosis capable competencies across agencies and among all clinicians. Dr. Amy Salomon of Advocates for Human Potential will evaluate the program. When fully implemented, the system will use the Comprehensive, Continuous, Integrated System of Care (CCISC) Outcome Fidelity and Implementation Tool (COFIT-100 ®) for measuring progress in CCISC implementation.
Arizona
This proposal is submitted by the Office of the Governor of Arizona and seeks to extend our state's existing co-occurring infrastructure and development that has occurred within our behavioral health system to our state's adult and juvenile criminal justice systems. The mission of this project is to build the workforce, clinical, and information infrastructure necessary to ensure that all individuals who come into contact with the criminal justice system are provided with a consistent and comprehensive approach to the detection, assessment, and treatment of co-morbid substance use and mental illness in a culturally competent manner that is reflective of evidence-based practices. This mission will be achieved through four key objectives. First, local and state criminal justice systems will implement a uniform process for ensuring that individuals within their custody are screened for the presence of both mental illness and substance use disorders. Second, individuals exiting adult and juvenile correctional systems who have screened positively for the presence of a co-occurring disorder will be diagnosed using an assessment process that is culturally and co-occurring sensitive and consistent with that which is in use within our state's Medicaid & block grant funded behavioral health system. Third, informational systems, including administrative databases and management information systems will be integrated to allow for transparency in clinically relevant information among and between criminal justice and behavioral health treatment systems and settings. Fourth, workforce development initiatives, the development of co-occurring coursework and programs within institutions of higher education, along with in-service training targeting criminal justice and behavioral health service professionals will be undertaken. In order to evaluate the viability of our approach, a quasi-experimental pilot demonstration study will be undertaken that incorporates pre-release screening, assessment, and transition planning for inmates of the state correctional system, and co-occurring and culturally competent post release services including housing supports and intensive case management and outpatient treatment services. This proposal will be administered by the Arizona Governor's Office for Children, Youth, and Families, Division for Substance Abuse Policy. The SAMHSA initiated Co-Occurring Policy Academy Team for the state of Arizona will serve as a Project Integrated Services Coordinating Council and will be organized into three working groups: Screening, Assessment, & Treatment Services; Workforce Development; and Information and Evaluation. Applied behavioral Health Policy, a unit of the University of Arizona that also co-manages the Pacific Southwest Addiction Technology Transfer Center (PSATTC), will support the Governor's office in overall project management and coordination by providing training, technical assistance and program evaluation support to the project.
Arkansas
To meet the needs of Arkansans dually diagnosed with substance abuse and mental health illness, the State of Arkansas, under the leadership of the Governor and his staff, proposes to institute standardized universal screening and assessment as a first step in its attempt to integrate the presently divided systems of substance abuse and mental health care. SAMHSA funding will also be used to train caregivers from both systems to better recognize co-occurring disorders, and to understand and create treatment plans that address the needs of these individuals. The barriers and facilitators to treatment throughout the process will be systematically evaluated.
To increase accessibility, effectiveness, and efficiency in these systems, Arkansas will first choose reliable and valid screening and assessment instruments and then implement them. This effort will begin with a statewide conference and training for identified training coordinators from each mental health and substance abuse facility who will then be contact persons for the project and who will have administrative support and backing. These individuals will then be responsible for training efforts and in-services in their respective sites. In addition, Arkansas will create a web-based training program that will be sustained even after the end of the project, and intended for the use of all providers to train them in the use of screening and assessment protocols and improve knowledge and skills.
The proposed plan also includes several critical infrastructure changes. A permanent dual diagnosis unit will be established to increase service coordination. Changes to reimbursement policies will be investigated and considered so that this does not continue to be a barrier to treatment. The licensing and credentialing criteria in both systems will be reviewed for potential modification that could lead toward a system wherein frontline caregivers are cross trained and certified to provide care to dually diagnosed persons. A more integrated information management system will be created. All of this is timely for Arkansas given the recent merging of the two State agencies—the Alcohol and Drug Abuse Prevention and Division of Mental Health Services—that provide services to persons with substance use disorders and persons with mental illness respectively. The newly created government entity, the Division of Behavioral Health, will focus on encouraging, supervising, and empowering these collaborative efforts. An evaluation component will evaluate the progress of the project and provide timely feedback to improve implementation and enhance the chances of achieving the project's goals.
Connecticut
Connecticut proposes to use CaSIG funds to better serve individuals with co-occurring disorders (CaDs) through the following infrastructure enhancements: 1) Standardized Screening and Assessment; 2) Service Coordination and
1. Standardized Screening & Assessment will be established to identify individuals with CaDs and their treatment needs, regardless of where the individual initially presents for care. The ultimate goal is that all substance abuse providers will be required to implement a brief screening tool for mental health concerns. In turn, all mental health providers will be required to implement a brief screening tool for substance abuse concerns.
2. Service Coordination and Network Building are essential to enhance the quality of services by removing barriers that impede access, retention, and favorable treatment outcomes, leading to a cohesive, coordinated, and integrated delivery of services and programs for individuals with CaDs, thus, reducing the burden on the individual to negotiate services and maximizing use of limited resources within both treatment "silos".
3. Develop infrastructure that allows information sharing to all stakeholders and promotes the use of data in a quality improvement framework.
The Enhancing psychiatric Services Pilot seeks to develop and implement effective, integrated, and culturally responsive clinical and administrative dual diagnosis enhanced care for Latinos/as with CaDs. The Addiction Services Pilot will design and implement an integrated system of services for individuals with CaDs, which includes use of system change technology with clinical practice technology at the system, program, and clinician competency levels to create comprehensive system change. These pilots will establish an integrated system of care for persons with CaDs and will implement a coordinated outreach, intake, and screening process to ensure that individuals who present in either system with CaDs are engaged in appropriate care.
The CT Department of Mental Health and Addiction Services (DMHAS), as the Single State Agency (SSA) for substance abuse services and the State Mental Health Authority (SMHA), has taken significant steps to increase capacity to provide accessible, effective, comprehensive, . integrated, and evidence-based services for adults with CaDs. Additionally, CT, as one of the 10 states selected to participate in the National Policy Academy on CaDs, is benefiting from the Academy's intensive policy-building forum to develop a State action plan for improving access to services for persons with CaDs. Building upon CT's existing initiatives and infrastructure, CT is well-positioned to make maximal use of the opportunity presented by SAMHSA's COSIG.
Delaware New
As part of its system transformation efforts, the Delaware Division of Mental Health and Substance Abuse is proposing an initiative to: 1) integrate mental health and substance abuse treatment through the development of a state level infrastructure to provide an organizational framework for planning and implementing integrated services and 2) pilot enhancement activities that will inform the development of a comprehensive, integrated approach to serving persons with co-occurring disorders throughout Delaware. This project will provide knowledge to the Division for planning and to the field on the challenges and successes possible for states engaging in the process of developing integrated systems that involve complex boundary spanning activities.
Delaware has participated in the federally supported Policy Academy focused on the development of strategies to introduce services for persons with co-occurring disorders. Based on this experience, and the input of stakeholders from other Delaware systems, professionals and consumers and advocates, the following infrastructure goals are proposed for this grant: 1) statewide screening for co-occurring disorders across four systems; 2) training and credentialing of professionals; 3) implementation of evidenced-based practice (EBP) integrated dual diagnosis (IDDT) treatment in four pilot sites; and 4) evaluation of services. Four service pilot sites and activities will be used to examine the effectiveness of the EBP IDDT service model and an enhanced training credentialing program will be used to test the feasibility and effectiveness of treatment delivery and infrastructure enhancement strategies being developed. This approach uses planning strategies that are already in place in Delaware by leveraging and building upon the experiences currently available at the program level. A feedback loop will be created between statewide planners, local service programs and consumers and advocates, using data from the pilots and the infrastructure activities to shape strategic planning for Delaware.
District of Columbia
The District of Columbia proposes to use the opportunity of the COSIG program to accelerate the steps already underway to:
- Establish an integrated approach to service delivery for persons with co-occurring mental illness and substance use disorders.
- Screen. all individuals who present for treatment in partner agencies for the presence of co-occurring disorders.
- Provide integrated clinical assessments for all individuals who screen positive for both MH and SA disorders
- Treat people with co-occurring conditions with the most appropriate interventions and recovery supports consistent with current science and best practices
- Create the financial incentives, programmatic infrastructure and information system supports so that clinicians and service programs will continue to improve screening, assessment, treatment, and recovery support for people with co-occurring conditions when the COSIO funding goes away.
- Build a learning network for continuous quality improvement that extends across historical gaps that have inhibited effective care:
- between mental health and substance use treatment agencies,
- across clinicians trained in mental health and those trained in substance use treatment,
- between professionals, consumers, and families,
- between the District of Columbia and other Federal, state and local groups working to improve the quality of care for people with co-occurring disorders.
The COSIG grant will be combined with the considerable resources already committed by the District of Columbia to intensify work initiated in 2001, and to construct the infrastructure so that, by 2007, there will be no "wrong" door for people with co-occurring conditions. With strong support from the District's first Director of Mental Health, Marti Knisely, and the District's new Director of Addictions Prevention and Recovery, Robert Johnson, we are changing the State's care delivery to the Comprehensive Continuous Integrated Systems of Care model (CCISC). Two leading experts on co-occurring disorders and systems change, Ken Minkoff, M.D. and Chris Cline, M.D., will continue to guide the District's efforts to integrate mental health and substance abuse services through clinical and system change training and consultation. Eric Goplerud and George Washington University will assist in creating pay-for-performance and value-based purchasing strategies that align financial incentives to support and sustain high quality assessment and treatment of co-occurring disorders. The evaluation is integrated into a continuous quality improvement and performance incentives. By the conclusion of the COSIG grant period, the District of Columbia will deliver state-of-the-art screening, assessment, and treatment for its residents with co-occurring mental illness and substance use disorders.
Hawaii
The collaborative and cooperative efforts of Hawaii's Department of Health, including the Adult Mental Health Division and Alcohol and Drug Abuse Division propose to develop and enhance the capacity and infrastructure of the State of Hawaii's service system to provide integrated, evidence-based treatment services to people who have co-occurring substance use and mental health disorders. The grant initiative will be managed through the Office of the Governor, with active participation of the State's Lieutenant Governor, who has agreed to co-chair the project's coordinating committee. This project will also include the establishment of collaborative relations and common agendas with the Departments of Human Services (responsible for the State's Medicare and Medicaid programs) and Public Safety (responsible for the State's criminal justice system). It is expected that this cross-system cooperation will foster the ultimate development of an infrastructure leading to a seamless and comprehensive system of care for people who have co-occurring disorders.
Three overarching long-range goals comprise the proposed project. The first goal is to establish a system spanning task force (the Project Taskforce) that will be responsible for the continuing development and implementation of action plans and protocols to (a) assess the status of the State's co-occurring disorder services system, (b) identify unmet needs, gaps, and other problems within this system, (c) develop and enact strategies to resolve these obstacles to care, and (d) build capacity and infrastructure to sustain a high-quality, integrated, and seamless system of care.
The second goal is to conduct a services pilot to test a locally developed set of capacity and infrastructure enhancement strategies. This pilot will promote the plans and protocols of the system-spanning task force that relate directly to the improvement of service to people who have co-occurring disorders. The pilot will be designed to sustain the system and service improvements that it implements.
The third goal is to develop a continuous quality improvement framework for co-occurring disorders services using an array of evaluation methodologies. All of the activities of this proposal will be evaluated with regard to their processes, impact, and outcomes. Evaluation information will be used to inform the project's activities, make recommendations for change when necessary, and document outcomes. This evaluation perspective will be completely interwoven into the activities and operations of the project so that the acquisition and use of evaluation information is as integral to the project as the consumer-focused interventions.
Louisiana
Louisiana has developed the Louisiana Integrated Treatment Services (LITS) Model for serving persons with co-occurring mental and substance abuse disorders. This model, developed through two SAMHSA Community Action Grants, was successfully piloted in one region of the state and has been adopted for statewide implementation. The COSIG grant will focus on implementation of the LITS Model in the State's remaining regions and on development of statewide infrastructure to support and sustain LITS. Major infrastructure developments will include (a) cross agency screening and assessments tools; (b) integrated management information and program evaluation systems; (c) funding structures that include new Medicaid funds for substance abuse services, maximizing current funding to support a broad range of services for people with co-occurring disorders; and (d) professional licensing standards that support integrated treatment. Regional implementation of LITS will include ongoing intensive education, cross training, and specialized consultation. Stakeholder involvement will be supported at both the State and local levels through direct partnership with consumer and community-based mental health substance abuse organizations. Organizational structure for the COSIG grant will include a State-level Coordinating Council with decision-making and oversight responsibilities; 10 regional steering committees; 20 regional LITS specialists; 10 regional LITS facilitators; and a full-time project director. Expert consultants will provide technical assistance throughout the project.
Maine
The State of Maine is poised to institute broad and far-reaching changes in its services to an estimated 10,000 people who experience psychiatric and alcohol or drug-related co-occurring disorders. These changes to create a welcoming system will be tested with diverse populations including Native Americans, migrant workers and immigrants from Asia and Africa and will be supported through infrastructure enhancements. As attested in the Governor's letter accompanying this proposal, the COSIG project supports a logical progression for Maine. With a Phase 1 SAMHSA Community Action Grant last year which garnered agreements from 58 agencies to implement co-occurring services, followed by Maine's selection to participate in SAMHSA's National Policy Academy on Co-occurring Disorders, Maine is ready to take the next steps represented in this proposal. Those steps are consistent with SAMHSA's capacity building goals as reported to Congress and its infrastructure enhancement goals needed to support the co-occurring system in the long run.
Specifically, the goals of COSIG Works for Maine are to work in nine diverse pilot sites and then replicate more broadly throughout the state activities to:
- Screen at least 3000 individuals per year for the presence of co-occurring disorders;
- Assess the level of severity of co-occurring disorders in at least 2000 people per year ;
- Treat both disorders in a comprehensive and coordinated manner in at least 1000 people per year;
- Train providers in 50 agencies per year to screen, assess and develop a treatment plan for people with co-occurring disorders; and
- Evaluate the impact of treatment services on individuals who have co-occurring disorders and their families.
The project will function at two levels: developing the state infrastructure to effectively monitor and serve people of all cultures who experience co-occurring disorders and implementing capacity-building goals in a variety of settings throughout the state. It includes a rigorous third party evaluation to determine whether the changes increase the percent of programs that screen, assess and treat people with co-occurring disorders and reduce the percentage of clients who experience impairment from the co-occurring disorders following treatment. The evaluation will help people to understand whether interventions are consistently effective in different treatment settings serving diverse ethnic and cultural populations.
Minnesota
Minnesota COSIG proposes to expand current standardized screening and assessment to quadrants 2 and 3 with infrastructure development activities in mental health centers and substance abuse agencies that are co-located and dually licensed as mental health centers and substance abuse agencies. These agencies will work in collaboration with primary care partners Neighborhood HealthCare Network and the American Indian Behavioral Health clinics to also improve service integration between primary care physicians, American Indian behavioral health services, and mental health and substance abuse agencies.
MN COSIG infrastructure development activities have been identified through consumer focus groups, provider workgroups and surveys, state policymakers and planners, and information gained from evidence-based research, Co-Occurring Center of Excellence publications, and consultation from national experts. Minnesota's COSIG proposal is a comprehensive plan to meet all five of the capacity building goals in SAMHSA's Co-Occurring Report to Congress (screen, assess, treat, train and evaluate). MN COSIG will build upon the extensive work currently underway by a mental health public-private partnership action group in Minnesota to conduct an analysis of the fiscal framework specifically targeted on services for quadrants 2 and 3 that will significantly increase the likelihood that services will be available for persons with co-occurring disorders.
As a result of MN COSIG, the State will have a formal state policy for Integrated Dual Disorder Treatment (IDDT) across a wide range of stakeholders who are invested in implementing and maintaining the IDDT infrastructure.
South Dakota New
South Dakota (S.D.) has committed to narrowing gaps in services for individuals with co-occurring disorders utilizing SAMHSA’s capacity-building goals. The State’s plan will concentrate on creating a sustained state-wide infrastructure that will implement quality training procedures on screening and assessment measures as well as address issues of staffing competency, licensure, and credentialing; service coordination and network building; financial planning; information sharing; and barrier reduction. South Dakota is dedicated to five core strategies: 1) establishment of a well-informed and coordinated state-level infrastructure, 2) development of a clear and concrete action plan with regional and local input, 3) development of a plan for the integrated screening process and identification of a screening instruments and assessment protocols, 4) development of a quality improvement process to monitor outcomes of the screening process, and 5) development and implementation of a system-wide training curriculum and plan for the 7 Community Mental Health Centers (CMHC’s), which are also Core Services Substance Abuse Agencies (CSA’s) with a roll-out to all CMHC’s and CSA’s to follow.
To develop this permanent infrastructure and complete the above named goals, the Governor’s Office has committed to facilitating the collaboration of the three service agencies under the Department of Human Services (DHS) and commissioned the Co-Occurring Disorders Steering Committee. This committee, along with a Co-Occurring Program Manager will spearhead the movement towards providing more efficient integrated services across the state. The Co-occurring Steering Committee will be composed of personnel from the State’s Division of Alcohol and Drug Abuse (DADA) and Division of Mental Health (DM11), Community Mental Health Centers (CMHC’s) Core Services Substance Abuse Agencies (CSA’s), other State divisions (e.g., Department of Corrections, Social Services), and stakeholders from the community (e.g., consumer advocacy groups, Native American organizations). Committees will be charged with oversight of the project in their areas and finding solutions to multilevel barriers to service integration.
With stakeholder input, independent evaluators will help develop the necessary training curriculum, collect data regarding training outcomes and clinical performance, then help to modify training and or implementation as needed. The project will be conducted at the seven CMITC’s/CSA’s and the HSC (State Hospital). Data collection and analysis will be built into all phases of the project. The project will enable success by providing opportunities to further identify barriers to integrated services, creative solutions, and a solid knowledge base for expanding into other regions or agencies in the State. As the system crystallizes across the State, South Dakota will be able to build on its success through future development of programs that provide comprehensive, integrated services to individuals with co-occurring disorders.
