Transforming County Drug & Alcohol Treatment Services into a System of Care

Transforming County Drug & Alcohol Treatment Services into a System of Care Cheryl Berman, PhD, LMFT Santa Clara Valley Health & Hospital System Behavioral Health Department of Alcohol & Drug Services ILC #42 March 25, 2015 1

DEPARTMENT OF ALCOHOL & DRUG SERVICES 2

DADS Adult System of Care (ASOC) FY2014 Serves 6,000 7,000 adults per year Two thirds (2/3) male Approximately 66% - 70% criminal justice Age 31-50 years 49% Caucasian 34% Hispanic / Latino 47% Primary Substance Meth 43% 3

Adult System of Care 4

Treatment Landscape No System County & Contract providers Operating independently No standardization Minimal oversight DADS Adult System of Care Minimal accountability Starting Point 1995 5

Access Decentralized Clients on their own to find tx Judges ordered to specific program Difficult clients need not apply Treatment DADS Adult System of Care Unique to each program Program-driven Not individualized One size fits all Starting Point 1995 6

Adult System of Care 7

Drug Medi-Cal Organized Delivery System Waiver / DADS System of Care Toll free Access Number Continuum of Care ASAM Criteria used for placement ASAM Assessment / Treatment Plan EBP Motivational Interviewing CBT Trauma Informed Relapse Prevention Psycho Education Groups 8

DADS Adult System of Care The System Access Gateway entry: 1-800 Number Satellite Sites entry: CJS-MH Drug Tx Court Dependency Drug Tx Court Detox Sites (after hours, post-detox) Re- Entry Resource Center 9

DADS Adult System of Care The System All clients accepted Screening out difficult clients Not appropriate for our program 10

DADS Adult System of Care Screening, Assessment & Referral Initially placed in level of care based on individual needs. Detox Res OP AMT Peri Transferred to most appropriate level of care, back and forth along the continuum as needs change. 11

DADS Adult System of Care Client Movement Up and Down the Continuum Direct Referrals: Provider to Provider As client s needs change Exceptions: Increased Level of Care (OP to Res) QI Consult and Authorization THU Referrals & Placement Authorized and managed by QI 12

DADS Adult System of Care Treatment Unique to each client Client-driven Individualized One size does not fit all 15

DADS Adult System of Care System Consent Standardized Forms LOC Screening Tool Continuum of Care (COC) Referral Summary Form Treatment Status Report (TSR) Treatment Plan Treatment Assessment 16

DADS Adult System of Care Utilization Efficient & Effective LOC determined by initial screening followed by TX Assmt (ASAM) Tx intensity matched to needs Problem severity (ASAM) Stages of change LOS based on clinical need 17

DADS Adult System of Care Ancillary Services Transitional Housing Psychiatric Evaluation & Medication Targeted Case Management 18

DADS Adult System of Care Important Milestones In-custody Screening Tx Status Reports (TSRs) Clients with meds in residential AMT clients in residential THUs for DWC men w/children Education of Judges 19

EVOLUTION 20

KEY ELEMENTS of TRANSFORMATION Innovative Partnership Hot Groups / NIATX QI Gateway Continuum of Care Performance Measures Learning Institute Clinical Standards 21

DADS Adult System of Care 1995-1996 Hot Groups (Steering Committees) County & Contract Staff (all levels) Planning, designing a System Single entry point Continuum of Care 22

DADS Adult System of Care 1995-1996 Initial Hot Group Issues For Gateway Screening Tool Referral process (client to assessment) For the System Assessment Tool Referral process (client movement along the continuum) 23

DADS Adult System of Care 1995-1996 QI Division was Created: Monitor effectiveness of initial screening and referral Authorize client movement to different modality at Intake) Monitor flow of clients through System Care coordination-helping clients stay in treatment 24

DADS Adult System of Care Provider Performance Measures Purpose of PMs: Moving the elephant Apply pressure for change Change thinking & behavior Develop Systems Thinking 25

DADS Adult System of Care Provider Performance Measures Focused on clinical Providers have always participated in developing PMs Once mastered, old PMs are replaced by new ones 26

CLINICAL STANDARDS 27

Clinical Timeline 1995 Planning for managed of system of care 1996 Managed System of Care 1996-97 Project Match Training 1997-98 DADS Psychiatrists 2000 ASAM/Individualized Treatment (Dr. Mee-Lee)* 2001 Best Practices 2003 Internal Certification (State Certification) 2004 Licensed Clinical Supervisors 2006 ORS/SRS (Scott Miller) 2006 IJS (Integrated Justice Services Assessment and treatment assessment) 2008 Trauma Informed Seeking Safety 2008 NIATX Change Leaders & Coach 2012 Trauma Informed Walk Thru s 2015 Future Directions DDCAT System wide assessment Integration DADS/MH Behavioral Health Develop Co-occurring Training Requirement for System of Care 28

PROJECT MATCH Matching Alcoholism Treatment to Client Heterogeneity 1986 1996 12 STEP FACILITATION THERAPY Based on principles of AA philosophy and encourages participation COGNITIVE-BEHAVIORAL THERAPY Based on social learning and designed to provide skills for avoiding relapse MOTIVATIONAL ENHANCEMENT THERAPY Based on motivational psychology and designed to help patients mobilize personal resources to effect change. 30

ASAM PPC-2R MULTI-DIMENSIONAL ASSESSMENT DIMENSION 1 Acute Intoxication and/or Withdrawal Potential DIMENSION 2 Biomedical Conditions and Complications DIMENSION 3 Emotional, Behavioral or Cognitive Conditions and Complications 32

ASAM PPC-2R MULTI-DIMENSIONAL ASSESSMENT DIMENSION 4 Readiness to Change Assessed for both Substance Abuse and Mental Health Problems DIMENSION 5 Relapse, Continued Use or Continued Problem Potential Assessed for both Substance Abuse and Mental Health Problems DIMENSION 6 Recovery/Living Environment Assessed for both Substance Abuse and Mental Health Problems 33

Santa Clara Valley Health & Hospital System DADS Adult Managed Care Services Clinical Guidelines Table Stage of Change Interventions Counselor s Tasks Precontemplation Contemplation Consciousness Raising, Social Liberation As above, plus Emotional Arousal, Self Evaluation Raise Doubt: increase client s perception of risks and problems with current behavior Tip the balance: Evoke reasons to change, risks of not changing; strengthen client s self-efficacy for change of current behavior 43

Clinical Guidelines Table Stage of Change Preparation Action Interventions Emotional Arousal, Self- Evaluation, Commitment Commitment, Reward, Countering, Environment Control, Helping Relationships Counselor s Tasks Help client determine best course of action to take in seeking change Help client to take steps toward change and identify triggers to use and strategies to prevent relapse 44

Clinical Guidelines Table Stage of Change Interventions Counselor s Tasks Maintenance Relapse Recycling Helping, relationships, Environmental reevaluation, Self- Liberation, Reinforcement Management Based on assessed Stage of Change to which client has regressed or recycled Help client identify, sample and practice drug-free solutions and sources of pleasure, affirm client self efficacy Help client renew processes of contemplation, preparation, and action, without becoming stuck or demoralized because of relapse 45

BEST PRACTICE STANDARDS 2001 Examples of issues addressed: Clinical documentation Response to client homicidality/suicidality Confidentiality Client rights Client-Counselor relationship Counselor as change facilitator Therapeutic alliance 47

BEST PRACTICE STANDARDS Includes sections on Clinical Decisions. All decisions, level of care placement, treatment planning, continued services, transfer, discharge plans are based on evaluation of client using the six ASAM dimensions and considers the client s stage of change. 48

Dual Diagnosis Capable Address symptoms and functional impairment Address issues related to psychotropic medication Train and supervise addiction counselors to deal with issues related to co-occurring illness Maintain more flexible position on client relapses in either MH or SA related areas 49

MONTHLY CLINICAL SUPERVISORS MEETINGS Sharing information, both clinical and administrative Interventions to use when working with dual diagnosis clients Interventions to use when working with unmotivated clients Challenging cases/case presentations Implementation of new clinical requirements Difficult staff Criminal justice issues 51

Internal Counselor Certification 1. ASAM 2. Stages of Change 3. Best Practices 4. Managed System of Care 5. Unicare 6. 42 CFR 7. Dual Relationships 52

DADS Adult System of Care Constants for almost two decades Innovative Partnership (IP) Meetings System Business Meetings Maintaining connection Hot Groups Finding solutions for Systemic problems Continuous process improvement Learning Institute/Partnership Evidence Based Practices System of Care 54

DADS Adult System of Care Transformation Requires Strong Leadership Motivated staff at all levels Implementation Team Training Time Communication Collaboration Patience & Perseverance 55

DADS Adult System of Care Transformation Requires Guiding Principles Learning Organization Participative Management Continuous Quality Improvement Plan, Do, Study, Act 56

REFERENCES American Society of Addiction Medicine (1996). Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM PPC-2). Chevy Chase, MD, The Society. Project MATCH Monograph Series (1995). National Institute on Alcohol and Alcoholism. Rockville, MD, NIH Publication. 57

CONTACT Cheryl Berman cheryl.berman@hhs.sccgov.org 58

For more information on the ILC Meeting Summaries http://uclaisap.org/integration/html/learning-collaborative/ Archived Recordings http://vimeo.com/channels/ilcintegration Mailing List http://lists.ucla.edu/cgi-bin/mailman/listinfo/ilc E-mail cteruya@ucla.edu with additional questions! 59