Health Care Delivery System: A Case Study
My current practicum at the Johnson Unit of Sacred Heart Medical Center while enrolled in the Portland State University Masters in Social Work Program has been, thus far, a rewarding and enriching experience. The focus of this paper will be my observations of the Unit and will overlay the information from readings and presentations from classes. I will develop concepts that I think could be useful if integrated into the behavioral health service delivery system of SHMC and the Johnson Unit. Substance abuse is the most common and clinically significant comorbid disorder among adults with severe mental illness, (Drake, et al). Since the problem of dual diagnosis became clinically apparent in the early 1980’s, researchers have established
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three basic and consistent findings. First, co-occurrence is common; about 50 percent of individuals with severe persistent mental disorders are affected by substance abuse. Second, dual diagnosis is associated with a variety of negative consequences. Third, the parallel but separate mental health and substance abuse treatment systems that operate in our community deliver fragmented and ineffective care. Most patients that are common to the Unit, experience difficulty navigating the separate systems or make sense of disparate messages about treatment and recovery. The co-occurrence of a severe mental illness and a substance abuse or dependence disorder is common enough to be considered the expectation more than the exception.
Dual Diagnosis Services Treatments and interventions are offered within programs that are part of service systems.
Dual diagnoses treatments combine or integrate mental health and substance abuse interventions at the level of the acute care interaction. The health care delivery system has moved rapidly toward endorsing integrated treatment approaches for patients with dual diagnosis, (Center for Mental Health Services, 1994; Osher and Drake; 1996). An integrated treatment program utilizes the professional strengths of the team approach, which SHMC embraces. As treatment for severe mental disorders are typically provided by multi-disciplinary treatment teams that include a range of different professionals; psychiatrist, registered nurse, master level clinicians and case-managers, treatment for dual diagnosed patients should also be provided this model. Because the educational and prescriptive message is integrated, there is no need for the patient to reconcile two messages, thus the approach is …show more content…
seamless. Integrated dual disorder treatment (IDDT) is an evidence-based practice that has been found to be effective in the recovery process for clients with DD. In IDDT, the same clinicians or teams of clinicians, working in one setting, provide mental health and substance abuse interventions in a coordinated fashion. As an evidence-based psychiatric rehabilitation practice, IDDT aims to help the patient learn to manage both illnesses so that he/she can pursue meaningful life goals. The critical ingredients of IDDT include assertive outreach, motivational interventions, and a comprehensive, long-term, staged and individualized approach to recovery, ( SAMSHA, Co-Occurring Disorders:
Integrated Dual Disorders Treatment, 2003).
In addition to the integration of services, it is also important to integrate assessment, treatment planning and crises planning. One of the things I have noticed while performing social work assessments at the Behavioral Health Unit at Sacred Heart Medical Center, is the limited scope substance abuse and dependence issues, when identified and occasionally considered as a primary Axis I diagnosis , are then not treated as a primary problem.
Symptom management and treatment for mental health disorders in acute care is essential. The concept of assessing substance abuse and dependence more thoroughly is also essential for responsible treatment protocol for Axis I diagnoses.
Screening and Assessment
Screening. Patients with severe mental illnesses should receive routine screening for any regular use of non-prescribed psychoactive drugs for three reasons. First, attempts at controlled use of psychoactive substances by individuals with severe mental illness are likely to lead to a substance abuse disorder over time. Second, use of even small amounts of alcohol or other drugs is likely to be associated with negative outcomes among these individuals. Finally, persons with severe mental illness are likely to be unaware of or confused about the consequences of their substance use, and any report of regular use is likely to be associated with substance use disorder. Several procedures could improve the detection of substance abuse disorders and the potentially harmful effects among psychiatric patients. Mental health professionals should be educated about alcohol and drug use and subsequently should maintain a high index of suspicion for A&D use disorders. Furthermore, clinicians should pay attention to reports of patients past substance abuse-related problems, because patients are more likely to report past use than current use.
A variety of self-report screens for substance abuse disorders can be completed as part of an initial intake interview for a patient with a severe mental illness. Among them are brief instruments such as the Drug Abuse Screening Test, the Michigan Alcoholism Screening Test (MAST), the CAGE questionnaire and the Dartmouth Assessment of Life Style Instrument. However, a clear consensus supports combining the use of self-reports with collateral reports and laboratory tests.
Assessment
Assessment of dually diagnosed patients consists of three steps: detection, diagnosis and specialized assessment for treatment planning. Literature in both the addiction field and the mental health field has emphasized the concept of stages of change or stages of treatment, and demonstrated the value of stage-wise treatment (Drake et al, 2001).
One of the more commonly used standardized assessment instruments in the substance use disorder field is the Addiction Severity Index (ASI). Leonhard and colleagues, ( PubMed; 2000 Mar;18(2):129-35), examined the validity of the ASI in a sample of 100 patients consecutively admitted to a public mental hospital, two-thirds of whom had a diagnosis of a psychotic disorder. In that study, the ASI was compared with the CAGE questionnaire, a drug abuse version of the CAGE, the Chemical Abuse and Dependence Scale, the short form of the MAST, and the Drug Abuse Screening Test. The researchers found strong correlations between the ASI and the other scales and concluded that even with a minimum cut-off score, the ASI alcoholism scale is diagnostically as accurate as the CAGE or the short MAST for outpatients with psychiatric illnesses.
Carney and associates, (PubMed; 1998 Jul;59(4):447-54), reported preliminary data on the use of the Time Line Follow Back, which uses a calendar and various aids to memory to help patients recall their use of alcohol and other substances over time intervals of varying lengths.
Carney and associates compared results of the Time Line Follow Back over a 30-day interval with results of the ASI 's 30-day assessment of alcohol use in a sample of 79 outpatients with severe mental illness. They found an excellent level of agreement between the two assessment instruments (kappa coefficient of .79), and a correlation of .75 between the two approaches on the number of days respondents reported that they had been drinking. The Time Line Follow Back procedure may actually yield higher estimates of drinking behaviors than the ASI for a 30-day interval. Given that even moderate amounts of alcohol or other substance use may lead to adverse consequences for persons with severe mental illness, the Time Line Follow Back appears to offer a highly promising assessment approach that should be further examined in future
research.
Staged interventions Effective programs incorporate, implicitly or explicitly, the concept of stages of treatment. In the simplest conceptualization, stages of treatment include forming a trusting relationship (engagement), helping the engaged patient develop the motivation to become involved in recovery-oriented interventions (persuasion), helping the motivated patient acquire skills and supports for controlling illnesses and pursuing goals (active treatment), and helping the patient in stable remission develop and use strategies for maintaining recovery (relapse prevention).
Both mental illness and addiction can be treated within the philosophical framework of a "disease and recovery model" (Minkoff, 1989) with parallel phases of recovery (acute stabilization, motivational enhancement, active treatment, relapse prevention, and rehabilitation/recovery), in which interventions are not only diagnosis-specific, but also specific to phase of recovery and stage of change. The principles and strategies of integrated dual disorder treatment include integration of treatments for the mental illness and the addiction, use of strategies to engage people in treatment, use of pharmacological and psychosocial interventions that are matched to the patient 's stage of change, and use of a long-term perspective. Should the behavioral health professionals embrace the treatment of co-morbid disorders within the context of the Unit, this will set a strong example for all providers of treatment within our community. It is easier for mental health agencies and clinicians to blend the treatment of co-existing disorders than what has been shown by time and experience by the substance abuse treatment providers throughout not just our community, but throughout the country, (Drake, 2001).
Plan
To begin a comprehensive diagnosis, assessment and preliminary treatment of dual diagnosis patients in context of the Unit, could precipitate more timely discharges. Utilizing the services of the Transition Team for continuing stabilization in the context of community resources could produce favorable outcomes. Having the Transition Team becoming more critically aware of substance abuse and dependence assessment and treatment issues and developing close relationships with the in-patient and out-patient providers that have dual diagnosis treatment components would provide a more comprehensive treatment protocol for individuals with severe persistent mental illness and substance abuse diagnoses. Another step towards eliminating possible revolving door admits to the Unit could be designated specific slot purchases with treatment providers that can prove good treatment outcomes for co-morbid patients.
Summary
To date, hospitals and health systems have tended to take the lead in forming comprehensive health services and combining mental health and substance abuse treatment. It is good practice for clinicians to investigate reasons for the use of non-prescribed substances by those with severe and enduring mental illness; to explore beliefs regarding the effects of substances; to examine attitudes towards intervention; and to determine the progression of drug careers is an essential part of an early dual diagnosis intervention. The consequences of dual diagnosis include poor medication compliance, physical co-morbidities, poor health, poor self-care, increased risk of suicide or risky behavior, and even possible incarceration. All of these factors contribute to increased burden and reduced capacity of the health care system to adequately treat patients. Screening, assessment, and integrated treatment plans for dual diagnosis to address both the substance use disorder and the mental illness are strongly recommended. Clinicians, services, patients and treatment regimens should work in tandem to meet the particular clinical needs of patients with co-morbid disorders. Patients need to be supported and not blamed or punished with administrative discharges for poor treatment compliance. Innovative approaches to improve treatment compliance for patients with co-morbid mental illness and SUD can be cost-effective and make a significant public health contribution.
Bibliography
Drake RE, Goldman HH, Leff HS, et al. "Implementing Evidence-Based Practices in Routine Mental Health Service Settings" Psychiatric Services 52 (2001): 179-182.
Drake RE, Wallach MA: Is moderate drinking realistic for persons with severe mental disorder? Hospital and Community Psychiatry 44:780-782, 1993
Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K, et al. "Implementing Dual Diagnosis Services for Clients with Severe Mental Illness" Psychiatric Services, 52:469-76, 2001
Minkoff K. "Development of an Integrated Model for the Treatment of Patients with Dual Diagnosis of Psychosis and Addiction." Hospital and Community Psychiatry, 40 (10), 1031-1036, October 1989
SAMSHA, Co-Occurring Disorders: Integrated Dual Disorders Treatment, 2003
PubMed1998Jul;59(4):44754http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=10716096
three basic and consistent findings. First, co-occurrence is common; about 50 percent of individuals with severe persistent mental disorders are affected by substance abuse. Second, dual diagnosis is associated with a variety of negative consequences. Third, the parallel but separate mental health and substance abuse treatment systems that operate in our community deliver fragmented and ineffective care. Most patients that are common to the Unit, experience difficulty navigating the separate systems or make sense of disparate messages about treatment and recovery. The co-occurrence of a severe mental illness and a substance abuse or dependence disorder is common enough to be considered the expectation more than the exception.
Dual Diagnosis Services Treatments and interventions are offered within programs that are part of service systems.
Dual diagnoses treatments combine or integrate mental health and substance abuse interventions at the level of the acute care interaction. The health care delivery system has moved rapidly toward endorsing integrated treatment approaches for patients with dual diagnosis, (Center for Mental Health Services, 1994; Osher and Drake; 1996). An integrated treatment program utilizes the professional strengths of the team approach, which SHMC embraces. As treatment for severe mental disorders are typically provided by multi-disciplinary treatment teams that include a range of different professionals; psychiatrist, registered nurse, master level clinicians and case-managers, treatment for dual diagnosed patients should also be provided this model. Because the educational and prescriptive message is integrated, there is no need for the patient to reconcile two messages, thus the approach is …show more content…
seamless. Integrated dual disorder treatment (IDDT) is an evidence-based practice that has been found to be effective in the recovery process for clients with DD. In IDDT, the same clinicians or teams of clinicians, working in one setting, provide mental health and substance abuse interventions in a coordinated fashion. As an evidence-based psychiatric rehabilitation practice, IDDT aims to help the patient learn to manage both illnesses so that he/she can pursue meaningful life goals. The critical ingredients of IDDT include assertive outreach, motivational interventions, and a comprehensive, long-term, staged and individualized approach to recovery, ( SAMSHA, Co-Occurring Disorders:
Integrated Dual Disorders Treatment, 2003).
In addition to the integration of services, it is also important to integrate assessment, treatment planning and crises planning. One of the things I have noticed while performing social work assessments at the Behavioral Health Unit at Sacred Heart Medical Center, is the limited scope substance abuse and dependence issues, when identified and occasionally considered as a primary Axis I diagnosis , are then not treated as a primary problem.
Symptom management and treatment for mental health disorders in acute care is essential. The concept of assessing substance abuse and dependence more thoroughly is also essential for responsible treatment protocol for Axis I diagnoses.
Screening and Assessment
Screening. Patients with severe mental illnesses should receive routine screening for any regular use of non-prescribed psychoactive drugs for three reasons. First, attempts at controlled use of psychoactive substances by individuals with severe mental illness are likely to lead to a substance abuse disorder over time. Second, use of even small amounts of alcohol or other drugs is likely to be associated with negative outcomes among these individuals. Finally, persons with severe mental illness are likely to be unaware of or confused about the consequences of their substance use, and any report of regular use is likely to be associated with substance use disorder. Several procedures could improve the detection of substance abuse disorders and the potentially harmful effects among psychiatric patients. Mental health professionals should be educated about alcohol and drug use and subsequently should maintain a high index of suspicion for A&D use disorders. Furthermore, clinicians should pay attention to reports of patients past substance abuse-related problems, because patients are more likely to report past use than current use.
A variety of self-report screens for substance abuse disorders can be completed as part of an initial intake interview for a patient with a severe mental illness. Among them are brief instruments such as the Drug Abuse Screening Test, the Michigan Alcoholism Screening Test (MAST), the CAGE questionnaire and the Dartmouth Assessment of Life Style Instrument. However, a clear consensus supports combining the use of self-reports with collateral reports and laboratory tests.
Assessment
Assessment of dually diagnosed patients consists of three steps: detection, diagnosis and specialized assessment for treatment planning. Literature in both the addiction field and the mental health field has emphasized the concept of stages of change or stages of treatment, and demonstrated the value of stage-wise treatment (Drake et al, 2001).
One of the more commonly used standardized assessment instruments in the substance use disorder field is the Addiction Severity Index (ASI). Leonhard and colleagues, ( PubMed; 2000 Mar;18(2):129-35), examined the validity of the ASI in a sample of 100 patients consecutively admitted to a public mental hospital, two-thirds of whom had a diagnosis of a psychotic disorder. In that study, the ASI was compared with the CAGE questionnaire, a drug abuse version of the CAGE, the Chemical Abuse and Dependence Scale, the short form of the MAST, and the Drug Abuse Screening Test. The researchers found strong correlations between the ASI and the other scales and concluded that even with a minimum cut-off score, the ASI alcoholism scale is diagnostically as accurate as the CAGE or the short MAST for outpatients with psychiatric illnesses.
Carney and associates, (PubMed; 1998 Jul;59(4):447-54), reported preliminary data on the use of the Time Line Follow Back, which uses a calendar and various aids to memory to help patients recall their use of alcohol and other substances over time intervals of varying lengths.
Carney and associates compared results of the Time Line Follow Back over a 30-day interval with results of the ASI 's 30-day assessment of alcohol use in a sample of 79 outpatients with severe mental illness. They found an excellent level of agreement between the two assessment instruments (kappa coefficient of .79), and a correlation of .75 between the two approaches on the number of days respondents reported that they had been drinking. The Time Line Follow Back procedure may actually yield higher estimates of drinking behaviors than the ASI for a 30-day interval. Given that even moderate amounts of alcohol or other substance use may lead to adverse consequences for persons with severe mental illness, the Time Line Follow Back appears to offer a highly promising assessment approach that should be further examined in future
research.
Staged interventions Effective programs incorporate, implicitly or explicitly, the concept of stages of treatment. In the simplest conceptualization, stages of treatment include forming a trusting relationship (engagement), helping the engaged patient develop the motivation to become involved in recovery-oriented interventions (persuasion), helping the motivated patient acquire skills and supports for controlling illnesses and pursuing goals (active treatment), and helping the patient in stable remission develop and use strategies for maintaining recovery (relapse prevention).
Both mental illness and addiction can be treated within the philosophical framework of a "disease and recovery model" (Minkoff, 1989) with parallel phases of recovery (acute stabilization, motivational enhancement, active treatment, relapse prevention, and rehabilitation/recovery), in which interventions are not only diagnosis-specific, but also specific to phase of recovery and stage of change. The principles and strategies of integrated dual disorder treatment include integration of treatments for the mental illness and the addiction, use of strategies to engage people in treatment, use of pharmacological and psychosocial interventions that are matched to the patient 's stage of change, and use of a long-term perspective. Should the behavioral health professionals embrace the treatment of co-morbid disorders within the context of the Unit, this will set a strong example for all providers of treatment within our community. It is easier for mental health agencies and clinicians to blend the treatment of co-existing disorders than what has been shown by time and experience by the substance abuse treatment providers throughout not just our community, but throughout the country, (Drake, 2001).
Plan
To begin a comprehensive diagnosis, assessment and preliminary treatment of dual diagnosis patients in context of the Unit, could precipitate more timely discharges. Utilizing the services of the Transition Team for continuing stabilization in the context of community resources could produce favorable outcomes. Having the Transition Team becoming more critically aware of substance abuse and dependence assessment and treatment issues and developing close relationships with the in-patient and out-patient providers that have dual diagnosis treatment components would provide a more comprehensive treatment protocol for individuals with severe persistent mental illness and substance abuse diagnoses. Another step towards eliminating possible revolving door admits to the Unit could be designated specific slot purchases with treatment providers that can prove good treatment outcomes for co-morbid patients.
Summary
To date, hospitals and health systems have tended to take the lead in forming comprehensive health services and combining mental health and substance abuse treatment. It is good practice for clinicians to investigate reasons for the use of non-prescribed substances by those with severe and enduring mental illness; to explore beliefs regarding the effects of substances; to examine attitudes towards intervention; and to determine the progression of drug careers is an essential part of an early dual diagnosis intervention. The consequences of dual diagnosis include poor medication compliance, physical co-morbidities, poor health, poor self-care, increased risk of suicide or risky behavior, and even possible incarceration. All of these factors contribute to increased burden and reduced capacity of the health care system to adequately treat patients. Screening, assessment, and integrated treatment plans for dual diagnosis to address both the substance use disorder and the mental illness are strongly recommended. Clinicians, services, patients and treatment regimens should work in tandem to meet the particular clinical needs of patients with co-morbid disorders. Patients need to be supported and not blamed or punished with administrative discharges for poor treatment compliance. Innovative approaches to improve treatment compliance for patients with co-morbid mental illness and SUD can be cost-effective and make a significant public health contribution.
Bibliography
Drake RE, Goldman HH, Leff HS, et al. "Implementing Evidence-Based Practices in Routine Mental Health Service Settings" Psychiatric Services 52 (2001): 179-182.
Drake RE, Wallach MA: Is moderate drinking realistic for persons with severe mental disorder? Hospital and Community Psychiatry 44:780-782, 1993
Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K, et al. "Implementing Dual Diagnosis Services for Clients with Severe Mental Illness" Psychiatric Services, 52:469-76, 2001
Minkoff K. "Development of an Integrated Model for the Treatment of Patients with Dual Diagnosis of Psychosis and Addiction." Hospital and Community Psychiatry, 40 (10), 1031-1036, October 1989
SAMSHA, Co-Occurring Disorders: Integrated Dual Disorders Treatment, 2003
PubMed1998Jul;59(4):44754http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=10716096