The integration of care for individuals with co-occurring mental health and substance use disorders continues to elude our healthcare and social service systems despite a nearly universal acknowledgment of its importance, both to the individuals afflicted with these conditions and the viability of the organizations on which they depend. A Surgeon General’s report of 20 years ago concluded approximately half of all individuals with a lifetime substance use disorder also have a lifetime history of at least one mental health condition. This report concluded the same of the converse. About half of all individuals with one or more lifetime mental health conditions also have a lifetime history of at least one substance use disorder (U.S. Department of Health and Human Services, 1999). This is hardly newsworthy to anyone with even the most cursory understanding of current behavioral health trends. The seeming ubiquity of mental health crises, including unprecedented rates of attempted and completed suicides, coupled with an enduring opiate abuse epidemic suggest the persistence and coincidence of mental health and substance use disorders pose increasingly grave threats to public health and welfare. These threats are compounded by the economic consequences of such widespread comorbidity. Individuals dually diagnosed with mental health and substance use conditions incur significantly higher healthcare costs than most and experience mediocre outcomes, at best (Curran et al., 2008). Nevertheless, many factors continue to militate against genuine service integration and to relegate those with co-occurring disorders to the role of “misfit” during their darkest hours. The existence of separate and distinct funding and regulatory structures (e.g., Office of Mental Health, Office of Alcoholism and Substance Abuse Services, etc.) and disparate treatment approaches and philosophical orientations within and among behavioral health service provider agencies are merely a few of many obstacles to integration. There have been some promising developments, however, not least of which is the formation of Co-Occurring System of Care Committees (COSOCCs) throughout the Lower Hudson Valley Region. These entities, comprised of numerous and diverse stakeholders, are applying innovative approaches to span the schism that has separated mental health and substance use services for much too long.
In late 2017, the Mid-Hudson Regional Planning Consortium (RPC), an entity charged with the planning and coordination of various transformative initiatives presently underway within our state’s behavioral healthcare system, convened key stakeholders throughout a seven-county region in order to explore enduring impediments to effective service integration and potential solutions. This forum featured a presentation and facilitated dialogue by Dr. Kenneth Minkoff, a preeminent authority on co-occurring disorders and service integration. He and his colleagues espouse a Comprehensive, Continuous, Integrated System of Care (CCISC) model that offers a framework through which various dimensions of the integration process may be addressed (Minkoff & Cline, 2004). This model contains several unique elements, one of which promotes the efficient use of existing resources (and within known resource constraints) in implementing desired changes. For instance, behavioral healthcare providers often lament longstanding obstacles to progress associated with the multiple and competing fiscal, regulatory, programmatic, and logistical dimensions of the integration process. The CCISC model presses providers and other stakeholders to implement necessary changes within the context of current resources and regulatory structures. It does not ignore the import of these structures or the imperative to modify and to align them with integrative activities; it simply suggests providers cannot wait for this to occur before they enact meaningful changes. Other facets of the CCISC model, including its emphasis on the utilization of best practices and attention to facilitating change within various domains of the healthcare sector (e.g., system level, program level, clinical level, etc.), are no less important to its success. Moreover, this model sits atop several organizing principles that distinguish it from others that have promoted integrated care for individuals with co-occurring disorders. A cardinal principle, that of recipient engagement, is of paramount importance to the model’s success. To this end, it advances a corollary principle – the expectation that dual diagnosis is an expectation, not an exception – that informs other aspects of the model and its implementation. The CCISC model is perhaps most unique in this respect. Unlike other approaches to service integration, it does not delineate mental health and substance use disorders according to prevailing (and often outdated if not outright atavistic) criteria that classify some as “primary” and others as “secondary.” The prevailing practice, predicated on a belief one diagnosis and its associated cluster and constellation of symptoms is of greater “primacy” than another, inevitably perpetuates the longstanding divide the CCISC model aims to overcome. This does not suggest certain mental health conditions cannot produce greater functional impairments than certain substance use disorders or vice versa. Minkoff and his colleagues suggest the “Four Quadrant” model, one that situates dually diagnosed individuals in one of four quadrants in accordance with the relative severity of their mental health and substance use disorders, may prove helpful in identifying stage-matched service interventions (Minkoff & Cline, 2004). Nevertheless, such arbitrary distinctions as “primary” and “secondary” fail to recognize the inextricable link between conditions and may lead clinicians to focus interventions and resources on the management of one diagnosis to the detriment and neglect of others. The CCISC model also encourages individuals and entities charged with the treatment of individuals dually diagnosed with mental health and substance use disorders to administer assessments of their adherence to the model’s core principles and objectives. This is accomplished through the administration of a specialized assessment tool (i.e., COMPASS-EZ) at multiple levels within organizational hierarchies. For instance, it is not uncommon for C-suite executives to promulgate progressive policies that fail to gain acceptance by those responsible for their implementation. That is, the glossy brochures and marketing materials that litter providers’ waiting rooms and front offices often obscure the realities of what is truly available to recipients after they gain admission to their programs. Application of the COMPASS-EZ at every level within an organization and repeated at periodic intervals in an iterative manner consistent with principles of Continuous Quality Improvement (CQI) ensures uniform adherence to guiding principles and a consistent approach to an exceptionally vulnerable population.
Innumerable obstacles to the integration of care for individuals with co-occurring conditions will surely remain for some time to come. The application of the CCISC approach through a diverse set of stakeholders operating under the auspices of COSOCCs holds considerable promise for genuine progress. It is also fully aligned with many other initiatives presently underway at the payer, regulatory, system, and provider levels that share its key objectives.
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