Integrated treatment produces better outcomes for individuals with co-occurring mental and substance use disorders. Without integrated treatment, one or both disorders may not be addressed properly. Mental health and substance abuse authorities across the country are taking steps to integrate systems and services and promote integrated treatment.
Systems and Service Integration are Closely Interrelated
Systems Integration involves the development of infrastructure within mental health and substance abuse systems to support integrated service delivery. It can occur in systems of any size, including an entire state, a region, county, agency or program.
Systems integration focuses on reorganizing the framework within which agencies and programs operate. It includes integrated system planning, implementation, and continuous quality improvement including developing mechanisms for addressing: financing, regulations and policies, program design and certification, inter-program collaboration and consultation, clinical “best practice” development, clinician licensure, competency and training, information systems, data collection, and outcome evaluation
Services Integration refers to the process of merging separate clinical services to meet the individual’s substance abuse, mental health, and other needs. Services integration has two levels: Integrated programs are changes within an entire agency that help practitioners provide integrated treatment; and Integrated treatment occurs at the individual-practitioner level and includes all services and activities.
Services integration means providing at a minimum: integrated screening for mental and substance use disorders; integrated assessment; integrated treatment planning; integrated or coordinated treatment; and continuing care. The overall vision of an integrated system is to effectively serve individuals with co-occurring disorders no matter where they enter the system.
Develop a Shared Vision for an Integrated System
The key to a successful integrated mental health and substance abuse system is developing a shared vision before integration begins. The mental health and substance abuse systems may co-exist well, but each has its own distinct culture and language. If these differences are not recognized when system integration begins, the process may be difficult. Bridging cultural gaps can be thorny for practitioners unfamiliar with the operations, approaches, knowledge base and treatment philosophies of other systems of care.
An Ideal Integrated System is Based on A Common Vision
Planners need to agree on system goals and objectives, and how to measure effectiveness. A shared vision guides the development of programs and policies, and the allocation of scarce resources.
The first step in promoting integration efforts is to articulate and disseminate the shared vision. A shared vision can be thought of as a set of principles that recognizes and validates the role of mental health systems, programs, and approaches along with addiction systems, programs, and approaches.
Stakeholders Need to Be Involved
Create the shared vision by allowing stakeholders to develop and share their goals for the integrated system. Significant stakeholder involvement and input from the grassroots are essential for the vision to be meaningful and effective.
Stakeholders who participate in the development of a shared vision work hard to address differences in philosophy, culture, and terminology between systems.
Stakeholders who are active in the process tend to appreciate the differences in agency culture. For example: How each partner operates; Different communication styles; Greater understanding of each other’s role; and Appreciation for each other’s’ approach to serving their individuals with co-occurring disorders.
Shared visions can also lay the basis for future key documents, like policy directives, state charters, and logic models. There is much value in revisiting the shared vision periodically to ensure it remains relevant, especially when changes occur.
Workforce Development Activities Promote a Shared Vision.
Cross-training or shared curricula can help practitioners from each system understand their different infrastructures, operating procedures, values, and cultures. Activities like these build personal relationships, increase teamwork across systems, and foster respectful working relationships.
Interagency training around common interests and needs can be particularly valuable. Training can promote dialogue to explore common ground, including values. Interactive training with breaks and meals can help build new relationships and refresh existing ones. In addition, training on the “ins and outs” of each other’s systems is essential.
Here are a few examples of how to create and promote a shared vision: Use a “wiki space” to create a consensus document, allowing stakeholders to provide input for the basis of the shared vision; Sponsor a meeting of supervisors systems that includes modules on co-occurring disorders to promote dialogue across systems; and Create a shared curriculum for practitioners within different systems.
Build Consensus Across Service Settings
Integration takes time and requires commitments. At a minimum, consensus is needed across three levels: administration; mid-level management; and field or direct service
It is a fluid, rather than a static process. The right attitude is the most essential ingredient for successful integration. Stakeholders should expect the process to be both challenging and frustrating, but also rewarding. Commitment to open communication is paramount. Dedication among administrators needs to come early, so they can serve as a model for the vision of working towards an integrated system.
In order to succeed, the benefits of integration must be clearly articulated for each stakeholder. Stakeholders must be allowed to define their needs and see some progress towards shared goals to stay engaged over time. Clearly defining goals and objectives avoids confusion. Build respect by treating stakeholders as equal partners working for the general good of the community.
Time strategic communications so that they occur when change is near to maximize momentum for change. Announcing integration efforts too early can increase frustrations if service systems are not yet ready to support change.
As with any major change, efforts to integrate systems and services may initially result in stakeholder resistance. Early resistance can be countered through consensus-building activities such as the following: Solicit input from those who will be affected by change; Create and share a common vision; Articulate the benefits for each stakeholder group; Distribute basic information including goals and progress achieved; Celebrate achievements.
Conducting activities specifically designed to build consensus can be effective. A variety of methods can be used. It may be helpful to develop a written communications plan to guide outreach to significant target audiences, such as: elected and government officials; other agencies; practitioners; individuals with co-occurring disorders and their families; and advocacy groups.
Build a shared vision of what systemic change would mean by sharing information through Web sites, listservs, and newsletters. Conducting a meeting of all stakeholders can “rally the troops” and provide information to a wide variety of stakeholders.
Develop Long-Term Plans for Sustainable Change
Agencies or systems working towards system change or integration should consider creating a long-term plan for their work. Creating a plan formalizes the shared vision of integration and encourages partners to address specific areas such as: areas of conflict between the systems or agencies, differences in how the agencies or systems function, and barriers to coordinated care.
Plans also create a roadmap for effecting change by aligning goals, strategies and action steps across agencies and systems. By completing a plan, systems and agencies commit and invest in system integration. Even as agency leaders and staff experience turnover, the roadmap remains to help new staff understand the vision and pick up on tasks. Building capacity and the infrastructure needed to integrate systems takes time and focus. A plan sets up a way to build towards a lasting change.
A successful, transformative long-term plan must show:
- Presence of leadership and authority from each system or agency
- Willingness to invest time and resources to transform systems
- Commitment to change
- Meaningful participation by individuals with co-occurring disorders and their families
- Commitment to cultural competence
- Steps that promote sustainability
- Mechanisms for demonstrating effectiveness such as benchmarks and outcomes
- Ability to hold the agency or system accountable for performance
States undertaking this work have learned that integration requires short- and long-term planning, with concrete goals and realistic timelines. States have learned that embedding changes into policies, administrative rules and procedures is an important vehicle for sustainability. Another valuable way to guide planning for integration efforts is to set up demonstration projects to model the systems change. Plans for sustainable change must also pay careful attention to resource requirements.
- Connecticut developed planning tools such as a logic model, a diagram of activities, a timeline of events, a map of co-occurring locations, and a system model.
- Michigan developed its long-term plan for systems integration using a cross-agency working committee. Michigan also developed clarifications for funding sources and availability to align funding goals.
- Pennsylvania’s planning document to integrate services for co-occurring systems of care includes their vision, guiding principles, and strategies.
Define Integrated Services and Treatment
Once systems agree on a shared vision, it is important to define how services and treatment will be provided in an integrated way. Many states have found the following tools and resources helpful in defining integrated services and treatment:
- Integrated Treatment for Co-Occurring Disorders is a part of SAMHSA’s Evidence-Based Practices KIT Series. Formerly called Integrated Dual Disorders Treatment, the model and corresponding benchmark measures are used in many states to guide mental health agencies in developing co-occurring capability. Dartmouth Psychiatric Research Center continues to test and enhance the model. Dartmouth has partnered with Hazelton to produce additional resources on this model. (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/codi-kit.aspx)
- Substance Abuse Treatment For Persons with Co-Occurring Disorders TIP 42 is a part of SAMHSA’s Treatment Improvement Protocol (TIP) series. The protocol is used in many states to guide substance abuse treatment agencies in developing co-occurring capability and training practitioners. (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/tip42-codi.aspx)
- Dual Diagnosis Capability in Addiction Treatment (DDCAT) and Mental Health Treatment (DDCMHT) are process measures to guide addiction treatment settings in developing co-occurring capability. Parallel measures are available for mental health treatment settings. Agencies use these measures and the corresponding guides to identify strengths and weaknesses, create action plans and implement changes. (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/ddcat-ddcmht-index.aspx)
- Comprehensive, Continuous, Integrated System of Care (CCISC) is a model that can be used by either mental health or substance abuse service organizations seeking to become co-occurring capable. The model is based on eight principles and includes 12 steps that promote systems, services and treatment integration. The guide for this model includes tools for assessing organizational and practitioner competencies. (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/ccisc-model.aspx)
Establish Benchmarks and Measure Progress
States have used these resources and tools to develop specific guidance and criteria for agencies and practitioners. Many states have adopted or adapted a combination of measures to set benchmarks and assess progress over time. States have used measures to:
- Determine which aspects of integrated treatment are already in place
- Define priorities for change
- Determine training needs
- Inform service planning by comparing progress between agencies
- Target resources
Agencies use measures to:
- Guide quality improvement
- Establish concrete action steps
- Provide feedback to practitioners
- Gauge progress over time
Defining integrated services and setting benchmarks helps states and agencies maintain a focus on the goals of integration. Demonstrating results using standardized measures also helps when building wide-spread consensus for integration and seeking new funding streams.
Develop Infrastructure for Systems Integration
Creating an integrated system of care for individuals with co-occurring mental health and substance abuse disorders requires states to examine policies, financing, program standards, licensing, performance measurement, and management information systems. Changes across these multiple levels provide a foundation to support practitioners in providing integrated services and treatment.
- Reviewing state statutes, policies, regulations and administrative rules (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/develop-infrastructure.aspx#statutes)
- Making changes in financing or budget appropriations (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/develop-infrastructure.aspx#budget)
- Developing interagency agreements and joint guidelines, policies and procedures (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/develop-infrastructure.aspx#agreements)
- Refining management information systems (http://www.samhsa.gov/co-occurring/topics/healthcare-integration/develop-infrastructure.aspx#information)
Reviewing of State Statutes, Policies, Regulations, and Administrative Rules
Policy documents formalize a shared vision of integrated services and link this vision to particular standards and requirements. Examples include:
- The Connecticut Department of Mental Health and Addiction Services created a Commissioner’s Policy Statement and Implementing Procedures which lays out definitions and guiding principles for the provision of services to individuals with co-occurring disorders. They also implemented a statewide requirement that all state-operated and department-funded mental health and addiction treatment programs administer standardized admission screenings. (http://www.ct.gov/dmhas/lib/dmhas/policies/chapter6.4.pdf)
- The Commissioner of the Maine Department of Health and Human Services established an integrated care policy requiring all agencies to be co-occurring capable. Language was also added to the MaineCare (Medicaid) regulations so that the definition of every relevant service, such as comprehensive assessments or intensive outpatient services, includes explicit mention of co-occurring disorders. (http://www.maine.gov/dhhs/cosii/provider/documents.shtml)
- Missouri has added co-occurring skills to its core certification requirements for agencies.
Making Changes in Financing or Budget Appropriations
Systems may develop flexible funding streams by combining funding from multiple sources, such as federal block grant funds or state funding. SAMHSA has released a position statement with guidance on blending Substance Abuse Prevention and Treatment and Community Mental Health Services Block Grant funds to support services for individuals with co-occurring disorders. Other strategies include:
- Modifying Medicaid regulations regarding service definitions and billing codes so that co-occurring services are reimbursable
- Negotiating for Medicaid-managed care contracts to cover integrated care
- Creating performance-based contracts that align financial incentives/disincentives with system goals
Through contracts, systems can require specific service models and payments can be linked to performance. For example:
- In Illinois, separate state mental health and substance abuse treatment authorities provide cross-over funds to agencies in the other system so that they can extend their services to include care for people with co-occurring disorders.
- Alaska incorporated language into requests for proposals and contracts that required agencies to develop action plans for integrating services.
- In South Carolina, service organizations can be reimbursed by Medicaid for screening for co-occurring disorders.
Developing Interagency Agreements and Joint Guidelines, Policies and Procedures
Interagency agreements or guidelines can spell out how agencies will work together. Areas of collaboration might include use of common
- Screening instruments
- Intake tools
- Data collection instruments
- Performance indicators
Agreements may also define the referral process and guidelines for sharing client information. Joint guidelines can ensure that agencies are using common practices to provide care. For example:
- In South Carolina, to comply with HIPAA requirements, the Departments of Mental Health and Alcohol and Other Drug Abuse Services have signed a Memorandum of Understanding to protect the confidentiality of protected health information. The agreement also defines guidelines for collecting and sharing de-identified data among the Departments to improve treatment.(http://www.samhsa.gov/co-occurring/topics/healthcare-integration/develop-infrastructure.aspx#south-carolina-memo)
- Maine has developed a resource manual outlining clinical guidelines for integrated care. It guides policy, programs, and staffing relating to provision of services. The guidelines address eleven different areas, including screening and assessment, client records, and integrated programming. (http://www.ccsme.org/userfiles/files/ME%20Clinical%20Guidelines%202010.pdf)
- The Arizona Department of Health Services has developed a Practice Protocol that outlines best practice guidelines for assessment, treatment, and psychopharmacology of individuals with co-occurring disorders.(http://www.azdhs.gov/bhs/guidance/pph.pdf)
Refining Management Information Systems
One key to sustaining integration efforts is refining or integrating management information systems across mental health and substance abuse agencies. Integrated management information systems help states to collect data on the following:
- Prevalence of co-occurring disorders within the state
- Needs of individuals with co-occurring disorders
- Services provided to individuals with co-occurring disorders across systems
- Cost of treatment
Refinements to management information systems include coding data to allow cross-system comparisons, developing capacity to share information across systems and establishing data elements that specifically identify co-occurring disorder services.