Research and practice in the fields of mental health and alcohol and drug treatment services increasingly acknowledge the prevalence of significant levels of
co-occurring mental health and substance use disorders among consumers served in publicly-funded systems. It is
essential for state and local govern-
ment authorities to develop a solid
understanding of the key trends and
issues in this area. Understanding these areas is the first step in making the case for integration of systems and services that is necessary to effectively address the needs of individuals with complex, multiple problems. Although every
local system is unique, some of the most troublesome emerging trends across the United States include:
The repeated use of inpatient psychia-tric settings to treat individuals with substance induced mood disorders.
Despite being given a diagnosis of
depression to justify hospital charges, these individuals manifest symptoms that would be better addressed in an
adequately configured chemical
dependency treatment setting. This practice is clinically inappropriate and has
significant adverse consequences.
Despite the best intentions of treatment
professionals, administrators and policy-
makers, clients with this type of
co-occurring disorder generally do not get better as a result of interventions to treat the depression without addressing the substance abuse or chemical dependence. Upon discharge from the
hospital, linkages to outpatient mental health services fail without effective drug or alcohol interventions. A return to a
substance abuse pattern occurs, leading
ultimately to depression, suicidal
ideation and re-hospitalization. This practice is wasteful of limited public funds expended on the most expensive services without positive treatment
outcomes.
An inability to sustain individuals with co-occurring mental health and
substance use disorders in traditionally configured mental health or chemical dependency treatment settings.
Although many individuals with
co-occurring disorders may be admitted to mental health or substance abuse
services in the public sector before they have been treated in an inpatient setting, without integrated care that addresses the full range of illness and treatment needs, the service system may be unsuccessful in establishing effective relationships with these challenging clients. The result is too often a high level of premature discharge from care. These
individuals, as they fall out of service, are at great risk of becoming homeless when they lose housing and related
supports. They may regularly seek out costly emergency services (sometimes with great frequency) during times of crisis, as well as become frequent
customers of other publicly funded systems, including jails (see below), hospital emergency rooms and shelters.
The frequent incarceration of persons with co-occurring disorders for
relatively minor misdemeanor offenses that reflect psychopathology or
substance abuse patterns more often than true sociopathy.
The phenomenon of “trans-institutionalization” is increasingly shifting the custodial costs of caring for this population from the human service systems to the criminal justice system. As local jailors throughout the nation have
confirmed, the jails in which these
individuals are housed are neither
configured nor philosophically prepared to offer much in the way of meaningful treatment to promote recovery. Individuals with co-occurring disorders can
become frequent visitors to local
correctional settings and may utilize a disproportionately high percentage of misdemeanor and low-level felony jail bed nights. These jail services are costly, especially when overtime expenses are incurred for increased supervision and observation of individuals at risk for
suicide or other destructive behaviors.
By exploring these and related causes for the failure of existing treatment
systems to effectively meet the needs of persons with co-occurring mental health and substance use disorders, local mental health and chemical dependency treatment authorities can work together to identify the precise nature of the
local populations that could benefit most from a more integrated approach to the provision of treatment and supports. Trying to ascribe blame for the problems identified is less useful than
looking at the system through the eyes of consumers and developing services that make sense from their perspective as our customers.
Find “Hard” Data to Make the Case
Finding the facts required to make the case for integrated care at the local level can present a number of specific
challenges. Most systems have great difficulty sharing information with their sister systems. The obstacles are often the product of both technological and regulatory barriers. Nevertheless,
there are some important sources of
information that can help to identify where local system gaps may lie. Local data sources can be used to isolate
populations with co-occurring disorders that are being either excluded or
inappropriately served by existing
mental health and substance abuse
services providers. Although individual client files in treatment settings
are confidential, aggregate data sets
can be made available and are extremely
useful. Information that can be
collected and evaluated includes:
- Diagnostic information from
inpatient psychiatric settings,
- Admission information from detoxification and residential alcohol/drug treatment facilities,
- Screening and risk assessment information from local jails, and
- Clinical encounter information collected by local affiliated systems, including Health Care for the Homeless programs, public health and community clinics, shelters, street ministries, crisis telephone lines, etc.
Creating valid data sets that demonstrate the propensity of treatment systems to successfully engage and serve persons with co-occurring disorders is an essential task in making the case for integrated services. With increased communication and collaboration across public systems, it is not difficult to accomplish.
For example, unlike mental health and substance abuse treatment information, jail booking data is generally within the public domain. If a local mental health or substance abuse/chemical dependency treatment authority requests regular reports of booking data from the jail serving their jurisdiction, these lists can be electronically compared to the complete set of individuals who are currently or who in the past have
received mental health and/or drug and alcohol treatment without violating any regulations related to confidentiality. If reduction of jail episodes has been established as a valid outcome measure for the success of the treatment system, the frequencies with which current and former clients are booked and
incarcerated offers a mechanism for
determining how successfully the
system is engaging and treating its
client population.
Locate “Soft” Information
Although outcome-oriented public policy is increasingly being shaped and driven by “hard” data, softer sources of information nonetheless remain critical to building the case for integration.
Anecdotal information about system
difficulties providing effective care to persons with co-occurring disorders can offer a note of reality, urgency and
humanity that often is not communicated by simple statistical reports. In short, putting faces on the problems being
defined will help to illustrate the
compelling issues faced by both policymakers and the public as they advocate for changes to the status quo.
Mental health consumers, individuals in recovery, family members, advocates and line staff at treatment agencies are usually more than willing to share their experiences of trying to make a “siloed” and categorical system work to meet the needs of clients with multiple-problems.
When coalitions are diverse and inclusive, when
their voice incorporates systems that have traditionally been
philosophically divided competitors for scarce resources, the
recommendations that emerge are often creative and compelling.
Here are a few examples of how to collect this type of information:
- Conduct key informant interviews and focus groups with system stakeholders, including individual line staff from treatment agencies, consumers and clients receiving services and concerned family members.
- Contact organizations such as local chapters of the National Alliance for the Mentally Ill and the National Mental Health Association, Alcoholics Anonymous, Narcotics Anonymous, etc. These groups are usually more than willing to assist in gathering this type of data.
- Scan local media reports for incidents that point towards potential gaps and barriers across systems. Reporters can also be encouraged to pursue human interest stories about individuals with multiple problems who may be homeless and visible to the larger community.
Make Constructive Use of Critical Incidents
The occasional tragic event involving the injury or death of a public sector client
or the victimization of a citizen by a
mental health or substance abuse system consumer can also provide remarkably strong opportunities to make the case for systems integration. When these events grab the media headlines, the natural instinct of those involved in providing, managing or funding
treatment services may be to minimize the system failures that contributed to the incident. Although this approach may be an (usually unsuccessful)
attempt to limit public criticism or
liability, a counter-intuitive approach of embracing the incident as a strong
indicator of the need for system change can prove more valuable and effective in the long run.
These media events provide a rare
window of opportunity to garner the public support and the attention of key stakeholders and policymakers that is required to move what are perceived as intractable systems towards an
integrated approach to the most
challenging public sector clients.
For example, several years ago, in King County, Washington, a retired firefighter was stabbed to death on the streets of Seattle in the presence of his family. The attacker was a person with mental illness who had only recently been released from the local jail.
Rather than minimize the significance of this incident, within hours local elected officials had created a
high-level task force to review what had
occurred and to propose the changes to the system that would make such
assaults less likely in the future.
The momentum created by this incident and the subsequent work of the task force resulted in important changes to the statutes involving jail release as well as the creation of two new and innovative treatment programs — a Mental Health Court and a Crisis Triage Center.
Assess the Political Climate
The above story from King County indicates the importance of insuring the active participation of key elected and appointed officials and the value of including active and vocal community organizations in the processes of identifying system gaps and barriers and developing meaningful solutions. Systems change is difficult without the political will to “make something happen” and is more likely to occur if it has been ratified by the informed voice of community opinion.
Key stakeholders to involve together in local efforts to promote systems change that can improve treatment outcomes for persons with co-occurring disorders may include: mayors, county executives and city/county council members; mental health and alcohol/drug system commissioners or directors; sheriffs, police chiefs and jail administrators; judges;
and representatives from local chapters of NAMI, NMHA and chemical
dependency/substance abuse advocates, including groups such as Mothers Against Drunk Driving (MADD).
Efforts will be most successful when they do not begin with a call for large amounts of additional money to support systems change but rather a careful
review of how current resources are
expended. Pilot projects can often be
mobilized through the creative use of existing funds.
Once these efforts make the case for the added value of systems change, local authorities (and the general public) may become more willing to consider how to establish long-term funding streams to support them. Future issues of The Change Agent’s Tool Box will explore this strategy in greater detail.
Put It All Together
Once the precise nature of the local problems have been identified and supporting data collected to confirm the
problem definition, there is great value in developing and producing concept papers that outline core issues and highlight the needs for an integrated approach to problem solution through system change. This task is best approached strategically. All of the stakeholders that have been involved in or consulted through a region’s initial efforts can be invited to participate in the process of crafting the materials that make the case for systems change. The greater the number of interested parties involved, the more value and authority the recommendations will carry. Problem statements and proposed solutions have more authority when they have been both conceptualized and ratified by a broad base of key system players and public allies. There is great value in promoting shared “ownership” of both the core problems and the identified solutions.
Formation of systems integration advisory groups is a useful tool in promoting systems change. Such groups should have open memberships; no individual or organization should perceive that they do not have a place at the table. Meetings should be held on a regular basis (e.g. monthly) and carefully staffed. Agendas should be developed that put the advisory group in the position of
leading the strategic planning
effort and identifying concrete recommendations and action steps to their
senior policy level sponsors. A logical progression of advisory group activities can include:
- Data collection and analysis.
- Identification of existing system gaps and barriers.
- Clear and precise problem statements rooted in valid data.
- Articulation of a vision of what the systems would look like if these gaps and barriers were eliminated, (e.g. “No Wrong Door” to mental health and substance abuse treatment, regardless of an individuals presenting problems or where they first appear in the system).
- Development of “boundary spanning” staff roles in your system, (e.g. System Integration Administrators whose job duties include strategic planning across systems).
- Recommendations for systems changes that can be achieved
incrementally, (e.g. pilot projects utilizing existing resources that lead to confirmation of the problems that have been identified and the solutions that have been recommended).
- Proposals for structural adjustments to existing systems that will help achieve needed systems changes (e.g. the integration of mental health and drug and alcohol system entry points to facilitate the cross training of staff, dual certification of provider agencies and sharing of resources to enhance both efficiency and effectiveness).
Market New, Integrated Solutions
The goal of these efforts is to bring
together consumers, families, providers, advocates, planners and administrators to speak in a single voice about the changes that are needed to improve treatment outcomes for persons with
multiple problems. When coalitions are
diverse and inclusive, when their voice incorporates systems that have traditionally been philosophically divided competitors for scarce resources, the recommendations that emerge are
often creative and compelling.
This material was prepared by David M. Wertheimer, M.S.W., M. Div., Service and Systems Integration Administrator for the King County (WA) Department of Community and Human Services. For additional information on this topic, contact him at davidmwertheimer@aol.com or at (206) 726-0102.
