C. CCISC-Eight Principles
In order to provide more welcoming and accessible services to Maine
adolescents and adults
with co-occurring disorders, the organizations signing this memorandum of
understanding have reached a consensus to build on the Comprehensive, Continuous,
Integrated System of Care (CCISC) model for designing systems changes in
order to improve outcomes within the context of existing resources. This
model is based on eight principles (Minkoff, 1998, 2000), which are:
1. Dual diagnosis is an expectation, not an exception. This expectation
has to be included in every aspect of system planning, program design,
clinical procedure, and clinician competency, and incorporated in
a welcoming manner into every clinical contact.
2. The core of treatment success in any setting is the availability of empathic,
hopeful treatment relationships that provide integrated treatment and coordination
of care during each episode of care, and, for the most complex individuals,
provide continuity of care across multiple treatment episodes.
3. Assignment of responsibility for provision of such relationships can be
determined using a consensus model for system level planning, based on high
and low severity of the psychiatric and substance disorder.
4. Within the context of any treatment relationship, case management and
care, based on the client's impairment or disability, must be balanced with
empathic detachment, confrontation, contracting, and opportunity for contingent
learning, based on the client's goals and strengths, and availability of
appropriate contingencies. A comprehensive system of care will have a range
of programs that provide this balance in different ways.
5. When mental illnesses and substance disorders co-exist, each disorder
should be considered primary, and integrated dual primary treatment is required.
6. Mental illness and substance dependence are both examples of often persistent,
bio-psychosocial disorders that can be understood using disease, recovery,
and trauma, and other promising practice models. Each disorder has parallel
phases of recovery (acute stabilization, engagement and motivational enhancement,
prolonged stabilization and relapse prevention, rehabilitation and growth)
and stages of change. Treatment must be matched not only to diagnosis, but
also to phase of recovery and stage of change. Appropriately matched interventions
may occur at almost any level of care.
7. Consequently, there is no one correct dual diagnosis program or intervention.
For each individual, the proper treatment must be matched according to quadrant,
diagnosis, disability, strengths/supports, problems/contingencies, phase
of recovery, stage of change, and assessment of level of care. In a CCISC,
all programs are dual diagnosis programs that at least meet minimum criteria
of dual diagnosis capability, but each program has a different "job", that
is matched, using the above model, to a specific cohort of clients.
8. Similarly, outcomes also must be individualized, including reduction in
harm, movement through stages of change, changes in type, frequency, and
amounts of substance use or psychiatric symptoms, improvement in specific
disease management skills and treatment adherence.
D. CCISC-Four Core Characteristics
Using these principles, all organizations signing this memorandum
of understanding agree to work toward implementing a CCISC in Maine
with the following four core characteristics:
1. The CCISC will be implemented initially within the context of existing
treatment operational resources by maximizing the capacity to provide integrated
treatment proactively.
2. The CCISC will promote participation from all components of the mental
health and substance abuse systems with the expectation of achieving, at
minimum, dual diagnosis capable standards and, in some instances, dual diagnosis
enhanced capacity.
3. The CCISC will incorporate utilization of a full range of outcome-based
best practices and clinical consensus best practices.
4. The CCISC will promote an integrated treatment philosophy and common language,
and develop specific strategies to implement clinical programs, procedures,
and practices throughout the system of care.
E. Statewide Priority Issues
All organizations signing this memorandum of understanding agree to
work on the action steps listed in this section over the next year
in order to support the implementation of a welcoming system for individuals
with co-occurring disorders.
Stakeholders from the three regions of the department have identified
the priority issues that they believe need to be addressed first as
they plan for and implement a welcoming system for individuals with
co-occurring disorders in their region. In the first year of implementation,
all participating organizations agree to the tackle the following statewide
priority issues:
1. Make sure the system is welcoming (with no wrong doors) for adolescents
and adults with co-occurring disorders, through a process of examining
resources and identifying service needs within the continuum of care
to improve system integration.
2. Identify and advocate for removing barriers to access to and engagement
in services for adolescents and adults with co-occurring disorders, particularly
crisis, case management, and, in those areas where they currently exist,
Assertive Community Treatment (ACT) Team services.
3. Assign staff to contribute to the development of regulations indicating
how Medicaid funds for either mental health or substance abuse services can
be used flexibly to reimburse services for individuals with co-occurring
disorders.
4. Assign staff to comment on the content of, and contribute to the adoption
of, proposed new licensing regulations for the provision of welcoming, accessible,
integrated services for adolescents and adults with co-occurring disorders.
5. Develop regional training steps that will facilitate intra/inter-agency
coordination to enable substance abuse and mental health agencies to provide
services that are, at minimum, dual diagnosis capable and, in some instances,
dual diagnosis enhanced.
F. State Government Action Planning
Over the next year, the department agrees to carry out the action
planning steps listed in this section in order to support the implementation
of a welcoming system for individuals with co-occurring disorders.
1. The department will review all of its initiatives, including requests
for proposals, and ensure their alignment with all sections of the
memorandum of understanding.
2. To support the statewide priorities identified in Sections E-1 and E-2,
the department will move toward the collection of co-occurring disorders
data for all the relevant services that it funds by:
a. Reviewing the Enterprise Information System for its compatibility with
data collection by the Office of Substance Abuse, with the aim of developing
an infrastructure to support the collection of co-occurring disorders data;
and
b. Determining what data should be collected through grants and contract
reporting and an infrastructure to support the collection of this data.
3. To support the statewide priority identified in Section E-3, the department
will convene a group representing providers, consumers, and family members
to work toward the adoption of regulations that indicate how Medicaid funds
for either mental health or substance abuse services may be used flexibly
to reimburse services for individuals with co-occurring disorders.
4. To support the statewide priorities identified in Sections E-1, E-2, and
E-3, the department will advocate for funding parity by all mental health
and substance abuse funding sources.
5. To support the statewide priority identified in Section E-4, the department
will engage participating organizations in the promulgation of licensing
regulations for the provision of welcoming, accessible, integrated services
for adolescents and adults with co-occurring disorders.
6. To support the statewide priority identified in Section E-5, the department
will develop clinical pathways and ways to support co-occurring mental health
and substance abuse professional competencies.
7. To support all five statewide priorities identified in Section E, the
department will:
a. Streamline documentation and paperwork requirements related to services
for individuals with co-occurring disorders; and
b. Provide technical assistance to participating organizations participating
as they develop and implement policies and protocols to support a welcoming
system of services for individuals with co-occurring disorders.
G. Region I Action Planning
Over the next year, the participating organizations located in BDS
Region I agree to address the issues and implement the action steps
listed in this section as they plan for and implement a welcoming system
in their region.
1. Region I organizations will carry out the following action planning
steps to implement the statewide welcoming priority stated in Section
E-1:
a) Adopt this memorandum of understanding as the guiding principles of the
co-occurring disorders initiative. Circulate the approved memorandum of understanding
to all staff, and provide training to all staff regarding the principles
and the CCISC approach.
b) Develop and implement screening protocols for co-occurring mental health
and substance use disorders.
c) Participate in regional planning for the collection of a minimal data
set that is compatible with state-wide data collection planning on mental
health, substance abuse and co-occurring disorders in the individuals they
serve.
d) Participate in a self-survey of their organization or department using
the COMPASS annually to evaluate the current status of dual diagnosis capability.
e) Each agency will develop an action plan that addresses co-occurring capacity
and share action plan with other regional agencies participating in the initiative
and with other stakeholders as appropriate.
2. Region I organizations will carry out the following action planning
steps to implement the statewide barrier removal priority stated in
Section E-2.
a) Create an integrated planning process in Region I that will include current
planning groups.
b) Participate in regional meetings hosted by the Co-Occurring Collaborative
of Southern Maine to identify barriers and gaps and plan for the expanded
access in crisis services including emergency rooms, case management, outpatient
services, residential services and ACT teams for individuals with co-occurring
mental health and substance use disorders.
c) Agencies and the department will develop plans to incorporate consumer
and family stakeholder co-occurring voice in the planning and delivery of
crisis, case management, and ACT team services and appropriate peer recovery
activities.
3. Region I organizations will assign knowledgeable staff to participate
in the development of Medicaid regulations as described in the statewide
priority in Section E-3.
4. Region I organizations will assign knowledgeable staff to comment
on new licensing regulations as described in the statewide priority
in Section E-4.
5. Region I organizations will carry out the following action planning
steps to implement the statewide training priority stated in Section
E-5:
a) Review the curriculum that is being developed and, in addition to the
overall review, enhance the curriculum to address the training needs of adolescent
providers.
b) Work in conjunction with other regions to maintain consistency in developing
a knowledge base.
c) Identify appropriate clinical and administrative staff to participate
as trainers in the system-wide train-the-trainer initiative and to assume
responsibility for implementation of the training plan of the organization
and department.
H. Region II Action Planning
Over the next year, the participating organizations in BDS Region
II agree to address the issues and implement the action planning steps
listed in this section:
1. Region II organizations will carry out the following action planning
steps to implement the statewide welcoming priority stated in Section
E-1:
a) Adopt this memorandum of understanding as the guiding principles of the
co-occurring disorders initiative.
b) Develop and implement screening protocols for co-occurring mental health
and substance use disorders.
c) Participate in regional planning for the collection of a minimal data
set that is compatible with statewide data collection planning on mental
health, substance abuse, and co-occurring disorders in the individuals they
serve.
d) Participate in a self-survey of their organization or department using
the COMPASS annually to evaluate the current status of dual diagnosis capability.
e) Based upon the findings of the COMPASS evaluation, each agency will develop
an action plan that strengthens the delivery of services for co-occurring
conditions. Agencies may share their plan with stakeholders and agencies
participating in the initiative.
2. Region II organizations will carry out the following action planning
steps to implement the statewide barrier removal priority stated in
Section E-2:
a) Examine and review policies and procedures that present barriers to a
welcoming system for individuals with co-occurring disorders. When necessary
and as resources allow, agencies may assign staff to participate in system-wide
efforts to develop systemic policies and procedures to support welcoming
access in both emergency and routine situations.
b) Include co-occurring disorders case discussions in existing inter-agency
and intra-agency clinical care meetings.
3. Region II organizations will assign knowledgeable staff to participate
in the development of Medicaid regulations as described in the statewide
priority in Section E-3 and will:
a) Advocate within their provider association groups (such as the Maine Association
of Mental Health Providers, Maine Association of Substance Abuse Providers,
and the Maine Hospital Association) to work collaboratively with the department
to impact regulatory changes that will enhance services for individuals with
co-occurring disorders.
b) Promote periodic meetings among all participants and stakeholders to share
current information on regulatory activities.
4. Region II organizations will assign knowledgeable staff to comment
on new licensing regulations as described in the statewide priority
in Section E-4; and will:
a) Advocate within their provider association groups (such as the Maine Association
of Mental Health Providers, Maine Association of Substance Abuse Providers,
and the Maine Hospital Association) to work collaboratively with the department
to impact licensing changes that will enhance services for individuals with
co-occurring disorders.
b) Promote periodic meetings among all participants and stakeholders to share
current information on licensing activities.
5. Region II organizations will carry out the following action planning steps
to implement the statewide training priority stated in Section E-5:
a) Work with the department to develop training opportunities focused on
knowledge, skills, values, and attitudes necessary for staff to deliver services
to individuals with co-occurring disorders.
b) Review the curriculum that is being developed and, in addition to the
overall review, enhance the curriculum to address the training needs of adolescent
providers.
c) Work in conjunction with other regions to maintain consistency in developing
a knowledge base.
d) Identify appropriate clinical and administrative staff to participate
as trainers in the system-wide train-the-trainer initiative and to assume
responsibility for implementation of the training plan of the organization
and department.
I. Region III Action Planning
Over the next year, the participating organizations located in BDS
Region III agree to address the issues and implement the action planning
steps listed in this section as they plan for and implement a welcoming
system in their region.
1. Region III organizations believe that the statewide welcoming priority
described in Section E-1 will be accomplished as a result of the completion
of all the action planning steps in this memorandum of understanding.
2. Region III organizations have combined two priorities-to examine resources
and identify service needs to improve system integration, which is part of
Section E-1-with the statewide priority to remove barriers described in Section
E-2. They will carry out the following action planning steps pursuant to
these combined priorities:
a) Develop a resource guide, to be updated yearly, that addresses such service
as mental health, substance abuse, housing, crisis, legal, case management,
medical services, self-help groups, vocational education, SSI/SSDI, TANF,
etc.
b) Provide organizations with the resource guide.
c) Advocate for mental health and substance abuse training for medical providers.
d) Have a resource list of Region III on the State Website.
e) Link organizations with websites to the State Website for the resource
list.
3. Region III organizations also have combined two other statewide
priorities-assigning staff to participate in the development of Medicaid
regulations, as described in the statewide priority in Section E-3,
and assigning staff to comment on new licensing regulations, as described
in the statewide priority in Section E-4. They will carry out the following
action planning steps pursuant to these combined statewide priorities:
a) Establish a group composed of members who are well grounded in both the
mental health and substance abuse regulatory environment.
b) Know what the regulations are, identify the barriers to service (disconnects),
and provide cross-training to mental health and substance abuse providers.
c) Appoint two individuals (one mental health and one substance abuse representative)
as co-chairs of this group to act as a receptacle for and conduit to BDS
Central Office and to keep larger regional work group informed.
d) Determine where State is regarding dual licensing and other changing policy.
e) Streamline paperwork so there can be single oversight.
f) Measure improvement in quality of care with improved services.
g) Explore the idea of "single release of information"-
- Ask community-affiliated Information Management Specialists to
have a dialogue about barriers to single release.
- Consider asking
for help to facilitate this dialogue, if necessary.
- Explore issues
of informed consent and release of information.
4. Region III organizations will carry out the following action planning
steps to implement the statewide training priority stated in Section
E-5:
a) Use COMPASS as a tool to evaluate providers' status around dual diagnosis
treatment capability and to identify program strengths and system gaps. Using
this data, providers that identify strengths areas can develop presentations
to offer to other programs.
b) Conduct an assessment of staff training needs, based on use of CODECAT,
to evaluate clinician dual diagnosis competencies and areas in need of development.
c) Identify training resources available to regional providers, locally,
regionally, and nationally. Agencies will collaborate to co-sponsor particular
trainings, or may invite other providers to join in training sessions they
are holding.
d) Survey the types of training that are being done nationally, to identify
the core competencies that are generally accepted as "best practices" in
the treatment of co-occurring disorders. Use this information to plan for
Maine-based training.
e) Provide staff training, based on "dual diagnosis best practices model," in
the areas of:
- Screening.
- Assessment.
- Diagnosis.
- Treatment planning.
- Discharge planning.
- Aftercare.
f) Train staff in the principles of teamwork communication and
in understanding their roles within a multidisciplinary team.
J. Other Actions to Create a Welcoming System
Nothing in this memorandum of understanding should be construed to
stop any regional group of stakeholders or any organization from addressing
additional priorities and taking additional action steps in order to
promote and support a welcoming system for adolescents and adults with
co-occurring disorders.
