Quarterly Evaluation Report
October 1, 2004 through December 31, 2004
Pages 1 -43
Produced by: Andrew L. Cherry, DSW ACSW
Oklahoma Endowed Professor of Mental Health
OK-COSIG Project Evaluator
Table of Content
TOC \o "1-3" \h \z \u
This is to acknowledge the hard work and personal investment of all the people who contributed to the development and success of the Oklahoma Co-Occurring State Incentive Grant (OK-COSIG) proposal. The two years of work that went into this successful proposal can never be adequately captured in an evaluation report. This type of focused and sustained effort, however, takes leadership and vision from the top. It also took the willingness of personnel at all levels to risk venturing into this unknown area of providing care and treatment for people with co-occurring disorders. Their contributions and efforts will be recorded in this and future issues of the OK-COSIG Quarterly evaluation.
How this quarterly evaluation report is organized
This is the first quarterly report to be issued on the OK-COSIG project. As such the organization and focus may change as new quarterly reports are produced. This first report will not cover a great deal of the history before the Grant was awarded to the ODMHSAS. This will be delineated in future quarterly reports. This quarterly report will first provide a brief overview of the COSIG program at both the Federal and State level. The preliminary evaluation plan will also be presented. The methodology that was used to produce this first report, the documents collected, and documents archives for this first quarterly report will be referenced. A summary of the salient activities of the OK-COSIG staff, the program evaluator, the ODMHSAS, the leadership, the personnel on workgroups, and advocate groups will provide a description of events, activities, accomplishments, and tasks yet to be finished.
note: The Quarterly Reports produced over the five year life of this
project will be data for the year-end reports. These reports will also form the
basis for the final report on the Process Evaluation. To maintain the highest
level of accuracy, corrections will be made on quarterly reports as errors are
identified or clarifications are needed. These changes will be issued as new
pages that will replace the pages with errors. The new pages will retain the
old text, but the old text will appear with a
strikethrough to indicate
that it was changed. The new added text will be underlined. All
revision dates will appear at the bottom of the page.
This project was supported by funding awarded by the ODMHSAS and SAMHSA. Points of view in this document are those of the author and do not necessarily represent the official position or policies of ODMHSAS.
Over two years of work paid off on October 5, 2004 when the ODMHSAS received a Co-Occurring State Incentive Grant (COSIG) awarded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Oklahoma became one of four states to receive a grant on the second round of COSIG funding in 2004. This brought the total number of states receiving COSIG funding to eleven. Being one of the states funded in the second round has its advantages; we in Oklahoma will study and learn from their successes and the problems they encountered in their first year.
In this first quarter of the OK-COSIG Project the work of the Project Manager was on organizational and start-up tasks. A Program Specialist was identified and hired. Workgroups and committees met to consider their role now that the OK-COSIG Project has been funded. Work on contacts with the ZiaLogic group and the OK-COSIG evaluator were in progress. The training specialist position was not filled but interviews were being conducted to fill this position.
There were two major events that were instrumental to the process necessary to affect statewide infrastructure change, a two day Pre-Site Visit for the National Policy Academy on Co-Occurring Disorders, and a COSIG Grantee Meeting in Bethesda MD. The Pre-Academy Site visit was a two day workshop to prepare participants for the National Academy in January. The work at the Pre-Academy Site visit was a clear statement that ODMHSAS administration is committed to providing treatment services for people with a co-occurring disorder as an integrated part of the services provided by the Department. The seriousness of the commitment of the administration could not be missed. The Commissioner Terry Cline, Chief Operating Officer, Dave Statton, Deputy Commissioner of Mental Health. Rand Baker, Deputy Commissioner, Substance Abuse Ben Brown, and the majority of the other members of the Administrative Team were present and actively participated in the two day workshop. This level of interest will support and promote integrated co-occurring service delivery throughout ODMHSAS. The preliminary vision for the State was, A healthy Oklahoma: All persons with or at risk for co-occurring disorders have access to a recovery-oriented consumer-driven system of care. The Academy to be held in January will provide a great deal of guidance in developing organizational change strategies.
The second event was the national COSIG Grantee Meeting in Bethesda, MD, organized and staffed by SAMHSA personnel and COCE team members. This meeting brought together all the states that are COSIG recipients to share their experiences and their plans to integrate co-occurring services into the services systems of substance abuse and mental health. This group will provide technical assistance and resources such as information on screening tools, best practices, funding approaches, competency based curricula, etc. Resources that will allow the OK-COSIG implementation team to concentrate on planning co-occurring services that are consumer driven and designed to meet the service needs of Oklahoma consumers.
In the remainder of this first year there is a great deal of work to do to test screening scales, to plan the pilot project, and delineate the details of the evaluation plan. The objectives and activities that need to be accomplished to meet the goals of the OK-COSIG project are clear and specific. As is often said about complicated projects, however, “The devil is in the details.” The planning tasks for this five year project have begun and much progress has been made in this first quarter of the project. The OK-COSIG Project is on the cutting-edge of mental health and substance abuse treatment.
On October 5, 2004, the Oklahoma Department of Mental Health and Substance Abuse
Services (ODMHSAS) received notice that their Co-Occurring State Incentive Grant
(COSIG) proposal, to improve Treatment of persons with Co-Occurring Substance
Related and Mental Disorders in Oklahoma that was submitted on June 5, 2004, had
been approved for funding by the Department of Health and Human Services,
Substance Abuse, and Mental Health Services Administration (DHHS/SAMHSA). The
five year award was in the amount of 3.3 million dollars. In the first phase
(the first three years of the grant) the project will
to focus on
infrastructure development and enhancement that will provide integrated
treatment for persons with co-occurring disorders that is accessible, culturally
competent, and grounded in evidence-based practices. The last two years, of
reduced funding, will be used to continue the evaluation of the project and
continued collection and reporting of performance data.
The COSIG was designed by SAMHSA to assist states with infrastructure development and enhancement. To accomplish the aims of the grant, the ODMHSAS selected two goals that will help facilitate infrastructure development and enhancement of services to people with co-occurring disorders in Oklahoma.
The overarching goal of the OK-COSIG project is to improve the delivery of state-funded services for people in Oklahoma with a co-occurring disorder. The project will use two interventions to promote system infrastructure change. A standard protocol for the screening and assessment of mental health and substance abuse problems will be developed, evaluated, and field tested. Finally, a model of integrated treatment will be developed that is accessible, culturally competent, and grounded in evidence-based practices.
Develop, implement, and evaluate a standard protocol for the screening and assessment of mental health and substance abuse treatment service recipients in all State funded programs.
Develop, implement, and evaluate an integrated treatment model for persons with co-occurring disorders that is accessible, culturally competent, and grounded in evidence-based practices.
This COSIG award signals the beginning of a process that is designed to integrate services for people with co-occurring disorders into the organizational structure of ODMHSAS. The methods used in this process will empower consumers and advocates. Most importantly, it will result in the development of a system of care that is far more effective and available to people with a co-occurring disorder than ever before in State funded mental health and substance abuse treatment facilities in Oklahoma.
Description of people with co-occurring disorders
Data from a SAMHSA sponsored survey in 2002 show that there were 33.2 million adults aged 18 or older with a serious mental illness or a substance use disorder. Of these 33 million adults, 40.4% (13.4 million) had a serious mental illness, 47.4% (15.7 million) had a substance use disorder, and 12.2% (4.0 million) had both a serious mental illness and a substance use disorder.
Among the general population about 7% of people have serious mental illness. Among people with a substance abuse disorder the percentage is almost three times the norm. Some 20.4% of people with a substance abuse disorder have a serious mental illness (SAMHSA, 2003).
Those with a co-occurring disorder are clearly different and their treatment and service needs will be different from people with a substance abuse disorder. In another SAMHSA study of treatment episode data in 2000, people with a co-occurring disorder were most likely to be abusing alcohol (51%) as compared to people admitted for a substance abuse disorder (42% were alcohol addicted). Use of other substances (cocaine, marijuana, opiates, and stimulants) was lower among people with co-occurring disorders (45%) as opposed to people admitted with a substance abuse disorder (55%).
We can expect that better than half of the people with a co-occurring disorder will be abusing alcohol when they seek treatment.
There was also a difference in gender among people admitted with a co-occurring disorder and those admitted with a substance abuse disorder. Some 40% of people admitted with a co-occurring disorder were female compared to 28% for people admitted with a substance abuse disorder.
We can expect that about 40% of people needing treatment for a co-occurring disorder will be adult females.
Of those admitted with a co-occurring disorder previous treatment episodes were similar, 63% of people with a co-occurring disorder had been in treatment in the past as opposed to 59% of people who were admitted for substance abuse. It was also similar for people reporting 1 to 4 episodes of past treatment, 42% of people with co-occurring disorder, and 46% of people with a substance abuse disorder. An important finding is that people who reported 5 or more treatment episodes were significantly higher among people with co-occurring disorders, 21% as opposed to 13% among people admitted for a substance abuse disorder (SAMHSA Treatment Episode Data Set, 2000).
A person admitted with a substance abuse disorder who has had 5 or more previous treatment episodes, should be considered at high risk of having a co-occurring disorder.
The employment characteristics of people with a co-occurring disorder are also important when planning support services during recovery. Although, only 34% of people admitted with a substance abuse disorder were employed full-time or part-time, only 25% of people with a co-occurring disorder were employed full-time or part-time. The unemployment rate for both was about the same, slightly over 20%. There was, however, a major difference among those not in the workforce. Among people admitted with a co-occurring disorder, 52.8% were not in the workforce compared to 41.9% of people admitted with a substance abuse disorder.
We must expect that people with a co-occurring disorder are going to have less work experience and need more employment rehabilitation services than people with a substance abuse disorder.
Description of people from Oklahoma with co-occurring disorders
Based on the SAMHSA, National Household Survey on Drug Abuse (NHSDA) for 2001, it is estimated that 7.3% of all adults have a serious mental illness (SMI) in the United States. Oklahoma had the highest estimate for all 50 states. Some 10.4% of the population age 18 years or older have a SMI. Additionally, the survey found that 20.3% of people with SMI also had a substance abuse problem. If this percentage from this survey is used to estimate the number of people in Oklahoma with co-occurring disorders, the number could be as high as 54,000 persons. ODMHSAS data from the Integrated Client Information System (ICIS) collected in 2003, found only 4,000 persons identified as having a co-occurring disorder. This suggests a significant undercount caused by a lack of recognition and diagnostic skills among current professional staff. While the number of people in Oklahoma with a co-occurring disorder is still only an estimate, the people with co-occurring disorders who are not receiving the most effective treatment are experiencing high recidivism rates and numerous treatment episodes. The COSIG is designed to address this lack of appropriate treatment and care.
Overview of COSIG Program
SAMHSA's CMHS and CSAT in 2003 began offering COSIG grants to State-level agencies to help the State agency “develop and enhance the infrastructure of States and their treatment service systems to increase the capacity to provide accessible, effective, comprehensive, coordinated/integrated, and evidence-based treatment services to persons with co-occurring substance abuse and mental health disorders, and their families.”
The Center for Co-Occurring Excellence (COCE) and SAMHSA COSIG staff will provide the following kinds of Technical Assistance (TA) to the OK-COSIG implementation team to help us reach our goals and do a scientifically sound evaluation under this grant.
Process of Care Component:
The COCE and COSIG staff, in addition to providing assistance with developing a co-occurring curricula, and identifying screening and assessment tools, and models that have been used in other COSIG states, will also assist in the development of data fields that document key aspects of the processes of care received by individuals with co-occurring disorders. The COCE and COSIG staff will also help assess the nature and quality of the services being delivered and the capacity of the State COSIG to implement a standard set of quality indicators.
The COCE will provide TA on the Evaluation Component:
They will also help design the OK-COSIG evaluation so that the process evaluation provides information on how organizational and financing infrastructure changes that are implemented will influence systems change and capacity expansion across ODMHSAS sectors and models of service delivery. An evaluation of the changes in processes of care will contribute to the development of evidence-based performance measures at agency and State levels.
Background on the Federal COSIG initiative
Over the last ten years, “it has become widely recognized that people with co-occurring addictive and mental disorders are a large and significantly underserved population in this country. These individuals experience multiple health and social problems and require services that cut across several systems of care, including substance abuse, mental health and primary health care services, as well as a host of social services. Many people with co-occurring disorders are homeless or located within the criminal justice system. None of these systems of care is, on its own, well equipped to serve individuals with co-occurring addictive and mental disorders. At the same time, new evidence is emerging from the research community about effective services that can have substantial positive outcomes for people with co-occurring disorders” (excerpt from: SAMHSA Position on Treatment for Individuals with Co-Occurring Addictive and Mental Disorders).
“Historical barriers to improving services to people with co-occurring disorders have included definitional problems (e.g., how to define "integrated treatment" or "co-occurring disorders"), lack of prevalence data, philosophical differences between the substance abuse and mental health fields, and concerns over adequacy of resources and/or the ability to access resources. While these barriers remain problematic in some areas, particularly the lack of resources, an atmosphere of collaboration is growing within the mental health and substance abuse fields as both fields recognize the critical need for effective treatment for co-occurring disorders, the multiplicity and complexity of problems experienced by people with co-occurring disorders, and the need to draw on the strengths of both fields in addressing these problems” (excerpt from: SAMHSA Position on Treatment for Individuals with Co-Occurring Addictive and Mental Disorders).
“In June 1998, SAMHSA's Center for Substance Abuse Treatment (CSAT) and Center for Mental Health Services (CMHS) supported a dialogue among representative State Substance Abuse and Mental Health Directors through the National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the National Association of State Mental Health Program Directors (NASMHPD). A major outcome of that meeting was a conceptual framework for considering the issue of how best to serve people with co-occurring addictive and mental disorders. This framework is based on recognition of the multiplicity of symptoms and variations in severity of dysfunction related to co-occurring addictive and mental disorders, thereby encompassing the full range of people who have co-occurring addictive and mental disorders. The framework specifies three levels of service coordination--consultation, collaboration, or integration--which can improve consumer outcomes across the population of individuals with co-occurring addictive and mental disorders. The model represents a major step forward in conceptualizing the issue, and adoption of the three levels of coordination as currently depicted in the model would be a substantial improvement in treatment for individuals with co-occurring disorders” (excerpt from: SAMHSA Position on Treatment for Individuals with Co-Occurring Addictive and Mental Disorders).
Background on the State of Oklahoma COSIG initiative
In Oklahoma the systems of care for persons with a serious mental illness (SMI) or a substance abuse problem developed along parallel tracks. They have been seen in separate treatment facilities by staff with different types and levels of expertise and credentialing. Funding is also a barrier to the consumer who is a person with a co-occurring disorder. The Oklahoma Health Care Authority (OHCA) is the State agency responsible for the provision of Medicaid funding, using a fee-for-service model to fund providers. The OHCA requirements for provider qualifications, however, severely limit reimbursement for substance abuse services in the State Medicaid plan. Of the 4,000 persons identified as having co-occurring disorders within ICIS in 2003, 87% received services in the mental health sector. Only 21% received services covered by Medicaid.
The COSIG project will develop the infrastructure necessary to realize this vision by capitalizing on the strengths of the existing system and systematically addressing the barriers to integration that exist within the State. These efforts will be build on the strengths identified in the 2004 report, funded by the Center for Substance Abuse Treatment (CSAT), entitled, System of Care Assessment for Persons with Co-occurring Disorders. Current strengths are in the areas of training, information technology, the leadership of ODMHSAS, and the active involvement of service recipients, advocates, and consumers.
Overview of COSIG Evaluation plan
The Fidelity Assessment will determine the extent to which the OK-COSIG project has implemented the components needed to provide services and treatment to people with a co-occurring disorder. The Fidelity Assessment will document deviations and will record the reasons for the changes and any consequences that result from the changes. The Fidelity Assessments will be conducted at the provider agencies that will be participating in the pilot project.
The process evaluation will record the composition of the OK-COSIG Implementation Team, the OK-COSIG Advisory Group, and the clients served to ensure representation of diverse peoples. Special efforts will be made to involve members from different age groups, race and ethnic backgrounds, cultural heritage, sexual orientations, varying degrees of disabilities and literacy, and persons whose primary language is other than English in the Advisory Group and Implementation Team.
Training. Professionals who will be providing services and treatment to people with a co-occurring disorder will be trained at two levels – in the use of the screening and assessment protocol, and in the use of the integrated treatment model. In relation to both types of training the Evaluator will assess who has been trained, the extent of the training, the number or proportion of training sessions attended, the level of learning that takes place, the trainees perception of the training environment, and satisfaction with the training experience. The Evaluator will also assess the trainees’ beliefs and attitudes regarding mental illness and substance use disorders and their knowledge of the screening and assessment protocols and the integrated treatment model. Self-report instruments to assess these areas will be developed over the course of the first funding year with consultation from ZiaLogic, COCE, SAMHSA COSIG and with input from the OK-COSIG Advisory Group. The instruments will be piloted at the initial training provided by ZiaLogic to the OK-COSIG Advisory Group and, based on the pilot, the instruments will be adjusted and approved for use by the OK-COSIG Project Manager and the OK-COSIG Advisory Group. Assessments will be conducted at the various service pilot sites at the beginning of training and at the end of training. Data will be analyzed using appropriate statistical tests.
Grant Related Activities and Events. A relational database of grant funded events and activities, including planning meetings, OK-COSIG Advisory Group meetings, consultation meetings between ODMHSAS and ZiaLogic staff, trainings, site visits by trainers and evaluation staff, and other relevant activities will be created by the Evaluator. The number and identities of persons attending each event will be recorded along with the agenda and meeting minutes of each event. A summary report of activities and events will be produced every quarter and distributed to the Governor’s liaison and the OK-COSIG Advisory Group.
Pilot Project Services. Information about services provided to recipients, staff providing services, and service costs are regularly recorded in the ODMHSAS, ICIS system, as described above. The Evaluator will work with Decision Support Services Division to extract this information for each of the services pilot sites on an annual basis for each year of funding. Data from the first planning year will provide a baseline against which data from the pilot sites at years two and three can be assessed. Annual reports will be developed by the Evaluator and submitted to the OK-COSIG Project Manager, the OK-COSIG Advisory Group, and the Governor’s liaison.
Service Coordination and Networking. The assessment of coordination and networking will be strictly qualitative and based on a combination of key informant interviews with program administrators at the State, regional, and local levels and focus groups with provider staff at the services pilot sites during the second and third years of funding, and at a random sample of seventeen regional provider sites, half at mental health facilities and half at substance abuse facilities, during the fourth and fifth funding years. Sites for this assessment will be selected to provide equal coverage of all service areas within the State. The semi-structured interview guide to be used in this assessment will be developed during the first funding year with input from the Project Implementation Team.
Service Recipient Outcomes for Services Pilot: The Project Evaluator with the assistance of the ODMHSAS Decision Support Services Division, will track clients and arrange for reassessments at three and six month observation periods post-intake. The Co-occurring Disorders Specialist will be responsible for coordinating the reassessments with an emphasis on the independent verification of current levels of service recipient functioning. Service recipients, who are assumed to be transient, will be tracked with a combination of procedures. First, service recipients will be asked at intake and each reassessment to provide information on their current residence, plans to move, and the name of a family member and/or friend who will be likely to know their whereabouts over the next year. The service recipient will also be asked to provide written permission to the Evaluator to contact family members. Second, service recipients included in the outcome evaluation will be contacted by either mail or phone on a monthly basis to verify their address and other contact information. These procedures have become a standard method for locating participants in longitudinal research (van Kammen & Stouthamer-Loeber, 1998; Sullivan, et al., 1996).
Three measures of outcome will be employed: The assessment instrument developed by the ODMHSAS working group and approved by the OK-COSIG Advisory Group will be repeated at three and six month observation periods. Currently, the Client Assessment Record (CAR) is in use with mental health service recipients and, unless changed by the screening and assessment working group, will be the assessment instrument used with persons with co-occurring disorders identified by mental health service providers. This instrument assesses mood/affect, thinking processes, substance use, medical/physical issues, medications, family involvement and problems, interpersonal relationships, role performance, socio-legal involvement, self-care/basic needs, and communication ability. Each item is rated for past and present functioning and results will be recorded in a numeric score. For substance abuse service recipients the Addiction Severity Index is currently being used as the primary assessment tool. The ASI is a semi-structured interview that covers seven domains: medical, employment/support, drug use, alcohol use, legal, family/social relationships, and psychiatric status. The ASI has established reliability and validity, both predictive and construct (McClelland et al., 1992).
Cultural Appropriateness of Evaluation. The evaluation process will institute several steps to insure cultural competency. First, staff hired to assist with the assessment process that is integral to the evaluation will be recruited to reflect the current cultural groups likely to be served: American Indian, Hispanic, and African American. Second, the OK-COSIG Advisory Group will have members deemed to reflect the cultural diversity of the State and this group will be charged with approving all instruments and processes within the evaluation, as well as, the cultural sensitivity of the interpretation and reporting of evaluation results. Third, all instruments will be cross translated for members of ‘language minority’ communities. Fourth, all members of the implementation team, all mental health, and substance abuse service providers, and all members of the evaluation team will receive periodic training through ODMHSAS in cultural sensitivity and competence.
Plans for Using the Findings of the Evaluation. The evaluation findings will be distributed to members of the OK-COSIG Advisory Group, to the Governor’s liaison and to members of the eight Regional Advisory Boards, and to the mental health and substance abuse service providers at the services pilot sites. After approval is obtained from the OK-COSIG Advisory Group and the Governor’s Office, the findings will be posted on the evaluator’s web site and the ODMHSAS web site. As reports are prepared the Project Evaluator, Program Specialist, and Project Manager will meet with the OK-COSIG Implementation Team and the OK-COSIG Advisory Group to review findings and make recommendations to ensure continuous quality improvement. As recommendations and plans for corrections are made, the Project Evaluator and the Program Specialist will be responsible for monitoring the impact of such changes
Involvement of Members of the Target Population in the Design and Implementation of the Evaluation. The OK-COSIG Advisory Group will have a primary role in examining and approving all training and evaluation protocols being planned for use in the project. The OK-COSIG Advisory Group will have both service recipients and advocacy groups, forming approximately 40% of the membership, from the services pilot sites and other service regions within the State. All training materials, data collection protocols, including informed consent processes, will be piloted with the OK-COSIG Advisory Group and, based on this experience, will either be approved for use in the project or recommended for modification.
This Quarterly Report is based on information collected in field notes by the evaluator from meetings and workshops, debriefings after meetings, and interviews conducted by the evaluator with State agency personnel that are involved at some level in the OK-COSIG project. Agendas, formal minutes, memos, letters, emails, and draft documents related to the OK-COSIG project were collected and reviewed. Two previous technical assistance reports were studied in reference to the development of the consensus that a gap in services existed for people with a co-occurring disorder. Additionally, a number of federal documents have been used to guide the OK-COSIG project and these publications were also used in formulation of this first quarterly evaluation report on the OK-COSIG project. The following is a list of sources of field notes and related documents that informed this first quarterly report and will be archived with materials collected in the first quarter of the OK-COSIG project.
Source of Field Notes
1) A two day meeting of COSIG Grantee Meeting in Washington D.C. — December 16-17, 2004
2) A two day Pre-Site Visit for the National Policy Academy on Co-Occurring Disorders, Oklahoma City − December 13-14, 2004.
3) One half-day onsite visit to Tulsa Center for Behavioral Health (TCBH) − December 29, 2004.
4) Two committee meetings with the OK-COSIG Leadership Workgroup.
5) Twelve meetings, Todd Crawford, COSIG Program Manager
6) Four meetings, L. D. Barney, COSIG Program Specialist
7) Six telephone conference calls, Todd Crawford
8) Eighteen emails, Todd Crawford
8) Three conference calls and two emails, Donald Baker
9) Minutes from the Advisory Group meeting on 12-20-04
10) One teleconference with the co-program directors and ZiaLogic.
1) System of Care Assessment for Persons with Co-occurring Disorders, April 2004. Developed for the ODMHSAS under the Center for Substance Abuse Treatment State Systems Technical Assistance Project, Contract No. 270-99-7070.
This report reviewed organizational, funding, policy and procedural, and program operational characteristics of the ODMHSAS system of care for persons with a co-occurring mental illness and substance use disorder.
2) Building Consensus for Strengths Based Case Management in Oklahoma: Final Report, January 2000. Prepared by Kathy Otis, Grant No. 1KD1 SM2455-01.
3) The Scope of Work for COSIG/CCISIC Implementation in the State of Oklahoma, October 25, 2004.
4) The COSIG proposal resubmitted in 2004.
5) COSIG committee meeting minutes, documents, draft documents, memos, emails, and drafts of policy and procedures created before and during this first quarter.
1) Hand outs and notes from the Pre-Academy Site Visit workshop for the 2nd National Policy Academy on Co-Occurring Mental and Substance Abuse Disorders meeting.
2) Hand outs, CDs, Power Point presentations, and notes from the COSIG Grantee Meeting.
Implementation Activities and Events:
October 1, 2004 through December 31, 2004
The work to implement the OK-COSIG project is well underway. During this first quarter of the first funding year a number of committee meetings and related events have contributed to the efforts to design the plan that will guide the development the Oklahoma integrated system of care for people with a co-occurring disorder. These efforts converge to support the goals and objectives of the OK-COSIG project.
These early meetings have also been an opportunity to develop working relationships, review strengths, opportunities, and issues that will come up as the goals and objectives of the OK-COSIG project are realized.
Leadership Workgroup Committee—November 17, 2004
At this meeting the Evaluator, Dr. Andrew Cherry was introduced to the committee members. Todd Crawford, the Program Manager presented a timeline by Objectives and evaluation requirements under the COSIG grant. Todd also went over a timeline chart that identified activities and tasks that needed to be accomplished over the next five years.
Conference call with Dr. Minkoff—November 22, 2004
A teleconference meeting took place on November 22, 2004 between Dr. Minkoff and Dr. Cline of ZiaLogic, and the Leadership team: the Deputy Commissioner for Mental Health, Mr. Rand Baker; Deputy Commissioner for Substance Abuse, Mr. Ben Brown; and Deputy Commissioner, Domestic Violence and Sexual Assault, Ms. Julie Young. Mr. Todd Crawford, Program Manager, and Dr. Cherry, Project Evaluator to discuss the COSIG process and the expertise that ZiaLogic would be providing to make this integration of co-occurring services into the ODMHSAS structure a success.
Pre-Site Visit for the National Policy Academy—December 13 & 14, 2004.
A two day, Pre-Academy Site Visit workshop before the 2nd National Policy Academy on Co-Occurring Mental and Substance Abuse Disorders. These two days were focused on developing a vision for the state of Oklahoma that will represent the foundation for priorities, strategies, and plans. A reality assessment was also begun. The reality assessment was a review and description of current issues in Oklahoma and the policy actions taken to address the critical issues. A third focus was on priorities and gaps between the vision of what ODMHSAS and the reality of where the state is today. Additionally, strategies involved in the overall aim of the agency were tentatively identified.
This Pre Academy site visit was designed to facilitate the development of goals and issues that the team will work on at the Academy meeting in January.
As noted earlier, the attendance of the Commissioner, Terry Cline; Chief Operating Officer, Dave Statton; Deputy Commissioner of Mental Health, Rand Baker; Deputy Commissioner, Substance Abuse Ben Brown; and the majority of the rest of the Administrative Team was extremely important for setting the level of importance of the COSIG project.
Identified Strengths, Opportunities, Weaknesses, and Threats
During the Pre-Academy Site Visit, participants identified a number of ODMHSAS strengths, opportunities, weaknesses, and threats.
Strengths: There is good collaboration between state agencies such as Behavioral Health, DHS, and ODMHSAS. There are a number of other initiatives that have been funded, for example, one through the Robert Wood Johnson Foundation that can be organized and developed into an integrated treatment system. There is money for cross-training of provider staff working in the field. There is an integrated data system that will be instrumental in monitoring and evaluating change brought about by the OK COSIG project. There are eight PAC programs currently up and running. There are a number of support groups “Double Trouble” in particular that can advocate for people with co-occurring disorders and develop support groups for people in recovery.
Opportunities: The COSIG grant will be helpful in developing a consumer driven recovery process within state funded treatment facilities in Oklahoma. This project will also be able to identify and provide services that are coordinated between mental health, substance abuse, and domestic abuse providers. The structure of the evaluation as well as focusing on fidelity of program implementation and the process of implementation will also provide opportunity to assess outcome at multiple levels, state providers, and individuals.
Weaknesses: The services provided by mental health agencies, substance abuse agencies, and domestic abuse agencies are separate and only provide parallel treatment and services. There are too few cross-trained professionals. The geography of Oklahoma and parts of the state that are considered frontier pose major challenges.
Threats: There needs to be serious attention paid to outreach.
There are gaps in the data about people who are in need of services. People being served are currently being screened for mental health, substance abuse, or domestic violence, depending on the services the agency provides. No one is currently being screened for all three possible situations.
Native American concerns and service needs, along with other minority groups must be included in the final plan.
Those with co-occurring disorders that are in prison also need to be served.
There is also a concern among professionals in the fields of substance abuse and mental health that they will loose their identity if they cross-train and develop clinical skills providing services and treatment to people with a co-occurring disorder.
These concerns will need to be addressed in the planning for recruiting and training a skilled workforce of practitioners.
COSIG Grantee Meeting—December 16-17, 2004
This was a meeting of representatives from all eleven COSIG states. COSIG staff from SAMHSA, and COCE staff organized it and the presentations. The seven states that began their COSIG project last year presented the work they were involved in over the first year of their grant.
Three people represented Oklahoma at this two day meeting in Bethesda, MD, Todd Crawford, Program Manager, L. D. Barney, Program Specialist, and Dr. Andrew Cherry, Program Evaluator.
This two day meeting provided the opportunity for program managers and evaluators to network and discuss their projects. It gave those from states in the second round a chance to hear about the programs being implemented in the seven states that had been in operation for a year.
This meeting also provided the opportunity to see what COCE had to offer in terms of TA and to dialogue with the authors directly about their recommendations and reports. The information and knowledge of available TA support from the SAMHSA COSIG staff and COCE will allow this first year of planning of the OK-COSIG to focus on developing a model that will be the best fit for people in Oklahoma who need service for a co-occurring disorder.
COSIG Advisory Committee Meeting—December 20, 2004.
Some 25 people attended this meeting. The purpose was to provide information to the group about the progress to date and the activities and events over the first quarter. A major task that was accomplished was the development of a workgroup of 15 advocates that will meet monthly to work on the screening and assessment instrument protocols and choose screening and assessment instruments to be used by service providers. Those serving on the workgroup are:
Donna Wood-Bauer – OCARTA
Melody Riefer – ODMHSAS, representing persons with lived experience
Charles “Chuck” Miller – lived experience
Suzie Seymour – lived experience
Mary McCormick/Tom Wisely – Oklahoma Mental Health Consumer Council
Juan Guerrero – DBSA
Nancy Petree – NAMI
Dr. Powitzky/DOC representative – Department of Corrections
Steve Stewart – 12 & 12
Cathy Bates – lived experience
Kimberly Cox – Norman Alcohol Information Center (NAIC)
Tom Orr/Janet Hackworth/Larry Smith – Grant Lake Community Mental Health Center
Cindy Hunnicut/Billy Ray – Central Oklahoma Community Mental Health Center
Jennifer Freeman – Family & Children’s Services of Tulsa
Dr. Blankenship/Didi Herron – Associated Centers for Therapy, Inc.
The Advisory Committee will next meet at 10 a.m. to 1 p.m. on January 21 at the department’s Shephard Mall offices. The group will meet monthly and report quarterly to the full COSIG Advisory Committee.
Leadership Workgroup Committee—12-22-2004
The committee members were given an update on the COSIG Grantee Meeting held in Bethesda, MD.. The discussion then focused on the Pre-Academy Site visit held in Oklahoma City. Questions related to the strategic purpose of the academy, and how OK-COSIG would be integrated into the Policy Academy goals was discussed.
There was discussion about the Committee choosing Screening and Assessment Instruments and their need for more direction in their role. Training issues were also a concern with the screening and assessment tools to be selected.
Onsite visit to TCBH − December 29, 2004
On the 29th of December, the project evaluator conducted a half-day onsite visit at the Tulsa Center for Behavioral Health (TCBH). This visit was used to introduce the evaluator, Dr. Cherry to the staff of the TCBH Co-Occurring program. The session was also used as a workshop. Todd Crawford led a discussion and planning session on a treatment program that would meet the service and treatment needs of people with a co-occurring disorder.
Five Major Shareholder Groups were Active
There were five of the six major shareholder groups active in this first quarter. Shareholders from these five groups were involved at all levels of planning. Continued collaboration with these and other shareholders will provide guidance in shaping the services provided for people with a co-occurring disorder in Oklahoma, and will contribute to the design of the evaluation plan. The shareholder groups were:
1. The COD Leadership Workgroup ─ ODMHSAS
2. COSIG Advisory Group
3. Providers of SA & MH
4. Practitioners providing treatment in SA & MH.
5. Screening and Assessment Committee
6. Professional State Licensure bodies were not active this quarter but engagement activities have begun and this group will be more active in the second quarter.
OK-COSIG Objectives by Timeline for Year One
In the first two months of funding, a co-occurring disorder training specialist will be hired (Activity 1.2.1).
Status: In progress. Interviews have been conducted with candidates.
Status: In progress. The contract is in the final stage of being concluded.
Status: This is a work in progress. The COCE is also working on licensure/credentialing requirements. In the next quarter of this project a licensure/credentialing workgroup needs to be constituted to lay the ground work for the changes that will be necessary for professional licensure bodies to certify practitioners competent to provide treatment to people with a co-occurring disorder.
Status: In progress.
Status: In progress.
Status: The first quarterly report was submitted on January 10, 2005.
The Quarterly Report is a summary report of activities and events for the quarter and is distributed to:
1) The Governor’s liaison and oversight committee,
2) The oversight committee, and
3) The COSIG Advisory Group.
Objectives by Timeline for the next Nine months.
Progress on Project Goals and Objectives
Develop, implement, and evaluate a standard protocol for the screening and assessment of mental health and substance abuse treatment service recipients in all State funded programs.
The committee on Screening and Assessment have been formed and have met in this Quarter, while at the COSIG grantee meeting in December, two scales the Dali and the Mimi, short in length, easy to administer, high in reliability and validity have been identified from those compiled by COCE, to put forth for evaluation by the workgroups.
Dartmouth Assessment of Lifestyle (DALI)
Two-page 21-item version of the DALI, screening for substance abuse symptoms (alcohol, marijuana, cocaine, and heroin) only. Administration time: 5-10 minutes.
Developed for use in mental health settings; can be used with SMI individuals.
Only 18 items are used to sum a total score; ≥ 3 indicates a moderate likelihood of a diagnosable substance abuse problem. Scoring time: <5 minutes.
Can be administered by interviewer with minimal training or be self-administered.
The Modified DALI has been used in combination with the modified MINI in a four quadrant system in New York State.
M.I.N.I. Screen Modified
Four page, 22 item version for screening for mental health symptoms only (Mood, Anxiety, Trauma (exposure, symptoms), and Psychotic Disorders). Administration time: 5-10 minutes.
Adapted for use in substance abuse settings.
Contains a screen (1 question) for risk of self-injury.
Can be administered by interviewer with minimal training or be self-administered.
Instrument is divided into 3 sections; a summary score is used to determine the likelihood of mental illness. Scoring time <5 minutes.
COCE has compiled a set of diagnostic tools that are available and can be used on this project.
Develop consensus among providers, service recipients, consumer advocates and other interested parties on a standard screening and assessment protocol for use in mental health and substance abuse treatment settings.
Discussions of screening and assessment tools have been a central theme at committee meetings and presentations during this Quarter.
Other States have spent a year struggling with the issue of a standard screening and assessment protocol. Their experiences will be invaluable for meeting this objective.
Train all mental health and substance abuse treatment providers in the screening and assessment protocol.
This component of the COSIG plan is in the early planning stages.
COCE and other COSIG states have begun this process and we will utilize the lessons they have learned so far.
Develop, implement and evaluate an integrated treatment model for persons with co-occurring disorders that is accessible, culturally competent, and grounded in evidence-based practices.
The work to develop an Oklahoma model of integrated treatment for people with a co-occurring disorder in Oklahoma was the focus of the work groups that met this Quarter.
The National Policy Academy on co-occurring mental and substance abuse disorders will meet in January 2005 with the ODMHSAS leadership to help develop strategies that will facilitate COSIG efforts to meet this goal. Additionally, COCE and seven other COSIG states have had a year’s experience trying to implement a model of integrated treatment. Their experience will be invaluable in the planning to meet this goal.
Develop consensus among providers, service recipients, consumer advocates, and other interested parties on the elements of an integrated treatment model for persons with co-occurring disorders.
Discussion of an integrated treatment model for persons with co-occurring disorders has been a central theme at committee meetings during this quarter.
The ODMHSAS staff assigned to the COSIG project are experienced and sensitive to advocates and consumers.
Establish joint licensure/certification and funding processes for both mental health and substance abuse staff.
Establishing joint licensure/certification is in the early discussion stage.
There is some information becoming available on strategies that are being used in other COSIG states. These models may be useful in our own licensure efforts.
Develop contracting procedures that create strategic incentives for the implementation of integrated treatment systems at the provider level.
Work on this objective is in the early planning stage.
There is some information on using strategic incentives coming out from the other COSIG states that will be useful in accomplishing this objective.
Train all mental health and substance abuse treatment providers in the use of a comprehensive, integrated system of care model for persons with co-occurring disorders.
A model that could be used to train mental health and substance abuse treatment providers is in the early discussion phase.
COCE is working on developing curricula that can possibly be adapted for use in Oklahoma.
During this first quarter, the focus of the work was on the COSIG project Goals 1 and 2. This is where the majority of the work will need to be done to develop an integrated system of care that meets the service needs of people with a co-occurring disorder.
There have been discussions about the changes that are needed at the Department level to support an integrated system of care.
The Implementation Team recognized a need to develop a cadre of specialized clinicians trained to provide treatment and services to people with a co-occurring disorder. To assemble this group of professionals, the thinking at this time is that the most efficient approach is to cross-train those working in the field who have clinical skills in mental health or substance abuse.
The first step in the training process is to identify core and advanced training curricula that will equip practitioners to provide a system of care based on best practices and a procedure so that practitioners can stay current with the field. Such curricula should support credential requirements. The OK-COSIG team will be in part guided by the work being done at the National Center for Co-Occurring Excellence, in Bethesda, MD. That group is working to identify appropriate best practices and educational needs of practitioners who work with people with a co-occurring disorder.
The outcome of cross-training with a co-occurring curriculum will be two-fold. There will be a cadre of trained practitioners that can serve and treat people with a co-occurring disorder. Statewide there will be competent professionals that can screen, discuss, and refer people with a co-occurring disorder to appropriate treatment.
To help accomplish this task, a stakeholder’s workgroup will need to be convened to work on developing a co-occurring credential. The workgroup will need to identify the range of practice skills needed by co-occurring professionals and the training requirements to develop skill sets and the knowledge required of these professionals.
One approach that would help organize the tasks needed to support and sustain the changes at the screening/assessment and treatment levels would be to develop a Department Level Goal and a Provider Level Goal with Objectives and Activities that will integrate and sustain a COD service system into the overall system of mental health and substance abuse treatment in Oklahoma. See the section in this quarterly report under Observations and Recommendations.
Observation and Recommendations
The planning meetings, committee meetings, and workshops over this first quarter have drawn attention to a number of critical issues that will need attention from both the Project Manager and the Program Evaluator as the project unfolds.
1) Over the next quarter, planning meetings will need to focus and work on the implementation plan.
2) Special attention will need to be paid to the involvement of the domestic violence in the system of care developed for persons with a co-occurring disorder.
3) An Evaluation Advisory Committee needs to be constituted to provide another view in the planning and conducting of the Evaluation on this project.
4) One approach that would help organize the tasks needed to support and sustain the changes at the screening/assessment and treatment levels would be to develop a Department Level Goal and a Provider Level Goal with Objectives and Activities that will integrate and sustain a COD service system into the overall system of mental health and substance abuse treatment in Oklahoma.
Department Level Goal: Integrate and sustain a COD service system into the overall system of mental health and substance abuse treatment services.
Support professional treatment community.
Provider Level Goal: Integrate and sustain a COD screening service system into the overall system of mental health and substance abuse treatment services.
Objectives: Support the use of a scientifically based screening and assessment instruments.
Support the use of and evaluation of scientifically based best practices.
5) Attention must be given to identifying and developing strategies to overcome clinical, organizational, and administrative barriers. This needs to be a focus in the second quarter of this project.
6) In Oklahoma, a person with or without a co-occurring disorder who is seen by a substance abuse treatment provider will have a reduced probability of being covered by Medicaid funding and receiving the necessary care. Funding represents a clear and present problem for the establishment of an integrated co-occurring disorders program within Oklahoma (this is an abridged excerpt form the OK-COSIG proposal).
7) One of the tasks is to involve members from different age groups, race and ethnic backgrounds, cultural heritage, sexual orientations, varying degrees of disabilities and literacy, and persons whose primary language is other than English in the Advisory Group and Implementation Team.
Assertive outreach efforts will be made to engage culturally diverse clients. Given past history, an emphasis will need to be placed on involving the American Indian population of the State.
Over the last 25 years treatment interventions have been developed that have successfully treated both mental illness and substance abuse. Until recently, however, the mental health and addiction treatment facilities functioned in a parallel system of care; neither system was designed to treat people with both a mental health and a substance abuse disorder. The initiatives planned by the ODMHSAS will go a long way to develop and integrate into the ODMHSAS structure a model of service and treatment for people with co-occurring disorders. Of those initiatives, the OK-COSIG project is a cutting-edge program that will help bridge the gap between the fields of mental health and substance abuse to provide effective services and treatment to people with a co-occurring disorder.
The documents in this Appendix have also been useful in preparing this quarterly report.
Locus of Care by Quadrant of Severity (1998)
The locus of care is based on the National Association of State Alcohol and Drug Abuse Directors-National Association of State Mental Health Program Directors (NASADAD—NASMPHPD) treatment matrix.
Severity: Low AOD & MH.
Locus of Care: PCPs, CHCs
Severity: High AOD & Low MH
Locus of Care: SA
Severity: Low AOD & High MH
Locus of Care: MH
Severity: High AOD & High MH
Locus of Care: State hospital, jails/prison, ERs
Primary Locus of Care and Coordination of Care Based on Quadrant of Severity
Primary Locus of Care by Severity
Based on the severity of their disorders, people with co-occurring mental health and substance abuse disorders currently tend to receive their care in the following settings:
Service Coordination by Severity
Based on the severity of their disorders and the location of their care, the following levels of coordination among the SA, MH and PCP system is recommended to address the needs of individuals with co-occurring mental health and substance abuse disorders:
ASAM-PPC-2R Definitions (page 9, 10 and 11).
Dual Diagnosis Capable programs have a primary focus on the treatment of substance-related disorders, but also are capable of treating patients who have relatively stable, diagnostic or subdiagnostic co-occurring mental health problems related to an emotional, behavioral or cognitive disorder.
Dual Diagnosis Enhanced programs, by contrast, are designed to treat patients who have more unstable or disabling co-occurring mental health disorders in addition to their substance-related disorders.
Essential Elements. Certain elements must be in place in any treatment program that accepts patients with co-occurring mental health and substance-related disorders:
Linking Services. Specific policies and procedures enhance the linkage of services required by patients with co-occurring mental health and substance-related disorders: