This is to acknowledge the hard work and dedication of all the people who contributed to the progress made during the third quarter on the Oklahoma Co-Occurring State Incentive Grant (OK-COSIG), now called the Integrative Systems Initiative (ISI). Work over the last three months has focused on committee assignments and tasks needed to bring to fruition integrated services for people with a co-occurring problem. The ISI committee members come from ODMHSAS, other state and local agencies, members from the community, and consumers. The business of the committees during this quarter has been to develop the infrastructure needed to support the implementation of integrated services for people with a co-occurring disorder.

A major training initiative was also conducted during this quarter led by Dr. Minkoff and Dr. Christie Cline. They also meet with the leadership of ODMHSAS and the ISI staff and reviewed the progress made.

SAMHSA’s Co-Occurring Center for Excellence continues to be responsive and helpful. The telephone conferences sponsored by SAMHSA’s Co-Occurring Center for Excellence over the last quarter have consisted of both educational presentations and discussion groups with other COSIG personnel from the other 11 COSIG states. The second Evaluation Discussion Group took place on June 16^th. These opportunities to share experiences, hear what is working, and discuss problems that occur during implementation. I also wish to recognize the people behind the scene that have also given their time, energy, and formidable talent to the work done on the ISI project. The enthusiasm of the professionals and consumers for the work to be done on the COSIG project continues to be high. This enthusiasm will go a long way in helping the OK-COSIG project reach its goals and accomplish its objectives.

How this quarterly evaluation report is organized

This third quarterly report will begin with a brief overview of the work accomplished by the COSIG staff and the OK-COSIG evaluation team in the last three months (April 1 through June 30, 2005). This will be followed by a list of the implementation activities that were carried out during the quarter. Next a summary of the work completed by the ISI Advisory Group sub-committee will be described. An overview of the evaluation project will follow. Then the objectives by a timeline will be described in terms of their status and the resources that are being employed to meet the objectives. Finally, the section on emerging themes will conclude the report.

Editorial note: The Quarterly Reports produced during the year of this project will be data for the year-end reports. The year-end reports will be the data used for the five year report. 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.

Disclaimer:

This project is 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.

Executive Summary

In this third quarter of the OK-COSIG Project, the major focus was on training, and the work of the ISI Advisory Group subcommittees. During this quarter at least 100 people were involved in the initial phases of training in the Comprehensive Continuous Integrated System of Care as developed by Dr. Minkoff. Dr. Minkoff and Dr. Christie Cline conducted trainings at the three regions where the pilot studies will be conducted. The evaluation of these trainings is a very positive component and has engaged the mental health and substance abuse treatment providers around the state. The training that will be provided by the COSIG staff has also been defined. Although the Educational Training Outline may be revised as trainings are conducted and the training needs become more evident, this document provides an excellent starting place to train clinicians who will be providing services to people with co-occurring disorders at specific levels of competency (i.e., intermediate and advanced).

The screening instrument called the ODMHSAS Integrated Screen has been vetted by the ISI Advisory Group subcommittees Screening and Assessment subcommittee. At the end of this quarter, the pilot to test the reliability and validity of the screen is well underway. In the next quarter, the analysis of the ODMHSAS Integrated Screen will be completed so that the screen, given no unforeseen complications, will be ready to use at the pilots sites. During the next year, validity and reliability testing on this screen will continue as it is being employed at mental-health treatment centers and substance abuse treatment centers around the state.

In the final quarter of this first year of this five year project, the challenge for the COSIG staff, the ISI Advisory Group subcommittees, the consultants, the Department, and the evaluation team will be to use what has been learned over the last nine months to give direction and guidance to the systems integration efforts and begin to show concrete changes and results in integrating the two parallel systems of mental health and substance abuse treatment services.

The COSIG Evaluation Project website is up and running. This report and the previous quarterly reports can be accessed at the website. The address is:

http://faculty-staff.ou.edu/C/Andrew.L.Cherry-1.Jr/okcosig_project.htm

Third Quarter Overview

This is the Third Quarterly report on the OK-COSIG project (now called ISI) to improve Treatment of persons with Co-Occurring Substance Related and Mental 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 systemic infrastructure change: 1) a standard protocol for the screening and assessment of mental health and substance abuse problems will be developed, evaluated, and field tested, and 2) a model of integrated treatment that is accessible, culturally competent, and grounded in evidence-based practices. The following sections of this 3^rd Quarterly Report will delineate the work toward accomplishing these two objectives.

Implementation Activities and Events:

April 1, 2005 through June 30, 2005

After nine months of this five year project, the work necessary to integrate the departments of Substance Abuse, and Mental Health to support the provision of services to people with a co-occurring disorder is beginning to take form. The vision is turning into concrete ideas that are needed to facilitate integrated services. The following is a day by day list of major activities from which data was collected and analyzed. This list does not constitute the entire body of work and activities during the third quarter, but it is a good representation of the work that was accomplished.

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April Activities

April 5, 2005. Evaluator meeting, Tulsa.

A meeting was held with Dr. Dennis Combs and Dr. Michael Basso from Tulsa University and Andrew Cherry, the COSIG evaluator regarding their evaluation of the TCBH program for people with a co-occurring disorder. This team from Tulsa University is going into its second year. They are collecting data at the program level to determine the outcome of clients that are going to the program. They are using nineteen psychological scales as a pretest and post test. The project started in 2004 and will end in 2005.

April 11, 2005. Teleconference with L. D. Barney, Co-Occurring Program Specialist.

The discussion focused on the goals of the Minkoff training that occurred toward the end of March. Three goals for the training were: 1) to begin the change process by letting providers know that an integrative initiative was underway, 2) to begin to establish the standard that working with people with a co-occurring disorder is the expectation not the exception, and 3) programs that provide services for people with a co-occurring disorder will employ a “welcoming” attitude.

April 21, 2005. Screening and Assessment subcommittee meeting, Tulsa.

The focus of the meeting was on the purpose of the ODMHSAS Integrated Screen, ODMHSAS proposed requirements, the implementation method to be used, and when providers will be required to use it.

April 21, 2005. Evaluation subcommittee meeting, Tulsa.

Preliminary plans for the development of the Evaluation subcommittee were discussed. Tasks were identified that would need the attention of the evaluation subcommittee.

April 25, 2005. Teleconference with L. D. Barney, Co-Occurring Program Specialist.

Planning for coordinating work on the ODMHSAS Integrated Screen with the Screening and Assessment committee was the major topic for the meeting.

April 1, 2005. Workforce Development Committee and Training Committee meeting, Oklahoma City.

The Workforce Development Committee discussed clarifying purpose, core competencies, and building community connections.

April 1, 2005. Training Committee meeting, Oklahoma City.

The Training Committee meeting , discussions centered on the outline for training and curriculum development.

April 15, 2005. Finance Committee meeting, Oklahoma City.

A meeting of the Finance Committee was held covering the subject of reimbursement methods for providing co-occurring treatment.

April 14, 15, & 16, 2005. LD Barney, Program Specialist attended an ASAM conference.

Discussions centered on providing co-occurring treatment to clients. At this meeting, sound research was discussed that positively supported ODMHSAS’s plan to provide DTR in treatment settings in the community.

April 22, 2005. Training Committee meeting, Oklahoma City.

At this meeting of the Training Committee the discussion from the previous meeting continued. The identification and selection of training materials and questions about how the training would be implemented at the model sites were discussed.

April 22, 2005. Screening and Assessment subcommittee, Oklahoma City.

There was a general meeting to discuss methods for providing oversight and integration for all the other subcommittees In addition, the Screening and Assessment Committee continued to work on an integrated screening instrument which will be used at the model sites.

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May Activities

May 4, 2005. Workforce Development meeting, Oklahoma City.

Members of the Workforce Development Committee from several of the COSIG project sites and consumers met to discuss licensure and basic compensation for co-occurring eligible programs.

May 5 & 6, 2005. DTR Trainings, Oklahoma City.

Two DTR trainings were conducted at the NAMI 18^th Annual conference 2005, Recovery in Progress.

May 6, 2005. COSIG meeting, Tulsa.

There was a COSIG meeting held at TCBH at 1 pm. At this meeting, COSIG staff added a Domestic Violence provider (DVIS) to provide services for domestic violence victims and batters. A representative of Family & Children’s’ was informed that their agency is a member of the Tulsa pilot providers.

May 10, 2005. Training Committee meeting, Oklahoma City.

Training Committee met to review the curriculum provided by Minkoff and Cline for an integrated model of treatment.

May 11, 2005. Screening and Assessment Subcommittee meeting, Tulsa.

The committee continued the discussion on the items and subscales within the ODMHSAS Integrated Screen.

May 12, 2005. Finance Committee meeting, Oklahoma City.

The Finance Subcommittee meeting resulted in recommendations to explore reimbursing Substance Abuse treatment providers who treat people with a co-occurring disorder the same amount that is reimbursed for Mental Health services for a person with a mental disorder. It was noted that there is a $65 to $70 difference between reimbursement for SA and MH services reimbursement.

May 18, 2005. Evaluator meeting with Support Services, Oklahoma City.

At this meeting, the discussion focused on the structure of the ICIS database, the elements that would be needed to evaluate the impact of the COSIG project, HIPAA compliance, and the form in which the data would be provided to the principal investigator of the evaluation project.

May 23-26, 2005. Dr. Minkoff and Dr. Christie Cline conducted trainings

Drs. Minkoff & Cline conducted trainings on their Comprehensive Continuous Integrated System of Care (CCISC) model in Tulsa, Tahlequah, and McAlester on the 23^rd, 24^th, and the 25^th of May.

May 23, 2005. A lunch meeting with Dr. Minkoff, the COSIG staff and the Project Evaluator

At this meeting it was agreed that Dr. Minkoff’s fidelity tools would be included as data in the overall Project evaluation plan.

May 24, 2005. Teleconference with Don Baker, Evaluation Project Consultant.

Planning for submission of the COSIG Evaluation application with the OU IRB.

May 24, 2005. Teleconference with Howard Vogel, DTR.

Discussion of DTR’s role in the pilot projects and its interface with the COSIG evaluation.

May 25, 2005. SAMHSA WebCast.

This WebCast focused on The Role of Prevention in Addressing Co-Occurring Substance Use and Mental Health Disorders.

May 25, 2005. Screening and Assessment subcommittee meeting, Tulsa.

Meeting at 12 & 12 to finalize methodology used to gather data on the screening instrument to begin to test the validity and reliability of the ODMHSAS Integrated Screen.

May 26, 2005. Dr. Minkoff and Dr. Christie Cline conducted a wrap-up meeting with the ODMHSAS administration staff.

This wrap up session for the ODMHSAS administration staff on May 26^th at the Central Office reviewed the progress that has been made, and offered suggestions that could facilitate the efforts.

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June Activities

June 1, 2005. Screening and Assessment meeting, Tulsa.

The discussion at this meeting revolved around the ODMHSAS Integrated Screen meeting HIPAA regulations and whether the service contracts with ODMHSAS would cover the cost of administrating the ODMHSAS Integrated Screen.

June 3, 2005. Teleconference with Sonya Brindle, Oklahoma University, Institutional Review Board.

Discussion regarding tentative evaluation plan for the submission of the COSIG Evaluation application with the OU IRB.

June 7, 2005. Teleconference with Jennifer Freeman at Family & Children’s, Tulsa.

Discussed the methodology being used to test the screening instrument and the best ways for the agency to implement this data gathering process at their agency.

June 8, 2005. SAMHSA WebCast.

This was an important WebCast because it was on the use of the ASAM and client placement criteria.

June 10, 2005. ISI Advisory Committee meeting, Oklahoma City.

At this meeting each of the subcommittees reported on the work that they were involved in to date.

June 16, 2005. SAMHSA, COSIG Evaluation Symposium Teleconference.

Progress on the evaluation projects was reviewed. Problems conducting large scale evaluations and strategies were discussed.

June 16 & 17, 2005. NAMI sponsored DTR training for Recovery Support Specialist, Oklahoma City.

This was a two day training of Recovery Support Specialists. The Recovery Support Specialists are consumers who have been hired by individual mental health treatment programs, paid for out of a supplemental grant from ODMHSAS.

June 17, 2005. NAMI sponsored DTR training for Recovery Support Specialist, Oklahoma City.

Evaluator spent the day observing the training of the Recovery Support Specialists in OKC

June 22, 2005. Teleconference with Melody Riefer, Director, Office of Consumer Affairs.

Planning for how the COSIG evaluation will identify and measure the contributions of the Recovery Support Specialist at the COSIG pilot.

June 28, 2005. Teleconference with Todd Crawford

Discussed the implications and procedure for making changes in Chapter 30 so as to implement integrated services.

June 29, 2005. Screening and Assessment meeting, Tulsa.

At this meeting, now that the pilot test for the ODMHSAS Integrated Screen was under way, the committee moved on to a discussion and review of assessment instruments and how they would be used in conjunction with the screen.

Summary of the work of the ISI Advisory Group subcommittees

A great deal of work was accomplished by the five ISI Advisory Group subcommittees. During this 3^rd quarter the subcommittees met 12 times and the ISI Advisory Group committee met once. During these meetings the subcommittees identified tasks and the work that they were responsible for completing. Although there is a great deal of work to be completed, the subcommittee structure is producing good results as you will note in this summary. Continued collaboration with these subcommittees and other shareholders will provide direction and guidance in making the integrative initiative a reality. The subcommittee’s combined effort will also contribute and help shape the design of the evaluation plan.

The PowerPoint presentation that was distributed for the June 10, 2005 meeting of the ISI Advisory Group can be viewed from this link Oklahoma Integrated Services Initiative (OISI) progress report.

The committees of the ISI Advisory Group and their work that will be presented in this section are:

1. The Workforce subcommittee,

2. The Training subcommittee,

3. The Screening and Assessment subcommittee,

4. The Evaluation subcommittee,

5. The Financial subcommittee, and

6. The Systems Integration subcommittee.

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The Workforce subcommittee

The committee began its work by defining the broad tasks it will work on. The committee will first examine issues related to programmatic level of competencies, and then licensure and credentialing issues.

The first task was to define the proposed competency-skill levels of clinicians working at programs that provide basic, intermediate, and fully integrated services to people with a co-occurring disorder. The committee agreed that the competency levels should be derived from the core values, principles, and language found in SAMHSA’s publication, TIP 42 (starting on page 56). The core values, principles, and language from TIP 42 will be slightly revised to be Oklahoma specific. An example of the values and components of the recovery philosophy are:

Values.

People are people first.

Need to be patient, flexible, and culturally competent.

Need to add linguistics.

Want to hire the people we serve.

Need to network with those in the community for interpretive services.

Must state a recovery philosophy.

Recovery Philosophy.

Recovery is a belief that it is possible and lifelong.

It can be a reality.

People must take individual responsibility.

An example of the Oklahoma specific components that will be included in the competencies of clinicians will be taken from the OK Recovery Collaborative. They are:

Consumer Driven

Recovery Oriented

Committed to providing the highest quality care.

Utilize integrated data systems, policies, and procedures.

Easily Accessible

Efficient purchasing of healthcare maximizes limited resources.

The Workforce subcommittee produced a document that delineates the level of learning and competency that will be expected from agencies and clinicians who provide services for people with co-occurring disorders, called Workforce Development Competencies (May 21, 2005). This document can be found in Appendix A in this quarterly report.

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The Training subcommittee

The work of the Training subcommittee was coordinated with the Workforce subcommittee. Once the competencies were identified by the Workforce subcommittee, the Training subcommittee set about the work of identifying educational components that would train practitioners at specific levels of competency: the core level, intermediate level, and advanced level of learning. The document that was reported out of the committee, the Educational Training Outline can be found in Appendix B of this 3^rd Quarterly Report.

At subsequent Workforce committee meetings discussions focused on how to implement the training, how to include training in trauma, and motivational interviewing. Discussions were also initiated related to selecting Change Agents that will be involved in the training and Integrative State Initiative. Doctor Kenneth Minkoff will begin a two day “train the trainer” workshop, August 17^th & 18^th.

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The Screening and Assessment subcommittee

During the 3^rd Quarter the work on the one page ODMHSAS Integrated Screen continued. The committee’s work agenda called for the development and preliminary testing of the ODMHSAS Integrated Screen. In this process, committee members reviewed other scales that are being used around the country to screen and assess people with substance abuse and mental health disorders. For example, the DALI and DALI modified, the MINI Short and the MINI modified, and the SSI-SA were reviewed for possible use in part or in whole. A review of the scales has been completed by the SAMHSA Center for Co-Occurring Excellence. The matrix for evaluating screening instruments that describes these screening instruments can be found in the Appendix of the Second Quarterly Report.

Of the short screens that are being used in the field, the UNCOPE was viewed as an example of a very good six question screen to the detect possibility of a substance problem.

Committee members went over each question on the ODMHSAS Integrated Screen. This process was completed over two committee meetings. The final version was kept to a one page instrument with 16 questions.

The committee also reviewed the plan to determine the reliability and validity of the ODMHSAS Integrated Screen that was developed by the evaluator.

HIPAA rules that could be applicable to the process of gathering data and the data collected were discussed in depth. For the pilot study of the ODMHSAS Integrated Screen no HIPAA restricted information will be gathered. The data gathered will be de-identified at the site where pilots of the ODMHSAS Integrated Screen will be carried out. The program sites where the ODMHSAS Integrated Screen will be tested, will keep a control list of the identification number on the ODMHSAS Integrated Screen that will match the person screened so that at a later point in time, the results of the ODMHSAS Integrated Screen can be compared to the full assessment conducted when the person is admitted for treatment. As would be expected, not all who are screened will be admitted, even so by matching the findings of the ODMHSAS Integrated Screen with the ASI or CAR Scale will provide a concurrent validity measure of the ODMHSAS Integrated Screen.

Initially, the Tulsa program called 12 & 12 began piloting the scale May 31, 2005. A week later the Tulsa program at Family & Children’s Services began collecting data for the pilot. Starting in July the Oklahoma program, Northcare will begin gathering data on the screen. At the June 26 meeting, 12 & 12 reported that they had completed 100 screens. Additionally, 38 refused to participate. Of these approximately 30 were already in the mental health system and had no domestic violence problems. This suggests that at least 30 (73%) of the individuals who refused had been treated for a mental illness and were calling 12 & 12 for help with a substance abuse problem

A standard introduction is read to the caller and if the caller agrees to participate, in addition to the items on the screen, the date completed, gender, and race/ethnicity are the only additional information collected on the ODMHSAS Integrated Screen. A copy of the ODMHSAS Integrated Screen that is being piloted can be found in Appendix C.

Plan to test the ODMHSAS Integrated Screen

The plan to test the reliability and validity of the OK-COD Screen that is being developed will be fairly comprehensive but not unduly complicated. The process to establish reliability and validity will start with the programs 12 & 12, Family & Children, and Northcare intake staff collecting approximately 400 completed ODMHSAS Integrated Screens. The response to each item and demographic information will be entered into an SPSS 11.01 data file by case.

The first step in the analysis, after data management tests have confirmed the veracity of the data file, will be to check the domains: substance abuse, mental health, and trauma/domestic violence. The factor analytical program in SPSS will be used to determine the factorial validity of the three scales. This procedure will determine if the items in each of the three domains are unique enough to their particular domain to be defined by their factorial loadings. First, Principal Component analysis will be used in conjunction with the Varimax rotation. This analytical procedure will identify items that may be tapping into more than one domain. Basically, this analysis will reveal items that have factorial loadings that differentiate them from the other domains.

Once identified as a set of items that have some degree of factorial validity, they will identify the three specific domains; the SPSS reliability analysis will be used to determine the Alpha Reliability Coefficient for each of the three scales. During this procedure, weak items that reduce the overall reliability will be evaluated and possibly rewarded or discarded. Items that reduce the value of the Alpha Coefficient for a scale will be discarded if the integrity of the scale can be maintained without the item.

To determine face validity for each scale, the history of the construction of the scale was taken into consideration. The items used in the ODMHSAS Integrated Screen were taken or are found in other recognized scales that measure substance abuse, mental health, and domestic violence/trauma. This activity supports a claim of face validity.

At a later date, concurrent validity will be determined by comparing the findings of the ODMHSAS Integrated Screen with the ASI from SA providers and the CAR from MH facilities currently being used by 12 & 12, Family & Children, and Northcare. This will be a smaller sample because of the time delay between asking for services and being admitted to a treatment program. The 12&12 staff suggested that 1 in 10 people who call for help are admitted for treatment and given a full assessment.

The same procedure will be used at all three agencies. Once the data has been collected, the results of the reliability and validity from each agency will be compared. This will provide some measure of what the reliability will be when the providers around the state begin to use the screen.

Based on the preceding analyses, the evaluator will be able to make a fairly informed statement as to the reliability, and validity of the ODMHSAS Integrated Screen.

Based on past experience, the scales in the screen will probably have moderately good reliability somewhere in the .60 to .80 Alpha range. If it is not a reliable or valid screen, more work will be needed from the committee and the screen will need to be retested.

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Questions to be used in the validation of the ODMHSAS Integrated Screen

The data collected on the ODMHSAS Integrated Screen in addition to the questions used to screen. Data on these questions will not break HIPAA rules.

Sociodemographics

age,

gender,

education, and

race/ethnicity

Validity questions

A. How did the ODMHSAS Integrated Screen compare to the full screen used by the agency?

1. Did the ODMHSAS Integrated Screen match the full screen on detecting mental illness?

2. Did the ODMHSAS Integrated Screen match the full screen on detecting domestic violence and trauma?

3. Did the ODMHSAS Integrated Screen match the full screen on detecting substance abuse or misuse?

B. How did the ODMHSAS Integrated Screen compare to the full assessment used by the agency? This validity check will come later because the individual being screened will not go through a full assessment until they are admitted to the treatment program.

The unique number used on the ODMHSAS Integrated Screen will provide the identification necessary to match the outcome of the ASI and CAR. The information on the ASI or CAR is collected on the ICIS intake data form. An extracted data file of the cases used to test the ODMHSAS Integrated Screen with case ASI or CAR data will be used to test concurrent validity.

1. Did the OK-Integrated Screen match the full assessment on detecting mental illness?

2. Did the OK-Integrated Screen match the full assessment on detecting domestic violence and trauma?

3. Did the OK-Integrated Screen match the full assessment on detecting substance abuse or misuse?

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The Finance subcommittee

The Finance subcommittee reports that there are clear and distinct differences between mental health treatment providers and substance treatment providers that may be difficult to overcome without some major changes at the provider agency level or at the funding level.

One issue is the different assessment tools used by the two types of treatment providers (substance abuse treatment and mental health treatment). More mental health consumers are eligible for mental health funding and reimbursement via Medicaid, (e.g., the disability classification, inability to work, etc.) than consumers of substance abuse treatment; therefore, third party reimbursement for substance abuse treatment is often limited to the ODMHSAS substance abuse contract monies, private insurance, and Medicare.

Another issue is that many substance abuse treatment facilities utilize unlicensed Certified Alcohol and Drug Counselors (CADC) to provide substance abuse treatment to dually diagnosed individuals. The Oklahoma Health Care Authority does not reimburse for services that are provided by CADCs. If the substance abuse facility utilizes a licensed mental health professional, however, the facility would be able to bill Medicaid (assuming the consumer is TXIX eligible) but would bill under a mental health code.

An important issue that has come up in several meetings and workshops, including the program planning meetings conducted in March is that most substance abuse facilities do not have access to a doctor, and would have to refer the medication services to a mental health facility.

The committee recommended that ODMHSAS continue to encourage community mental health treatment providers to become certified to provide substance abuse treatment. It was also noted that substance abuse treatment facilities are seeking to hire licensed counselors, but practitioners with these credentials are in short supply. This makes it even more important that service providers develop a network with other providers.

The committee also recommended that an enhanced Medicaid rate specifically for co-occurring treatment services be developed. This rate would reflect the additional cost involved in assessment and treatment for both mental health and substance abuse. The committee suggests that residential reimbursement for those with a co-occurring disorder should be the same as paid for a person receiving residential treatment for a mental health problem.

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Evaluation subcommittee

There were a number of informal meetings among members of the Evaluation subcommittee. At a meeting in April preliminary plans for the development of the Evaluation subcommittee were discussed and members proposed. Tasks were identified that would help guide the COSIG program evaluation.

At a second meeting with David Wright and other Support Services personnel, and Mark Reynolds and the Evaluation and Data Analysis Section personnel met to discuss the structure of the ICIS database, the elements that would be needed to evaluate the impact of the COSIG project, HIPAA compliance, and the form in which the data would be provided to the principle investigator of the evaluation project.

The ICIS data is actually kept in several files that are separate from each other. Mark Reynolds, however, will be able to combine these data fields into one data file. His group puts together data file extracts from the different sources on a regular basis for other Department sections that need the information. An IRB application will need to be submitted with the OU IRB and with ODMHSAS IRB clearly delineating the data elements to be included in the extracted data file and how the data file will be HIPAA compliant. A brief overview of the HIPAA legislation can be found in Appendix D.

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Systems Integration subcommittee

During this Quarter, the Systems Integration subcommittee reviewed the purposes and goals of the system integration efforts. The committee also reviewed membership of the other ISI Advisory Group subcommittees and made several recommendations. The committee is also developing a Memorandum of Understanding that will support the collaboration and integration of care across all participating agencies in the model program sites. Dr. Minkoff & Dr. Christie Cline made several recommendations. Work on amending Chapter 30 was begun with suggested wording from Drs. Minkoff and Cline.

One of the committee’s major tasks will be to take the recommendations of the other ISI Advory Group subcommittees and develop strategies to implement the subcommittee recommendations. Committee members agreed to set a regular meeting schedule of the 3^rd Friday in each month.

Overview of COSIG Evaluation plan

Fidelity Assessment

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.

Progress: The subcommittee structure that was put in place last quarter has been very productive in this 3^rd quarter. The information and observations of the roadblocks to the systems integration effort that is coming out of these subcommittees will be valuable in developing strategies that will result in an integrated treatment system.

Three days of training provided by Dr. Minkoff & Dr. Christie Cline to the pilot sites in Tulsa and the Vinita area on their Comprehensive Continuous Integrated System of Care (CCISC) means that providers at all of the pilot site have received training on the integrated system of care.

The three assessment tools developed by Minkoff and Cline (the Co-occurring Disorder Educational Competency Assessment (CODECAT), the CCISC Outcome Fidelity and Implementation (COFIT), and the Agency Self-Survey (COMPASS) will be incorporated in the evaluation of the pilot sites as baseline and outcome data.

Analysis of four program planning meetings at the two COSIG pilot sites

During the second quarter two program planning meetings were held in Norman and two were held in Tulsa. Those attending the planning meetings instituted by the evaluator were administrators and clinicians from the pilot programs. These planning sessions were held in Norman on March 10, 2005, and in Tulsa on March 23, 2005. There were two sessions per day, one in the morning and one in the afternoon. The following is a summary of the findings. The purpose of the planning meetings was twofold. They would be useful for collecting baseline information for stage one of the fidelity evaluation. They would also present an opportunity to begin to establish a platform for developing a common understanding about integrated services that are necessary for affective treatment in the case of people with a co-occurring disorder.

Several questions guided the program planning sessions. For example, three broad questions were: What do you think of when you hear the term co-occurring disorders?” What type of treatment interventions and approaches have you heard of that might be useful in treating people with co-occurring disorders? What will we need to do to be able to provide integrated-services to people with a co-occurring disorder?

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In the view of the participants at these four sessions there were a number of issues that would need to be addressed to provide adequate treatment in an integrated treatment system.

1. There is a serious manpower issue:

Hiring professional staff is difficult because of the level of compensation in Oklahoma than in surrounding states. It is going to be difficult to attract and maintain a cohort of credentialed specialists to treat people with co-occurring disorders given the current level of compensation.

Professionals are an integral part of an integrated service system; however, there is also a need for more community based services that include peer support services.

The question needs to be asked, if we did things differently and used other effective services in addition to talk therapy could we improve treatment effectiveness for people with a co-occurring disorder?

2. Lack of coordinated services:

A major problem identified is with the coordination of the different kinds of services to provide a continuum of services. The lack of coordination between detox treatment and residential treatment reduces the effect of both services.

There is a disconnect between residential, outpatient, and community support services that will need to be overcome before integrated-services can be provided.

3. The current infrastructure of mental health and substance abuse programming needed to support treatment gains from the COSIG initiative is inadequate.

While the component programs of the infrastructure are present for the most part at the pilot sites, the coordination among these programs is extremely weak and no one entity has responsibility for coordinating services to provide a vital component to recovery from a co-occurring disorder--“a continuum of care and services.”

The coordination among service programs that could provide a therapeutic transition from detoxification to residential or outpatient treatment is inadequate to support treatment gains made during detoxification. Additionally, the coordination of services between residential and outpatient programs, and community support services is inadequate to maintain treatment gains made during residential or outpatient treatment.

4. Lack of Community Capacity.

A current problem is the lack of treatment capacity.

5. Lack of Psychiatric Support Services:

Substance Abuse providers need access to psychiatric services (Psychiatric evaluation and medication evaluation) when the assessment suggests the involvement of psychiatric issues. Then they will need maintenance services for their client.

6. Staff training is needed.

In addition to hiring credentialed professionals to work providing services to people with a co-occurring disorder, there is the issue that the clinical people already working in agencies will need quality training. Currently clinicians are either trained as substance abuse counselors or mental-health practitioners.

7. Rural areas will have fewer resources to implement treatment for people with the Co-Occurring disorder.

8. The consensus among the participants was that over the next couple of years agencies and staff will embrace the integrated approach for treating people with the co-occurring disorder.

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Process Evaluation

The process evaluation will record the composition of the OISI Leadership Group and the ISI Advisory Group, and the progress made during this first year of planning and preparing for the evaluation at the pilot sites.

Progress: A great deal of progress has been made in this quarter. The committee and subcommittee structure is beginning to solidify and has the potential for giving direction, guidance, and motivating the State efforts to integrate services provided by the mental-health treatment community and the substance abuse treatment community.

Organizing the process of data collected by subcommittee area of responsibility has evolved into an effective tool for moving the implementation process forward. There continues to be a need to refine the process but it has been given a great deal of structure in the collection of process evaluation information and data.

Training. Professionals at the three pilot sites have been provided training by Dr. Minkoff & Dr. Christie Cline on their Comprehensive Continuous Integrated System of Care (CCISC). The following is a summary of the evaluation of the trainings by the individuals who attended. The full report of this evaluation was compiled by the Evaluation and Data Section of ODMHSAS.

In summary, it is clear that Dr. Minkoff & Dr. Christie Cline did an excellent job at the trainings they provided in March and May. The participants indicated that they learned a great deal and have a better understanding of integrated-services needed by people with a co-occurring disorder. The following are a few highlights from the report.

§§§§§§§§§§§§§§§§§

Evaluation of the regional planning and preparation for persons

with co-occurring disorders

Dates, places, and the number of people attending the workshop.

March 29, 2005 – Woodward, 27 participants

March 30, 2005 – Lawton, 21 participants

March 31, 2005 - Oklahoma City, 50 participants

May 23, 2005 – Tulsa, 29 participants

May 24, 2005 – Tahlequah, 14 participants

May 25, 2005 – McAlester, 6 participants.

The self identified, professional background of the people attending the workshops was well proportioned to those professionals in the treatment community and that the pilot sites.

40 attended; 29.4% of the total trained were LPC/LMFTs

39 attended; 28.7% of the total trained were CADCs

31 attended; 22.8% of the total trained were Social Workers

12 attended; 8.8% of the total trained were RNs or LPNs

2 attended; 1.5% of the total trained were Students

1 attended; 0.7% of the total trained was a Physician

1 attended; 0.7% of the total trained was a Psychologist

30 attended; 22.1% of the total trained who did not fit in one of the categories above.

Overall ratings for all six workshops

Among those who evaluated the workshops

No one rated the workshops as Poor

7 or 4.8% rated the workshops as Fair

60 or 40.8% rated the workshops as Good

80 or 54.4% of the participants rated the workshops as Excellent

Speaker evaluation: Minkoff – comments from participants

Excellent presentation style delivery, obviously well versed in practice situations.

It was an outstanding presentation. One of the best workshops I have attended in 2-3 years.

Validating of Mental Health Service system deficient & provided hope of change & identified opportunities to initiate change.

Enjoyed the resources provided.

Used dry humor and straight talk to address serious issues and maintain interest of audience.

Talked too much and too long.

After lunch the info was dry & hypothetical.

Rarely let other presenter talk

It was over my head. Not the dual diagnosis part but the other info seemed more for my bosses.

Missing/incomplete handouts initially.

Not enough group interaction.

Talked way too much.

Talked way to fast at times. Very knowledgeable & has good info to pass along but too much at once.

Speaker evaluation: Christine Cline– comments from participants

Could be a little more charismatic but you have a wonderful calmness & understanding of subject matter.

Great and well done presentation.

It was refreshing to hear someone identify how clinicians feel (frustrated) with our existing OFMQ system of too much control and not enough of working as a team to help cunsumers on their level of needed care & how agencies are in non-compliance of state regulations for client care.

I am excited about the direction that Dr. Cline is taking the state with Co-Occurring consumers. She does a great job.

Obvious great depth of knowledge about practical issues of practice as well as philosophy of treatment.

Did not get to talk enough.

Too dry " We have to Challenge" is NOT a workable solution.

First time hearing about this topic should have slowed it down less information presented slower.

Comments regarding future training

More on Co-Occurring Treatment. Treatment of borderline personality disorders.

What is treatment completion in a dual diagnosis program? What would the criteria be?

More on Mental Illness and Chemical Dependency Disorders among people with the Co-Occurring disorder.

Dual Diagnosis, SAMHSA access information.

Motivational Interviewing.

2 Months

· In the first two months of funding, a co-occurring disorder training specialist will be hired (Activity 1.2.1).

Status: Completed. Dr. Khepra Khem was hired as the training specialist on January 6, 2005. Andrea Vigil was hired January 24, 2005.

3 Months

In the first three months after the award date, a contract will be executed with Drs. Cline and Minkoff to provide technical consultation (Activity 1.1.1.)

Status: Completed in February and was extended to a two year contract. The contract is in the final stage of being concluded.

In the first three months after the award date, the State’s licensure bodies and the ODMHSAS will complete their review of the licensure/credentialing requirements (Activity 2.2.1).

Status: This work continues. The Workforce subcommittee is working on licensure/credentialing requirements. They are in the process of identifying competency levels that will be used in the credentialing process.

In the first three months after the award date, the ODMHSAS and the Contracts Division will complete their review of contracting procedures and rules, and issue a report of their findings.

Status: This task is being worked on by the Finance subcommittee of the ISI Advisory Group.

In the first three months after the award date, ODMHSAS Contracts Division will have reviewed existing contracting procedures and will produce a report and a set of recommended changes.

Status: In progress.

A Quarterly report will be produced each quarter. The first quarterly report is due January 10, 2005.

Status: The first quarterly report was submitted on January 10, 2005. The second quarterly report was submitted on April 10, 2005. Third quarterly report will be emailed to the COSIG staff on July 10, 2005. A hard copy will follow.

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 ISI Advisory Group.

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Objectives by Timeline for the next Six months.

6 Months

First six months after the award date, the OK-COSIG Advisory Group will approve of a screening and assessment protocol for implementation in the selected pilot sites (Activity 1.1.2 thru Activity 1.1.4).

Status: This task has been moved to the ISI Advisory Group subcommittee on Screening and Assessment. The ODMHSAS Integrated Screen is being piloted at three agencies. Data from this pilot of the ODMHSAS Integrated Screen will be collected and analyzed in the next quarter.

First six months after the award date, the OK-COSIG Advisory Group will receive an overview and training in the integrated treatment model (Activities 2.1.1 & 2.1.2).

Status: Completed. The ISI Advisory Group subcommittee on training submitted their Educational Training Outline to the ISI Advisory Group in June, 2005. This document can be found in Appendix B of this 3^rd Quarterly Report.

First six months after the award date, the [licensure bodies] and the ODMHSAS will modify and approve changes to the licensure/credentialing requirements (Activity 2.2.2).

Status: This task is in progress. The Workforce subcommittee is dealing with this issue.

First six months after the award date, ODMHSAS and the Oklahoma Health Care Authority (OHCA) will complete their review of rules defining billable services and will issue a report of their findings (Activity 2.2.3).

Status: This task is in progress. The Systems Integration subcommittee has begun the work on the language needed in Chapter 30 to develop an integrated system of service.

First six months after the award date, the ODMHSAS and the Contracts Division will publish the changes to the contracting procedures used to fund mental health and substance abuse treatment providers.

Status: The work on contractual procedures used to fund mental health and substance abuse treatment is still in its earliest phase.

9 Months

Within 9 months, the training specialist and 10 staff members will have received train-the-trainer training from the consultants (Activity 1.2.2).

Status: Dr. Minkoff & Dr. Christie Cline will provide the train-the-trainer workshops in August of 2005

First nine months after the award date, the OK-COSIG Advisory Group will approve an integrated treatment model for the pilot sites (Activities 2.1.3 & 2.1.4).

Status: A great deal of progress has been made on this deliverables and it should be completed before the end of the next quarter.

Within nine months of the award date, the ODMHSAS contracting division will modify existing rules and procedures.

Status: Much progress has been made on this task but additional work is needed. This task needs to be completed before the pilot study begins.

12 Months

Within 12 months, 80 percent of clinical staff at the selected pilot program sites will have received training in the use of the screening and assessment protocol (Activity 1.2.3).
Within the first year after the award date, the co-occurring disorders training specialist and selected staff will have been trained in the integrated treatment model (Activity 2.4.1).
First year after the award date, the ODMHSAS and OHCA will publish changes to the rules covering billable services that include substance abuse treatment, group counseling and case management services (Activity 2.2.4).
The necessary modifications to the ICIS system to collect additional measures will be done during the first year of funding.
Self-report instruments to assess these areas will be developed over the course of the first funding year with consultation from ZiaLogic and with input from the OK-COSIG Advisory Group.
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.
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.

Progress on Project Goals and Objectives

Goal 1.

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.

Status:

The ISI Advisory Group subcommittee on Screening and Assessment has completed its work on identifying a potential screen. The ODMHSAS Integrated Screen is being piloted at three agencies to determine the validity and reliability of the instrument. The work on the instrument should be complete before the end of the next quarter.

Objective 1.1 –

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.

Status:

Discussions of screening and assessment tools have been a central theme at committee meetings. The process for using the screen is still in rough draft form. The plan is for the screen to be used by intake workers at both substance abuse treatment centers and mental health treatment centers.

Resources:

The experience of other states in trying to develop a screen, the information provided by SAMHSA’s Center for Co-Occurring Excellence, and research methodology used to validate psychometric scales is being employed in the pilot test of the ODMHSAS Integrated Screen.

Objective 1.2 –

Train all mental health and substance abuse treatment providers in the screening and assessment protocol.

Status:

This work is pending. When the screening and assessment protocol has been determined, the training will begin.

Resources:

COCE and other COSIG states have begun this process and we will utilize the lessons they have learned so far.

Goal 2.

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.

Status:

The work to develop an Oklahoma model of integrated treatment for people with a co-occurring disorder in Oklahoma has been well informed and supported by the Comprehensive Continuous Integrated System of Care (CCISC) that has been designed by Dr. Minkoff.

Resources:

The National Policy Academy on co-occurring mental and substance abuse disorders that met in January 2005 with the ODMHSAS leadership helped 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.

Objective 2.1 –

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.

Status:

During the 3^rd quarter, more than 80 clinicians and staff members from the substance abuse treatment and mental health treatment communities participated in training on the Comprehensive Continuous Integrated System of Care (CCISC) provided by Dr. Minkoff & Dr. Christie Cline.

Resources:

Service Planning Guidelines for Co-Occurring Psychiatric and Substance Disorders, developed By Dr. Minkoff, April, 2005.

Objective 2.2 –

Establish joint licensure/certification and funding processes for both mental health and substance abuse staff.

Status:

Establishing joint licensure/certification is in the early discussion stage. This will be an issue that the ISI Workforce subcommittee will work on during the next quarter.

Resources:

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.

Objective 2.3 –

Develop contracting procedures that create strategic incentives for the implementation of integrated treatment systems at the provider level.

Status:

Work on this objective is in the early planning stage.

Resources:

There is some information on using strategic incentives coming out from the other COSIG states that will be useful in accomplishing this objective.

Objective 2.4 –

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.

Status:

The ISI Advisory Group subcommittee on training has developed an Educational Training Outline that will provide additional training.

Resources:

Service Planning Guidelines for Co-Occurring Psychiatric and Substance Disorders, developed By Dr. Minkoff, April, 2005.

Tip 42 which is titled: TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders. The material in this manual will be included in the training curricula. The Treatment Improvement Protocols (TIPs), was developed by the Center for Substance Abuse Treatment (CSAT), part of SAMHSA which is within the U.S. Department of Health and Human Services (DHHS). This manual provides information on the empirically based best-practice guidelines for the treatment of substance use disorders.

The TIP 42 manual can be downloaded from the internet and it is free. The internet address is: http://media.shs.net/prevline/pdfs/bkd515.pdf

Emerging Themes

During this third quarter, a great deal of work was accomplished. This work resulted by building on the efforts put forth over the first two quarters. The third quarter can be defined by two major areas where accomplishments were the greatest, training, subcommittee work, and the development and testing of the ODMHSAS Integrated Screen.

Engaging the community of mental health treatment and substance abuse treatment providers

The intensive training over the last nine months in combination with presentations at statewide conferences, and provider meetings held by the ODMHSAS to inform the provider community about the purpose and objectives of the Integrated State Initiative (ISI) has been extremely successful. Based on an informal survey of substance abuse treatment and mental health treatment providers, there is widespread knowledge about the initiative to provide integrated services to people with a co-occurring disorder. While few can actually put a name to the initiative, they are aware that the Department is moving toward an integrated system of care for people with co-occurring disorders.

The empowerment of consumers

The Department’s effort to empower consumers has the potential to be very effective in the provision of mental health services. Developing the Office of Consumer Affairs within the ODMHSAS structure as a program to promote the involvement of consumers in the provision of mental health services may positively influence the outcome of clients involved in the COSIG pilot project sites. The Recovery Support Specialist Program provides a much needed mechanism for including consumers in the provision of mental health services. Although the professional literature on the consumer movement is sparse, the studies and conceptual papers that are available suggest that consumers can have a major positive effect on both treatment staff and client outcomes.

Subcommittee organization and work

The subcommittees have been very active during this 3^rd Quarter. They have identified a number of problems and strategies to deal with roadblocks and disconnects. Their work will continue over the next quarter and should be fruitful in terms of giving direction and guidance to the effort to integrate substance abuse and mental health treatment services. The question is, how will the recommendations from the committees be implemented. Given the committee structure, it seems logical that the Integrative Systems subcommittee would take these recommendations to the Leadership with strategies and practical approaches for making changes at the Departmental and contractual levels.

Pilot site program issues

Based on interviews and planning meetings, the indications are that there is a need for additional training of existing personnel at several of the pilot sites. The training outline developed by the Workforce subcommittee will be essential in this task of writing this educational training.

Based on observation and previous experience, the Memorandum of Understanding that will be endorsed by the agencies involved in the pilot projects will be helpful and give direction to the agencies. Even so, there is going to be a need for a Memorandum of Understanding at each of the pilot sites that specifically spells out the relationship between pilot programs in the region. This process could take many forms but it needs to include and have the support of the administrators of the agencies in each region. In this scenario, there are two memorandums of understanding. One memo of understanding would be between the Department and all providers of co-occurring services in Oklahoma. The second memo of understanding would be among the local providers in a region such as the Tulsa area in which the relationships between agencies would be spelled out in greater detail.

The COSIG project implementation timeline

Although a great deal has been accomplished, and the COSIG staff and ISI committee members have worked diligently, the timelines may be too short. For example, the work on credentialing in the review of contracts, and policies, that involve other state agencies will take more time to accomplish. Additionally, the groundwork for beginning the pilot study at the pilot sites may not be completed in the time proposed in the grant application. Prudence would suggest that the sites be well prepared and all the components in place before starting a pilot study on the impact of integrated services. If the start of the pilot study is delayed several months to ensure that they are in a state of readiness, it will be well worth the wait.

Postscript

During this third quarter, the activities related to the COSIG project were numerous and intense. The work needed to reach the goals and objectives continues to move ahead at a rapid pace. The length of this quarterly report is testimony to the work and activities involved in trying to implement an integrated system of service for people with a co-occurring disorder. The conundrum that makes the process difficult and complicated is that there is no schematic that provides a step by step plan for integrating the two service systems. In fact, there is a great deal of history that suggests these parallel systems of care are extremely difficult to synthesize into one server system. Even more frustrating, is the reality that an integrated system may not improve outcomes among people with a co-occurring disorder. In a plethora of studies, however, when the service needs of the individual are considered, and those services provided in an adequate regiment, persons with the mental health problem, or a substance abuse problem, or the person with a co-occurring problem of mental illness and substance addiction have increasingly better outcomes, then individuals who are placed in a standardized program to treat a disorder. The State Action Plan and the COSIG project will play a prominent role in the development of individualized services for people with a co-occurring disorder that will improve outcomes among the individuals seeking services.

APPENDIX

The documents in this Appendix are products of work completed in the 3^rd quarter.

APPENDIX A

WORKFORCE DEVELOPMENT COMPETENCIES

CORE LEVEL OF TRAINING AND COMPETENCY

Must Complete 8 Hour Training: Goals 1-4 ( see training-outline)

With 70% Mastery

Certificate Earned: Core Level COD and TRAUMA

ALL STAFF – No exceptions

INTERMEDIATE LEVEL OF LEARNING AND COMPETENCY

Education: Minimum of Bachelors in a

Mental Health related field to include:

(1) Bachelor or master in a mental health

related field including, but not limited to,

psychology, social work, occupational

therapy, family studies; or

(2) A current license as a registered nurse

in Oklahoma; or

(3) Certification as an Alcohol and Drug

Counselor. Allowed to provide substance

abuse rehabilitative treatment to those

with alcohol and/or other drug dependencies

or addictions as a primary or secondary

DSM IV Axis I diagnosis; or

(4) Current certification as a Behavioral Health

Case Manager from ODMHSAS and meets

OHCA requirements to perform case

management services, as described in

OAC 317:30-5-585(1)

Must Complete 4 days plus training Goals 5-8( see training-outline)

With 80% mastery

Certificate Earned: Intermediate COD and TRAUMA from ODMHSAS

Comprehensive Continuous Integrated System of Care (CCISC)

Ø TIP #42 (p. 58) INTERMEDIATE Co-occurring Disorders and TRAUMA Programs: Programs which by choice or lack of resources are capable of identifying individuals with co-occurring disorders at a basic level. These programs have the ability to screen for co-occurring disorders and symptoms or situations related to trauma. However, these programs have limitations by virtue of the training of their staff and facility resources and may not be equipped to provide integrated specialized services. Staff in these programs have basic clinical competencies such as:

1. Perform a basic screening to determine whether COD might exist and be able to refer the client for a formal diagnostic assessment by someone trained to do this.

2. Form a preliminary impression of the nature of the disorder a client may have, which can be verified by someone formally trained and licensed in mental health diagnosis.

3. Conduct a preliminary screening of whether a client poses an immediate danger to self or others and coordinate any subsequent assessment with appropriate staff and/or consultants.

4. Be able to engage the client in such a way as to enhance and facilitate future interaction.

5. De-escalate the emotional state of a client who is agitated, anxious, angry or in another vulnerable emotional state.

6. Manage a crisis involving a client with COD, including a threat of suicide or harm to others. This may involve seeking out assistance by others trained to handle certain aspects of such crises; for example, processing commitment papers and related matters.

7. Refer a client to the appropriate mental health or substance abuse treatment facility and follow up to ensure the client receives needed care.

8. Coordinate care with a mental health counselor serving the same client to ensure that the interaction of the client’s disorders is well understood and that treatment plans are coordinated.

v Consumers may access these programs for services when either a mental- health or substance-use problem is predominant. These programs will provide prevention- education in the community.

Ø TIP#42 (p. 60) INTERMEDIATE Co-occurring Disorders and TRAUMA Programs: The primary focus of these programs is the treatment and stabilization of individuals with co-occurring disorders and symptoms of or situations related to trauma. These programs have the ability to assess, diagnose, treat, and stabilize individuals that are unstable or significantly disabled. These programs have co-occurring disorders trained staff and the facility resources to provide intensive and integrated specialized services. Staff in these programs have intermediate clinical competencies such as:

1. Use the current edition of criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4^th edition (American Psychiatric Association 2000) to assess substance-related disorders and Axis I and Axis II mental disorders.

2. Comprehend the effects of level of functioning and degree of disability related to both substance-related and mental disorders, separately and combined.

3. Recognize the classes of psychotropic medications, their actions, medical risks, side effects, and possible interactions with other substances.

4. Use integrated models of assessment, intervention, and recovery for persons having both substance-related and mental disorders, as opposed to parallel treatment efforts that resist integration.

5. Apply knowledge that relapse is not considered a client failure but an opportunity for additional learning for all. Treat relapses seriously and explore ways of improving treatment to decrease relapse frequency and duration.

6. Display patience, persistence, and optimism.

7. Collaboratively develop and implement an integrated treatment plan based on thorough assessment that addresses both/all disorders and establishes sequenced goals based on urgent needs, considering the stage of recovery and level of engagement.

8. Involve the person, family members, and other supports and service providers (including peer supports and those in the natural support system) in establishing, monitoring, and refining the current treatment plan.

9. Support quality improvement efforts, including, but not limited to consumer and family satisfaction surveys, accurate reporting and use of outcome data, participation in the selection and use of quality monitoring instruments, and attention to the need for all staff to behave respectfully and collaboratively at all times.

ADVANCED LEVEL OF LEARNING AND COMPETENCY

Education: Masters level in a Mental Health

Related field OR Licensed Professional

MUST have Intermediate COD Certificate from ODMHSAS

Must complete 5 days plus training: Goals 9-13 (see training-outline)

With 80% mastery

Certificate Earned: Advanced COD

Ø TIP #42 (p. 59) ADVANCED Co-occurring Disorders and TRAUMA Programs: Person-centered strengths based treatment of individuals with co-occurring disorders and symptoms or situations related to trauma. For example personnel-staff have the ability to assess, diagnose, and treat co-occurring disorders and symptoms or situations related to trauma. However, these programs may have limitations by virtue of facility resources and may not be equipped to provide intensive and integrated specialized services. Staff in these programs have six areas of intermediate clinical competencies:

1. Competency I: Integrated Diagnosis of Substance Abuse and Mental Disorders.

2. Differential diagnosis, terminology (definitions), pharmacology, laboratory tests, and physical examination, withdrawal symptoms, cultural factors, effects of trauma on symptoms, staff self-awareness.

3. Competency II: Integrated Assessment of Treatment Needs. Severity assessment, lethality/risk, assessment of motivation/readiness for treatment, appropriateness/treatment selection.

4. Competency III: Integrated Treatment Planning. Goal-setting/problem solving, treatment planning, documentation, confidentiality, legal/reporting issues, documenting issues for managed care providers.

5. Competency IV: Engagement and Education. Staff self-awareness, engagement, motivating, and educating.

6. Competency V: Early Integrated Treatment Methods. Emergency/crisis intervention, knowledge and access to treatment services, when and how to refer or communicate.

7. Competency VI: Longer Term Integrated Treatment Methods. Group treatment, relapse prevention, case management, pharmacotherapy, alternatives/risk education, ethics, confidentiality, mental health, reporting requirements, family interventions.

v Consumers may access these programs when they experience problems with co-occurring disorders and trauma: the symptoms are mild to moderate severity. These programs will focus on engaging consumers as a partner in their treatment plan.

To maintain certification at Intermediate or

Advanced Level must accomplish 3 CEU hours

in COD and TRAUMA—annually.

APPENDIX B

Integrated Services Initiative (COSIG GRANT)

EDUCATIONAL-TRAINING OUTLINE

This educational-process is designed to guide staff through a series of WHOLISTIC (complete or whole) interactive-exercises that emphasize RECOVERY that is physical, mental, emotional and spiritual. Certainly, we want to protect the rights of individual expression. We intend to establish trainer-teams that will be referred to as CHANGE-AGENTS; consisting of at least three (3) people to include the lead trainer, a therapeutic professional and a Consumer-Participant. First, we will establish guidelines that use non-judgmental and supportive behavior standards for all training participants and group facilitators. Next, facilitators will avoid the inclination to play expert; realizing that adult-learners may come to the seminar with years of experience that is valuable and respected. The facilitation process is designed to be encouraging by thoroughly processing workshop content, confronting moments of discomfort and by guarding established guidelines. Remembering that successful adult-education is learner-centered, focused on relevant needs with active engagement that reinforces the information presented. These educational workshop-seminars will utilize an experiential-learning technique by stressing the importance of CASE-DISCUSSIONS and ROLE-PLAY with hands-on-practice.

Our mission is to promote a PERSON-CENTERED environment that provides treatment for the whole-person, using integrated strategies whose focus is on RECOVERY from Co-Occurring Disorders and Traumatic experiences. Our first message is: people can and do recover. However, we need a system that believes there is no wrong door. We will use the term multiple-diagnosis because we expect that mental-health and substance addictions co-exist with traumatic experiences. Therefore, multiple-diagnosis is an expectation, not an exception.

To be sure, our success greatly depends on Consumer-Participants being included at every level of program development. This engagement will ensure that we consider the concepts, thoughts, and ideas of those for whom we provide service. Consumer-Participants will be involved in all phases of these trainings, providing: input, feedback, and oversight for the integration of service. Without a doubt, this experiential-learning process is designed to guide staff through interactive-exercises using the best-evidence and consensus-based methods that are cultural and gender-competent. Further, staff will learn the strength-based person-centered skills that reinforce a WELCOMING environment that accepts the philosophy of: no wrong door and that multiple-diagnosis (COD & TRAUMA) is an expectation not an exception.

In addition, workshop-participants will learn to integrate mental health, substance-use and trauma-experiences by learning and then following The Comprehensive, Continuous, and Integrated System of Care (CCISC); which includes an integrated treatment philosophy that is based on eight evidence-based principles for successful intervention techniques. CHANGE-AGENTS will specifically include: skills for leisure, exercise and recreation; plus dental-care and information on good nutrition. PLEASE SEE THE AGENDA BELOW:

PART ONE------CORE-LEVEL OF LEARNING

All employees are to receive this level of training including: doctors, administrators, receptionists, fire-safety-security-residential, maintenance, outreach, case-management and clinical personnel

GOAL 1

Introduce the CHANGE AGENT training team to seminar-participants then introduce trainee-participants to each other. Next, introduce the new ODMHSAS philosophical approach and training-education process to seminar-participants.

LEARNING OBJECTIVES

CHANGE AGENT TEAM: self-introduction
Identify trainee-participants expertise and the representing agencies.
Describe with broad clarity the overall purpose of the educational-seminar; emphasizing the White House mandate to TRANSFORM Mental-health care in America and as it relates to Oklahoma’s system of care transformation.
Present a full GLOSSARY OF TERMS to include definitions of: medical compared to behavioral; best practice, evidence and consensus-based curricula
Define and describe with specific clarity our new philosophies:

-Multiple Diagnosis (COD and Trauma) is the expectation not the exception.

- The NO WRONG DOOR concept

- Presenting a Welcoming Environment

6. Discuss how to remove barriers for agency implementation of the CCISC Model

REVIEW LEARNING OBJECTIVES FROM GOAL 1 WITH QUESTIONS AND ANSWERS

GOAL 2

Help seminar-participants understand the need to provide INTEGRATED-SERVICES.

LEARNING OBJECTIVES

Define Co-Occurring Disorder (COD) and Trauma related issues
Reveal the high prevalence of Co-Occurring Disorders (COD) and their connection to Trauma.
Reveal its impact on treatment outcomes for both mental health and substance-use programs.
Clearly define and discover how to implement Integrated-Services.

REVIEW LEARNING OBJECTIVES FROM GOAL 2 WITH QUESTIONS AND ANSWERS

GOAL 3

Introduce the seminar-participants to the recovery-oriented system of care that promotes the strengths-based person-centered model approach to helping people.

LEARNING OBJECTIVES

Define recovery as a wholistic process that includes both physical and mental issues.
Define six principles of the strengths-based person-centered approach.
Using 2-3 case studies, seminar-participants will demonstrate via role-play: a Welcoming environment; how to interact with people by focusing on the person’s strengths; while not centering on problems or weaknesses.
Follow-up with class discussion of the role-play emphasizing the seminar-participants’ strengths while noting (without harsh criticism) how improvements could be made.
Describe and define how staff should set and maintain boundaries between them and consumers; how to help Consumer-Participants without enabling them; discuss and define consequences, if clear boundaries are not maintained.

REVIEW LEARNING OBJECTIVES FROM GOAL 3 WITH QUESTIONS AND ANSWERS

GOAL 4

Introduce the seminar-participants to cultural and gender-competent ingredients and principles.

LEARNING OBJECTIVES

Define five cultural-competent ingredients; demonstrate expected skills by using role-play to model behavior.
Define six gender-competent principles; demonstrate expected skill by using role-play to model behavior.
Using 2-3 case studies, seminar-participants will demonstrate via VIDEO-TAPED role-play, how to interact with people using cultural and gender competent skills. Seminar-participants will be required to apply the strengths-based person-centered principles during this hands-on-practice demonstration.
Follow-up with class discussion of the role-play emphasizing the seminar-participants strengths while noting (without harsh criticism) how improvements could be made.

REVIEW LEARNING OBJECTIVES FROM GOAL 4 WITH QUESTIONS AND ANSWERS

PART-TWO------INTERMEDIATE-LEVEL OF LEARNING

All professional employees are to receive this training to include: doctors, administrators, case managers, outreach and other therapist or clinical workers. Agency Directors have discretion for employee assignment to this training.

GOAL 5

To introduce seminar-participants to the (CCISC) model: COMPREHENSIVE, CONTINOUS, and INTEGRATED SYSTEM OF CARE.

LEARNING OBJECTIVES

List, define, and discuss the eight principles of the CCISC model as outlined by COSIG grant consultants: Drs. Minkoff and Cline (2005).
Identify the barriers to agency implementation;
Discuss how to remove barriers for agency implementation of the CCISC Model.
Discuss how each principle can be applied within the provider plan of action.
Define and discuss—Wholistic-healing skills to include: the 12-step program as the spiritual component; leisure, recreation, dental-care, exercise and nutrition.
Define and discuss—Wholistic self-care skills for employees working in direct services for Consumers; include discussion about how to keep from burn-out.

REVIEW LEARNING OBJECTIVES FROM GOAL 5 WITH QUESTIONS AND ANSWERS

Goal 6

Learn and DEMONSTRATE the ability to utilize a welcoming technique, for screening and assessing all persons who enter the system of care for Co-Occurring Disorders, through the use of ONE standardized instrument and approved protocol.

LEARNING OBJECTIVES:

DEMONSTRATE on video, the ability to apply the NO WRONG DOOR concept in a standardized welcoming technique to be applied to each and every person being served.
DEMONSTRATE on video, the ability to screen and assess for the presence of Co-Occurring Disorders—including Trauma.
REVIEW video-demonstration and provide FEEDBACK on the staff persons’ ability to apply the WELCOMING-NO WRONG DOOR philosophy while using the standardized protocol-instrument for screening and assessment.
REVIEW video and provide FEEDBACK on the employee’s ability to implement the methods for scoring and evaluating the SCREENING AND ASSESMENT instrument.

REVIEW LEARNING OBJECTIVES FROM GOAL 6 WITH QUESTIONS AND ANSWERS

GOAL 7

Introduce seminar-participants to the BASIC (ASAM) competencies required by program-services and clinicians.

LEARNING OBJECTIVES

Define the ASAM basic-level of care for mental health, substance-use and trauma-informed programs. These competencies have the ability to screen for mental-health, substance-use and trauma.
Demonstrate (using ROLE-PLAY with critique) the competencies required of ASAM basic-level of care programs.
Demonstrate (using ROLE-PLAY with critique) the competencies required of clinicians who work at the ASAM basic-level of care.

REVIEW OF OBJECTIVES FROM GOAL 7 WITH QUESTIONS AND

ANSWERS

GOAL 8

To introduce seminar-participants to the therapeutic technique:

MOTIVATIONAL INTER-VIEWING

LEARNING OBJECTIVES

Define Motivational Inter-viewing
Discuss approaches that enhance motivation to change behavior including how to reduce inhibitors to change, provide positive alternatives and changing the environment.
Discuss how the MI approach is used in counseling, including: clarifying the Stages of Change.
Discuss the key ingredients needed for a successful counseling agenda and style.

5. Discuss the key elements of motivational inter-viewing, including: how to respect the participants’ right to choose; self-confrontation and participant-centered counseling.

Discuss the key strategies to motivational inter-viewing including how to: express empathy, avoid arguing, roll with resistance, deploy discrepancy, and support self-efficacy building.
Define and discuss the role of AMBIVALENCE and the best method to resolving ambivalence.

8. Identify situations in which motivational inter-viewing may be useful.

9. Define and DEMONSTRATE reflective listening skills.

10. Identify and DEMONSTRATE components of motivational inter-viewing, including: Feedback, Responsibility, Advice, Empathy, and Self-Efficacy.

11. Identify and DEMONSTRATE how to avoid TRAPS and recognize change talk.

12. List and discuss common types of defensiveness and resistance displayed by participants.

13. Review methods to get around resistance and address defensiveness.

REVIEW LEARNING OBJECTIVES FROM GOAL 8 WITH QUESTIONS AND ANSWERS

PART THREE------ADVANCED-LEVEL OF LEARNING

All professional, therapeutic, and clinical personnel are to receive this training. Agency Directors have discretion for employee assignment to this training.

GOAL 9

To provide seminar-participants with examples of Consensus-based practices and Evidence-based practices in providing assistance to persons with COD and Trauma issues.

LEARNING OBJECTIVES

Describe existing common practices for Substance-use programs when dealing with mental-health issues.
Describe existing common practices for Mental-Health programs when dealing with substance-use issues.
Seminar-participants will be able to describe two examples of evidence-based models for persons with COD and TRAUMA.
Seminar participants will be able to describe two examples consensus-based practices for persons with a severe TRAUMA, mental and substance-use disorders.
Identify 3 to 6 techniques for working with persons with COD that are grounded or rooted in TRAUMA-INFORMED consensus-based and evidence-based practices.
Identify three challenges to using consensus-based and three challenges to using evidence-based practices.

REVIEW LEARNING OBJECTIVES FROM GOAL 9 WITH QUESTIONS AND ANSWERS

GOAL 10

To increase seminar-participants’ understanding of the guiding principles and essential program components for treating persons with co-occurring disorders.

LEARNING OBJECTIVES

Identify at least three needs for consumers with COD issues that are not generally covered by a substance-use program.
Identify at least three needs for consumers with COD issues that are not generally covered by a mental-health program.
Describe 3-7 essential components which are grounded or rooted in

TRAUMA-INFORMED and evidence-based practice for COD consumers.

Describe 3-6 guiding principles which are grounded or rooted in TRAUMA-INFORMED and consensus-based practice for COD consumers.

REVIEW LEARNING OBJECTIVES FROM GOAL 10 WITH QUESTIONS AND ANSWERS

GOAL 11

To introduce seminar-participants to the steps for: INCREASING THERAPEUTIC SKILLS.

LEARNING OBJECTIVES

Identify then DEMONSTRATE using role-play—at least three key principles for effective THERAPEUTIC SKILLS.
Identify at least two practices that will help seminar-participants to implement

THERAPEUTIC SKILLS using consensus and evidence-based practices.

DEMONSTRATE using role play how to use therapeutic skills while maintaining professional boundaries between counselor and consumer.

REVIEW LEARNING OBJECTIVES FROM GOAL 11 WITH QUESTIONS AND ANSWERS

GOAL 12

Introduce seminar-participants to the INTERMEDIATE (ASAM) competencies required by program-services and clinicians.

LEARNING OBJECTIVES

Define the ASAM intermediate-level of care for mental health, substance abuse and Trauma-informed programs. These competencies have the ability to screen for mental-health, substance-use and trauma.
Demonstrate on video the competencies required of ASAM intermediate-level care professionals other than Clinicians.
Demonstrate on video the competencies required of Clinicians at the ASAM intermediate-level care.

REVIEW LEARNING OBJECTIVES FROM GOAL 12 WITH QUESTIONS AND ANSWERS

GOAL 13

Introduce seminar participants to the ADVANCED (ASAM) competencies required by program-services and clinicians.

LEARNING OBJECTIVES

Define the ASAM advanced-level of care for mental health, substance abuse and trauma-informed programs. These competencies have the ability to screen for mental-health, substance-use and trauma.
Demonstrate competencies required of ASAM advanced-level of care programs.
Demonstrate the competencies required of the clinicians at the ASAM advanced-level of care.

REVIEW LEARNING OBJECTIVES FROM GOAL 13 WITH QUESTIONS AND ANSWERS

Prepared by Khepra NuRa Khem, Ph.D, L.D. Barney, Todd Crawford & June Elkins-Baker with guidance from the Integrated Services Initiative Advisory Group (ISIAG): Training Sub-Committee

APPENDIX C

ODMHSAS INTEGRATED SCREENING FORM

Mental Health___________________________________________________________

Within the last 90 days (3 months) have you had a significant period in which you have:

1. Experienced serious depression (felt sadness, hopelessness, loss of interest,

change of appetite or sleep pattern, difficulty going about your daily activities)? Yes No

2. Experienced serious anxiety or tension

(felt uptight, unreasonably worried, inability to feel relaxed)? Yes No

3. Experienced hallucinations (heard or seen things others don’t hear or see)? Yes No

4. Experienced thoughts of harming another person

or had trouble controlling violent behavior, or rage? Yes No

5. Experienced thoughts of harming yourself? Yes No

6. Attempted suicide? Yes No

7. Been prescribed medication for any

psychological or emotional problem? Yes No

Trauma and Domestic Violence_____________________________________________

1. Have you ever been afraid of your partner

and/or a family member? Yes No

2. Have you ever been hit, slapped, kicked, emotionally or

sexually hurt, or threatened by someone? Yes No

3. If you answered yes to questions 1 or 2, is the person who

hurt or threatened you still a part of your life? Yes No

4. Have you ever used gestures, threats, and/or thrown or broken

objects as a means to intimidate your partner or a family member? Yes No

5. Have you ever pushed, restrained, hit, slapped or used

any other physical means to harm your partner or a family member? Yes No

6. Have you experienced trauma in your life? Yes No

Substance Abuse_________________________________________________________

During the past year have you:

1. Drank alcohol and/or used other drugs more than you intended? Yes No

2. Tried to stop drinking alcohol and/or using other drugs, but couldn’t? Yes No

3. Experienced problems caused by drinking alcohol and/or

using other drugs, and you kept using? Yes No

4. Drank alcohol and/or used other drugs to alter the way you feel? Yes No

5. Been preoccupied with drinking alcohol and/or using other drugs? Yes No

6. Needed to drink more alcohol and/or use more drugs to get the same

effect you used to get with less? Yes No

APPENDIX D

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The HIPAA legislation had four primary objectives:

Assure health insurance portability by eliminating job-lock due to pre-existing medical conditions
Reduce healthcare fraud and abuse
Enforce standards for health information
Guarantee security and privacy of health information

The HIPAA legislation is organized as follows:

Title I:

Guarantees health insurance access, portability and renewal

Guarantees coverage and renewal
Eliminates some pre-existing condition exclusions
Prohibits discrimination based on health status

Title II:

Preventing healthcare fraud and abuse

Fraud and abuse controls
Administrative Simplification (AS) provisions (Subtitle)
Medical Liability Reform

Title III:

Medical Savings Accounts
Health Insurance tax deduction for self-employed

Title IV:

Enforcement of group health plan provisions

Title IV

Revenue offset provisions. The HIPAA rules and detail requirements stem from the Administrative Simplification (AS) provisions of HIPAA, which fall under Title II (Fraud and Abuse) of the HIPAA act itself.

Summary of Administrative Simplification Provisions

Standards for electronic health information transactions. Within 18 months of enactment, the Secretary of HHS is required to adopt standards from among those already approved by private standards developing organizations for certain electronic health transactions, including claims, enrollment, eligibility, payment, and coordination of benefits. These standards also must address the security of electronic health information systems.

Mandate on providers and health plans, and timetable. Providers and health plans are required to use the standards for the specified electronic transactions 24 months after they are adopted. Plans and providers may comply directly, or may use a health care clearinghouse. Certain health plans, in particular workers compensation, are not covered.

Privacy. The Secretary is required to recommend privacy standards for health information to Congress 12 months after enactment. If Congress does not enact privacy legislation within 3 years of enactment, the Secretary shall promulgate privacy regulations for individually identifiable electronic health information.

Pre-emption of State Law. The bill supersedes state laws, except where the Secretary determines that the State law is necessary to prevent fraud and abuse, to ensure appropriate state regulation of insurance or health plans, addresses controlled substances, or for other purposes. If the Secretary promulgates privacy regulations, those regulations do not pre-empt state laws that impose more stringent requirements. These provisions do not limit a State's ability to require health plan reporting or audits.

Penalties. The bill imposes civil money penalties and prison for certain violations.

Retrieved on 6-6-5 from http://www.cms.hhs.gov/hipaa/hipaa2/general/background/h3103sum.asp