SummaryThe Connecticut Department of Mental Health and Addiction Services implemented three related policies that help staff provide consistent, high-quality treatment to people with "co-occurring" (mental health and substance abuse) disorders. The policies include mandatory screening for both disorders using validated tools, a learning collaborative and evaluations to promote quality improvement, and financial incentives to clinics achieving various service benchmarks. The department also offers training to help providers with various issues related to these policies. The three policies enhanced access to high-quality treatment that has produced positive outcomes with respect to substance use and mental health symptoms.Suggestive: The evidence consists of post-implementation data on the number of private, nonprofit local mental health authorities qualifying as enhanced care clinics and the number of public and private centers implementing the integrated treatment model, along with post-implementation trends in patients' substance use and mental health symptoms at several of these sites.
Developing OrganizationsConnecticut Department of Mental Health and Addiction Services
Date First Implemented2006
Vulnerable Populations > Co-occuring disorders
Problem AddressedMany people have co-occurring disorders that, if not adequately treated, may lead to homelessness, incarceration, and/or premature death. Treatment is most effective if both the mental health and substance use components are addressed at the same time, yet few individuals with co-occurring disorders receive such integrated treatment.
- Many individuals with co-occurring disorders: Approximately 8.9 million adults suffer from both a mental and substance use disorder at the same time.1
- Risks of inadequate treatment: Those with co-occurring disorders who do not receive adequate treatment (sometimes due to the failure to diagnose the disorders) face an increased risk of homelessness, incarceration, illness, and premature death (including by suicide).2
- Unrealized potential of combined treatment: Patient outcomes often improve when individuals receive integrated treatment that addresses both the mental health and substance abuse disorders at the same time.3 Yet only 7.4 percent of those with co-occurring disorders receive this type of treatment.4 In most areas, separate systems exist for diagnosing, assessing, and treating the two types of disorders. Barriers to combined treatment include payment systems that do not reward such an approach, licensing requirements, and inadequate provider education and training.
Description of the Innovative ActivityThe Connecticut Department of Mental Health and Addiction Services implemented three policies that help staff provide consistent, high-quality treatment to people with "co-occurring" (i.e., mental health and substance abuse) disorders. The policies include mandatory screening for both disorders using validated tools, a learning collaborative and evaluations to promote quality improvement, and financial incentives to clinics achieving various service benchmarks. The department also offers ongoing training to help providers with various issues related to the policies. Key program elements are outlined below:
- Mandatory screening for both disorders using validated tools: Following a pilot program, the department mandated in 2007 that all mental health and addiction treatment programs use validated tools to screen for both mental health and substance use disorders at admission. The mandate requires use of either the Mental Health Screening Form-III or the Modified MINI Screen for mental health disorders, and the Simple Screening Instrument for Alcohol and Other Drugs or the CAGE Adapted to Include Drugs for substance use. On average, it takes about 11 minutes to complete both screens. These instruments have been shown to be accurate, reliable, and efficient with respect to gathering information, and easy to use and score (including offering clear cut-off scores). If a program is non-compliant, the department requires a corrective action plan to remedy the problem. In the rare case in which this plan also does not result in compliance, the department may fine the program.
- Learning collaborative, evaluations to promote improvement: Since 2007, the department has offered a co-occurring learning collaborative to promote quality improvement. Participating sites receive evaluations based on a scheduled site visit conducted by department staff. The visit, which can take up to a full day, includes a meeting with the site director; interviews with clinical leaders, supervisors, clinicians, and clients; a tour of the physical site; and a review of documents, such as brochures, medical records, policy manuals, and patient activity schedules. Assessors provide a detailed report of their findings using the Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index, (http://www.samhsa.gov/co-occurring/news-and-features/ddcat.aspx), or the Integrated Dual Disorders Treatment (IDDT) fidelity scale (http://store.samhsa.gov/product/SMA08-4367). The DDCAT covers 35 program elements subdivided into 7 domains (see sub-bullets below). They also work with sites to create action plans to promote quality improvement. Site representatives also attend technical assistance and training meetings with other collaborative participants. The DDCAT-based dimensions include the following:
The IDDT scale covers similar domains/items as the DDCAT, but is designed for mental health programs working to increase their co-occurring capability.
- Program structure: General organizational factors that foster or inhibit comprehensive, high-quality treatment.
- Program milieu: The culture of the program, including whether the staff and physical environment are receptive and welcoming.
- Assessment: The degree to which clinical activities achieve assessment benchmarks.
- Treatment: The degree to which clinical activities achieve treatment benchmarks.
- Continuity of care: Long-term treatment and external supportive care.
- Staffing: Staffing patterns and operations that support assessment and treatment.
- Training: Appropriateness of training and support to ensure that staff can provide high-quality treatment.
- Financial incentives to clinics achieving service benchmarks: In 2006, the Connecticut Department of Social Services (the state’s Medicaid agency) established a voluntary subclass of mental health and substance abuse clinics known as Medicaid "enhanced care clinics" or ECCs. To qualify, clinics must meet the requirements of three policies on quality of care, increased access, and integration with primary care. The Department of Mental Health and Addiction Services developed the quality of care policy, which requires integrated treatment for individuals with co-occurring disorders, in collaboration with the Department of Social Services and providers. Those meeting these benchmarks receive a 25-percent increase in fee-for-service reimbursement from the state for Medicaid-funded outpatient behavioral health services. The Integrated Care Policy Benchmarks include:
- Staffing: Have clinicians with intermediate or advanced competencies to work with individuals with co-occurring disorders.
- Assessments: Perform formal, integrated, and comprehensive assessments.
- Access: Provide care to those with moderate to high symptom acuity and severity of disability.
- Specialty care: Provide psychopharmacologic and addiction pharmacotherapy interventions onsite (except methadone or buprenorphine).
- Training academy: In 2007, the department launched a training academy that offers regular sessions designed to help providers with various issues related to the three policies, including how to use the screening tools effectively, conduct integrated assessments, and deliver integrated services.
Context of the InnovationThe Connecticut Department of Mental Health and Addiction Services provides a wide range of treatment services to adults, including inpatient and outpatient care, 24-hour emergency care, day treatment, psychosocial and vocational rehabilitation, restoration to competency and forensic services (including jail diversion programs), outreach services for homeless individuals with serious mental illness, and comprehensive, community-based mental health treatment and support services. The department currently oversees six state-operated clinics, one state hospital, and 150 private facilities that offer mental health and/or substance abuse treatment.
Through academic partnerships with Yale University, the University of Connecticut, and Dartmouth Medical School, the department has a decade-long history of participating in research on co-occurring disorders. In the fall of 2005, the department received a Co-Occurring State Incentive Grant (more commonly known as COSIG) from the Substance Abuse and Mental Health Services Administration (SAMHSA), one of four states to receive such a grant that year. This five-year, $4 million grant allowed the department to begin developing and implementing the policies, which are seen by department leaders as part of an ongoing commitment to enhance services.
ResultsThe three policies enhanced access to high-quality treatment that has produced positive outcomes with respect to substance use and mental health symptoms.
Suggestive: The evidence consists of post-implementation data on the number of private, nonprofit local mental health authorities qualifying as enhanced care clinics and the number of public and private centers implementing the integrated treatment model, along with post-implementation trends in patients' substance use and mental health symptoms at several of these sites.
- Enhanced access to high-quality treatment: Six of the state’s seven private nonprofit local mental health authorities have qualified as Medicaid enhanced care clinics. In addition, all 13 of the state’s local mental health authorities (public and private) are active participants in the Co-Occurring Disorders Initiative and have implemented the integrated dual disorders treatment (IDDT) model, achieving increasing levels of fidelity over time.
- Positive patient outcomes after 6 months of treatment: Two statewide evaluations found that the integrated treatment sites have produced positive patient outcomes, achieving significant reductions in substance use and mental health symptoms in the first 6 months after initiating treatment.
- Less substance use: A 2009 evaluation found that 77.8 percent of patients in intensive outpatient programs for 6 months had abstained from alcohol and illegal drugs during the previous month, well above the 47.4-percent abstinence rate at intake. In addition, the percentage employed or attending school rose from 26.3 percent at intake to 39.5 percent 6 months later. A separate evaluation found that 72 percent of patients in enhanced residential programs for 6 months had abstained from alcohol and illegal drugs during the previous month, well above the 16-percent rate at intake. In addition, the percentage with no arrests in the previous 30 days rose from 84 percent at intake to 100 percent after 6 months in the program.
- Fewer mental health symptoms: A 2009 evaluation at two outpatient clinics found that 6 months after beginning treatment, patients reported significant declines in the number of days they experienced mental health issues each month, including serious depression, serious anxiety, and hallucinations. In addition, the number of patients attempting suicide during the previous month dropped significantly at both facilities.
Planning and Development ProcessKey steps included the following:
- Committee and workgroup formation: In 2005, the department formed the Co-Occurring Steering Committee, which met monthly and served as the primary statewide governance structure to coordinate and oversee development and implementation of quality improvement initiatives, including the three policies described above. Additional multi-stakeholder workgroups were formed on issues related to the policies, such as workforce development, screening, and facilities. These workgroups included a diverse group of stakeholders, including state employees, experts from academia, and representatives from other organizations.
- Pilot testing: In 2006, the department began pilot testing the screening and systematic program evaluation (e.g., DDCAT) components, with 30 clinics testing the four validated screening tools and state assessors using DDCAT to evaluate 30 percent of addiction treatment programs funded and operated by the department. Following the pilot programs, the department implemented both programs statewide. Also in 2006, the Department of Social Services unveiled the aforementioned enhanced care clinic model.
- Vision statement related to integrated treatment: In 2007, Commissioner Thomas Kirk issued a four-page statement defining the department’s vision to offer integrated mental health and addiction treatment services for individuals with co-occurring disorders. Since that time, the statement has served as a framework to guide the department's policies and activities in this area. Over the next 2 years, the commissioner released several one-page documents that update progress toward the vision.
- Release of program guidelines: The Department of Social Services issued guidelines related to provider competencies and requirements for achieving designation as an enhanced care clinic.
Resources Used and Skills Needed
- Staffing: The three policies and the creation of the academy required the hiring of a full-time manager for the initiative.
- Costs: Data on program costs are not available. Major expenses include salary and benefits for the full-time manager of the initiative, payments to outside expert consultants on integrated care, and increased payments as a result of the aforementioned 25-percent rate increase for enhanced care clinics.
Funding SourcesSubstance Abuse and Mental Health Services Administration (U.S.); Medicaid
Funding for the policies came from a combination of state revenues, Medicaid and grants from SAMHSA, including the aforementioned COSIG.
Tools and Other ResourcesLinks to the four integrated screening tools are available at: http://www.ct.gov/dmhas/cwp/view.asp?a=2901&q=392802.
The commissioner’s policy statement is available at: http://www.ct.gov/dmhas/lib/dmhas/policies/chapter6.4.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
The DDCAT Toolkit, which includes the DDCAT Index and guidance on how to enhance services, is available at: http://www.samhsa.gov/co-occurring/ddcat/.
SAMHSA’s Substance Abuse Treatment for Persons With Co-Occurring Disorders (TIP 42) can be ordered or downloaded at: http://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons-With-Co-Occurring-Disorders/SMA12-3992.
SAMHSA’s Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (TIP 48) can be ordered or downloaded at: http://store.samhsa.gov/product/TIP-48-Managing-Depressive-Symptoms-in-Substance-Abuse-Clients-During-Early-Recovery/SMA12-4353.
More information on substance abuse recovery can be found at: http://www.recovery.org/.
Getting Started with This Innovation
- Set clear goals: State health department policymakers should be as specific as possible in detailing plans for integrated treatment, thus allowing providers to know what they need to achieve and why. For example, the department's policy on mandatory use of screening tools was preceded by a training session that explained the benefits of validated screening, showed staff how to use the tools, and detailed how their use would be evaluated.
- Consult outside experts: Mental health and addiction experts from academia and health department leaders at other states that are integrating the mental health and substance abuse systems can likely provide valuable guidance to those considering this type of program. For example, leaders of the Connecticut Department of Mental Health and Addiction Services engaged in frequent consultations with researchers from Dartmouth and other experts inside and outside the state. These individuals helped them make informed decisions about a range of implementation issues.
- Communicate clearly: When the department implemented these policies, some mental health and addiction treatment providers believed they already provided integrated treatment for people with co-occurring disorders, even though fidelity reviews indicated otherwise. To address this issue, the commissioner released a policy statement and followup communications via various channels (e.g., e-mail, letters, newsletters) that clearly defined integrated treatment, acknowledged the progress to date, and laid out the clear expectation that further improvements be made.
Sustaining This Innovation
- Track and report program’s impact on outcomes: Although process milestones are important, it is also critical to track and report on the program's impact on patient outcomes over time. Such data make the program's benefits clear and hence serve to sustain interest and engagement among providers and funders.
- Highlight success stories: Support for statewide policies may vary widely among clinics. In cases in which staff resists implementing a new policy, it can be helpful to highlight the experiences of other providers who have enthusiastically adopted the policy and achieved positive results. Program leaders can give these early adopters time to talk about their experiences during meetings attended by representatives of other clinics (e.g., during learning collaborative sessions), and can also summarize their experiences in e-mail updates.
Contact the InnovatorRhonda Kincaid, MEd
State of Connecticut
Department of Mental Health & Addiction Services
410 Capitol Ave
PO Box 341431
Hartford, CT 06134
Innovator DisclosuresMs. Kincaid reported coauthoring content for the DDCAT toolkit Web site as a paid consultant to Westat. Westat operates the Innovations Exchange under contract to AHRQ. In addition, information on funders is available in the Funding Sources section.
References/Related ArticlesMore information on the Connecticut Department of Mental Health and Addiction Services' Co-Occurring Disorders Initiative is available on the department's Web site at: http://www.ct.gov/dmhas/cwp/view.asp?a=2901&q=335022.
Drake RE, O'Neal EL, Wallach MA. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. J Subst Abuse Treat. 2008;34:123-138. [PubMed]
Rollins AL, O'Neill SJ, Davis KE, et al. Substance abuse relapse and factors associated with relapse in an inner-city sample of patients with dual-diagnoses. Psychiatry Services. 2005;56(10):1274-81. [PubMed]
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Original publication: June 06, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.