building and sustaining coalitions: optimizing care through cross-system collaboration

Building and Sustaining Coalitions:

Optimizing care through Cross-System Collaboration

First Things First…

“DUAL DIAGNOSIS”…What is it?

Definitions Dual Diagnosis

› A mental health diagnosis and a developmental disability (common descriptor in services for developmental disabilities)

› A mental health diagnosis and a substance abuse disorder (common descriptor in mental health services)

“Dually Served”› Receiving eligible services from more

than one system

Historically….MYTH: Individuals with ID cannot have a verifiable mental

health disorder • PREMISE: Maladaptive Behaviors are a function of ID• REALITY: The full range of psychiatric disorders can be

represented in persons with ID & DD• TREATMENT IMPLICATIONS: Psychiatric diagnosis can be

made using the DSM IV-TR, the DM-ID, Behavioral Equivalents ,interviews reports, observation and screening tools for most people with ID

Adapted from Robert Fletcher, DSW, ACSW - 2004 -

Frequency

Co-occurring Psychiatric conditions are as likely to occur in individuals with developmental disabilities as in the general population.

In fact, some research indicates the possibility that mental illness occurs at a higher rate in this population. (Stress Vulnerability Model)

WHY WE CAREWHY WE CARE

Challenging Issues for Current Services Delivery

Current research and our own statewide information indicated that many of the behaviors and challenges that define this group of individuals are not typical of the majority’s needs.

This particular group has sophisticated and inter-dependent needs.

“No special needs group strains the service capacity of community

mental health/mental retardation services to a greater extent than

people with dual diagnoses of developmental disabilities and psychiatric conditions.”

(National Association for the Dually Diagnosed, 2006)

“We all have different gifts, so we all have

different ways of saying

to the world who we are.”

~ Fred Rogers

Parolee

Student

ME

Addict

Where do I fit?

Family Family MemberMember

CITIZEN

EMPLOYEE

How do I choose?

Where do I go?

Collaboration

What is COLLABORATION?1 : to work jointly with others or together especially in an intellectual endeavor

2 : to cooperate with or willingly assist an enemy of one's country and especially an occupying force

3 : to cooperate with an agency or to cooperate with an agency or instrumentality with which one is instrumentality with which one is not immediately connectednot immediately connected

Is COLLABORATION Credible?

• INDUSTRY EXAMPLE

Collaboration Collaboration createscreates a forum a forum withinwithin which which consensusconsensus about the about the problemproblem can can be sought, be sought, mutually agreeable solutions mutually agreeable solutions cancan be invented, and be invented, andcollective actions to resolve the problem.collective actions to resolve the problem.IF COLLABORATION IS SUCCESSFUL, NEW SOLUTIONS EMERGE THAT. NO SINGLE PARTY COULD HAVE ENVISIONED AND ENACTED

• *http://science.nasa.gov/media/medialibrary/*http://science.nasa.gov/media/medialibrary/2010/03/31/OSS EPO Phase III report.pdf 2010/03/31/OSS EPO Phase III report.pdf

What Other People say about Collaboration

• Cross-system collaboration changes the way individual systems operate and how existing agencies do their work.

• Agencies and systems become more accessible under the positive influence of collaboration and demonstrate a greater readiness to tackle policy, procedural, and attitudinal barriers

*http://www.ncsacw.samhsa.gov/files/Shared%20Values%20and%20Guiding%20Principles.pdf

Leveraging Cross-SystemsCollaboration

“IF COLLABORATION IS SUCCESSFUL, NEW SOLUTIONS EMERGE THAT. NO SINGLE PARTY COULD HAVE ENVISIONED AND ENACTED”…

…If Collaboration is successful, professionals in different agencies can work across organizational boundaries and individual agency mandates to produce results.

Looking For SolutionsLooking For Solutions

California’s Mental Health/Developmental Services

Statewide Task Force

Statewide Needs Assessment

results in proposal for a demonstration project to meet the needs of multiply served, multiply diagnosed individuals.

*see www.sdrc.org or www.mosaiclink.org for full report

California – Dual Diagnosis

• 16.1 % (1 in 6 people) of the total number of people served by the Regional Center System are listed as having co-occurring psychiatric conditions.- underestimate of actual need due to data constraints

• 76% of these individuals are adults.• 17% of individuals with MI-DD are listed as

having Pervasive Developmental Disorders. • 27% of persons residing in Developmental

Centers are listed as having co-occurring developmental and psychiatric conditions.

California – Summary Consistent with National Outcomes and Dual Diagnosis

ResearchoMultiple systems- overlapping systems careo increased cost, inefficient ando fragmented services, often with disparate

messageso sometimes counterproductive services ando growing need due to ongoing progress of the de-

institutionalization movemento Current problem of Trans Institutionalization

Institutional Movement • 200 years ago -- severe or disabling challenges

housed in jails…. no public mental health system or specialized system of care

• Mid 1800’s – Moral treatment movement – seeking to hospitalize and treat

• Mid 1900’s – more than ½ million people in state psychiatric hospitals… a system stretched beyond it’s limits

• Mid- 1900’s – medications for effective treatment of serious mental illness begin to emerge

De-Institutionalization Movement

• 1960’s Normalization Principle first developed in Scandinavia and articulated by Bengt Nirje later expounded upon by Wolf Wolfensberger in US.

• Normalization movement provided a construct for a better life and was a primary impetus behind the DE Institutionalization movement.

Coming full circle…TransInstitutionalization

• “For many individuals unable to access care in the community, the only options to receive treatment is by accessing care through the some of the most costly and inefficient points of entry into the healthcare delivery system including emergency rooms, acute crisis services, and ultimately the juvenile and criminal justice systems. “

http://www.floridasupremecourt.org/pub_info/documents/11-14-2007_Mental_Health_Report.pdf

The Issue…ACCESS TO Effective SERVICES….

• Systems begin to specialize• Budgets allocated to expertise and services • Encourages specialization but also segregation• No unified approach is legislated

– Exception : MOUs

Who can’t say no?

Looking For SolutionsLooking For Solutions

Looking for Effective Outcomes in Dual Diagnosis

• Increase a person’s ability to cope with day to day life stressors

• Improve cross systems coordination including crisis care coordination

• Create key linkages in support networks that would improve access to eligible services across systems

• Identify areas where new resources were needed.

One Model of many…One Model of many…

Solutions Building Community Solutions Building Community Collaborative… Collaborative…

Effective Strategies in Cross Systems Collaboration

.

©2010

SBCC – Phases I to III A Model of Collaboration

PHASE ICOMMUNITY EDUCATION

PHASE ICROSS SYSTEMS

PLANS

PHASE ICRISIS CARE

COORDATION

PHASE IICLINIC

CONSULTATION FOR MI/DD +

CERTIFICATE OF EXCELLENCE

PHASE IIIADD ADOLESCANTS+ GROUP THERAPY +

online Training

STEERING COMMITTEE

SAT TEAM

Focus on Comprehensive ASSESSMENT, CONSULTATION and RESOURCE CONNECTIONS

Consulting Psychiatrists Clinical Psychologist/Behavior Specialist DD Navigator Mental Health Navigator Forensic Navigator Substance Use Disorders NavigatorCommitment to Community Tenure for targeted

Individuals

SUPPORT, ASSESSMENT & TREATMENT TEAM

SAT TEAM

SUPPORT …..NAVIGATION SAT TEAM

• Regional Center• Behavioral Health• Hospitals/ERs• PERT, Probation, Courts, Parole• Drug and Alcohol System• Schools

SUPPORT..ASSESSMENT….

• Psychiatric• Clinical• Behavioral• Forensic • Substance Use Disorders

TREATMENT

SUPPORT …..ASSESSMENT…TREATMENT SAT TEAM

Frequent Recommendations from the Team

• Neurological exam or psycho-neurological exam• Medication review& history• IM medication• Medication Education for ind. , staff or family• Escalation hierarchy including behavioral

strategies for individuals with dual diagnosis.• Adapt the Wellness Recovery Action Plan (WRAP)• Reiss Profile• Consider Individual and Group Therapy (SKILLS

System)

EFFECTIVE STRATEGIES• SUPPORT ASSESSMENT AND TREATMENT (SAT)

TEAM..• COMMUNITY EDUCATION TO ALL INTERESTED

STAKEHOLDERS• CRISIS CARE COORDINATION• CROSS SYSTEMS PLANS• CONSULATION CLINIC• NEW RESOURCE DEVELOPMENT

– ADAPTED WRAP– REISS PROFILE– SKILLS SYSTEM ; GROUP THERAPY – SKILLS COACHING– ONLINE TRAINING TO MEET GROWING INTEREST

OutcomesOutcomesOpen doors to Eligible services across systems through Expert NavigationEscalation Hierarchies and Cross Systems Plans that create options to eviction notices, 911 calls, ER and Inpatient staysIncrease Training & Discharge Planning with ERs and Inpatient staff to reduce returnsComprehensive Medical, Psychiatric and Behavioral Consultation across system of experts with available training.Meaningful Recommendations for Community TenureAdapting Existing Tools and Strategies to fit this specialty populationTraining… training… training… in Dual Diagnosis and systems protocol to all Community Stakeholders creates

CROSS SYSTEMS COLLABORATION

Other Effective Models…Other Effective Models…

Santa Clarita Valley Dual Diagnosis Coordinating Council

A subcommittee of the Santa Clarita Valley Interagency Committee

SCV Interagency Committee

• Child & Family Center (MH Provider)• 5 School Districts (Special Education and Pupil

Services Directors• Sheriff• DCFS (Assistant Regional Administrators)• DMH (AB 3632 Program Head)• DMH Wrap Around• Wrap Around (Program Manager)• Family Preservation (Program Manager)

SCV Interagency Committee (2)

• Full Service Partnerships• CCS ( California Children’s Services)• Dept of Probation• Regional Center• Guests: Kaiser, City of Santa Clarita Anti Gang Task

Force, AB 3632 Placement Unit • Northeast Valley Health Corporation, a Federally

Qualified Health Center (FQHC)• SCV Early Start

SCV Dual Diagnosis Coalition

• Los Angeles County Department of Mental Health

• Department of Child and Family Services• North LA County Regional Center• SCV SELPA: 5 School Districts• Child & Family Center

Comprehensive and Integrated Services

• Mental Health including counseling, parent groups, psychiatric services, TBS if qualified, case management, family therapy etc

• DMH incl. systems navigators, funding• Regional Center Services i.e. case management,

assessment, ABA etc• Educational services in the schools

(e.g., referral, assessment, special education services, additional adult assistance, etc.)

No Wrong Door

• “Warm Handoff” • Participants know who to call• Participants know referral criteria and

processes for each agency and share that information with their colleagues

• The committee is collectively responsible for the families presented. No single agency can do it alone.

AB 3632

• Dual Educational Diagnosis: Must have an ED educational diagnosis in order to qualify for DMH AB 3632 Services, along with any other educational diagnosis (language, ID , Autism)

• DMH/C&FC: Treats the mental health issues, and can address only a limited amount of the behavioral issues through TBS

• Regional Center: Can access in-house behavioral therapy through vendored contractors, housing

AB 3632 (con’t)

• Special Education: Can add education services, additional adult assistance, small classroom, speech and language, adaptive PE etc.

• If DCFS or AB 3632: Wraparound can add a host of supportive services including parent partners, in home therapy, strength based partnerships, flex funds

• Interagency , TDM’s, Wraparound, IEP’s, Meetings and collegial relationships: Can track progress and keep communication vibrant and goal-directed

AB 3632 Today

• The Governor’s Veto• Lawsuits and Court Cases• MOU’s with School Districts and DMH• Status Quo until June, 2011.• MHSA/Prop 63 and other options, scenarios,

and alternatives• Reasons for hope

Additional Factors to Consider• “It takes a village…”• Small Geographic Area Coalitions• Cost Effectiveness• Communication• Interpersonal Relations with Agency Reps• Stretch traditional boundaries and procedures• Training: Dr. Fletcher, Developmental Disabilities

Coordinator, SCAAN, City of SC• Outcomes: what and how to measure?• MOU’s

Other Community Partners• City of Santa Clarita: Family education groups,

trainings, small grants, parks and recreation, community services

• Sheriff: Identification programs• CLEAR• SCAAN• Downs Syndrome Parent Group• LARC Ranch

Other Partners (con’t.)• ARC: Socialization and Recreation, Family Support (in NOHO)• Kaiser Permanente: Special evaluation unit for Autism

Spec.• UCLA• Diagnostic Center• TLC (Transition Learning Center): Charter School for

transition aged youth education and support• COC: Supports TLC and Asperger’s Services Group on

campus (funded by William S. Hart Unified School District)

The Panel• • Paul Frisina, Director of Special Education, Sulphur Springs School District• • Lisa Kimura, Branch Supervisor, North LA County Regional Center, Santa Clarita

office• • Paul McIver, DMH District Chief, Children, Youth and Families Program

Administration• • Larry Schallert, Director of Adult, Education and Outreach Services, Child and

Family Center• • Laura Shotzbarger, Assistant Regional Administrator, Department of Child and

Family Services• • Sandee Sumber, Director of Student Support Services, Castaic Union School

District• • Peggie Webb, Executive Director, Mosaic Connections and Non-Profit

Organization Management Consultant• • John Youngbauer, Behavioral Services Supervisor, North LA County Regional

Center