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Co-occurring disorders defined as, “where an individual has at least one mental disorder as well as an alcohol or drug use disorder” (Center for Substance Abuse Treatment (CSAT), in press) – affect millions of Americans each year.  According to SAMHSA’s 2014 National Survey on Drug Use and Health, approximately 7.9 million adults in the United States had co-occurring disorders in 2014. Individuals with co-occurring mental health and substance use disorders in Anne Arundel County are recognized as a population with poorer outcomes and higher costs in multiple clinical domains. They are commonly underserved in both mental health and substance use treatment settings, with resulting over-utilization of resources in the criminal justice system, the primary health care system, the homeless shelter system, and the child protective system. In addition to having poorer outcomes and higher costs, individuals with co-occurring disorders are sufficiently prevalent in all healthcare settings, including behavioral, medical and primary care, that they can be considered an expectation, rather than an exception.

People with co-occurring disorders can and do recover. In order to provide more welcoming accessible, integrated, continuous, and comprehensive services to these individuals, a coalition of clinical behavioral health and on-clinical human services entities in Anne Arundel County have agreed to adopt the Comprehensive, Continuous, Integrated System of Care model for designing systems change to improve outcomes.

 

1. Is a model for the implementation of best practice principles of practice for persons with co-occurring mental illness and substance use issues. It was developed and copyrighted by Kenneth Minkoff, M.D., and a “Train the Trainers” Curriculum was developed by Christie Cline, M.D., MBA for use with this model. 
2. The basic characteristics of the model emphasize the need to continuously and simultaneously:
   1.  Focus on three levels:
      1. Systems level change  (Collaboration and Partnerships)
      2. Program level change (Co-Occurring Steering Committee)
      3. Workforce level change (Change Agent Committees and ROSC)
   2. Use existing resources efficiently
   3. Incorporate Evidence Based Practices (EBP)
   4. Use:
      1. An integrated service philosophy
      2. Motivational enhancements of rolling with resistance, developing empathy, developing discrepancies, avoiding argumentation, and supporting self-efficacy.
      3. Stages of Change:
         1. Pre-contemplation
         2. Contemplation
         3. Preparation
         4. Action
         5. Maintenance
   5. System Standards:
      1. Welcoming
      2. Accessible
      3. Integrated
      4. Continuous
      5. Comprehensive
3. The model uses eight principles:
   1. Co-occurring is an expectation, not an exception.
   2. Treatment should be based on empathetic, hopeful, integrated, and continuous relationships.
   3. Use of the Four Quadrants for assessment, treatment matching, and individualization of treatment and recovery plans.
   4. Use of case management and on-going coordination of care.
   5. When both disorders are present, both should be considered Primary.
   6. As bio-psychological disorders, treatment and recovery strategies should be within the context of “disease and recovery” models.
   7. Treatment must be individualized.
   8. Individualized treatment in turn facilitates the availability of continuing, empathetic, supportive treatment approaches and recovery supports.

 

Co-Occurring Steering Committee – Established in 1999 members include key stakeholders across the system committed to the utilization of the CCISC model and ensuring that Anne Arundel County provides an accessible, comprehensive behavioral health system for all residents. Participants on the Steering Committee are representatives from Anne Arundel County Department of Health and Anne Arundel County Mental Health Agency, mental health and substance use providers, hospital representatives, community and cultural organization representatives and more. Their goal is to ensure providers and referring agencies are able to successfully identify, refer and treat individuals with Co-Occurring issues.  They provide input, direction and influence on behavioral health action planning in the county. Meetings are held monthly and for more information call 410-222-7858 0r email mhaaac@aol.com.

Change Agents- A subcommittee of the Co-Occurring Steering Committee, the Change Agents represent frontline staff from a variety of organizations. They’ve included individuals in recovery, peer specialists, mental health and substance abuse providers, frontline clinicians, and administrative staff.  In addition to keeping the Co-Occurring Steering Committee informed of challenges and successes facing the community, they are committed to making improvements across the behavioral health system taking on such initiatives as the creation of a behavior health toolkit for physicians and creation of co- occurring core competencies and resources. The Change Agents meet monthly; to find out more information on how to get involved cal 410-222-7858 or email mhaaac@aol.com.

Recovery Anne Arundel - Established in 2008, under the auspice of the Anne Arundel County Department of Health, Recovery Anne Arundel started as a small group of those interested in becoming change agents for individuals in or seeking recovery. Now its own nonprofit, this team of committed people educate and empower others on the experience and process of recovery, through advocacy and special events. Group meets monthly. For more information go to https://recoveryannearundel.org/event/monthly-meeting-2/all/.

Healthy Anne Arundel Coalition – The Coalition’s Steering Committee includes public sector agencies, health care providers and payers, community and faith-based groups, businesses and educational institutions. The purpose of the Coalition is to locally prioritize the State Health Improvement Process (SHIP) and to develop and implement actionable strategies to improve public health. The Coalition Steering Committee decided to focus on three health improvement priorities from 2016 to 2019:  (1) obesity prevention, (2) the management of substance abuse and mental health as co-occurring disorders and (3) access to care. For more information https://www.aahealth.org/healthyannearundel/.

System Collaboration and Partnership-Addressing co-occurring issues and promoting behavioral health requires partnership with other systems. Click HERE for a list of groups, committees and taskforces that work together to address the health and wellbeing of Anne Arundel County residents.

The goal of the Behavioral Health Toolkit website is to assist healthcare providers in identifying mental health and substance use conditions and facilitate access to services. It contains training and technical assistance on integrating primary and behavioral health; resources on how to screen for behavioral health conditions; linkages to treatment; and supports that address mental health and substance use issues affecting children, adolescents and adults.  For more information go to https://www.aahealth.org/behavioral-health-toolkit/.

The below documents provide a compilation of guidelines for co-occurring competency and excellent care. You will find co-occurring skills, knowledge and resources generated by a multitude of individuals (mental health and substance use providers, administrators, nurses, peers, family members, etc.) and from a multitude of sources. Most resources are links to websites so that they can be accessed freely and quickly. These documents do not replace face to face dialogue, supervision, training and hands on experience but offer a starting point for further exploration.

This is a working document.  As new resources are discovered and as the understanding of effective co-occurring treatment evolves, it will be refined.  Future edits include more emphasis on trauma informed care, cultural and linguistic competence, issues across the lifespan, harm reduction, outcome measures and further integration with physical health.

 We sincerely welcome feedback, input and additional resources, email mhaaac@aol.com.

-The Change Agents

• Introduction
• The Overview and Definition of Co-Occurring Disorders & Integrated Care
• The Integrative Screening for Co-Occurring Disorders
• The Integrative Assessment of Co-Occurring Disorders
• Person-Centered Treatment Matching & Treatment Planning
• Evidence-Based Individual, Group, and Family Treatment
• The Application of Motivational Interviewing
• The Value and Application of Natural Supports, Twelve Step Recovery, Peer Supported Recovery, and other Self-Help Resources
• Continuous Quality Improvement and QA Measurement Processes & Tools for COD Services