Minnesota Online Mental Health Services Manual
For Children's and Adult Mental Health
HOW THE MANUAL IS ORGANIZED
About the Manual
Minnesota’s public mental health for children and adults is a state supervised, county administered system. Services are based on various federal and state rules, regulations, policies and procedures. About 600 public and private agencies provide services. The Minnesota Department of Human Services (DHS) Online Mental Health Services Manual is a reference tool for both new providers—whether individuals or members of an agency—as well as for experienced providers. The information provided is meant to further enhance the information found in the MHCP Provider Manual.
NOTE: The manual must be used in conjunction with federal rules and regulations, with Minnesota statutes and rules, and with the MHCP Provider Manual
Organization and Navigation
The manual is offered in an online format only. This means it can be updated immediately and can offer links to other important material, whether on this or other government websites. This allows the manual to be comprehensive while remaining easy to navigate.
The manual is divided into a number of chapters, each with multiple subsections. Links to external information, for example, the MHCP Provider Manual and Minnesota rules and statutes are included. A helpful list of abbreviations and acronyms, with definitions, is listed below for your reference.
Abbreviations and Definitions
We have provided a list of abbreviations and a list of definitions as reference material for those using the manual.
Outline of Chapters and Sections
Currently not all of the Chapters and sections are available.
Common elements of Chapter 7 - Services
For chapter 7, Services, each service type has the following sections.
Disclaimer
Although DHS has made reasonable efforts to assure that the contents of this manual are both accurate and up to date, DHS cannot be responsible for matters beyond its scope or level of detail, provider implementation of information, or future developments.
The manual is not intended to provide legal, financial, ethical or clinical advice. Providers are responsible for seeking professional advice, as appropriate, to operate their business.
This information is available in other forms to people with disabilities by calling (651) 431-2321. TTY/TDD users can call Minnesota Relay at 711 or (800) 627-3529. For Speech-to-Speech Relay, call (877) 627-3848.
Mission
The Children’s Mental Health (CMH) Division at the Department of Human Services is the state mental health authority for children. The division administers policies and recommends practices to ensure consistent, effective, and accessible mental health services and supports for Minnesota’s children and families. CMH works with many public and private partners across the state so that children and adolescents with mental health needs can develop and function as fully as possible in all areas of their lives.
CMH implements technical assistance, funding, training, infrastructure development, as well as standards of delivery and professional service. These services are used by MCOs, counties, tribes, providers, schools, and families to help fulfill the mission of the public mental health system.
CMH also guides numerous strategic initiatives to better meet the needs of children and adolescents who are at risk for, or are struggling with, mental health issues. The division invests resources to transform the children’s mental health system by
These efforts are grounded in the division’s values.
Values
Emphasizes resilience
Mental health services are most effective when they support the healthy growth and development of children and adolescents. This means, for example, recognizing and cultivating their strengths, multiple developmental needs, and capacity to develop coping skills that are sufficient to manage their current mental health issues.
Integrated
Children’s mental health services must be integrated with the other systems of care, including primary health care, education (from early childhood to post-secondary), child welfare, juvenile justice, and social services. Integration will help ensure that children’s mental health needs are addressed at the right time and place with appropriate, clinically informed supports.
Youth guided, family driven
Guidance from youth and families informs effective mental health services. Communities must develop an array of services for consumers and families that is flexible and appropriate (including level of intensity).
CMH supports families and communities in creating service delivery mechanisms that are locally appropriate and culturally competent. CMH supports services such as home-based services, parent support groups, day treatment facilities, mobile crisis support, partial hospitalization, and respite care as part of this effort.
Developmentally appropriate
To be effective, mental health services must be developmentally appropriate. Individualized service plans should reflect the developmental needs of the child or adolescent, whether emotional, intellectual, physical, social, or cultural.
Children’s cognitive, social, and language skills develop over time; their developmental stages must be recognized. Services must be (a) described in ways that do not go over the child’s head and (b) delivered in ways that do not underestimate the child. Providers must assess whether their services are developmentally appropriate for adolescents who transition into the adult mental health system.
Uses research informed and evidence-based practices
CMH is committed to ensuring that children and adolescents receive excellent mental health care. Thus, the organization is moving toward an “evidence-based” culture. Research informed and evidence-based practices account for the latest research when selecting the most effective course. CMH promotes evidence-based practices to improve the quality and increase the number of effective treatments.
Using research informed practice means that providers and parents have the latest scientific evidence on which to base clinical decisions and evaluate treatment outcomes. It means that provider and family can account for a child’s unique characteristics, circumstances, and culture; it means they can combine their expertise and experiences with evidence in order to determine the best approach for a child or adolescent. For further information, please visit the Children's Evidence-Based Practices webpage.
Culturally competent
Culture influences (a) individual and family beliefs about mental health and mental illness, and (b) how families and practitioners perceive and respond to emotional problems. If care is to be individualized and culturally appropriate, it must address needs as they are understood in the child’s and adolescent’s culture. Mental health services cannot be effective unless they are culturally competent.
Supports family involvement
As primary caregiver and coordinator of care, a child’s family is an invaluable source of information. The family’s expertise must be allowed to drive the child’s assessment, care planning, service delivery, and service evaluation. All service planning should actively address the needs of children and adolescents for security, permanence, and cultural ties within family relationships.
Provides a complete service array
CMH is committed to ensuring that, for children and adolescents with mental health needs, the right services are available at the right time and in the right setting, from birth to age 18. Services range from community-based rehabilitation services to inpatient services. Minnesota is a leader in building the community-based service side of the continuum in order to support children in their normal environment and thus avoid more intense services whenever possible.
Serves a broad population
The children's public mental health system must support children and adolescent’s healthy growth and development at all stages. The system must promote optimal health for each child, including those who experience moderate symptoms of mental distress. To that end, state and federal efforts supported expansion of the children’s mental health service population. In 2003 federal legislation increased the flexibility and scope of the rehabilitation option benefit under Medicaid. As a result, Children’s Therapeutic Services and Supports became available to children and adolescents who meet the criteria for emotional disturbance (as defined by state law) rather than being limited to severe emotional disturbance.
Adult Mental Health Mission and Values
Mission
The Adult Mental Health Division promotes and supports recovery and mental wellness, and works to ensure that recovery based programs and services are available throughout the state. The division administers policy and practice to ensure consistent, effective and accessible mental health services and supports for individuals. In Minnesota, individual's access publically funded mental health services in several ways. Some mental health services require approval through the individual's county of residence and some services require approval through an individual's designated managed health care plan. Minnesota has a wide range of service providers, including non-profit health clinics and centers, independent licensed mental health professionals, county-run services and state-run services.
Values
Recovery
The guiding principle for mental health services in Minnesota is people can and do recover from mental illness. . Recovery is defined as a journey of holistic healing and discovery that leads to personal growth and life satisfaction.
Hope
In a recovery-focused mental health service system, people living with mental illness are encouraged, supported, and empowered to build meaningful lives. A recovery-based system is person-centered and fosters personal responsibility. It offers hope that things will improve and that life’s goals can be met.
Personal Choice
Treatment planning and services should build on the person’s strengths, and acknowledge the individual’s right to make choices. Providers will encourage and welcome peer and family involvement.
Holistic Approach
Mental health providers will recognize the whole person, mind, body, spirit and connection to community. Understanding of and respect for the person’s beliefs, values, customs and traditions are necessary to support recovery.
Evidence Based and Best Practice Services
The Adult Mental Health Division is committed to implementing a number of evidence-based practices (EBP) in the array of services. Evidence-based practices provide research-based strategies to help people living with mental illness to achieve the goal of recovery.
Individual Placement Support (IPS)/Supported Employment (SE), Illness Management and Recovery (IMR), Integrated Dual Diagnosis and Treatment (IDDT), and Assertive Community Treatment (ACT) are four evidence-based practice approaches that the Division has promoted through statewide staff training and funding. In 2009, Minnesota added Certified Peer Support (CPS) services to its state plan. The Center for Medicare & Medicaid Service (CMS) states that, "Peer support services are an evidence-based mental health model of care...the experience of peer support providers, as consumers of mental health and substance use services, can be an important component in a State's delivery of effective treatment." Starting in 2011, Minnesota will add Certified Dialectical Behavioral Treatment (DBT) intensive outpatient services to its service array.
Chapter 3 - Public Mental Health Delivery System
1. Overview
2. State Mental Health Authority
7. Children’s Mental Health Collaborative
8. Adult Mental Health Initiatives
10. Managed Care Organizations
B. American Indian Tribal Governments
Minnesota is a state-supervised, county-administered public mental health system. The Adult Comprehensive Mental Health Act and Children’s Comprehensive Mental Health Actestablish this framework for Minnesota’s public mental health system. Three agencies/organizations have specific roles and responsibilities within the system:
• The state mental health authority (SMHA), part of the Minnesota Department of Human Services
• The local mental health authority (the county board of commissioners and its administrative agency, or multi-county mental health authority)
• American Indian tribal governments.
Increasingly Managed Care Organizations (MCO’s) are responsible for administering public mental health services for recipients who access services through the Minnesota Health Care Programs (MHCP) prepaid plans. Not all public mental health recipients are eligible for Minnesota Health Care Programs and not all services within the public mental health system are paid for by MHCP. The public mental health system includes all mental health services that are paid for by the state and/or the county, usually for individuals enrolled in one of the Minnesota Health Care Programs or for individuals receiving county based or county-contracted mental health services.
In addition to these organizations, consumers and their families, advocacy organizations, local and state advisory councils, Tribal Governments, providers, other state departments, the Federal agencies (Center for Medicare and Medicaid Services [CMS] and Substance Abuse Mental Health Services Administration [SAMSHA]), private health systems, and the State Legislature all play key roles in shaping Minnesota’s public mental health system.
2. State Mental Health Authority
The State Mental Health Authority (SMHA)
The Chemical and Mental Health Services Administration of the Minnesota Department of Human Services is the state mental health authority (SMHA). Minnesota is a state supervised, county administered system described in the Comprehensive Mental Health Acts. The state’s role is to:
• Define and disseminate statewide policy for mental health service delivery
• Monitor compliance with established state and federal policy
• Coordinate development of state and local mental health system plans, including statewide goals and objectives
• Develop new services and new methods of service delivery based on best practices
• Monitor and evaluate the performance of local service delivery systems, by county or region as the unit of analysis
• Develop and disseminate programs, service delivery, and administration standards
• Allocate funds to local systems through grants
• Administer state and federal health care program funds (Medicaid, MinnesotaCare, General Assistance Medical Care)
• Demonstrate the accountability of these systems to the State Legislature and to federal funding sources.
• Provide technical assistance to local administrative agencies (Counties, health plans, service providers, Adult Mental Health Initiatives, Children’s Mental Health Collaboratives and Family Services Collaboratives)
• Provide technical assistance to tribal governments and other tribal entities.
• Provide policy and technical assistance on a range of mental health program areas and support systems to address the needs of children, adolescents and adults MHCP covered services
Mental health staff specialists also work in areas of interagency coordination, fiscal policy and budgeting, planning, evaluation and information support.
Medicaid (or Medical Assistance in Minnesota) is funded jointly with state and federal funds. The Centers for Medicare and Medicaid Services (CMS) administers Medicaid nationwide. Federal law requires that there be a designated State Medicaid Agency (42 CFR 431.610). In Minnesota, DHS is the designated state agency. Each state is required to develop and adhere to its own administrative “State Plan.” As the State Medicaid Authority, DHS manages that state plan.
The Minnesota Department of Human Services (DHS) often collaborates with other state agencies to provide more comprehensive and integrated benefits to citizens of Minnesota.
These include:
• Minnesota Attorney General’s Office
• Office of Ombudsman for Mental Health and Developmental Disabilities
• Minnesota Gambling Control Board
• Minnesota Department of Commerce
• Minnesota Department of Corrections
• Minnesota Department of Education
• Minnesota Department of Employment and Economic Development
• Minnesota Department of Health
• The Department of Human Rights
State law assigns the responsibility of day-to-day administration of local community mental health systems to the county board of commissioners. Each county board is responsible for:
• system planning;
• implementing and coordinating programs of service delivery among local providers;
• coordinating client care through case management;
• deciding how to allocate locally generated funds and state funds which flow through the county; and
• reporting data and information requested by the SMHA.
For children’s mental health services, county boards must establish a local coordinating council (LCC) to implement these local responsibilities and evaluate local needs.
There are emerging relationships between counties and Managed Care Organizations (MCO’s) as the MCOs role in the public mental health system evolves. Two examples of these types of relationships include the County Based Purchasing and the Preferred Integrated Networks (PINS).
The Children’s and Adult Mental Health Acts also define an array of public mental health services each county must ensure, within the limits of legislative appropriations, is available to those who reside within the county. Counties may provide those services directly with county staff or contract with outside providers for these services. Counties must also meet the Maintenance of Effort spending obligations established by Minnesota Statute 245.4835.
Services identified in the Adult Mental Health Act include:
• Education and preventive services MS 245.468
• Screening MS 245.476
• Emergency mental health services including a 24-hour, crisis telephone line MS 245.469
• Outpatient services MS 245.470
• Employment support services and programs MS 245.4705
• Community support and day treatment services MS 245.4712
• Residential treatment services MS 245.472
• Acute care hospital inpatient services MS 245.473
• Regional treatment center inpatient services MS 245.474
• Case management services MS 245.462, subd.3, and MS 245.4711
Services identified in the Children’s Mental Health act include:
• Education and prevention services MS 245.4877
• Mental health identification and intervention services MS 245.4878
• Emergency services MS 245.4879
• Outpatient services MS 245.488
• Family community support services MS 245.4881
• Day treatment services MS 245.4884, subdivision 2
• Residential treatment services MS 245.4882
• Acute care hospital inpatient treatment services MS 245.4883
• Screening MS 245.4885
• Case management MS 245.4881
• Therapeutic support of foster care MS 245.4884, subdivision 4
• Professional home-based family treatment MS 245.4884, subdivision 4
• Mental health crisis services MS 245.488, subdivision 3
The 2003 Legislature authorized the Children and Community Services Act (CCSA) (MS,256M.01 – 256M.80 which created a fund for counties to address the social service needs of children, adolescents, and adults, not already provided for by public assistance or public health care programs. CCSA funds can be used for services related to child protection, crisis, keeping a person in their home or the least restrictive setting, assessments, guardianship, case management, and licensing. (MS 256M.70 Subd. 2)
Each county submits a biannual adult mental health plan/grant application, in which they describe their mental health services, needs, priorities, grant funding projections and goals. This plan/application process has been simplified as increased emphasis is placed on outcomes. In developing the plan, each county receives input from its statutorily required local mental health advisory council (LAC).
Counties also receive state grants for adult mental health services and consolidated grants for other human services (including children’s mental health services). CCSA consolidated several allocation sources including children’s mental health grant. Therefore, beginning in 2003 counties no longer received state grants specifically for children’s mental health services. With consolidation of children’s services funds, counties no longer submit a children’s mental health plan, though a new children’s services plan does include children’s mental health-related performance indicators.
Counties also allocate local county property tax dollars for the provisions of social services and mental health services for adults and children.
7. Children’s Mental Health Collabortives
While each county in the state is responsible for administering an organized system of care, interagency services are increasingly provided and coordinated through the partnerships established by Children’s Mental Health Collaboratives.
A Children’s Mental Health Collaborative is a local interagency entity designed to integrate the service systems for children with or at risk of severe emotional disturbances and their families. There are currently 44 Children’s Mental Health Collaboratives in Minnesota.
At the county level, Local Coordinating Councils (LCCs) recommend mechanisms for local organization of children’s services, and in many cases coordinate services at the individual client and provider organization level. Local Children’s Mental Health Collaboratives can by statute choose to assume the responsibilities of coordination and role of the LCC, LAC, or other county coordinating bodies.
The Children’s Mental Health Division provides oversight and technical assistance to Children’s Mental Health and Family Services Collaboratives including:
• Review and approval of collaborative applications
• Monitoring compliance regarding governance, participation and planning
• Determination of goals for integrating services and funding
• Setting statewide priorities and outcomes for collaboratives
Because Children’s Mental Health Collaboratives are locally designed and driven, there are many models. Nevertheless, they share some common characteristics, such as a multiagency governance structures that include the participation of minimum mandated partners:
• one county
• one school district or special education cooperative
• one mental health entity
• one juvenile justice or corrections entity.
These entities must agree to develop an integrated service system with families and community agencies. Each collaborative is also required to develop an integrated fund. Many Children’s Mental Health Collaboratives participate in the Local Collaborative Time Study (LCTS) which claims federal funds that are directed to the collaboratives’ integrated funds to support prevention and early intervention services.
Links to Collaborative Information:
Children’s Mental Health & Family Services Collaboratives:
Children’s Mental Health Collaboratives Legislation:
Family Services Collaboratives Legislation:
8. Adult Mental Health Initiatives (AMHI)
With the closure of Moose Lake Regional Treatment Center in the early 1990’s , counties were encouraged to develop partnerships with neighboring counties in the catchment area to plan for and develop acute care and community-based mental health treatment for those who had been served by the state hospital. Learning from the success of that approach, the SMHA developed legislation that was passed in 1996 to create and provide grant funding for voluntary regional partnerships across the state to expand this planning and service expansion effort. This resulted in 16 regional county initiatives identified as Adult Mental Health Initiatives (AMHIs); ranging in size from single, large county efforts in the seven county metropolitan area to county partnerships encompassing up to 18 counties. The AMHI’s continue to monitor, evaluate and reconfigure their service models while, at the same time, each county retains its role as the local mental health authority. A map of the state with the county groupings of AMHIs is available online.
Purpose
The overall purpose of the AMHI is to:
• Provide an expanded array of services for consumers
• Improve access and coordination services without cost shifting
• Integrate state facilities’ human resources into the community mental health system, and
• Use funding streams and reimbursements creatively
This approach has permitted the development of services which a small or sparsely populated county could not implement independently. Cross county collaboration also generates creativity in service planning and increased community based services as opposed to reliance on institutional forms of care. These service system redesign efforts emphasize a recovery-focused, consumer-centered approach to support independent living and community integration, and reduce utilization of more restrictive service settings.
The AMHI efforts are planned by a diverse group of local stakeholders. Adult Mental Health Division staff members are assigned to each of the AMHI’s to provide ongoing technical assistance and policy direction. The design of each AMHI is unique to the needs of people in that area. Each AMHI is strongly encouraged to incorporate evidence-based and research informed practices into their service delivery system.
Examples of new or expanded services include:
• Expanded availability of psychiatric services during the transition from hospitals to community-based services
• Focus on cultural competence, accessible services and better service coordination
• Community education to educate and support citizens and key stakeholders, such as health service providers, law enforcement and court personnel
• Alternative intensive case management models, including Assertive Community Treatment (ACT) teams.
• Housing with support options.
9. State Mental Health Advisory Councils
State law establishes the State Advisory Council on Mental Health (Council) and a local mental health advisory council (LAC) in each county (or counties working cooperatively).
The State Advisory Council, with 30 members appointed by the Governor, serves as the state’s planning council. Membership on the Council includes consumers and families, advocates, providers, government staff, legislators, a county human services director, county commissioners, representatives of mental health professional disciplines, and others. The Council meets monthly and has several subcommittees.
State law also established a Subcommittee on Children’s Mental Health (Subcommittee) of approximately 30 members. The Council and Subcommittee file a formal report to the Governor and Legislature biennially on every even numbered year.
The Chairs of the Council and Subcommittee have joint planning meetings each month to discuss common strategies, direction and ways to assure collaboration.
The Council seeks information from LACs on areas of service needs within the counties and provides outreach and coordination to the LACs.
American Indian Mental Health Advisory Council (AIMHAC)
The Department of Human Services also has an American Indian Mental Health Advisory Council (AIMHAC), which advises the SMHA on the mental health service needs and preferences of American Indians. One of the major activities of the Council is an annual, statewide conference that brings together national experts, local service providers and others to learn about state of the art mental health services for American Indians. Each member of the council is authorized by the tribal resolution and appointed by the DHS commissioner. The Council meets quarterly.
10. Managed Care Organizations (MCOs)
A number of mental health services reimbursed through the MHCP fee-for-service programs are now being administered through managed care organizations. As the state Medicaid authority and state agency that supervises the MHCP programs, including Medical Assistance, MinnesotaCare and General Assistance Medical Care, DHS contracts with MCOs to provide and administer services to MHCP enrollees through their service networks.
The 2007 Governor’s Mental Health Initiative prompted several changes in the public mental health system including the creation of a model comprehensive mental health benefit set that is available to enrollees in all MHCP, including prepaid medical assistance programs. More information on this Initiative is available online.
The 2011 legislation has also made changes to the relationship between MCO’s and state paid services. More information around this initiative will be updated at a later date.
Many types of entities provide public mental health services in Minnesota including:
• Private agencies or individual providers (for profit or non-profit),
• Counties
• County owned or funded community mental health centers,
• School Districts
• Veterans’ Administration
To be reimbursed for services covered under MHCP, providers, including counties who provide direct services, must meet the service requirements and be an enrolled MHCP mental health provider with DHS. For MHCP recipients enrolled in a publicly funded and DHS contracted managed care organization, (MCO), providers, including counties who provide services, must have a contract with the respective MCO to provide that service. Providers, including counties who provide services, must have a contract with an MCO to provide services to MHCP recipients enrolled in the respective publically funded, DHS contracted MCO.
As the local mental health authority, counties must ensure a system of care that includes the designated mental health services in the Adult and Children’s Mental Health Acts. Counties may contract with outside private providers to offer that service to county residents who meet the established requirements.
School Districts are required to provide mental health services if the service is required for the student to fully participate and benefit from public education. These services are typically provided through Special Education according to a student’s Individual Education Plan (IEP). If the student is enrolled in MHCP, the school district may bill the MHCP for the services. Schools may be the payer or a provider under different circumstances. For example, many schools are beginning to contract with outside providers to provide mental health services to students in and those not involved in special education.
The Veterans Administration is a public entity that provides mental health and other services to men and women from the armed forces. They do not receive funds from MHCP as it is a federally funded entity that serves as both a provider and a payer.
B. American Indian Tribal Governments
Tribal governments have a unique legal status. They are sovereign nations under the U.S. Constitution and under federal law. Although the establishment of the United States subjected the tribes to federal power, it did not eliminate their internal sovereignty nor subordinate them to the power of state governments. Tribes retain the powers of self-government over their lands and members. As such, they are responsible for administering funding, determining policy, and providing leadership for day-to-day administrative activities.
Congress enacted the Indian Self-Determination and Education Assistance Act (P. L. 96-638) that gives tribes the authority to administer and operate their own health services and health programs within their communities. To provide the quantity and quality of health services necessary to elevate the health status of American Indians and Alaska Natives, Congress passed the Indian Health Care Improvement Act. P. L. 94-437. This health-specific law supports P. L. 93-638 and encourages tribes’ fullest participation in planning and managing their health services.
The Code of Federal Regulations, Title 25, Volume 1 (25CFR83.1) describes a federally recognized Indian tribe. In Minnesota, the following six federally recognized Indian tribes are:
• The Minnesota Chippewa tribe:
o Fond Du Lac Band of Lake Superior Chippewa
• Lower Sioux Indian Community
• Prairie Island Indian Community
• Red Lake Band of Chippewa Indians
• Shakopee Mdewakanton Sioux (Dakota) Community
American Indians can access mental health services through state, county, tribal governments, and American Indian Health Boards. Minnesota Statute requires that twenty-five percent of the federal block grant funding be designated for mental health services for American Indian communities. Adults with serious and persistent mental illness or children with severe emotional disturbance are the two highest priority groups targeted for services. Currently, the federal block grant funds nine reservations and three urban American Indian mental health projects. These federal block grants are distributed through a request-for-proposal process.
Tribal governments have become increasingly interested in becoming providers of mental health services that can be reimbursed by Medicaid. A number of divisions within DHS meet regularly with tribal leaders and health services directors to plan this expansion of tribal health services.
Federal agencies are primarily responsible for administering funding, determining policy, and providing technical assistance to states and tribes. One of the largest is the Department of Health and Human Services.
A brief summary of several key federal agencies and their subdivisions are described below:
Department of Health and Human Services. The Department of Health and Human Services (DHHS) is comprised of thirteen administrations with distinct responsibilities. The following five administrations have some impact on the mental health system: Center for Medicare and Medicaid Services, Indian Health Service, Administration for Children and Families, National Institutes of Health, and Substance Abuse and Mental Health Services Administration
Centers for Medicare & Medicaid Services. The Centers for Medicare & Medicaid Services (CMS) major responsibilities are to administer funding, determine policy, and provide technical assistance to the Medicare and Medicaid healthcare programs. In conjunction with the Health Resources and Services Administration (HRSA), CMS runs the State Children’s Health Insurance Program (SCHIP), whose goal is to cover uninsured children in the United States.
Indian Health Service. The Indian Health Service (IHS) is the principal federal health care provider and health advocate for American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. The relationship, established in 1787, is based on Article 1, Section 8 of the Constitution.
Substance Abuse and Mental Health Services Administration. The Substance Abuse and Mental Health Services Administration (SAMHSA) was established by Congress under P.L. 102-321 on October 1, 1992, to strengthen the capacity of the nation’s health care system in providing prevention, diagnosis, and treatment services for people with co-occurring disorders: substance abuse and mental illness. SAMHSA houses the Center for Mental Health Services (CMHS), Center for Substance Abuse Prevention (CSAP), and Center for Substance Abuse Treatment (CSAT). Prior to 1992, the three centers functioned as independent entities. SAMHSA partners with states, communities, and private organizations to address their needs. It also works on the community risk factors that contribute to these illnesses. In addition to the three centers, SAMHSA also houses the Office of Applied Studies, Office of the Administrator, Office of Policy, Planning and Budget, and Office of Program Services.
Administration for Children and Families. In partnership with state, local and tribal governmental agencies, as well as with local public and private agencies, the Administration for Children and Families (ACF) promotes the economic and social well-being of families, children, and communities through family assistance (welfare), child support, child care, child welfare, and Head Start.
National Institutes of Health. The National Institutes of Health (NIH) is the steward of medical and behavioral research for the nation. It comprises 27 institutes and centers. The Office of the Director is responsible for setting NIH policy and for planning, managing, and coordinating the programs and activities of all NIH components. The two mental health institutes relevant to DHHS, National Institute of Mental Health and the National Institute of Child Health & Human Development, are highlighted below.
The National Institute of Mental Health, established in 1949, provides national leadership in understanding, treating, and preventing mental illness through basic research on the brain and behavior, and through clinical, epidemiological, and health services research.
The National Institute of Child Health & Human Development was created by Congress in 1962. NICHD supports and conducts research on the health issues of children, adults, families, and populations.
Social Security Administration. Under the supervision and direction of the Commissioner, the 14 offices of the Social Security Administration (SSA) administer the Federal retirement program, the Retirement, Survivors and Disability Insurance (RSDI) program, as well as the Supplemental Security Insurance (SSI) program for the aged, blind and disabled.
Advocacy organizations play an important role by providing education about mental illness to the general public and informing legislators about mental health issues and particular needs within the mental health system. They serve as a voice for individuals and families served by the public mental health system and partner with DHS, Counties, Managed Care Organizations, and others to address system change.
Some active advocacy organizations include:
Minnesota Association for Children’s Mental Health (MACMH) is committed to a mission of enhancing the quality of life for children with emotional or behavioral disorders and their families. Its activities include: educating the public to remove the stigma and barriers associated with children’s mental health disorders; informing families and professionals about children’s mental health issues, services, and resources; providing opportunities for parents and care givers to develop the skills required to effectively advocate for their children; advocating for the appropriate and timely delivery of services to children with emotional or behavioral disorders; and advising parents about rights and responsibilities in the multiple systems that serve their children.
PACER Center (Parent Advocacy Coalition for Educational Rights) is a national organization based in Minnesota whose mission is to expand opportunities and enhance the quality of life of children and young adults with disabilities and their families, based on the concept of parents helping parents. It provides assistance to individual families, workshops, materials for parents and professionals, and leadership in securing a free and appropriate public education for all children, including children with mental health needs.
Mental Health Consumer/Survivor Network (CSN) of Minnesota is a statewide primary consumer organization with nine regional offices. The mission of CSN is to transform, empower and build connections in Minnesota communities by promoting recovery and wellness. To address this mission, CSN provides education, advocacy and action, and support and resources. Resources include consumer “warmlines” phone services, Wellness Recovery Action Plans (WRAP) groups, peer support and recovery grants. CSN staff are working in partnership with DHS to train and certify Peer Specialists as a provider of billable Medicaid mental health rehabilitation services.
National Alliance for the Mentally Ill-Minnesota (NAMI-MN) has nearly 4,000 members and 22 local affiliates. NAMI-MN offers education, support and advocacy. The organization vigorously promotes the development of community mental health programs and services, improved access to services, increased opportunities for recovery, reduced stigma and discrimination and increased public understanding of mental illness. As an example, NAMI –MN offers support groups for family members called Family-to-Family, support groups called BRIDGES for consumers and Mental Health First Aid training to interested members of the general public.
Mental Health Association of Minnesota’s (MHA-MN) mission is to enhance mental health, promote individual empowerment and increase access to treatment and services for persons with mental illness. MHA-MN provides individual advocacy programs, education through workshops, on-line curricula and web pages, and issues advocacy addressing systems issues. REACH family support groups exist in a number of communities across the state.
Minnesota Disability Law Center (MDLC) serves as Minnesota’s Protection and Advocacy Agency and receives some of its funding from the Federal Center for Mental Health Services/SAMHSA. The MDLC is mandated to protect and advocate for the rights of people with mental illnesses and to investigate reports of abuse and neglect in facilities that care for or treat individuals with mental illnesses. These facilities, which may be public or private, include hospitals, nursing homes, community facilities, board and care homes, homeless shelters, jails and prisons.
Chapter 6 - Common Practice Elements for Service Framework
Chapter Outline
1. Introduction
a. Research informed Practices (EBP’s)
3. Components of Service Delivery
d. Summary and Clinical Recommendations
g. Reassessment
1) Introduction
This chapter describes the basic principles and service elements that help ensure that children and adults in Minnesota receive quality mental health services. The service elements are basic to all mental health services, regardless of provider. Some are required by Minnesota Health Care Programs (MHCP) and most other payers. Other elements are encouraged because the Mental Health divisions at the Department of Human Services have identified them as effective practices for ensuring the quality of care.
2) Components of Practice
a. Research Informed Practices (EBPs)
The Adult Mental Health Division (AMHD) endorses four of the Substance Abuse and Mental Health Administration (SAMHSA) identified Evidence Based Practices: Illness Management and Recovery (IMR), Integrated Dual-Disorder Treatment (IDDT), Supportive Employment (SE), and Assertive Community Treatment (ACT).
The DHS Children’s Mental Health Division has developed an evidence-based practice database to guide decisions by parents and providers in planning for child and adolescent care. This tool is the first of its kind to be used in practice to address the question of what works for whom under what conditions. The Minnesota database incorporates data collected from rigorous review of scientific literature that suggest different techniques or strategies for treating children with various mental health disorders. It includes current evidence on treatment for eight mental health disorders: Anxiety, Attention Problems, Autism, Depression, Disruptive Behavior, Eating Disorders, Substance Use, and Trauma. In practical terms, the new system provides a “map” of the treatment strategies that are most likely to be successful based upon a child’s disorder and demographic characteristics. Information about risks and side effects documented in the research are clearly presented as well.
Both divisions recognize that there are more research informed practices than those endorsed by SAMHSA.
b. Documentation
Documentation tells the treatment story, beginning with assessment and treatment planning through implementation, as explained in progress notes, and plan reviews. The thread of documentation is the reasoned clinical relationship between each sequential clinical decision made and described in the individual’s case documentation. When case documentation is through, the thread running through the record is clear; the assessment(s) support the treatment plan, the progress notes reflect implementation of the plan, and reassessments or treatment plan reviews lead to adjustments in the case conceptualization or in complete or thorough treatment planning.
Treatment Purposes
Documentation of an individual’s mental health status, treatment, and progress, is a practical and vital tool for Mental Health Professionals and Practitioners and individuals themselves to guide and implement the Individual Treatment Plan (ITP). Documentation can help providers evaluate treatment progress, and thoroughly assess new developments in an individual’s functioning, given previous clinical experiences. Effective monitoring of treatment progress is essential to ensure the individual reaches their highest level of functioning and achieves their treatment goals. Clear and complete case documentation is also important for communicating the course of treatment to all stakeholders, including the individual, family members, concurrent providers, or new mental health providers.
Legal Record
The thread of documentation establishes a written, legal record of the course of treatment. The documented record provides evidence that the needs of the individual have been assessed and an appropriate course of interventions have been selected to improve the individual’s mental health. Provider agencies and treating mental health professionals are liable for maintaining a complete record of treatment that justifies and explains treatment decisions in the event of any legal action or an audit by a health insurance provider.
Medical Necessity
Programs and interventions are typically not covered by health plans unless they are documented as medically necessary for a specific person at an identified time. Beyond this standard requirement, any service billed to Minnesota Health Care Programs (MHCP) or other payer sources must meet the payer’s criteria for medical necessity. Not all services and activities provided to individuals are billable.
Clear case documentation establishes medical necessity. The documentation is evidence that the individual is eligible for a given treatment based on the individual’s diagnosis, functional impairments, and impact those factors have on the individual’s life. The diagnostic assessment is the key to assessing medically necessary mental health services. However, the golden thread of documentation, which links the diagnostic assessment, functional assessment, ITP and progress notes together into a cohesive, effective documentation of the services provided, also must consistently substantiate medical necessity. An ITP that clearly documents the need for the mental health service requested, including intensity, is one criterion for meeting medical necessity standards.
While specific criteria for medical necessity are determined by each payer for each service, there are basic guidelines for establishing medical necessity. Many mental health services are not considered medically necessary without a primary DSM-IV diagnosis (major mental disorder or emotional disturbance) based on the results of a diagnostic assessment. The mental health service provided should be consistent with the diagnosis and recognized as the prevailing standard or current practice. In order for mental health rehabilitation services (adult/children) to be medically necessary, the individual’s functional impairment must be due to their mental health diagnosis and this impairment will be expected to improve as a result of the rehab service.
Certain symptoms or behaviors are important considerations or are especially indicative of the medical necessity of mental health treatment when assessing the need for services. One example is evidence of symptoms or behaviors that reflect danger to self, others or property.
Assessment of medical necessity must also be developmentally and age appropriate. For example in adults, significantly limited ability to perform the activities of daily living (that is, social, family, occupational or school functions) due to a mental illness can support the need for services. In children it is important to consider whether the child has significant impairment in educational and social functioning which may be associated with abnormally aggressive conduct or risk taking behavior. In infants, the provider must consider the baby’s capacity for soothing and being soothed, regulating sensory inputs and emotions.
Concurrent Documentation
While written reviews for detailed assessments can be completed without the individual, functional assessments, level of care assessments, treatment plans and progress notes can easily be completed with the individual present.
There are many benefits to concurrent documentation. They include increased individual involvement, and more clarity of the focus of treatment and ongoing sessions, giving the individual the opportunity to share what is or is not working.
Concurrent documentation entails a new skill set for providers of services to perfect. For example, individuals should always have the chance to review what is being written in the session. Documentation during sessions should always be done as appropriate, and be sensitive to the individual’s needs and level of comfort.
c. Family Involvement
Families often provide essential support, advocacy and coordination of care. A sense of belonging into one’s natural or family of choice can be critical to an individual’s strength, resiliency and recovery, whether as parent, child, sibling, husband, wife, grandparent, aunt or uncle. Involving the family in treatment planning or providing family psycho-education and other information can both strengthen the role of the individual and the family support network.
d. Cultural competence
Many groups exhibit distinct cultural characteristics, which can present special treatment issues. Culture goes beyond race and ethnicity. A wide spectrum must be considered, including but not limited to, family of origin, language, ethnicity, finances, socioeconomic status (SES); single parents, adoptive and blended families; disability, family history, immigration/citizen status, religion, sexual orientation, etc.
Effective mental health providers must be aware of cultural differences and be willing to educate themselves in order to provide the most valuable treatment. Research indicates that culturally-appropriate service improves diagnostic accuracy, increases adherence to recommended treatment, and reduces inappropriate emergency room and psychiatric hospital use. While providers in Minnesota have always needed to be culturally competent, the need is greater as the population has become increasingly more diverse over the last decade.
The new Outpatient Mental Health rule defines “cultural influences” as it relates to the new requirements around diagnostic assessments. This definition also applies to the clinical supervision guidelines as it pertains to services under the jurisdiction of the new rule. To learn about an incremental approach to cultural competence suited for organizations and individuals, see the first part of Guidelines for Culturally Competent Organizations, published by DHS (2004).
e. Service coordination
Providers and case managers of waivered services, acute care providers, and collaborative staff. This means that providers must coordinate with one another to promote consistency in planning goals and objectives, prevent duplication of services, and improve continuity of care and transitions between services. With proper coordination, services can be provided in the most appropriate manner for the individuals’ greatest benefit. Individual’s outcomes improve when providers coordinate individuals’ varied treatment needs effectively.
Service coordination means learning about local resources and building relationships within the local service area. This creates a pool of knowledge to draw on when developing individual treatment plans. Services are coordinated between individual providers within a single organization or between separate agencies. Different scenarios require different policies and procedures.
f. Clinical Supervision
Clinical Supervision is the formal provision, by a licensed mental health professional, of a relationship-based education and training that is work-focused which manages, supports, develops and evaluates the provision of mental health services.
A mental health professional who serves as a clinical supervisor undertakes a legal responsibility and professional trust, and a personal responsibility to ensure the quality of services provided. Failure to meet the standards of supervision may result in revocation of the supervisor’s license. Examination of state licensing laws makes it clear that supervisors are statutorily liable not only for their own negligence in failing to supervise adequately, but also for the actions of supervisees.
Functions of Clinical Supervision:
Refer to the specific covered services sections for supervision requirements.
3. Components of Service Delivery
There are six key elements in the service continuum for mental health:
a. Diagnostic assessment
b. Functional assessment
c. Level of Care assessment
d. Summary and Clinical Recommendations
e. Treatment Planning
f. Service delivery
g. Reassessment
a. Diagnostic Assessment (DA)
The Outpatient Mental Health Services rule, 9505.0370, 9505.0371 and 9505.0372 went into effect as of June 28, 2011. There are new standards and expectations for completing and billing for diagnostic assessments.
The diagnostic assessment is the first part of a three-tier assessment process that includes diagnostic, functional, and level of care assessments. It is a formal evaluation, conducted and written by a mental health professional based on data collected from different contexts, including personal interviews, past records, and other collateral information. The goal of the DA is to make a determination of a mental health diagnosis, establish a profile of the individual and describe the ultimate objective of treatment.
In order to make an accurate diagnosis, certain key elements are required. This includes a description of the symptoms the individual is experiencing, strengths and resources they have, clinical significance of the symptoms on the client’s functioning and other information relevant to these symptoms. A DA explains how the information was gathered; it describes the facts that substantiate the need for treatment, and the recommendations for treatment tailored to the individual at that point in time. It also identifies appropriate and culturally specific service needs. The diagnostic assessment is the key to accessing mental health services because it establishes the diagnosis, the need for services and the type of treatment needed.
The most common and accepted format to conduct a DA in Minnesota and the United States is from the DSM, which is currently in its 4th addition, revised (DSM-IVTR). For young children, the increasingly accepted standard is the DC: 0-3R, from which diagnoses may be cross-walked to the DSM standard for billing purposes. Information obtained through the interview, other records and collateral data is used to determine the diagnosis and information to complete the five axes.
The five axis include:
I. Clinical Disorders
Other Conditions that May Be a Focus of Clinical Attention
II. Personality Disorders
Development Disability
III. General Medical Conditions
IV. Psychosocial and Environmental Problems
V. Global Assessment of Functioning
A Mental Health Professional typically explores many factors when conducting a DA such as:
To perform an effective and comprehensive DA it can be especially important to consider other factors such as the individual’s:
The clinician must ask enough questions to determine whether additional data is needed. Relevant past records may include legal, inpatient-outpatient, social services, medical, and psychological testing. For children it is also important to include education records. These materials may provide critical information and unique perspectives on the individual’s current life situation, symptomatology and level of functioning not evident from a face-to-face contact. Medical records help to inform the assessor of possible medical bases for the individual’s current symptoms.
In addition to records and face-to-face contacts, collateral contacts made during the process of collecting information may include social workers, siblings, other family members or physicians.
The goal of the DA is not only to obtain a description of the problematic behavior, but to understand the meaning and function of the symptoms in relation to the individual and his or her environment and culture. To make these distinctions, the Mental Health Professional must assess the individual’s circumstances preceding the assessment period. This can be established through collateral contacts and may require specific detailing of the individual’s culture. For example, family members may identify other family members with the same condition or provide contextual information about family expectations, history, and roles. These sources of information may help the Mental Health Professional understand the immediate precipitants of current symptoms. For example, it could assess whether there was exposure to trauma. Reviewing previous records, collateral interviews and the diagnostic formulation are not separate processes; rather, the clinician continuously forms and tests tentative hypotheses for diagnostic possibilities, while eliminating competing differential diagnoses. These sources of information should not be overlooked in that process.
DA’s for children are typically interactive, and are generally considered best practice for children under age six. Providers can use physical aids and nonverbal communication to overcome barriers to therapeutic interaction between the physician and an individual who:
The need for interactive assessment is illustrated by the fact that for infants and toddlers, the capacity to self-sooth and regulate sensory input (light, touch, sound, excessive seeking of a particular stimulus) are indicators of level of functioning.
b. Functional Assessment (FA)
The functional assessment is the second step in the three-tier assessment process. A complete FA includes a narrative of how the individual’s mental health symptoms impact their day-to-day functioning in a variety of settings, and summarizes their related strengths and needs. It is also important to look at how factors other than mental health symptoms impact life functioning.
The assessment should primarily reflect the individual’s current functioning based on interviews and observational data. It is helpful to gather the data from the recipient in their home or community settings. To determine an individual’s functioning baseline it is important to take into account a person’s history and include input from other people associated with the individual. The assessment is non-judgmental as it describes what is rather than what should be.
The information obtained in the FA in turn helps determine goals and appropriate treatment interventions pertinent to what each individual’s needs are. By incorporating strengths in the assessment, the treatment plan can account for individual approaches toward completing a goal.
Statute requires that 11 domains be covered, but does not preclude further assessment in other domains not specified (M.S.245.462, subdivision 11a for adults, and M.S.45.4871subdivision 18 for children).
(1) mental health symptoms as presented in the child's diagnostic assessment;
(2) mental health needs as presented in the child's diagnostic assessment;
(3) use of drugs and alcohol;
(4) vocational and educational functioning;
(5) social functioning, including the use of leisure time;
(6) interpersonal functioning, including relationships with the child's family;
(7) self-care and independent living capacity;
(8) medical and dental health;
(9) financial assistance needs;
(10) housing and transportation needs; and
(11) other needs and problems.
Functional Assessments for Adults
In the Minnesota Health Care Programs MHCP system, the functional assessment for adults is an assessment, completed in a narrative format, that covers all domains specified in statute. The severity rating scale that has been attached to the functional assessment in the past is no longer required. The Level of Care Utilization System (LOCUS) has replaced the previous 5 point scale as the way to quantify functioning, risk of harm, medical, addictive and psychiatric co-morbidity, recovery environment, treatment and recovery history, and engagement and recovery status.
For adults, the FA is defined in statute for some services (e.g., ARMHS and MH-TCM) and other services link to these statutes requiring the use of these domains. Certain components must be completed separately, but in coordination with the diagnostic assessment. Typically the diagnostic assessment is completed by a Mental Health Professional from a separate provider agency, followed by the agency that completes the FA. However, this is not a requirement. While assessing for functioning is automatic in a diagnostic assessment, most DA’s do not cover the domains required by statute, nor do they go beyond describing functional barriers for the purpose of meeting the criteria for a diagnosis.
The adult FA has these main components: the status, functional strengths and/or impairments; and when present the link from the functional impairments to the mental illness The functional assessment needs to be individualized so that it is apparent how the functional impairments and their link to the mental illness play out in the day to day life of the individual. For the sake of case management services and rehabilitative services, the FA can be completed by a mental health practitioner as long as a clinical supervisor reviews and approves the assessment. Domain definitions and other helpful instructions can be found on the MHCP website.
Functional Assessments for Children
For children assessing for functioning should be automatic in a diagnostic assessment. A child’s DA must cover the domains required by statute. Functional assessment is present in every aspect of the assessment process, based on the recognition that children’s developmental progress in all areas (physiological, cognitive, emotional and relational) determines the expected level of a child’s functioning.
c. Level of Care (LOC)
The level of care (LOC) assessment is the third tier of the assessment process. Being able to match a client’s needs with the intensity of service is the purpose of a LOC tool. A LOC tool looks at a variety of characteristics to help determine what intensity of services and/or service components are necessary. For some tools it is a list of guidelines. For other tools the guidelines are weighted and have a scoring system to help come up with a conclusion. A good LOC tool will allow for exceptions based on clinical expertise. A good LOC tool will provide some flexibility, be informative, take into account individual differences, and allow for the involvement of clients in the process.
Level of Care - Adults
Adult Mental Health requires the Level of Care Utilization System (LOCUS) for the following services: IRTS, ACT, ARMHS, Partial Hospitalization, Day Treatment, ICRS and Adult MH-TCM. This requirement is as of October 1, 2010. There is a DHS approved LOCUS form (DHS-6249) that providers are to use.
Who can complete:
In addition to a Mental Health Professional, a mental health practitioner may complete the LOCUS under the supervision and guidance of a Mental Health Professional, preferably their clinical supervisor. Because the LOCUS is a clinical tool, the individual completing it must have a working knowledge and understanding of the client’s clinical picture. Therefore, the clinical supervisor will need to determine if the mental health practitioner has the training and experience to complete the tool and will also be required to review and indicate agreement with the completed assessment. Clinical supervisors need to sign the actual completed LOCUS at this time.
When to complete:
The LOCUS tool is meant to be a current assessment of an individual. If at the time of admission into another program, a LOCUS tool from another agency/service is used, it must be completed within 30 days prior to admission. Otherwise a new LOCUS will need to be completed.
The completion of the LOCUS is to follow the same admission, continuing stay and discharge timelines as a functional assessment. If current timelines are listed in program standards or a variance for a service type, providers will follow those timelines prescribed. If there is not a current timeframe of completing a functional assessment at the time of discharge, service providers should follow the guideline of completing a LOCUS as close to discharge as possible, but not greater than ten days from the expected discharge date. In assuring best practice, the LOCUS, as well as a FA, should be re-done if an individual has had a significant change in mental health symptoms, functioning and/or life circumstances.
Clinical Justification/Use of other assessments
DHS views the LOCUS as a component of a three-part assessment process that collects pertinent information to determine the need and eligibility for the six aligned services. However, we recognize that exceptions to a LOCUS level of care can and will occur. If the LOCUS score does not align with the given proposed service and an exception is proposed, documented clinical justification must be provided in order for an exception to be permitted. When exceptions occur, DHS will expect clinical justification to be present in the client’s file.
Use of other level of care assessment tools
Providers may use a level of care tool other than the LOCUS if it is a nationally instrument recognized instrument. The tool would need to be reviewed and approved by DHS for comparability to the LOCUS.
Copyright Notice for LOCUS Instrument
THE LOCUS INSTRUMENT IS PROTECTED BY FEDERAL COPYRIGHT LAW. You may photocopy and use the instrument in the original form. The sole permitted electronic use and/or storage of this instrument in an unmodified, read-only image of the original paper document in "PDF" (Portable Document Format).
The PDF can be downloaded from http://www.communitypsychiatry.org. You are not permitted to change the instrument in any manner including electronic modifications. You may not store the instrument except as an unmodified PDF file as posted at the above website. You may not change or store the instrument in spreadsheet, database, word processing or other file formats and/or programs. All electronic rights to this instrument are owned by Deerfield Behavioral Health, Inc. More information about electronic/software versions of the instrument can be obtained by contacting Deerfield Behavioral Health, Inc., at http://www.dbhn.com/locus.html.
Level of Care-Children
Children’s Mental Health requires all providers who bill MHCP to use the Child and Adolescent Service Intensity Instrument (CASII) for children ages 6-18 and the Early Childhood Service Intensity Instrument (ECSII) for children under 6 years old as a measure of each child’s symptoms and functioning. Effective February 2009, DHS began requiring that the CASII and ECSII be completed by counties to determine the level of care needed before admitting any child or youth to a mental health inpatient and residential program, and by residential treatment providers to assess the child’s ongoing status and treatment needs. Providers are required to enter in CASII and SDQ scores in the MN-ITS system at intake, every 6 months, and at discharge from treatment.
d. Use of a Summary of Clinical Recommendations (The Interpretive Summary)
The Interpretive Summary is used to synthesize the information obtained from the three tier assessment process (Diagnostic, Functional and Level of Care) to more clearly determine an individual’s needs and prioritize what is to be first addressed. It is an essential bridge or link from Assessment to Service Planning.
An Interpretive Summary:
e. Treatment Planning Process
Before entering into any mental health treatment, a treatment plan must be completed. An Individual Treatment plan is a written plan that documents the treatment strategy, the schedule for accomplishing the goals and objectives, and the responsible party for each treatment component (Minnesota statute 245.4871 subd. 21 for children and Minnesota statute 245.462 Subd.14 for adults).
The individual treatment plan focuses on the individual’s vision of recovery, their priority treatment goals and objectives and the interventions that will help meet those goals and objectives. The plan must be written in a way in which the individual and/or family have a clear understanding of the services being offered and specifically how it will address their concerns. Consequently, the individual must take part in the process of developing the ITP, to make sure the treatment is relevant to their priorities and incorporates their strengths.
Treatment plans are based on the most recent diagnostic and functional assessments and should include interventions that are appropriate to the level of care needs. Since it is based on information obtained from the assessment process, it must be completed after the DA, FA and LOC.
The plan must be achievable and based on the individual’s diagnosis and standards of practice for mental health treatment for people with that diagnosis. The objectives must be incremental and measurable. The ultimate goal is to reduce the duration and intensity of symptoms and service needs to the least intrusive level possible, which sustains mental health.
The plan identifies goals and objectives of treatment, treatment strategy, a schedule for accomplishing treatment goals and objectives, and the individual responsible for providing treatment to the adult with mental illness.
Treatment Plan Basics
Why treatment plans are important? The ITP is essential for treatment because it informs the provider and individual about the goals, type of services, service intensity, and progress indicators.
Ideally there would be one treatment plan for all providers working with a given individual. This would allow for better coordination of services, less redundancy in services, and better transitions from one service to the next. Minimally, providers should coordinate with each other to determine what each provider is doing in terms of interventions. It is important that two separate providers are not providing the same services/interventions to the same individual.
A treatment plan must be thorough enough to address the individual’s need for treatment interventions along with their recovery vision. The recovery vision should be linked to the large and small steps needed to reach the goal. The treatment plan should be seen as a living document that is reviewed each session to make sure the contents of the plan are still appropriate and manageable. It is a tool to guide the treatment process and should not be used only to meet the policy requirements of a service. Treatment plans should always be written so they are easily understood by the individual and family.
The ideal ITP for a child or adolescent individual:
Adult Considerations:
When completing treatment plans for adults, it is required that the following components are present on the plan. The following definitions apply:
Recovery Vision: Long –term, personal goals, stated in the individual’s words
Goal (Rehab/clinical): Intermediate to Long-term. What needs to be obtained from the mental health treatment in order to meet the Recovery Vision.
Objectives: Short-term (one treatment plan or less). What the individual will be able to accomplish at the end of the short-term treatment plan, it outlines the small steps the individual will take. Typically, they should be able to be completed in a 1-3 month period of time that is manageable to evaluate progress. It is advisable that there are fewer than 3-4 objectives, and they can be targeted sequentially and/or concurrently to attain the goal. They are measurable and observable.
Interventions: whether clinical or rehabilitation, the techniques that staff/therapist will employ to help an individual reach the short-term objectives, which in turn lead to the completion of the goals of the treatment. The treatment plan will include a proposed time-line for completion of interventions by the staff.
Treatment Plan Review
Best practice would dictate that treatment plans include short term and long term goals with established measures for evaluating progress towards each goal. Best practice is to establish short term goals that are attainable within 30-90 days. Therefore, if used effectively, the ITP will be treated as a living document and reviewed after each interaction with an individual in order to verify the ongoing value and relevancy of existing goals and progress towards a higher level of functioning or discharge. Treatment plans should be reviewed as frequently as needed, but at a minimum every 90 days.
f. Service delivery
i. Where Services are Delivered (home, community, office, etc.)
It is important to take into account that different settings are more impactful then others. To learn new skills, it is proven by research that individuals are more likely to learn new skills if they are taught within the same environment where one interacts with the world around them.
ii. Documentation of Service Provided (Progress Notes)
The progress notes, which are completed by the mental health provider, describe the delivery of a rehabilitative intervention. They are the official record of the treatment session. Based on progress notes, it should be obvious to another provider and/or other involved parties, that the treatment plan is being followed and that services are being directed towards the symptoms associated with the diagnosis and/or the functional impairment due to the mental health symptoms. The critical component for progress notes to maintain the thread of documentation and support medical necessity for the treatment provided.
Each payer has specific standards for progress notes.
Best practice dictates that progress notes at a minimum include:
There are various cues that can be used in the process of writing progress notes that help to capture the information necessary, not only for billing, but also to guide the treatment process. Some examples are SOAP or DAP. A format that fits well into documentation for mental health rehabilitation services is the acronym GIRPS – Goal, Intervention, Response to Intervention, Plan for next sessions and Significant Information.
Another way to approach the documentation of progress is to answer the following questions:
g. Reassessment/Review
There are specific requirements depending on each service that guide the minimum period for reassessment/review for the various pieces of documentation (DA, FA, LOC, Treatment Plan, and Progress Notes).
Best practice indicates that diagnostic assessments, functional assessments and level of care assessments are to be updated when there has been a marked change in a person’s symptoms, functioning, and/or major life events. This may mean a reassessment would be necessary prior to the minimum reassessment standards. Regardless of the circumstances around why assessments are updated or redone it is important to recognize that information obtained while updating an assessment will most likely impact the treatment plan. Therefore it would be essential to also review the treatment plan to determine if the goals, objectives and interventions are still appropriate.
Review of a diagnostic assessment. For adults a diagnostic assessment needs to be completed annually. This can be done using the guidelines for the standard or extended DA or an adult update can be used. An adult update of a standard or extended DA can only be done for years two and three. The purpose of an early assessment/update is to determine whether the diagnosis continues to accurately reflect the current clinical diagnosis. It is also used to determine if the individual continues to meet the criteria for a diagnosis of mental illness or emotional disturbance.
For children up to age 18, a complete annual DA is required for most services, with a few exceptions. This is due to the fact that for children developmental stages and appropriate level of functioning continually evolve. However even for adults, symptom sets can change in severity and thus change a diagnosis. Some diagnoses (children’s and adults) are short-term, and must be reassessed within a certain period of time to determine whether the symptoms have resolved or a new diagnosis is more appropriate. New conditions may have developed. New or additional treatment referrals may be necessary. A full assessment will always provide the most accurate information regarding the individual’s symptoms of mental illness.
Goals, objectives and interventions need to be reviewed regularly to determine if the goals and interventions are still appropriate and/or progress has been made. It is believed that the treatment plan should be discussed at each session. Changes should be made when necessary. It is also important to note that reviews need to be completed in written form.
Chapter 7 - Community Based Services
Overview
This chapter focuses on the different community based services concerning both children's and adult mental health in the fee for service MA (Medical Assistance) programs.
The list provided below is by no means exhaustive to the continuum of services offered throughout our system. The list is subject to change.
At this time the services identified to be covered in this manual are:
A. Outpatient services
B. Rehabilitation Services
C. Crisis Services
D. Employment Services
E. Housing Support Services
F. Case Management
Chapter 8
Integrated Dual Disorder Treatment
General information on integrated treatment for co-occurring mental illness and substance use disorders
The information on this page describes the experience of integrated treatment from the consumer perspective and suggests how to identify an integrated treatment program. This general information will be helpful to anyone, from consumers to family members to providers, who would like an introduction to integrated treatment.
What is involved in integrated treatment for individuals who have co-occurring disorders
The term ”co-occurring disorders” may be new to you; you may have heard the terms “dual diagnosis”, “dual disorders” or others to refer to the presence in an individual of both mental illness and a substance use disorder involving drugs or alcohol. Research shows that integrated treatment—treating both disorders at the same time rather than separately—produces the best recovery for individuals who have co-occurring disorders.
Integrated treatment is a nationally recognized evidence-based practice that calls for treatment providers to use a specific set of tools and techniques to help people with co-occurring disorders on their path to recovery. The following comments from Minnesotans who have received integrated treatment illustrate the effectiveness of this approach:
Effective treatment must address the multiple needs of the individual seeking help. Staff who are knowledgeable and skilled in co-occurring disorders have been trained to work with individuals on what they want to work on, to help people make the changes they’re ready to make and to explore with the client the areas that might be preventing you from making those changes. Staff will provide information to help the person understand the biological and environmental factors that contribute to mental illness and substance use disorders. They will help discover how both conditions interact together.
The treatment staff will help individuals focus on defining their own recovery, which involves a holistic, biopsychosocial assessment and a treatment plan. The treatment plan defines goals and the small steps to achieving them. The approach can be described as dividing a big task into smaller, more manageable tasks, with each smaller task tailored to the needs of the person seeking treatment.
Because of the multifaceted nature of co-occurring disorders, treatment may involve multiple components such as individual therapy sessions, group therapy and peer support groupssuch as Dual Recovery Anonymous or Double Trouble in Recovery. Individuals will be asked whether they want your family or other supportive people included in their treatment; family involvement is important to support treatment goals and change efforts.
There are several good overviews of the general approach to integrated treatment. Sections of the “Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices KIT”contain overview information for anyone wanting to learn more about what is involved in integrated treatment. The most useful portions for those thinking about seeking integrated treatment are a 4-page overview brochure that summarizes what integrated treatment is, why you should try it, and how it works. It is available in English and Spanish. An onlineintroductory video illustrates the basics of integrated treatment. It includes practice principles, philosophy and values, the basic rationale for integrated services and how the evidence-based practice has helped consumers and families. Several individuals who have received integrated treatment talk about how it has helped them. It is also available in English and Spanish. The video is also included on a DVD that is sent with the mailed version of the KIT (when in stock). Introductory PowerPoint slides give a more detailed overview of integrated treatment for co-occurring disorders. In addition to the downloadable version, an electronic copy is on the CD-ROM in the free mail-order KIT (when in stock). The slides provide background information about evidence-based practices in general, practice principles, and critical components of integrated treatment.
What individuals who have co-occurring disorders say about integrated treatment
In both their survey ratings and their comments, Minnesota individuals who received outpatient integrated treatment said they were very satisfied and that it was more effective than past treatment received separately for each disorder. Clients in a Minnesota hospital with integrated treatment also reported high and increasing satisfaction over time.
Also available are lengthier first-hand accounts about people who have had co-occurring disorders and what they say integrated treatment did for them. In addition to the stories on theintroductory video in the SAMHSA KIT, the Ohio Substance Abuse and Mental Illness Coordinating Center of Excellence (SAMI CCOE) hosts a number of written and audio Recovery Stories (look for the key words “SAMI/IDDT”) and the Co-Occurring Collaborative Serving Maine houses several videos about individuals who have co-occurring disorders.
What to look for in integrated treatment for co-occurring disorders
Anyone thinking about seeking integrated treatment may wish to begin by reviewing a brochure produced by the Substance Abuse and Mental Health Services Administration (SAMHSA) that guides the reader through a short set of questions to help determine whether help may be needed with mental illness and/or substance use disorders. It also lists websites and a toll-free number where individuals can get more information on integrated treatment and how to find a provider.
Once an individual finds a provider, the first sign that it is a competent integrated treatment program is that staff throughout the agency should make everyone feel welcome there. Staff should support clients and help them feel hopeful about their situation. They will describe the services they have to offer and ask you what kind of help is wanted. In some cases they may not be able to offer all the services needed and will make suggestions about where best to receive them..
If the individual and the staff decide that the treatment program is a good fit, they will help to establish goals for treating the whole person. The staff will ask about past experiences and family to develop an understanding about the situation. Sharing these details may feel uncomfortable, but the staff will approach these life experiences with an accepting and non-judgmental attitude. The treatment plan may require the expertise of more than one person, who will make up an “integrated” team and share information (with permission) in the interest of best helping..
How to get integrated treatment in Minnesota
Several programs in Minnesota participated in a 3-year state project to learn how to deliver integrated treatment for co-occurring disorders. There are various outpatient programs and hospitals in Minnesota that are interested in providing integrated treatment.
Providers take a variety of payment sources to fund treatment, including employer insurance and state-funded insurance programs. More information is available on the DHS website to find out eligibility for public Chemical Dependency Treatment Funds or Minnesota Health Care Programs.
Program preparation
Program change planning
Comprehensive clinical resources
Key clinical processes
Core clinical techniques
Minnesota progress toward integration
Resources from all sections
Program preparation
Programs often seek out general information as a preliminary step in exploring alternatives to an existing practice or program model. It is often spontaneous and unplanned, arising out of curiosity about existing practices and the possibility of doing something different and better. It is usually triggered by a series of questions such as, “Is there anything different we could do? Are there alternative approaches others are using that we should look into? How much do we really want to change what we are already doing? What kind of an investment can we make? Is this worth pursuing?” At this early stage, the program’s goal is to seek answers to such questions to decide whether to go on to the next step of planning for change.
General information on co-occurring disorders and integrated treatment
A program may first need to learn more about why integrated treatment has become an evidence-based practice. Several resources give overviews of the nature and purpose of integrated treatment for co-occurring disorders. Three short newsletters from the Minnesota project on co-occurring disorders (CODs) feature research and resources on the prevalence of CODs, the lack of treatment for CODs, and the effectiveness of integrated treatment. An overview paper on the epidemiology of co-occurring disorders from the Substance Abuse and Mental Health Services Administration (SAMHSA) describes in more detail the research evidence on co-occurring disorders and their treatment. A research article by some of the pioneers in integrated treatment points out the most effective components of the approach.
Sections of one of the major SAMHSA resources on the specific evidence-based practice (EBP) of integrated treatment, “Integrated Treatment for Co-Occurring Disorders: the Evidence-Based Practice Knowledge Informing Transformation” (KIT), also provide good overview information. These sections include “The Evidence”, which describes how the practice developed and the research on its effectiveness, and “How to Use the Evidence-Based Practice KITS”, an overview specifying who within an agency would do what and use which parts of this KIT. A demonstration video accompanies the KIT when ordered in print and may be viewed online.
Another resource is a series of “SAMI/IDDT” podcasts from the Ohio Substance Abuse and Mental Illness Co-Occurring Center of Excellence (SAMI-CCOE). Program staff can listen to what providers and administrators think about implementing and practicing integrated treatment.
Conducting an agency readiness assessment
A more formal step an agency may want to make is to gauge their current readiness to make an organizational change. The General Organizational Index (GOI) is a standardized tool that measures the organizational elements that contribute to successful implementation of an EBP such as integrated treatment. It measures agency-wide operating procedures that have been found to affect agencies’ overall capacity to implement and sustain any EBP. The GOI is included in Appendix D of the SAMHSA KIT chapter “Evaluating your program”, and a one-page readiness checklist appears earlier in the same chapter.
Other surveys may be used to measure staff attitudes toward EBPs and what they already know about integrated treatment. Three articles describe some of these surveys. One article summarizes research on a 15-item scale that measures staff attitudes toward EBPs in general; the items are listed in a table. A second article contains the 35-item Integrated Dual Disorder Treatment Model Knowledge Scale, which can be used to measure both initial practitioner knowledge about integrated treatment and gains in knowledge. A third article reports research on a 31-item questionnaire measuring knowledge on the identification and treatment of co-occurring disorders, as well as a 7-item questionnaire on staff attitudes toward treating clients with co-occurring disorders. In each case an author must be contacted for part or all of the instrument and its scoring instructions.
Program change planning
Once an agency decides to integrate treatment for co-occurring disorders, how does it go about getting started? A 2-page newsletter on organizational change from the Minnesota project gives an overview of the steps involved in change planning. Comprehensive guides to change planning and agency process assessments are also available.
General change planning
Two free comprehensive manuals describe the general process of exploring, selecting, and preparing to implement an evidence-based practice. One is written for human service administrators and practitioners broadly and another is focused more specifically on agencies providing substance use treatment.
“The Change Book” is another useful resource for planning a major organizational change. A section on strategies gives specific guidelines for working with individuals, groups and multiple levels within the organization. Another section on activities lists actual tasks that can be undertaken throughout the change process. “The Change Book” and its accompanyingworkbook are both free, and can either be downloaded or ordered in print form. The books are also available in Spanish.
Two sections of the SAMHSA KIT “Integrated Treatment for Co-Occurring Disorders” may be useful in planning for change for this specific EBP. “Getting started with Evidence-Based Practices” covers initial general tasks involved in implementing EBPs, including considerations of cultural competence, consensus-building, integrating EBPs into agency policies and procedures, and developing a training and evaluation structure. “Building Your Program,” intended for mental health and substance abuse authorities and agency administrators or program leaders, describes integrated treatment, why to implement it, and what to do, from recruiting stakeholders through creating a training plan.
Newsletters from the Minnesota project briefly describe the importance of staff selection in planning change and steps to help unify clinicians from the mental health and substance use treatment parts of an agency.
Conducting an agency process assessment
A baseline process assessment can help an agency gauge how its existing services match up against fully integrated treatment, and will provide actionable steps for moving toward integrated treatment. There are a few standardized program assessments that are used for this purpose, and the choice of which one to use usually depends on whether the program doing the self-assessment views itself as primarily a mental health program or primarily a substance use treatment program. A program that primarily provides mental health services could establish a baseline using the Integrated Treatment Fidelity Scale or the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index. The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index would be the instrument to rate initial fidelity for a substance use treatment program. In either case, information from the baseline assessment can be used to develop an agency work plan. The scales would be administered again sometime after the plan has been implemented to measure progress toward integration. A newsletter on fidelity reviews from the Minnesota COSIG project concisely describes their purpose and nature.
The Integrated Treatment Fidelity Scale has 14 program-specific items, with each rated from 1 (meaning “not implemented”) to 5 (meaning “fully implemented”). The items assess whether the treatment is provided as the evidence-based model prescribes. Ratings of “fully implemented” were determined through a variety of expert sources as well as through empirical research. The scale has undergone numerous drafts and reviews by many groups and was revised during the 3-year pilot testing of the KIT materials. The Integrated Treatment Fidelity Scale is included in Appendix B of the “Evaluating your program” chapter of the updated KIT. A separate inpatient fidelity index for use in psychiatric units is available from the Ohio Substance Abuse and Mental Illness Co-occurring Center of Excellence (SAMI- CCOE).
The DDCMHT or DDCAT Index is used to rate an outpatient program on seven dimensions containing 35 elements. Scores on each dimension range from 1-5 and together depict a program’s ability to provide integrated care. An overall score of 1-1.99 reflects a program that has the ability to treat persons with mental illness or substance use disorders only, a score of 3-3.49 defines a Dual Diagnosis Capable (DDC) program that can serve persons with mild to moderate co-occurring disorders, and a score of 4.5-5 indicates a Dual Diagnosis Enhanced (DDE) program that can serve persons with more severe dual disorders. A newsletter from an ATTC gives a thorough summary of the DDC Indexes. The DDCAT/DDCMHT materials, as well as research on the tools, are available on the Dartmouth University Addiction Services Research website.
Programs that meet at least a DDC designation will design their policies, procedures, screening and assessment, program content, treatment and discharge planning, service coordination and staff competencies to provide services for individuals with co-occurring mental illness and substance use disorders. A DDC mental health program would provide integrated services to address co-occurring substance use disorders within the context of the mental health services being provided. A DDC treatment program for substance use disorders would provide integrated services to address co-occurring mental illness within the context of the substance use services being provided.
Programs may find it useful to see an illustration of process assessments by viewing the results of the fidelity reviews in the Minnesota outpatient project. The findings, as described in another section of this website (links to page 18), provided evidence of increased integration of services over the 3-year course of the project.
Using the Minnesota “Co-occurring mental illness and substance use disorders competencies” to determine training needs
Minnesota produced a document describing the core competencies needed by clinicians who work with individuals who have co-occurring mental illness and substance use disorders. The list was developed by drawing from multiple national resources and was refined through three meetings with a group of interested stakeholders. Those providing input into the final form of this document included family members and individuals who have co-occurring disorders, mental health practitioners, substance use treatment providers, psychiatrists, educators, and state agency staff. Members represented outpatient, inpatient and rehabilitative services, managed care organizations, and community health centers.
The Minnesota core competencies are written for practitioners in both mental health and substance use treatment settings, and are intended to build on their existing skills, experience and education. The list of competencies may be used by agencies or individual providers to assess current skill levels and to gauge whether additional training on treatment of co-occurring disorders may be desired. Minnesota has also compiled a list of free or low-cost training in a curriculum guide that includes both online courses and print self-study materials.
Comprehensive clinical resources
Once the directions for change have been determined through a process assessment and review of needed training and policy changes, a wealth of resources provides information for administrators and clinicians on the clinical practices used to treat co-occurring disorders. These include several major, comprehensive resources on all aspects of integrating treatment.
Print resources
There are a number of free or low-costs resources on providing integrated treatment for co-occurring disorders in print or online. These curricula and their content are described in detail in the Minnesota document “Co-occurring Disorders Curriculum Options”. Some of the most comprehensive and least expensive of these resources are summarized below.
Three free print resources are available on the integration of clinical practices. Two are published by SAMHSA and one was produced by the Washington, D.C. COSIG project and its contractors.
Print curricula
Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices KIT.Training Frontline Staff: Integrated Treatment for Co-Occurring Disorders.(SAMHSA).
Training Curriculum: Co-Occurring Disorders Clinical Competency Certificate Training. (Washington DC Department of Mental Health).
Primary audience
Mental health providers
Substance use treatment providers
Both groups of providers
Size
406 pages (in chapters from 14 to 130 pages each)
561 pages
1035 pages
Format
Download or order print (when in stock)
Download or order print
Download
Supplements
Brochures
Demonstration video (if not in stock,available on YouTube)
In-service Training Manual; guides for administrators, SUD clinicians, MH clinicians
PowerPoints, pre- and post-tests, handouts
Content for:
Planning
x
x
Implementing
x
x
x
Measuring &
sustaining
x
Consumers &
families
Introductory video
Brochures
Online resources
There are also a number of online courses on integrated treatment for free or at low cost. Some of the more comprehensive of these curricula are summarized below; details on these and other online courses are available in “Co-occurring Disorders Curriculum Options”. Three were created by state agencies and the fourth was created by Dartmouth University and Hazelden Publishing.
Online curricula
Co-Occurring Mental Health and Substance Use Conditions.
Vermont Agency of Human Services
Co-Occurring Disorders: A Training Series.
The Louis de la Parte Florida Mental Health Institute, University of South Florida
Bridging Mental Health and Substance Abuse Services.
Co-occurring Collaborative Serving Maine (CCSME)
Co-occurring Disorders Integrated Treatment Series. Hazelden Publishing and Dartmouth University
Primary audience
Both groups of providers
Both groups of providers
Both groups of providers
Substance use treatment providers
Size
7 modules
9 modules
11 modules
7 webinars, 90 minutes each
Cost
Free
Free unless CEUs wanted ($25 per request; all may be requested at one time)
$75 total (first two modules are free)
Free. Will be available for one year following original broadcast dates of May to November 2010.
Evidence of completion provided
None
CEUs, 3 per course
Certificate of completion; CEUs available, 17 hours
None
Supplements
Online videos of individuals who have co-occurring disorders
Produced as a companion series to the commercial print curriculum available from Hazelden
Content for:
Planning
x
x
x
x
Implementing
x
x
x
x
Measuring &
sustaining
x
x
Consumers &
families
Videos
Commercial resources
Comprehensive commercial print products on integrating services are available for purchase, including:
Co-Occurring Collaborative Serving Maine (CCSME). No date. Co-Occurring Mental Health and Substance Use Trainer’s Manual. Primary audience: either mental health or substance use treatment providers. The training manual parallels the content in the CCSME online course summarized above. (Approx. $270 for manual, $40 for DVD of “Recovery stories”).
McGovern, M., Drake, R. E., Merrens, M., Mueser, K., & Brunette, M. 2008. Hazelden Co-occurring Disorders Program. Hazelden Foundation. Primary audience: substance use treatment providers. (Approx. $1300).
Mueser, K. T., Noordsy, D. L., Drake, R. E., Fox, L. 2003. Integrated treatment for dual disorders. NY: Guilford Press. Primary audience: providers who treat serious mental illness. (Approx. $55)
Skinner, W. J. W. (Ed.) 2005. Treating concurrent disorders: A guide for counsellors. Toronto: Centre for Addiction and Mental Health. Primary audience: either mental health or substance use treatment providers. (Approx. $46)
Key clinical processes
Detailed resources are available for two of the key processes involved in integrated treatment, screening and assessment and treatment planning. An overview of the sequence of these processes is included in a set of three newsletters on integrating service (issues 10-12, 2009). In addition to reviewing the specific resources described below, programs may wish to read the sections of this website about the processes that Minnesota outpatient (links to page 17) and inpatient (links to page 18) providers followed during their implementation of integrated treatment to learn what is involved at the agency level. Another useful resource is a first-hand account by clinicians on how their agency integrated treatment for co-occurring disorders.
Screening and assessment
Both newsletters on screening and assessment from the Minnesota COSIG project and an overview paper from the national Co-Occurring Center for Excellence (COCE) briefly summarize the purpose of screening and assessment for co-occurring disorders. In addition, Minnesota produced more lengthy screening guidelines for co-occurring disorders, including suggestions on screening tools to use. COCE also published a PowerPoint technical assistance document containing a detailed review of screening tools for mental illness, substance use disorders, and co-occurring disorders. The COCE website houses a number of presentations on screening and assessment as well. Minnesota also has available a summary of available assessment tools for co-occurring disorders and indicates when each is appropriate to employ; the document was written for inpatient providers but may be adapted for other settings. Interested providers may also want to see how increased screening improved rates of assessment, diagnosis, and treatment of co-occurring disorders (see last section of website).
Treatment planning using the stages of change
An informative series of newsletters on treatment planning (issues 4-6, 2006) is written for substance use treatment providers, but the overall approach also applies to integrated treatment of co-occurring disorders.
An important aspect of planning treatment for co-occurring disorders is matching the stage of change of the individual for each disorder with the appropriate stagewise treatment. A Minnesota newsletter briefly covers stages of change, and a short interactive tutorial on stages of change is available on the Canadian website of the Centre for Addiction and Mental health.
A number of detailed resources are available from one of the main researchers on change processes. Carlo DiClemente describes what he called the “transtheoretical model” of change in several presentations and a webcast, and DiClemente’s website contains a number of resources such as tools and links to other sites.
Another pair of webcasts from Pennsylvania also cover stages of change.
Two presentations particularly relevant to co-occurring disorders are DiClemente’s “Readiness for change and managing multiple problems” and “Practical approaches to staging change in dual diagnosis” by Nancy Piotrowski.
Minnesota newsletters describe groups for individuals in early and later stages of change. In addition, a video course available for purchase describes how to design treatment groups for individuals with co-occurring disorders using the stages of change.
Core clinical techniques
Additional resources are available on specific core techniques used in different stages in the process of integrated treatment, such as motivational interviewing, psychoeducation, cognitive behavioral techniques and medication management, as well as auxiliary supports.
Motivational interviewing
Motivational interviewing (MI) is a powerful technique for helping clients find their own reasons to act on a problem they would like to change. A thorough review article summarizes how MI is used and which components are most effective. The technique is so important that training on MI was a centerpiece of the Minnesota COSIG project (see last section of website). Agency staff can hear providers talk about their experiences using MI by downloading MP3 files from the SAMI-CCOE website.
Multiple resources on motivational interviewing are available at the website “Motivational Interviewing”, which is maintained by the Mid-Atlantic Addiction Technology Transfer Center (ATTC), funded by SAMHSA. Much of the content is provided by MI pioneers William R. Miller and Stephen Rollnick. The website links to manuals, DVDs, and training resources. Although the emphasis on the site is on treatment of substance use disorders, the general MI approach is used with a host of medical and behavioral issues (summarized in the Minnesota newsletter on MI). The bibliography contains a list of articles specific to co-occurring disorders. The ATTC also has a newsletter series on MI (Issues 10-12, 2006).
*A similar major resource is a comprehensive website co-sponsored by Miller and Rollnick. It also contains articles, tools and lists of resources on motivational interviewing.
Several free resources are intended for substance use treatment providers, but may be informative for any clinician. These include the SAMHSA “TIP (Treatment Improvement Protocol) 35: Enhancing motivation for change in substance abuse treatment” and the 2007 manual “Motivational Groups for community substance abuse programs”. The TIP is accompanied by aTraining Inservice Guide, a Quick Guide for Clinicians, and Quick Keys for Clinicians. Other manuals are on motivational groups and “Motivational enhancement therapy” for abuse and dependence.
Other training options include an online instructor-moderated course on MI, offered for a modest fee. A training series of 5 courses on MI is also available for purchase from the Center for Applied Behavioral Health Policy in Arizona. The University of Washington will send a free copy of the DVD “Video Assessment of Simulated Encounters-Revised (VASE-R),” which shows simulations of MI and offers an opportunity to test MI knowledge. Ordering instructions and tools for testing knowledge of MI by using the videos are available on the VASE-Rwebsite.
Research shows that training alone may not be enough to maintain MI skills. A strategy for doing so is to form “coaching circles” within a program facilitated by a staff member who is competent in MI. To this end, the Minnesota COSIG project produced a guide on how to conduct follow-up coaching circles to enhance MI skills. Individuals who have completed the 2-day basic MI training may request the guide at dhs.mentalhealth@state.mn.us (enter “Motivational Interviewing Skill Development Series” in the subject line).
Psychoeducation
Psychoeducation is an important strategy in integrated treatment. Often individuals with co-occurring disorders are unaware of why certain disorders co-occur and how they interact with each other. Psychoeducation may be provided individually but is often delivered in groups.
The Minnesota curriculum guide has a section on curricula for group psychoeducation for co-occurring disorders. The materials include “The Co-occurring Disorders Treatment Manual” and a workbook, free from the University of South Florida, and the 2-volume book set “The Basics: A Curriculum for Co-Occurring Psychiatric and Substance Disorders”, for sale by Rhonda McKillips.
Cognitive behavioral techniques
Cognitive behavioral techniques (CBT) long have been employed to help individuals with mental illnesses and, more recently, those with substance use disorders. CBT is a flexible, effective technique that helps individuals recognize and change inaccurate thoughts and replace unwanted behaviors with productive alternatives.
Although there are voluminous resources on CBT in general, there are fewer on integrated CBT for co-occurring disorders. A Minnesota newsletter gives an overview of the benefits of CBT for individuals who have co-occurring disorders. A set of three newsletters (Issues 4-6, 2010) from the Addiction Technology Transfer Center also addresses CBT for co-occurring disorders in one of them. A book chapter gives a more comprehensive summary of the strategy.
Integrated CBT is described in several online manuals focusing on different combinations of disorders, with some targeted to specific single disorders. These include manuals onsubstance use and psychosis, substance use and post-traumatic stress disorder, cocaine addiction, and alcoholism. There is also a CBT manual focused on corrections populationsand one on anger management for individuals who have co-occurring disorders.
A number of CBT self-help resources are available, some in print and some interactive. An online CBT self-help book is free but requires registration. There is a general CBT interactive online course and one focused on CBT for depression.
Medication management
Many individuals with co-occurring disorders take prescribed medications for mental illness, and prescriptions for substance use disorders are becoming more common (seeMinnesota’s newsletter on the latter). Clinicians may need to understand how medications interact, which medications to avoid in certain circumstances, side effects, and what to do when individuals do not take their medications as prescribed.
Kenneth Minkoff has practice guidelines available on psychopharmacology for individuals with co-occurring disorders.
A video course called “Medication management for persons with co–occurring mental illness and substance use disorders” is for sale by the Center for Applied Behavioral Health Policy. Additional resources are the free “Rx Database”, a 2011 searchable list of medications commonly prescribed for individuals with substance use problems and mental illness, and a 2008print version in a 61-page booklet. The Ohio Substance Abuse and Mental Illness Co-occurring Center of Excellence has a one page table showing recommended medication management for co-occurring disorders appropriate to each stage of change.
Recovery support
As integrated treatment of co-occurring disorders progresses, the focus often shifts from active treatment techniques to support of recovery and prevention of relapse. Recovery is described in a Minnesota newsletter, which includes a number of other references on recovery as well. A second newsletter describes relapse prevention strategies.
A pair of video courses on recovery and relapse prevention is available for purchase from the Center for Applied Behavioral Health Policy. The “Introduction” course covers what relapse prevention is, when it should begin, and how it differs from treatment; the “Approaches” course covers the specific skills that are taught in relapse prevention counseling.
The ATTC has free newsletters on Recovery support strategies and resources (Issues 10-12, 2004). They also offer sets of newsletters on Recovery-oriented systems of care (Issues 10-12, 2007) and Implementing recovery management (Issues 4-6, 2008). These publications are written for substance use treatment providers but may be generally informative. SAMHSA offers an entire Evidence-Based Practice KIT on Illness Management and Recovery for mental illness. The KIT may be downloaded or ordered on CD/DVD; an introductory video is included on the latter.
Family psychoeducation
Involving family members in the treatment of individuals who have co-occurring disorders may help to engage individuals in treatment, improve stability of mental health, reduce substance use, and prevent relapse. Family psychoeducation informs families about the nature and interaction of co-occurring disorders and suggests strategies to support recovery. Abrief summary of the purpose of family involvement appears on the Hazelden website.
A Minnesota slideshow explains the elements, purpose, and effects of family psychoeducation. Although it was prepared for substance use treatment providers, the contents also apply to mental health providers. Webcasts from Ohio describe family psychoeducation and how to involve family as treatment partners.
A pair of guides addresses family involvement in the treatment of co-occurring disorders. A facilitator’s guide provides information for clinicians on how to involve families, whereas afamily guide provides information to the involved family members.
Other manuals address either substance use or mental health, but may be informative for working with co-occurring disorders.
Finally, two research articles describe research-supported family interventions for co-occurring disorders. They are not available in free full-text format but the abstracts may be viewed online and copies of the articles ordered through the publishers or libraries:
Moore, B. C. 2005. Empirically Supported Family and Peer Interventions for Dual Disorders. Research on Social Work Practice,15, 231-245.
Mueser, K. T. & Fox, L. 2002. A Family Intervention Program for Dual Disorders. Community Mental Health Journal, 38:3, 253-270.
Peer support groups
Peer support groups long have been a mainstay in treatment of substance use disorders, and more recently for individuals with mental illness. A few peer group organizations specialize in supporting individuals who have co-occurring disorders. A Minnesota newsletter describes peer support groups for co-occurring disorders and summarizes research showing that they work better than single-focus groups for this population.
*One peer support organization for people with co-occurring disorders, Dual Recovery Anonymous, has information about these groups on their websites. Free pamphlets and brochures on Double Trouble in Recovery as well as commercial products are available on the Hazelden website. Two other peer support organizations, Dual Diagnosis Anonymous and Dual Disorders Anonymous (DDA), do not have current websites, but it may be possible to find groups in your area through other resources.
*A journal article entitled “Starting a Dual Diagnosis Anonymous Meeting: The Role of the Clinician” gives practical advice on how to run a meeting of a DDA peer support group for individuals who have co-occurring disorders. Another article describes the differences between traditional 12-step groups for substance use disorder and groups for dual disorders.
Specialized interventions
Occasionally a particular combination of co-occurring disorders may be either so common or so intractable that a specialized intervention may be needed. Three examples of these are briefly described below.
Dialectical behavioral techniques for co-occurring borderline personality disorder and substance use disorder
DBT is a psycho-educational model that teaches clients to be more skillful in their lives. Clients learn skills in the areas of mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness. It has been used separately for both borderline personality disorder and substance use disorder and also may be used when these disorders co-occur. Abrief overview of DBT is available online. Some materials, such as assessments and research articles, may be downloaded for free from the Behavioral Research and Therapy website under “Public Resources”. Treatment manuals and books must be purchased.
Seeking safety for co-occurring post-traumatic stress disorder and substance use disorder
Seeking Safety is a therapy to help people attain safety from co-occurring trauma or post-traumatic stress disorder (PTSD) and substance abuse. The emphasis is on establishing safety from substances, symptoms and dangerous relationships. The components of the treatment address cognitive, behavioral and interpersonal issues. The materials are for sale on a commercial site, but a number of chapters and articles can be downloaded for free to learn more about the therapy.
CBT for co-occurring schizophrenia and substance use disorder
Some clinicians have adapted CBT to treat individuals who have co-occurring schizophrenia and substance use disorder. Two research articles about the effectiveness of the approach are available in full-text format for free.
Minnesota progress toward integration
Integrated treatment, as a set of principles and practices, has been shown to improve recovery among individuals with co-occurring mental illness and substance use disorders. In 2006 the Substance Abuse and Mental Health Services Administration awarded a $3.35 million grant to the Minnesota Department of Human Services to work with programs to integrate their treatment of co-occurring disorders.
The goals of Minnesota’s Co-Occurring State Incentive Grant (COSIG) were to:
• Increase screening and assessment for co-occurring disorders
• Define competency standards for clinicians who want to provide integrated treatment
• Build networks between mental health and substance use providers
• Explore options to finance services for co-occurring disorders
• Share information on co-occurring disorders and integrated treatment through publications, newsletters and electronic news updates
Outpatient integrated treatment for co-occurring disorders
The COSIG project included as outpatient demonstration sites an initial group of 14 mental health programs co-located with 14 substance use treatment programs, 4 tribal behavioral health clinics and 2 state prison treatment programs. The sites progressed through several steps in their implementation of integrated treatment for co-occurring disorders:
• Participation in an assessment of their level of co-occurring services at the beginning of the project and two years following project implementation
• Designation of an implementation leader to champion and oversee the agency’s work plan
• Engagement of external stakeholders to provide feedback and help identify opportunities to maximize comprehensiveness of services throughout the service delivery system
• Formation of an internal steering committee to monitor and facilitate progress and incorporate stakeholder input
• Development of an agency-specific work plan with identified timelines and responsible parties
• Provision of staff time to participate in training, technical assistance, and consultation;
• Implementation of valid and reliable screening and assessment
• Improvement of documentation of integrated services and agency policies and procedures
• Reporting of data on services and outcomes for persons with co-occurring disorders to monitor progress
The participating outpatient programs also focused on integrating clinical practices in the treatment for co-occurring disorders, including use of the following specific treatment strategies:
• Standardized screening for mental illness and substance use disorders
• Person-centered and empathic engagement strategies based on client readiness for change
• Integrated assessment of mental illness and substance use disorders, including how the disorders interact
• Stage-wise treatment corresponding to the person’s readiness for change on each disorder
• Engagement of recovery supports such as self-help, peer-run supports and family involvement
At the conclusion of the project in September 2009, most of the participants reached a level of capability in treating co-occurring disorders known as “Dual Diagnosis Capable”. This designation means that each programs was deemed capable, based on an extensive, standardized program review, of delivering integrated treatment except at the highest levels of severity and acuity of the co-occurring disorder. Data illustrating these accomplishments are described below. The following programs reached at least the “Dual Diagnosis Capable” level:
Mental health treatment programs:
Central Minnesota Mental Health Center (Buffalo)
Chrysalis-Tubman Family Alliance (Minneapolis)
Fond du Lac Band of Superior Chippewa— Mental Health Services (Cloquet)
Hiawatha Valley Mental Health Center (Winona)
Human Services Incorporated—Adult Mental Health Day Treatment Program (Oakdale)
Lakeland Mental Health Center (Fergus Falls)
Neighborhood Counseling Center of Wadena Inc. — Outpatient Mental Health Services (Wadena)
Northland Counseling Center, Inc.—Outpatient Mental Health Clinic (Grand Rapids)
Zumbro Valley Mental Health Center— Outpatient Psychotherapy Services (Rochester)
Substance use treatment programs:
African American Family Services, Inc. (Minneapolis)
Central Minnesota Chemical Dependency Services (Buffalo)
Fond du Lac Band of Superior Chippewa— Tagawii Outpatient Chemical Health Program (Cloquet)
Human Services Incorporated— Adult Community Options Outpatient Program (Stillwater)
Lakeland Mental Health Center— Chemical Health Services (Fergus Falls)
Neighborhood Counseling Center—Chemical Dependency Outpatient Services of Wadena (Wadena)
Northland Recovery Center Outpatient Program (Grand Rapids)
Tubman-Chrysalis Co-Occurring Disorders Program (Minneapolis)
Zumbro Valley Recovery Partners* (Rochester)
Minnesota Correctional Facility Programs:
Atlantis Chemical Dependency Program (Stillwater State Prison)
Changing PATHS Chemical Dependency Treatment (Shakopee State Prison)
*This program is Dual Diagnosis Enhanced (DDE), a higher level of capability than Dual Diagnosis Capable, and is competent to treat individuals even at high levels of severity or acuity of the co-occurring disorder.
In 2009, four of these agencies received one-year extension grants from the Alcohol and Drug Abuse and Adult Mental Health Divisions to continue to progress toward the Dual Diagnosis Enhanced level of service. The four agencies, chosen through a competitive application process, were Chrysalis-Tubman Family Alliance (Minneapolis), Hiawatha Valley Mental Health Center (Winona), Neighborhood Counseling Center of Wadena (Wadena) and Zumbro Valley Mental Health Center (Rochester).
Inpatient integrated treatment for co-occurring disorders
As part of the effort to establish a continuum of care for treatment of co-occurring disorders in Minnesota, grant activities also focused on integration of services in several hospital psychiatric units. Using the principles of Integrated Dual Disorder Treatment (IDDT), six psychiatric hospital units participated in a transformative change process by looking at clinical protocols and workforce competencies:
CentraCare Health System/St. Cloud Hospital (St. Cloud)
HealthEast/Regions Hospital, units 4 and 7 (St. Paul)
Hennepin County Medical Center (Minneapolis)
Minnesota Department of Human Services, State Operated Services, Anoka Metro Regional Treatment Center, unit D (Anoka)
Minnesota Department of Human Services, State Operated Services, St. Peter Community Behavioral Health Hospital (St. Peter)
St. Joseph Hospital (St. Paul)
These hospital psychiatric units followed steps in the implementation process similar to those of the outpatient programs. These activities included:
• Participation in an assessment of their level of co-occurring services
• Selection of an implementation leader to champion and oversee the unit’s work plan
• Formation of an internal steering committee to monitor and facilitate progress and incorporate stakeholder input
• Development of a work plan with identified timelines and responsible parties
• Provision of staff time to participate in training, technical assistance, and consultation
• Improvements to documentation and unit policies and procedures to support provision of integrated treatment within hospital practices
• Implementation of valid and reliable screening and assessment instruments
• Review of data on services and outcomes for persons with co-occurring disorders to monitor progress
Similar to delivery of integrated treatment in outpatient settings, the specific clinical practices involved in integrated treatment in a hospital include:
• Screening individuals admitted to the psychiatric program for substance use disorders
• Conducting integrated assessments for co-occurring disorders, including how the disorders interact
• Using stage-wise treatment interventions that match the person’s readiness to change on each disorder
• Planning for discharge with greater communication with and continuity of care to the next program or support setting.
Providing integrated treatment of substance use disorders within a hospital psychiatric unit creates unique opportunities and challenges:
• Connecting treatment to patients personal recovery goals
• Balancing the need for safety with the person’s treatment choices based on their goals, readiness for change, preferences, priorities, and values
• Addressing co-occurring disorders to the extent possible based on a combination of patient factors such as symptom acuity and readiness for change and hospital factors such as anticipated length of stay and availability of chemical dependency treatment in the hospital or network
Motivational interviewing training project
*A major effort of the Minnesota COSIG project was to increase skill levels of the behavioral health workforce in the essential practice of motivational interviewing (MI). MI is an evidence-based clinical practice that has demonstrated effectiveness in treating individuals with co-occurring disorders. MI pioneers Rollnick and Miller define the technique as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” MI facilitates change in behavioral health issues such as smoking, substance use disorders, and mental illness, as well as in the behavioral components of medical problems such as diabetes, obesity and hypertension. MI as a core technique in integrated treatment is described in an earlier section of this website (links to page 11).
In 2006, the Adult Mental Health Division (AMHD) and the Alcohol and Drug Abuse Division (ADAD) of the Minnesota Department of Human Services (DHS) launched a series of trainings across Minnesota to improve workforce skills in MI. Working in partnership with Minneapolis Community Technical College (MCTC), Metropolitan State University, and Prairielands Addiction Technology Transfer Center, the two divisions sponsored MI training of more than 1900 mental health and addictions counselors. Prairielands Addiction Technology Center also funded a 3-day training for Minnesota motivational interviewing trainers to learn advanced skills from a national expert.
In addition to subsidizing provider trainings, the MI project accomplished the following:
• Generation of 13 MI trainers, 9 of whom are members of the national Motivational Interviewing Network of Trainers (MINT)
• Development of a standard Minnesota MI curriculum that was used for the introductory 13-hour training
• Creation of an 8-session skills development practice manual for follow-up to the 13-hour training
• Training of staff from an additional 26 mental and chemical health agencies in a MI Phase II project that focused on MI Skills Development Practice Classes
More than 200 clinicians at Minnesota demonstration COSIG sites received twelve hours of classroom MI instruction, followed by monthly instructor-led classes using a manual developed by the state. Clinicians were also offered the opportunity to submit an audiotape for review, which was coded using a standardized code.
Evidence of increased integration of treatment in outpatient programs
During the Minnesota Co-Occurring State Incentive Grant (COSIG), the outpatient agencies that participated in the project made considerable progress toward integrating treatment. Progress was monitored in two ways. First, agencies kept track of and sent in data (known as the co-occurring measures, or COMs) on how many new clients were screened, assessed, diagnosed and treated for co-occurring disorders. Second, project staff reviewed the programs at the beginning and the conclusion of the grant using established measures of fidelity to the integrated treatment model.
Increased rates of screening, assessment, diagnosis, and treatment
The COSIG required that certain data be collected and reported to SAMHSA by all state grantees. The Co-Occurring Measures (COMs) included:
• Proportion of new clients screened for both mental illness and substance use disorder
• Of those screened positive for both, percent diagnostically assessed for both disorders
• Of those assessed for both, percent diagnosed with both disorders
• For those diagnosed with both disorders, proportion treated for both disorders
• Of those treated for both disorders, whether the treatment provided involved minimal coordination, consultation, collaboration, or integration of services.
Data from three quarters of the COMs (links to document) indicate that on most of the measures, performance varied little across time. For example, screening rates started out high at 77% and remained close to that figure by the last quarter (73%). However, on two of the COMs substantial improvement was documented. Of those individuals who were diagnosed with co-occurring disorders, the proportion who were treated for both rose from 69% in quarter 2 to 80% by the 4th quarter. In addition, of those treated for co-occurring disorders, the proportion treated with the highest level of integration of services rose from 17% to 26%. These data suggest that the goal of improving the screening, assessment and treatment of co-occurring disorders was met during the COSIG.
Improved program-wide integrated practices
The outpatient programs received baseline measurements of their ability to deliver integrated services in 2007. They were reviewed again following training and technical assistance in 2009. The fidelity assessments require a lengthy visit to the program by at least two reviewers, during which managers, staff and clients are interviewed, groups and staff meetings are observed, and treatment records are examined. The assessment tools are described in detail in the process assessment section of this website (links to page 5).
Substance use treatment programs received assessments on the Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index at both times. Mental health programs first were reviewed using the Integrated Treatment Fidelity Scale. The second reviews used an index that became available after the baseline reviews were completed, the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index. Although the two indexes are not identical, there are a number of overlapping measures.
Within Minnesota, average scores on the DDCAT and on each of its 7 indexes (links to document) all rose from 2007 to 2009. On several of the closely related indexes from the Integrated Treatment Fidelity Scale and the DDCMHT, scores also rose from 2007 to 2009. Thus overall Minnesota agencies made progress toward integrating treatment during the project.
Minnesota’s participants also compare favorably on integration of treatment to other states that received COSIGs. On the DDC Indexes, programs rated as Alcohol-Only Services (AOS) or Mental Health-Only Services (MHOS) cannot accommodate individuals with co-occurring disorders; Dual Diagnosis Capable (DDC) programs focus on one disorder but are capable of treating individuals who have relatively stable co-occurring problems; Dual Diagnosis Enhanced (DDE) programs are able to treat individuals who have relatively unstable or more severe co-occurring disorders. The comparative data (links to document) show that from Time 1 baselines to Time 2 follow-up reviews, a substantially higher percentage of Minnesota programs than in other states reached the levels of DDC and DDE, and fewer remained at the AOS/MHOS levels.
