Conventional boundaries between single-focus
agencies have impeded the clinical progress of patients who have psychiatric disorders
and alcohol and other drug (AOD) use disorders (Baker, 1991;Schorske and Bedard, 1988).
The treatment
of patients with dual disorders is a clinical challenge, as well as a systems
challenge, requiring innovation and coordination. The goal of this chapter is to
help State and local administrators consider strategies for linkages across
systems in order to improve service delivery and treatment outcomes.
Profiles
of patients with dual disorders demonstrate that they are more or differently
disabled and require more services than patients with a single disorder. They have
higher rates of homelessness and legal and medical problems. They have more frequent
and longer hospitalizations and higher acute care utilization rates. For example,
among patients with schizophrenia, episodes of violence and suicide are twice
as likely to occur among those who abuse street drugs as among those who do
not.
Treatment and social needs of patients with dual disorders differ depending on the
type and severity of the disorders. Patients with dual disorders are generally
less able to navigate between, engage in, and remain engaged in treatment services.
Focusing on linkages highlights the fact that treatment providers, rather
than patients and their families, have the responsibility for coordinating diverse
and often conflicting treatment services.
Treatment must be suited to
patients' personal needs and characteristics, linking services across several different
systems of care. Instead of blaming patients for poor treatment outcomes as they
fall through the cracks of separate service systems, patients can be empowered
and better treated when given effective options.
Collaboration across
multiple systems and philosophies of care is needed to treat patients with dual
disorders effectively. The systems often affected include:
Alcohol prevention and treatment services
Drug prevention and treatment services
Mental health treatment services
Criminal justice systems
Legal services
Social and welfare services
General health care services
Child and adult protective services
Vocational rehabilitation programs
Housing agencies
Agencies for homeless people
Educational systems
HIV/AIDS prevention and treatment services.
For the treatment of
patients with dual disorders, the primary systems involved are AOD and mental health
treatment. Programs that focus on dual disorders operate in both the mental health
and AOD systems. Staff and administrative initiative is required to collaborate
across systems. At a minimum, both systems should be involved when developing
initiatives to improve linkages. This TIP is focused on the linkages between these
systems.
In order to work effectively together, AOD treatment providers and mental
health professionals need to understand and respect the different historical and
philosophical underpinnings of both systems. As explained in the third chapter, the
systems developed separately. There are inherent stresses and strengths among
medical, psychoanalytic, psychosocial, and self-help care orientations, as well
as between AOD treatment and mental health treatment.
These differences
have frequently been a source of conflict and have caused problems for some
patients. For example, if a patient with a dual disorder is told by his psychiatrist
that he needs psychotropic medication to treat his psychiatric disorder, but
members of his self-help AA group tell him to give up all mood-altering drugs to
recover from his AOD abuse, to whom does he listen?
Patients with dual disorders
challenge the treatment systems. Their involvement in treatment can become an opportunity
for providers to examine the philosophical and practical aspects of treatment.
Providers should acknowledge that no single field has all the answers and that a
need exists to integrate treatment by building upon and adapting from experience.
Clinicians who work with dual disorder patients must add to their existing
clinical skills. The development of a dual disorders program is an evolutionary
process that requires agreed-upon outcome measures and program evaluation.
Providers should review admission criteria. These criteria should be inclusive,
not exclusionary. Admission and placement criteria should be based on behaviors
and skills required to participate in and benefit from a program rather than
based solely on diagnosis.
Providers should find creative
ways to bridge the differing funding streams, target populations, legal and
regulatory mandates, and professional backgrounds and expertise.
Providers should accept the responsibility to provide integrated treatment -- not parallel
or concurrent treatment efforts that require the patient to integrate and
adapt to different and sometimes conflicting treatment models.
In spite of the historical and philosophical differences that have separated
the fields, the consensus panel identified several shared treatment concepts
that administrators can use to help move toward integration.
Treatment
should be provided in the least restrictive and most clinically appropriate setting
within a continuum of care.
Treatment should be individualized for each
patient.
The patient should be seen from a holistic, biopsychosocial perspective.
Self-help and peer support are valuable in the recovery process.
Families
need education and support.
Case management plays a key role in effective
treatment.
Multidisciplinary teams and approaches are necessary.
Group education and group process
are valuable elements of the treatment process.
Ongoing support, relapse
management, and prevention are necessary strategies.
Understanding that relapse
and recovery are processes, not single events, and that relapse is not synonymous
with failure is essential.
Cultural competence in programs and staff
is required.
Gender-specific approaches to treatment are necessary.
To establish and maintain linkages
among the various systems working with patients who have dual disorders, several
primary administrative areas need to be examined.
It is beyond the scope
of this document to provide detailed discussion of each area, but the following
discussion of problems and solutions will help readers in their problem solving.
The areas to be discussed in this chapter include:
Often there is little or no communication
or collaboration among various departments and levels of government that have
separate administrative structures, constituencies, mandates, and target groups.
There are also different Federal, State, and local planning cycles within
the AOD use and mental health treatment systems.
The Federal Government
requires two separate planning processes for programs receiving Federal funds: A
State mental health plan and a State substance abuse plan. The federally mandated
State planning processes required under the Public Health Service Act for mental
health treatment and AOD abuse treatment are separate and have no requirements
for coordination.
Amendments
are needed to the Public Health Service Act to encourage coordinated long-term
planning between the State mental health and AOD abuse treatment systems for patients
with dual disorders.
The development and use of long-term structural mechanisms
(such as coordinating bodies, task forces, memoranda of understanding, and letters
of agreement) can help improve planning for and
integration of services for patients who have dual disorders.
To accomplish this
goal, States might create a joint planning mechanism -- an officially organized
planning group -- that would: 1) have diverse composition, 2) carry out specific types
of tasks, and 3) maintain specific foci.
1. The planning organization
should have diverse composition.
There should be dedicated policy-level
staff from different agencies to work on the joint planning body.
The
planning group should be culturally competent and include a culturally diverse cross-section
of the population.
The planning group should include a significant
percentage of direct recipients of the services.
The planning group should
include family members of patients.
The planning group should include providers.
The planning group should include academic representation from schools of medicine,
nursing, psychology, social work, and public health.
2. The planning group should accomplish the following tasks:
The
group should set yearly objectives that are practical and outcome oriented, and
that can be tied to observable results on the service level.
The group
should examine existing licensing requirements and regulations that affect programs
that treat patients who have dual disorders. The goal should be to make the
programs compatible and to reduce duplication of licensing reviews where possible.
The group should alert AOD and mental health programs that provide
treatment for patients with dual disorders to existing Federal and State patient
protection and confidentiality laws that may be applicable for both fields.
The results, findings, and recommendations of the joint planning body should
be formally structured to feed back into the system and ensure that the initiatives
are implemented and maintained.
The group should recommend model policies
regarding dual disorders, and stimulate initiatives in program development and training.
There should be collaboration with universities and colleges to develop and integrate
coursework, field placements, and treatment research specific to patients with dual
disorders.
There should be a linkage with vocational rehabilitation and employment services.
3. The planning group should maintain the following foci:
Define
a needed array of services to address the
needs of the full spectrum of patients with dual disorders.
Encourage
county and other joint or collaborative planning with similar objectives for treating
patients with dual disorders.
Encourage the use of funding and contracting
mechanisms as incentives to ensure that services for patients with dual disorders
are included.
Ensure that competitive contract bids to operate treatment
services specify services for patients with dual disorders.
Award additional
points to proposals for programs that address the needs of patients with dual
disorders.
Require that local and county program plans submitted for State
funds address services for dually diagnosed patients as a special population.
Promote training and staff development strategies to encourage
acquisition of and recognition for skills in treating patients with dual disorders.
The planning group should identify and disseminate information regarding
the availability of Federal grants.
Because of diminishing fiscal resources and competition among many interest groups
for particular types of treatment, those who seek funds for the treatment of
patients with dual disorders have an increasingly difficult task. In many areas,
patients with dual disorders may not be recognized as a priority group for funding.
No specific monies are set aside for patients with dual disorders under
the block grants. The amount of funds that the Federal Government allocates
to States for the AOD and mental health block grant programs changes from
year to year and often includes mandated set-asides for specific groups (for
example, needle users, women, etc.). Set-asides tend to be different for mental
health and AOD abuse treatment and limit the amount available for special groups
not specifically targeted.
States often do not take advantage of Federal
monies that can be used for patients with dual disorders. It is difficult to
identify Federal grants that can be used for dual disorders, since grants and announcements
are scattered across many agencies such as the Substance Abuse and Mental Health
Services Administration (SAMHSA), CSAT, the Center for Substance Abuse Prevention
(CSAP), the National Institute on Drug Abuse (NIDA), the National Institute on
Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Mental Health (NIMH),
and the
Center for Mental Health Services (CMHS), to name a few.
Current reimbursement
practices inhibit integration of services and effective treatment, and there are
several problems related to reimbursement from both public and private third-party
payers. These problems include the following:
There are separate monies
for AOD abuse and mental health treatment.
The span of coverage limits
the types of services that can be provided in each setting.
Few standards
exist that define minimum benefits for either AOD abuse or mental health services.
Depending on the type of treatment program in which patients participate, the separation
of AOD abuse services and mental health services often drives the: 1) primary
diagnosis, 2) type of treatment, 3) level of treatment, and 4) level of reimbursement.
This causes competition for benefits rather than cooperation.
1. Facilitate the aggressive pursuit of Federal funds by the following actions:
Assign an individual to search for Federal grant programs serving patients with
dual disorders. This can be done at the State, local, and agency levels.
A lead Federal agency should be identified to screen grants applicable to
patients with dual disorders, and to encourage States to take advantage of potential
Federal funding. (CSAT might be the lead agency.)
At the State level,
technical assistance should be provided to screen for and assist local agencies to
pursue Federal mental health and AOD funding.
2. Facilitate the use of block grant funds for treating patients with dual disorders.
Work to create joint funding of programs. For example, New Jersey's Division
on Alcoholism and Drug Abuse and Mental Health cofunded a number of model
programs for patients with dual disorders.
Strive to share staff resources
in programs, thus spreading out monies. For example, mental health staff
can cofacilitate a dual disorders group in an AOD treatment program, and vice
versa. Similarly, a mental health program can provide staff to monitor medications
to avoid duplication of effort by the AOD treatment program.
Coordinate
the provision of services and the expenditure of funds within each block grant
area.
Encourage the allocation of more Federal dollars
for block grants and set-asides that include treatment for dual disorders.
There may be some innovative mechanisms other than set-asides to encourage use
of block grant funds for patients with dual disorders.
3. Promote Requests for Proposals (RFPs) for treating patients with dual disorders.
States should promote the development of RFPs specifying programs and services
for patients with dual disorders.
State grants might give extra points
for demonstrating linkages among the systems.
4. Encourage initiatives within third-party reimbursement mechanisms to cover treatment
for patients with dual disorders.
Play an active role in keeping
dual disorders a priority in health care reform efforts.
Encourage providers
and payers to more effectively communicate with each other.
Encourage
State-mandated benefit minimums that recognize that a more intense level of case management
than usual is needed for treating patients with dual disorders.
Educate
third-party providers that treatment for patients with dual disorders may be not only
more intense but also more lengthy.
Consolidate and coordinate reimbursement
rules for AOD abuse and mental health treatment.
Negotiate with local
health maintenance organizations and other providers of health and mental health
services to contract services for patients with dual disorders.
Encourage
managed care companies to cover and facilitate treatment for dual disorders.
Encourage States to establish standards for different levels of care and requirements
for staffing. Encourage the development or adoption of criteria such as those
developed by the American Society of Addiction Medicine with regard to dual disorder
typologies, levels of care, and reimbursement. Reimbursement should be linked to the
use of criteria.
Only limited
treatment and research data are available, and those that are available are not in
a standardized format. Existing data also tend to be general and not useful
to local planners for developing a continuum of care. Data collection systems
are mandated to be separate from each other.
It is difficult to gather prevalence data on patients with dual disorders
because many of them interact with several treatment agencies or systems, while
others do not interact with any.
There are systemic disincentives to gathering
data on patients with dual disorders. For example, Medicaid may cover a patient
who makes a suicide attempt as a result of major depression, but may not cover
a patient who makes a drug-induced suicide attempt.
At least on the State level, common identifiers in data collection should
exist for both AOD abuse and mental health treatment systems. Research should
be in a form that allows for evaluation of cost-effectiveness and outcome.
Outcomes should be measured across several categories encompassing biopsychosocial
issues. Examples might be 1) severity of AOD and psychiatric symptomatology, 2)
housing, 3) service involvement and utilization, and 4) vocational involvement.
Collaboration with local colleges and universities to conduct such research
should be encouraged.
State planning bodies should encourage or require
local needs and resource assessment and data collection. Local planners should
collect data from various systems, examining and comparing data from different
groups, programs, and locations. The State could gather all the data and compile
them for use in improved planning and in evaluating outcomes.
Confidentiality
laws must protect the patient, but also must allow for inclusion of anonymous
case number data in pools to promote better assessment and treatment outcome
studies.
There should be aggressive efforts to examine cost-effectiveness and outcomes
of specific models of treatment services for patients with dual disorders.
These research efforts can be incorporated into State and local initiatives,
perhaps involving local colleges and universities.
Linkages in the
development of programs for treating patients with dual disorders are impeded by several
factors:
Rigid models, resistance to changing programs, and turf battles
Regulations
and reimbursement rules
Clinical assumptions about dual disorders
Program development driven by
reimbursement rules rather than by patients' needs
Limited knowledge about what
is effective; absence of outcome research for program models
Absence
of good processes for disseminating information about existing programs throughout
the country
Lack of standards for comprehensive dual disorders programs
Lack of incentives for good program development on the State and local levels
Absence of State licensing criteria specific to dual disorders
Lack of
appropriately trained staff and other resources
Lack of ownership. Dual disorder
treatment systems are not "owned" by the AOD abuse or mental health treatment systems.
Therefore, development of dual disorder treatment programs is not a priority
in either system.
Provide financial incentives for integrated dual disorder treatment programs.
Provide grants for model program development.
Identify State and county
dual disorder experts.
Publish a State bulletin to facilitate information
exchange.
Encourage research on existing programs from both AOD abuse and mental health fields
by collaborative grants between States and universities.
Determine
how existing services can be adapted (such as with special tracks or staff
training to serve the dually diagnosed population) and help define which services
need to be developed and which are special and unique to groups (for example,
detoxification, longer-term residential programs, halfway houses). For example, the State
of New Jersey issued guidelines for a continuum of care that describe how
to adapt existing AOD abuse and mental health services and what services need
to be specialized to care for dual disorder patients. The guidelines serve
as a blueprint for systems integration.
Publish a State glossary of
terms to encourage communication across systems.
Make sure programs have
integrated expertise from both AOD abuse and mental health treatment fields through
a joint review process for RFPs as well as joint ongoing monitoring processes.
Review programs for gender and cultural competency.
Establish
a consumer feedback process to modify programs.
Encourage the involvement
of providers, patients, and their families in educating the public on the
needs of dual disorder patients and advocating for resources.
The screening process amplifies the tendency to look for a single diagnosis.
Staff in single-focus screening services are not trained to assess patients
for dual disorders.
There is no "gold standard" instrument to diagnose
dual disorders. Some of the instruments that are used often yield false positive
results.
Screeners are not adequately trained to make effective referrals
across systems, which can result in denial of treatment services.
Screening
for dual disorders may take longer than screening for a single disorder. For
example, psychiatric symptoms can appear or disappear as the AOD-induced symptoms
clear.
State policies should lengthen
the time frames in which screening and assessments are done for patients thought
to have dual disorders. State policies should recognize that screening and
assessment are ongoing processes.
The Federal Government should encourage
research to develop standardized screening and assessment tools for dual disorders.
These tools should be appropriate for people with severe and moderate
AOD and psychiatric problems.
There should be systems-wide training
of gatekeepers on the proper way to screen for dual disorders and on effective
ways to make referrals.
There should be widespread encouragement of
the multidisciplinary approach through joint staffing of screening centers
or on-call backup support.
There frequently is no single person or
agency responsible for following up on referrals and ensuring that patients are
linked to treatment and that services are coordinated. People with dual disorders
need others to help them obtain the services that they require, which are often
fragmented.
The Public Health Service Act requires that State mental health agencies that
receive Federal funds provide case management services to patients with severe
mental illness. However, a comparable requirement is not built into the Federal
mandate for AOD abuse treatment services. AOD abuse treatment agencies usually
do not have enough social service staff to handle the case management functions
of linkage or followup for many dual disorder patients.
States and agencies need to define criteria for patients who need and do not need
case management. Case management should be targeted to those who need it, while
less severely ill persons should receive other services.
Develop multidisciplinary
teams with expertise in dual disorders within AOD and mental health treatment
settings. Also, encourage the use of peer counselors to help engage patients with
dual disorders into appropriate treatment.
Encourage a continuum of
case management, defining who should get what level of case management. Levels
may range from treatment plan coordination while the patient is in treatment
to coordinating services within the community (such as Social Security Income
[SSI] and housing). Assertive mobile outreach teams can encourage out-of-treatment
individuals to become engaged in treatment. These efforts can help potential patients
who are reluctant to participate in treatment or who are unable to get to treatment.
States should help increase the case management function within the AOD abuse
treatment field. Ways to develop collaboration by including AOD treatment experts
in a mental health facility and in outreach operations should be found.
All
too often, treatment staff are knowledgeable about either mental health or
AOD treatment. They lack thorough training and education about dual disorder
patients.
There is often insufficient staff time available for the level of case management
required for dual disorder patients.
Staff selection is often driven more
by clinicians' academic degree and their ability to provide reimbursable services
than by clinicians' expertise in dual disorders.
Standards for staffing dual disorders programs should
be developed. These standards should include expertise in meeting the emotional,
social, psychological, biological, vocational, and recreational needs of the patient.
A certification process should be established for certifying
clinicians who have expertise in treating dual disorders. Third-party payers should
be encouraged to reimburse based on clinicians' knowledge, competence, and
expertise rather than on academic degree.
Clinicians in AOD
abuse treatment and mental health treatment usually are not trained in the other
discipline. The availability of staff trained in both fields is limited. Agencies
frequently lack the resources to recruit and retain staff who have sufficient education
and experience. There is both a shortage of qualified staff and an inability
to financially compensate qualified staff for their specialized abilities.
The diagnosis and treatment of dual disorders are not generally
understood by staff, administrators, and legislators, let alone the general public.
Agency directors and supervisors often assign whom they believe to be
the most appropriate staff member to work with dual disorder patients without
a clear idea of the knowledge and skills required.
Professionals
in AOD abuse and mental health treatment have accumulated biases against the
other discipline, as well as negative stereotypes of both patients and staff.
There are no structured incentives for individuals or programs to develop or
take part in training, such as pay differentials and career opportunities specific
to dual disorders. Opportunities and incentives for cross-training are lacking.
Consumers are not adequately involved in the training process.
Relatively few
academic programs involve training or research in this field.
Cross-training is one of the most effective tools administrators have for bridging gaps
between clinicians and services from different fields. Training programs that
provide knowledge about local networking can greatly improve linkages for patients
with dual disorders.
Hire administrators with clinical backgrounds
in dual disorders.
Expose administrators to what is currently being
done in the field of dual disorders through conferences, literature, visits
to facilities, and visits to other States.
Develop clear education
and experience guidelines for different levels of staff members who treat dual
disorder patients. These guidelines should be used to establish training goals
with staff and to establish opportunities for advancement.
Develop standards
for State, local, and facility training for various levels of staff.
Ensure that continuing education credits are available for both AOD abuse and
mental health staff.
Provide certification or credentialing for training
in the other discipline to promote sensitivity in AOD and mental health treatment.
Discuss with State certification board members their willingness to develop associate
credentialing on AOD treatment targeted to social welfare, mental health, and criminal
justice personnel.
Increase awareness of dual disorders for State legislative
and networking systems through appropriately detailed curricula on patients
with dual disorders.
Prepare a training plan for new staff and plan
ongoing training for existing staff.
Provide ample time to have staff fully
trained (2 to 3 years).
Coordinate with local universities and colleges
to create a dual disorders training track.
Create an individualized plan for each staff
person, defining strengths as well as deficits and areas of needed growth; identify
areas of greatest needs; define a training plan with a timetable and components.
Receive training at an established dual disorders treatment program.
Attend workshops on treating patients with dual disorders.
Include on-the-job
training:
AOD abuse and mental health jointly facilitated groups
Mental health
workers on an AOD abuse service
AOD abuse workers on a mental health service
Staff sharing.
Provide didactic inservice training:
Train mental health workers in AOD abuse treatment
Train AOD treatment staff about mental health treatment
Train staff
in dual disorders.
Provide staff with important articles
from the field by providing subscriptions to appropriate peer-reviewed journals.
Purchase textbooks on dual disorders.
Work with local universities,
colleges, and community college programs to create a dual disorders training track.
Disseminate information to the general population through newspapers, television, and
radio shows. Recovering people with dual disorders are good models.
Make presentations to community interest groups through speakers and speakers'
bureaus.
Consumers of treatment services should be offered a role in the training process
for staff in the AOD abuse and mental health fields.
Consumers should
be included on advisory boards for nonprofit and government treatment programs.
Consumers should be offered the opportunity to receive training in both fields to
enhance their skills as peer counselors and group cofacilitators, and to help start
AA and NA meetings that are sensitive to people with dual disorders, sometimes
called "Double Trouble" meetings. Organizations that can help provide education
to the public and patients include the National Alliance on Mental Illness, the National Association of Psychiatric Survivors, the National Association
of Right Protection and Advocacy, and groups such as the Manic Depressive
Association.
Families of patients should participate in Al-Anon and other support groups.
A large proportion of patients with dual disorders require social services.
The scope of social services is extremely broad, encompassing public and
private multisystems.
Federally mandated income support programs are notoriously
complex, each with its own set of regulations. Some, such as the Social Security
Income (SSI) maintenance program, are administered by the Federal Government,
while others are administered by the State and vary from State to State.
Income support programs include SSI, Medicaid,
Medicare, welfare, Aid to Families With Dependent Children (AFDC), and food stamps.
Regulations for each program are often not understood by professionals and others who
provide services to potential recipients. This makes it even more difficult for
the potential recipient to get and retain benefits.
Some programs, such
as SSI, require proof of a permanent and total disability. Mental health
problems often do not neatly fit into categories, making it difficult to obtain
this support.
Income support programs for single individuals have been
cut drastically in recent years.
Applications for these income support
programs are often taken at a site other than where either mental health or AOD
services are provided for the patient.
The complexity of the application and
appeal process adds to the stress of a person with a dual disorder.
Overburdened
staff who are processing income support applications often do not understand
dual disorders.
Federally mandated services for children, youth, and families
include services that fall under the child welfare system (for example, child protective
services and foster care placement).
Child welfare system staff are overburdened
and understaffed. A large percentage of caseloads involve family AOD use problems.
Most child welfare staff are not trained in recognizing or treating dual disorder
problems. Mental health and AOD abuse staff are not trained in child welfare. There
is a lack of knowledge of each other's systems and resources.
Other
social service programs serve a wide range of special needs populations, including
the homeless and victims of domestic violence or sexual abuse, who require
a broad array of support services. Although many users of these services
have mental health and AOD abuse problems, these services are often not available
on site. Social service staff often lack knowledge of how to refer people
with such problems into these systems.
Train SSI maintenance staff about patients with dual disorders.
Train
AOD abuse and mental health staff in a range of social service areas, including
income support, child welfare, and special populations.
Encourage an on-site
application process for income support programs at AOD abuse and mental health treatment
facilities. Mental health
and AOD abuse treatment programs can request training and support from Federal,
State, or local administrators of various income support programs.
Develop
mobile outreach approaches to assist patients with dual disorders in gaining access
to income support programs and other needed social service programs.
Encourage an ongoing exchange among policy-level staff of AOD abuse, mental health,
and Social Security agencies on Federal, State, and local levels.
Encourage a designated policy-level social services staff to create and maintain
links with AOD abuse and mental health treatment systems.
Allocate sufficient
social service staff time to assist patients who need a range of supports and
services.
The medical system is vast, covering a wide range of public and private programs
including primary, secondary, and tertiary care.
Public primary care clinics
are often overburdened, understaffed, and underfinanced. They are often oriented
to treating presenting physical problems, and staff may not be trained in
screening for either AOD abuse or mental health problems. The same problems often
exist in nonprofit primary care facilities. Staff are often not knowledgeable
about how and where to refer patients.
Historically, physicians have not
received any education about AOD treatment and little education about mental health
problems in medical school. Primary care physicians are often unaware of the signs
and symptoms of AOD use disorders, and may have only a basic understanding
of a few psychiatric problems such as depression and anxiety. For example,
persons who experience physical trauma, such as burn injuries or falls, often have
AOD use disorders. Yet, when presented with injured patients, primary care
physicians may not screen for AOD use disorders.
At hospital discharge, personnel
often have difficulty dealing with AOD abuse and mental health concerns. Patients
are sometimes discharged inappropriately with inadequate discharge planning
and linkage with aftercare services.
Staff in mental health and AOD abuse
treatment systems often do not know how to gain access to
medical systems and therefore are ineffective in providing information and ongoing
education.
AOD abuse and mental health staff
should take the initiative to conduct training sessions through established medical
organizations such as medical societies, hospital associations, nurses' associations,
and other professional organizations.
AOD and mental health planning
groups should publish materials that provide tips on linkage techniques for patients
with dual disorders, and target such materials to the medical community.
Many public health clinics operated by the local health department are under
the same administrative umbrella as the AOD programs. The local public health
director can encourage the development of interagency training sessions, protocols,
and policies and procedures to facilitate linkages between the clinics and
AOD abuse treatment services and network with the mental health treatment services.
Also, the local health director can help to establish stronger linkages
between AOD and mental health providers with HIV/AIDS prevention and treatment
systems.
The criminal justice is a top-down system. There is often no mandated joint
planning.
The mental health system has no formal responsibility for inmates with dual
disorders.
Incarceration is often a substitute for AOD abuse and mental health treatment. Treatment
may not begin until shortly prior to release.
Medical services for the
incarcerated are not reimbursable under Medicaid or any third-party payer. There is
often an interagency debate regarding who should pay for care.
Offenders
who should be committed are often released. Prerelease assessments are often
inadequate. There usually is no coordinated plan for release. No systemic funding
incentives to provide care exist. There is a range of custody status.
Criminal
justice staff often have AOD abuse or mental health problems. There are many inadequate
employee assistance programs within the criminal justice system.
The criminal
justice system and community AOD abuse and mental health treatment agencies may
compete for the same AOD abuse and mental health treatment dollars.
Establish
joint top-level planning by the AOD abuse, mental health, and criminal justice
fields.
Encourage funding that supports linkage at the service delivery level.
Work
with AOD abuse and mental health treatment monitoring and licensing regulations
to require and encourage cooperation with the criminal justice system.
Encourage funding for research and gathering data on persons with dual disorders
in the criminal justice system.
Formally identify the responsibility
of each system for providing specific services within the criminal justice
system.
2. County and locality
Include representatives from the criminal justice
system in local AOD abuse and mental health treatment planning groups.
Identify patients in each system who have an interest in cooperation.
3. Consumers
Educate consumer groups and the general public about the need for treatment of
persons with dual disorders in the criminal justice system.
Encourage consumer
groups to influence policy makers regarding linkages.
4. Pretrial process
Monitor and assess cases that involve AOD treatment
and mental health treatment issues.
Advise and train judges regarding
AOD treatment and mental health treatment options.
5. During incarceration
Conduct assessment for dual disorders at admission.
Provide treatment early in the incarceration.
Consider AOD abuse and mental
health treatment issues during the parole hearing.
6. During the probation-parole period
Conduct joint assessment by AOD,
mental health, and criminal justice staff prior to release.
Develop a
release plan that addresses AOD and mental health issues.
Develop a clear
contingency plan to address noncompliance.
Establish prompt and consistent
graduated sanctions of custody status.
Establish joint supervision of problem
cases.
7. Criminal justice staff
Provide EAP services that assess, identify,
and treat AOD and mental health problems of staff.
Cooperate with unions.
Provide training on screening and assessment.
Provide training to address
negative attitudes of criminal justice personnel regarding AOD abuse and mental
health treatment and patients with dual disorders.
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