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Supporting Individuals with Intellectual and Mental Health Needs A framework for Inter – Systems Collaboration Dr. Robert J. Fletcher Founder and CEO, NADD North Bay Regional Center March 8, 2012. Outline of Presentation. Barriers to Service Delivery At the National Level : - PowerPoint PPT Presentation
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Supporting Individuals with Intellectual and Mental Health Needs
A framework for Inter – Systems Collaboration
Dr. Robert J. FletcherFounder and CEO, NADD
North Bay Regional Center March 8, 2012
Outline of Presentation
Barriers to Service DeliveryAt the National Level :
Working Together or Not
Principles in Service PlanningA Framework to Promote Cross System
Collaboration
Fletcher, 2008
Dual Diagnosis Policy Issues
Individuals with MI and ID are among the most challenging persons served by both MH and ID Service Delivery Systems
The Typical Picture:
Fletcher, 2008
Dual Diagnosis Policy Issues
The Typical Picture:
Failure to plan services
Failure to fund flexible services
Failure to obtain technical assistance
Fletcher, 2008
Dual Diagnosis Policy Issues
The Typical Picture:
Failure to provide adequate training and technology transfer
Failure to share and assume joint responsibility
Failure to articulate a policy
Fletcher, 2008
Dual Diagnosis Policy Issues
MH providers perceive that they do not have the skills to serve adults or children with a dual diagnosis
DD providers do not understand the services that the MH sector offers
MH providers do not understand the services that the DD sector offers
The Typical Picture:
NASDDS Survey, 2004
Dual Diagnosis Policy Issues
Professional staff with specialized clinical experience
Comprehensive service coordination
Presence of consistent backup support
Living requirements with fewer people
People with MI and ID typically require:
Fletcher, 2008
Dual Diagnosis Policy Issues
MH System Short term episodic
treatment Focus on psychiatric
needs Recovery model Local authority Medication Treatment Consumer/Client /Patient
DD System Services/supports over
lifetime Emphasis on direct
support Self Determination State authority Behavioral Support
(PBS) Self – Advocate/
ConsumerLittle Collaboration
Fletcher, 2008
Dual Diagnosis Principles
Co-occurring disorders should be treated as multiple primary disorders, in which each disorder receives specific and appropriate services.
Collaboration of appropriate services and supports must occur as needs are identified.
Fletcher, 2008
Dual Diagnosis Principles
Service collaboration between systems is essential
Services provided to the individual are consistent with what the person wants and what supports are needed
Fletcher, 2008
Dual Diagnosis Principles
Services are determined on the basis of comprehensive assessment of both MH and DD needs of each individual
Services are based on individual needs and not solely on either MH or ID diagnosis
Fletcher, 2008
Dual Diagnosis Principles
Emphasize early identification and intervention
Involve the person and family as full partners
Coordinate at the system and service delivery level.
Fletcher, 2008
Dual Diagnosis Principles
The whole system must be designed to be welcoming and accessible to people with co-occurring disorders
People with co-occurring disorders shall be supported in the least restrictive environment.
Fletcher, 2008
Dual Diagnosis Principles
People with co-occurring disorders and their significant others, when appropriate, shall be empowered to make treatment decisions.
The system recognizes and values the long-term cost effectiveness of providing best practice services and supports for persons with co-occurring disorders.
In 65% of states, policy is developed in collaboration with other state agencies
Relationships with Mental Health 55% Effective, very
effective or extremely effective
45% Not or not very effective
Working Together or Not
Relationships with Corrections 73% Not or not very
effective 22% Effective 5% Very effective
NASDDDS, 2011
Financial Operations Operational authorities
State governments Local counties and municipalities Regional boards
Working Together or Not
Medicaid and Medicare funding Medicaid covers 75% - 95% of costs for DD
services, limited MH supports Some potential under Medicare
NASDDDS, 2011
In general, . . .
DD has primary responsibility for long term support
in 70% of states
Working Together or Not
MH has primary responsibility for psychiatric care
in 78% of states
NASDDDS, 2011
MH State Plan Services are available, But access is frequently difficult…..
MH programs are: Under – funded Stretched to the limit Lack expertise to meet needs of people with
ID / DD Unable to bill for necessary activities Include structural barriers
Working Together or Not
NASDDDS, 2011
Emergency Support and Response in 13 States
DD exclusively in 5 of 13 states (38%)
MH exclusively in 3 of 13 states (24%)
Working Together or Not
Mixed in 5 states (38%) Usually MH but DD
may support Usually DD but MH
may support DD provides but MH
contributes funding
NASDDDS, 2011
Top Barriers in 2010
Availability of funding, targeted flexible dollars Providers with sufficient expertise and interest Access to appropriate psychiatric treatment
and related services Lack of trained staff MH and DD staff Effective and timely crisis supports
Working Together or Not
NASDDDS, 2011
Effective Practice Elements Leadership
Commitment Clear lines of authority Independence Protection Commitment to
collaboration Focus on the
Individual
Working Together or Not
The person-centered planning process must determine what is important TO the person and what is important FOR the person.
- Michael Smull
NASDDDS, 2011
Essential Elements….. Effective Staff
The right person The right match Build trust,
dependability Focus on the
System DD/MH interface
Working Together or Not
Training Coordination
Its not a matter of showing up – it is who shows up. It must be someone with commitment and interest in the individual. Someone who cares.
- David Petonyak
NASDDDS, 2011
Effective Treatment Timely Access to:
Appropriate psychiatric treatment and medication management
Positive Behavioral analysis and supports Effective treatment strategies such as dialectical
behavior therapy, EMDR, etc. Community services, supports and resources Employment and meaningful opportunities to
participate in community life Supports in home and with family
Working Together or Not
NASDDDS, 2011
Top New Initiatives and Good Ideas Expanding Community Support Teams Developing new psychiatric practice standards Increasing DD expertise among MH Establishing Centers for Excellence for training,
leadership and technical assistance Deinstitutionalization creates opportunities Developing capacities through university programs Cross-System Planning Formats Strengthening crisis supports
Working Together or Not
NASDDDS, 2011
Fletcher - 2008
A Framework To Promote Cross Systems Collaboration
Cross Systems Task Force/Committee
Fletcher, 2008
Cross Systems Collaboration
Mission of a Dual Diagnosis Task Force/Committee
A Cross System Task Force is a mechanism to draw attention to and make recommendations about, policy and services for individuals with ID and MH needs
Fletcher, 2008
Cross Systems Collaboration
Purpose/Function of A Dual Diagnosis Task Force/Committee
Gather relevant data/formation
Identify strengths in service delivery systems
Identify challenges in service delivery system
Fletcher, 2008
Cross Systems Collaboration
Purpose/Function of A Dual Diagnosis Task Force/Committee
Generate options for improvement in service delivery systems
Promote cross systems education/training to enhance staff competencies
Advocate for policy initiative that advance cross systems collaboration
Fletcher, 2008
Cross Systems Collaboration
Composition Of A Dual Diagnosis Task Force/Committee
Representatives from Mental Health Departments
Representatives from ID/DD Departments
Representatives from provider agencies Family/consumer/advocate representatives
Fletcher, 2008
Cross Systems Collaboration
Stakeholders from other than MH & IDD systems could be included as appropriate, perhaps on an “as needed” basis. These include, but are not limited to representatives from:
Substance abuse Criminal Justice Health Department Social Services
Education Early Intervention Child Welfare Coordinated
Children’s Services
Adapted from Kline, et al, 1993
Five Aspects Of A Coordinated Care System
1. Collaboration
2. Comprehensiveness
3. Flexibility
4. Continuity
5. Leadership and Partnership
Adapted from Kine, et al, 1993
Coordinated Care System
1. Service Collaboration:
Policy level – linkage
Program level – integrated
Individual level – person-centered coordination
Adapted from Kine, et al, 1993
Coordinated Care System
2. ComprehensivenessNo One System Can Serve All People
with MH/IDMental Health EducationMH/DD Social ServicesChild & Family Substance AbuseHealth Criminal Justice
Fletcher, 2007
Vocational
Education
Social Serv.
Child & Family Serv.
MR-DD
Housing
Health
Criminal JusticeSubstance
AbuseMental Health
Coordinated Care System
PERSON
Adapted from Kine, et al, 1993
Coordinated Care System
3. FlexibilityFlexible Enough to Modify Traditional Approaches
Sufficient flexibility for: increase time/resources in assessments cross training modification of traditional approaches
Adapted from Kine, et al, 1993
Coordinated Care System
4. ContinuityKeep an eye on: changing needs changing systems propensity for behavioral problems need for long term treatment &
supports need to focus on multiple systems in
different contexts over a life span
Adapted from Kine, et al, 1993
Coordinated Care System
5. Leadership and Partnership
Partnership across systems Need leadership to facilitate
coordination Ensure accountability Political will
US HHS, 2005
Other Important Aspects of Policy Development:
Children and Adolescent Issues
Cross Systems Training
Cross Systems Crisis Intervention Service
Consultation and Treatment
Cross System Coordination: State/Local Level
Other Policy Recommendations
Fletcher, 2007
Children & Adolescent Issues
Train teachers, other professionals, and parents to recognize signs and symptoms of ED in children with ID
Improve transitional planning from school to adult systems system operations:
Fletcher, 2008
Training Issues
Need Cross-Systems Training Mutual understanding of different culture,
language and philosophy Acquire knowledge regarding how the other
system operations:- eligibility - funding- assessment - structure
Learn how habititative/treatment strategies are different from one system to another
Fletcher, 2008
Crises Intervention Service
A Cross System Approach
1. Provide short term crisis intervention with the goal of minimizing a need for hospitalization, crisis residential care or out-of-home placement
2. Staff from crisis service interacts with all appropriate systems
Fletcher, 2008
Consultation & Treatment Issues
Bio-Psycho social model in assessment
Rationale psychopharmacology Integrating mental health treatment
with behavioral approaches Effective cross-systems transitional
services Modifying individual and group
therapy
Fletcher, 2008
Cross Systems Planning & Coordination
State and Local Planning and coordination at local
level Planning and coordination at state
level Planning and coordination between
local and state level
If you need expert assistance to forge collaboration, get it!
Treat Collaboration as Seriously as You Do Your Budget
J. Jacobson, 2003
Service Planning and Policy
Plan cross systems services strategically
Design flexible service models that can change over time as individual needs change
Obtain technical assistance
Provide cross systems training to enhance agency and practitioner competencies
Provide incentives for assuming and sharing responsibility
Ament, 1987
Collaboration Strategies
Identify and clearly state specific purposes for collaboration
Allow time to consider all provisions, so that final decisions will be more fully supported
Negotiate written agreements for organizational responsibilities, program design, fiscal arrangements, and established time frames
Collaboration Means Sharing Resources and Authority
Make sure that each organization understands what it brings to the collaboration and reach a middle ground.
State Regional County Staff Training
Clinical Quality
Advocacy/Other
How are you doing now?
How could you improve over the next year?What plans can you make for the next 1-3 years?
ID/MI Discussion Matrix
Action to be Taken
Resources Needed to Complete Action
Date of Expected Completion
Responsibility Person(s) Organization(s)
System Strategies
State
Regional
County
Staff Training
Clinical Quality
Advocacy/Other
ID/MI Action Plan
THANK YOU!
For more information, please contact:
Dr. Robert J. Fletcher
NADD132 Fair Street, Kingston, NY 12401
Telephone: 845-331-4336
E-mail: [email protected] site: www.thenadd.org
