I often end each year by taking a look back and appreciating the good things that have happened during the year. This year, I was inspired to look back at the progress we have achieved through our Behavioral Health Transformation Project. It was just over five years ago that KCMH and its contractors formally began its effort to transform our service system into one that demonstrates the key principles of the Comprehensive, Continuous, Integrated System of Care Model (CCISC) for serving persons with co-occurring disorders. We began with a vision of accomplishing at least four things:
• ACCESS - we wanted to make sure that this priority population could access needed services,
• WELCOMING - our service sites would routinely make all who enter our doors feel that they are in the right place for them. They could openly share their problems with the expectation that they would be accepted as they are rather than being turned away,
• IDENTIFICATION – co-occurring disorders (COD) would not go unidentified so that we could address their complex needs,
• STAFF COMPETENCIES – would increase and improve with this population.
So what have we done? Well, back in 2005, not all of us saw COD’s as an expectation so we were not always ready for the people coming through our doors. At some sites, we did our jobs without thinking to ask about that “other disorder” that might complicate our services. We have universal screening now. Every person who presents to a MH or SA treatment site is also screened for the other disorder so that services can be arranged internally or with another provider. Back then, people with the other disorder were turned away from services – “you have to get MH treatment before you can receive SA treatment” or, “you have to be clean and sober for 30 days before you can be eligible for MH treatment”; this is no more. Some providers even had treatment contracts that spelled out how clients would be discharged from treatment if found to be actively using substances; this too is no more. We now have a KCMH Welcoming Statement that is used to train all of our staff to help us ensure that people seeking our service feel like they are in the right place to talk about all of their needs.
Back then, we didn’t universally know the science behind the interaction of psychiatric medications with licit and illicit substances. Thus, we had some doctors who stopped medications with those who were actively using substances while others kept medications the same while others changed medications. Now, we have a consensus set of guidelines for how to manage these situations set into KCMH policy (5.2.10) that for the most part reflects that the best medications for a person suffering from a disorder like Schizophrenia and active substance abuse is the same as for a person suffering from Schizophrenia without active substance abuse (but believe, me the policy is much more detailed than that so please read it). This enables all of our great medical staff that worked so hard to figure this all out to practice consistently using the latest science to inform their treatment decisions.
Our system also had several different practices in place regarding drug testing. Some did it with everyone; others never did it. Some imposed it involuntarily without a court order while others did so only on request from the client. Results were shared by some providers and held strictly confidential by others. We now have a set of guidelines (being pilot tested at two sites) that help us be consistent while still allowing providers with unique needs or requirements to fulfill their obligations. An essential principle of the guidelines is that drug testing is used to help clients achieve their goals and not for the purpose of punishing them.
The MH Assessment form has been improved as a result of this effort. Our consultants, Drs. Cline and Minkoff, recommended that we routinely discover periods where each client was doing their best in life and the things that contributed to that – we know this as our “Optimal Functioning” section of the Assessment. We also now have a tool in the assessment that identifies the level of service need using the national consensus Four Quadrant Model so that we can plan better services. This and other efforts have combined to raise our awareness of COD’s and we are much better at identifying it. In 2005, we diagnosed 11.4% of the persons we served (MH and SA, Adult and Child, KCMH and Contractors) with COD’s. Since that time, it has risen to 23.2% - not because COD’s are on the rise but because we are more aware of them and are more diligent about and skilled in finding them.
All organizations have instances in which they think and talk one way though certain policies may make it difficult to carry out the intentions. We have revised all of our (200+) policies such that they are in keeping with our CCISC principles (as well as the guiding principles of recovery vision and cultural competence). We can do more in this regard but we have eliminated several obstacles to COD competence that existed in our policy manual.
Maybe the thing that we notice the most is all the effort that has taken place to increase our staff competencies in serving persons with COD’s. Not only has our training division sponsored multiple events specifically about COD’s, it has also required all clinical training to address COD issues when appropriate. Several divisions and providers such as the Kern Linkage Program and the Children’s System of Care have organized monthly COD in-service training. Perhaps most notably, our change agents have created the Transformer newsletter which has helped us learn about such things as stage-matched treatment, motivational interviewing and drug use practices such as “eye-balling” in bite-size chunks each month. Nearly every month I am contacted by other CCISC systems in the country for the newsletter so they can use it and start producing their own. Speaking of Change Agents, they are an accomplishment of their own. Nearly 100 staff have participated as a change agent during the last 5 years with about 40 participating right now. This group comes together each month to learn new skills, influence and support system change, and train staff to better serve those with co-occurring disorders. In fact, there isn’t a single accomplishment I’ve mentioned in which they’ve not had a hand.
All providers have assessed themselves at least once using the COMPASS tool which led to action plans that created rewritten program descriptions, improved client orientation materials, mental health topics inserted into manualized SA treatment programs, resource lists have been expanded to include MH and SA self-help or other programs and much, much more.
Finally, let me ask when is the last time you heard the word, “welcoming” at the office? It was today or yesterday, wasn’t it? We didn’t even know this term in 2005. Its frequent use today shows that not only do we have more tools, more bells and whistles at our disposal, but that our culture has changed directly as a result of our transformational effort.
It has been a productive five years and this is only a partial list. For me, it began as a three-year project. Over time, I began to see that COD competency is dynamic. What is competent today may not be the same in a few years. So our transformational efforts will continue as KCMH continually improves itself in this and many other areas. There are many to thank for our results including all of our stakeholders, the Change Agents, the DDX Executive Steering Committee, Drs. Cline and Minkoff and all of you who have listened, learned and changed yourselves. We are better than we were four years ago and will be again four years from now. Congratulations and good luck!
Brad Cloud, Psy.D.