CO-OCCURRING DISORDERS CARE
COMMONWEALTH OF MASSACHUSETTSHEALTH POLICY COMMISSIONCO-OCCURRINGDISORDERS CAREIN MASSACHUSETTSA Report on the Statewide Availability of Health CareProviders Serving Patients with Co-OccurringSubstance Use Disorder and Mental IllnessMay 2019
TABLE OF CONTENTSI. Background on Co-Occurring Disorders Prevalence and Treatment 1Figure 1. Agencies responsible for licensing facilities and clinicians treatingco-occurring disordersFigure 2. Dually licensed SUD and mental health provider organizations, 2018Figure 3. Percent of population with more than 15 minute drive time to nearest duallylicensed clinic, 2018II. Provider-reported Access and Other Barriers to Integrated Care in theCommonwealth 3Figure 4. Licensed clinics by type, compared to survey respondentsFigure 5. Percentage of respondents that reported treating vulnerable populations withco-occurring disordersFigure 6. Prescribing and medication arrangements at provider sites that reportedserving patients with co-occurring disorders (n 98)Figure 7. Time to first appointment for MAT for people with co-occurring disordersFigure 8. Time to first outpatient appointment, by language spokenFigure 9. Percent of facilities that reported a lack of clinicians who speak languagesother than English as a moderate to extreme barrier to careFigure 10. Staff with basic training on co-occurring disorders, by percent of responsesFigure 11. Providers’ perceptions of barriers to careIII. Policy Recommendations 9Appendix A: Statutory Language 12Appendix B: Survey Methodology and Analytic Approach 13Appendix C: Inventory of Behavioral Health Provider OrganizationsLicensed to Provide both Mental Health and Substance Use DisorderServices, Names, Addresses, and License Types 14Acknowledgements 24
INTRODUCTIONThis Health Policy Commission (HPC) report, required byChapter 52 of the Acts of 2016, An act relative to substanceuse, treatment, and prevention (Appendix A), presentsnew information on the availability of providers in theCommonwealth treating patients with co-occurring mentalillness and substance use disorders (SUD). The brief providesinformation on the number of licensed mental health andsubstance use disorder treatment facilities and the resultsof a survey of provider organizations on their availabilityto provide treatment and perceptions of barriers to treatment for people with co-occurring disorders. Specifically,Appendix C includes an inventory of behavioral healthfacilities that have both mental health and SUD treatmentlicenses. Based upon the survey results and feedback fromstakeholders in the behavioral health field in Massachusetts,the brief concludes by identifying strategies to enhanceaccess to treatment and promote the development of integrated care delivery models to improve care for patientswith co-occurring disorders in the Commonwealth.The HPC is an independent state agency established byChapter 224 of the Acts of 2012, An act improving thequality of health care and reducing costs through increasedtransparency, efficiency and innovation. The mission of theHPC is to monitor the reform of the health care deliveryand payment systems in Massachusetts and to developinnovative health policy to reduce overall cost growth whileimproving the quality of patient care. Critical to this workis the integration of behavioral health into the health caresystem, which the HPC promotes through its certificationprograms, investments, research, and policy agenda supporting development and implementation of alternativepayment models that support care delivery reform.The HPC conducted this research and developed this briefin consultation with the Departments of Public Health(DPH) and Mental Health (DMH).I. BACKGROUND ON CO-OCCURRINGDISORDERS PREVALENCE AND TREATMENTDespite high prevalence, national rates of engagementin treatment for co-occurring disorders are low. In 2016,approximately 7% of adults with co-occurring disordersreceived both mental health care and substance use disordertreatment, 38.2% received only mental health care, and2.9% received only specialty substance use treatment.1Co-occurring mental health and SUD comorbidities wereidentified in 13% of adult inpatient and 4% of adult emergency discharges from Massachusetts acute care hospitalsin 2016.5 This indicates that people with co-occurringdisorders may not be getting the care they need in thecommunity.While data from ED discharges likely under reports theincidence of co-occurring disorders, the impact of identifiedco-occurring diagnoses on the ability to access timely carein the emergency department is significant. Forty percentof people who visited an ED with a primary mental healthdiagnosis and an identified secondary substance use disorder spent over 12 hours in an emergency department priorto discharge or transfer to another facility compared to27% of people with a primary mental health diagnosisalone identified during the ED visit. Likewise, 30 percentof those who visited an ED with a primary SUD diagnosisand co-occurring mental health diagnosis identified spentover 12 hours in an ED compared to 12% of those with aprimary SUD diagnosis without an identified co-morbidity.5Treatment of co-occurring mental illness and SUD presentsparticular challenges for providers. Factors such as distinct state licensure processes, staffing requirements, andtreatment philosophies have perpetuated separate pathsof treatment for each type of condition. Correcting forfragmentation through integration can improve care coordination, reduce administrative complexity for providers,and contribute to improved outcomes.6,7One of the unique complexities of treating co-occurringdisorders is the tendency for inadequately treated mentalillness to prompt self-medication, which can complicatethe presentation of psychiatric symptoms and eventuatein SUD.8 The clinical presentations of mental illness andSUD can confound each other: without proper training inrecognizing both, providers may misinterpret symptoms,misdiagnose patients, and ultimately provide suboptimaltreatment.9Nationally, an estimated 8.2 million adults ages 18 or older(3.4 percent of all adults) had co-occurring disorders in 2016.1Co-occurring disorders are more common among individualswith SUD: nationally, 43% of those identified as having SUDalso have mental illness. In contrast, 18% of individuals withmental illness also have SUD.1 In 2016, approximately 20%and 10% of Massachusetts adults reported past year mentalillness or SUD, respectively.2 Applying national prevalenceHEALTH POLICY COMMISSIONrates of co-occurring disorders to the Massachusetts population yields an estimate of 236,000 adult residents withco-occurring disorders in 2016.3,4-1-CO-OCCURRING DISORDERS CARE REPORT
A key component of effective co-occurring disorder treatment is the ability to treat both conditions equally andconcurrently. There are a number of such evidence-basedmodels, including Integrated Dual Disorder Treatment(IDDT)10, Dual Diagnosis Enhanced (DDE)11, Modified Therapeutic Community (MTC)12, and open accessscheduling.13 Some clinical and operational features ofevidenced-based care for co-occurring disorders includebut are not limited to: screening and assessment usingstandardized and culturally sensitive instruments, andreferral when appropriate; access to on-site prescribers toboth prescribe and monitor medications of both (or more)conditions, including medication for addiction treatment(MAT); assertive engagement strategies; integration ofprescribers into small, multidisciplinary treatment teams;psychoeducational classes, onsite modified mutual self-helpgroups and offsite dual recovery mutual self-help groups;and treatment and discharge plans that address all behavioral health needs and consider linguistic, cultural, socialand medical needs.11,14Availability of Licensed Treatment Facilitiesin MassachusettsBehavioral health treatment facilities in the Commonwealthare currently licensed to provide mental health servicesand SUD treatment services under distinct standards. Assuch, there are multiple licensing bodies: the process forbecoming licensed by DPH’s Bureau of Substance AddictionServices (BSAS) is separate from the process for becominglicensed as either a mental health clinic by DPH’s Bureau ofHealth Care Safety and Quality (BHCSQ) or as a psychiatric inpatient provider by DMH (see Figure 1). Despite thecomplexity of the licensure process, meeting both mentalhealth and SUD treatment licensure standards is one standard used to gauge an organization’s ability to care forpopulations with co-occurring disorders.15Using data from DPH and DMH, the HPC found that ofthe 447 licensed mental health clinics in Massachusetts, 38percent (169) held a license for both mental health and SUDservices.i There are an additional 139 BSAS counseling orOffice of Consumer Affairs andBusiness RegulationExecutive Office of Health andHuman ServicesResponsibilities for licensure of providers who treat mental illness andSUD aredivided across multiple state agencies.Figure 1. Agencies responsible for licensing facilities and clinicians treating co-occurring disordersDepartment ofMental HealthInpatient/RTP licensing division: acute hospitals withinpatient psychiatric units, intensive residentialtreatment programs for adolescentsCommunity Licensing Division:community based residentialtreatment facilitiesBureau of Health Care Safety andQuality: outpatient and inpatienthealth care facilitiesBureau of Health ProfessionsLicensureDepartment ofPublic HealthDivision ofInsurance:health insurersand risk-bearingproviderorganizationsDivision ofProfessionalLicensureBureau of Substance AddictionServices: LADC, inpatient SUDtreatment facilities; acute services;some outpatient facilitiesDrug Control Program:facilities that dispensecontrolled substancesBoard of Registration inNursing: RN, APRNBoard of Certification ofCommunity HealthWorkersBoard of Registration ofPhysician AssistantsBoard of Registration in Medicine:MD, DONote: some settings of carefor mental illness, SUD, andBoard of Registration ofco-occurring disordersare settings of careNote: somePsychologists: psychologistsnot included inthismentalchart illness, SUD, andfor(e.g., VA care, publichealth disorders are notco-occurringhospitals, and section 35depicted here (e.g., VeteransBoard of Registration of Socialunits).Affairs facilities, public healthWorkers: LCSW, LICSWhospitals, section 35 units, andindividual and group physicianBoard of Registration of Allied Mental Health andoffices).Human Services Professionals: LMHC, psychiatricrehabilitation counselors6iCO-OCCURRING DISORDERS CARE REPORT-2-Data updated on January 9, 2019.HEALTH POLICY COMMISSION
MAT sites that do not have mental healthclinic licensure. Of the 66 freestandingpsychiatric hospitals and acute hospitalpsychiatric units licensed by DMH, onlyeight hold a concurrent license from BSASfor inpatient withdrawal managementservices.Figure 2. Dually licensed SUD and mental health provider organizations, 2018Mental health clinics without a SUDlicense comprise nearly half (47%) of SUDand mental health outpatient facilities inMassachusetts (586 mental health clinics,and BSAS counseling and MAT sites).The 169 dually licensed outpatient clinicsites are located throughout Massachusetts but are more densely clustered inurban centers (see Figure 2). Half of thepopulation of the Cape and Islands livesmore than 15 minutes from the nearestdually licensed outpatient clinic. Similarly,more than a third of the population in theBerkshires and Pioneer Valley lives morethan 15 minutes from a dually-licensedclinic (Figure 3).Dually licensed provider sites are located throughout Massachusetts. In morerural areas of the state, these clinics are quite far apart, which may presentaccess barriers based on travel times and transportation barriers.II. PROVIDER-REPORTEDACCESS AND OTHER BARRIERSTO INTEGRATED CARE INTHE COMMONWEALTHFigure 3. Percent of population with more than 15 minute drive time tonearest dually licensed clinic, 2018Survey and Analytic ApproachThe HPC reviewed publicly availablenational data from the Substance Abuseand Mental Health Services Administration (SAMHSA), and state data fromthe Massachusetts DPH and DMH onfacilities offering specialized treatment forco-occurring disorders. The HPC foundthat the data did not give a robust picture of which providers offer integratedcare.ii To assess provider capability toserve patients with co-occurring disorders,the HPC then conducted a survey sent bye-mail to 144 multi-site facility providersiiEast MerrimackUpper North ShoreWest Merrimack/MiddlesexLower North Shore3%Central Massachusetts32%Berkshires25%16%22%34%Metro Boston8%Pioneer Valley / Franklin37%Metro 23%NNewFall River Bedford0%20%Cape and Islands50%The Massachusetts agencies that establishregulations, enforce their compliance, andfund behavioral health services at facilitiesare DMH, BSAS and the BHCSQ within DPH,and MassHealth within the Executive Officeof Health and Human Services.HEALTH POLICY COMMISSION-3-CO-OCCURRING DISORDERS CARE REPORT
and 778 independent facility providers and individual clinicians, to ascertain their self-assessment of the availability ofand barriers to timely and appropriate care for populationswith co-occurring disorders. Due to the limited responserate among individual clinicians this report includes findings only from facility-based respondents. Administratorsof facility-based providers answered questions about theirservice sites rather than about the individual cliniciansworking at their sites. Providers with multiple sites completed a single survey which asked them to answer eachquestion about specific services or populations served withthe number of sites within each HPC region which providedthe services described in the question. In order to encouragecandid responses to the survey questions, the HPC receivedblinded survey data.Throughout the report, the term provider will be used torefer to facility-based behavioral health providers, whichinclude clinics, psychiatric hospitals, and substance usedisorder treatment organizations, including both counseling and residential services. The term clinicians will beused when discussing individual providers such as licensedsocial workers, licensed mental health counselors, certifieddrug and alcohol counselors, psychologists or physicians.Details about the methodology for identifying providersto be surveyed, the survey’s administration, and the HPC’sanalytic approach are available in Appendix B.FindingsNearly all respondents reported accepting patients withco-occurring disorders and did not report having policies that exclude people with co-occurring disorders. Tounderstand providers’ assessment of their capacity to treatco-occurring disorders, the survey asked respondents toidentify each site’s primary service: mental health treatment,SUD treatment, or treatment for both. A slight majority(58%) of sites reported offering both mental health andSUD services as primary services. However, only a quarterof licensed outpatient sites are licensed for both SUD andmental health services (Figure 4). It is likely that providerswho provide services for co-occurring disorders were morelikely to respond to the survey but selection bias alonecannot account fully for this difference. This could meanthat providers who reported offering both types of servicesas primary services are at a minimum not likely excludingpatients with co-occurring disorders from treatment.CO-OCCURRING DISORDERS CARE REPORT-4-Figure 4. Licensed clinics by type, compared to surveyrespondentsiiiLicensed Clinic by Types,as of October 2018, N 586BSAS LicensedOnly24%47%29%Dually LicensedOutpatientMental HealthClinicSurvey respondents byPrimary Service, N 405Offer MentalHealth Primary25%17%58%Offer SUDPrimaryOffer bothMH/SUD asPrimaryiii Note on licensing: facilities that are licensed only as mental healthclinics may not describe themselves as having separate identifiable substance use disorder programs (104 CMR 140.801 and104 CMR 164.012). However, the clinical staff within thesefacilities, such as psychiatrists and licensed social workers, mayappropriately diagnose and develop a course of treatment for anybehavioral health disorder including substance use disorders.Additionally, mental health center regulations list licensed alcoholand drug counselors and other licensed mental health and substance abuse practitioners as some of the professional staff thecenter may include (105 CMR 140.530 (C)(6)). The licensureof substance abuse treatment program regulations also includesa multi-disciplinary team staffing model that may include psychiatrists, psychologists, social workers, all of whom couldappropriately develop treatment plans that address co-occurring mental health disorders. Finally, DMH hospital regulationsrequire all inpatient psychiatric hospitals to have protocols foraddressing substance use disorders at their facilities, regardlessof whether those facilities are concurrently licensed by BSAS(104 CMR 27.03).HEALTH POLICY COMMISSION
Vulnerable populationsFor providers that responded that they accept patientswith co-occurring disorders, which includes facilities thatprovide both mental health and SUD services and thosethat provide only one service, the HPC asked about theirability to treat people who may have special needs andwhether they provide mental health, SUD or both servicesto these populations. While all providers responded thatthey treat people with co-occurring disorders who identifyas LBGTQ and 98% reported treating people with a historyof non-adherence to treatment, only 80% reported treatingtransitional age youth (16 to 25 years old), 79% reportedtreating people with a history of judicial involvement, and76% reported treating people who are deaf or hard of hearing (Figure 5). And while most mental health clinics reportedproviding services to pregnant women with co-occurringdisorders, fewer facilities that provide only SUD servicesor both mental health and SUD services reported treatingpregnant women, denoting a potentially important accessissue. These findings, however, likely reflect that providersmay not have specialized services or particular expertisein treating special populations, rather than indicating thatthey actively exclude such patients. For example, only afew clinics that offer only mental health services as primaryservices reported treating patients with a history of judicial involvement, however it is unlikely that these clinicswould have information on a patient’s historical judicialinvolvement at intake.Almost all (90%) providers who reported acceptingpatients with co-occurring disorders indicated that theytreat common, mild mental illness. Fewer such providersreported being able to treat severe, rare conditions, especially eating disorders, which only 62% reported being ableto treat. Survey results showed few differences in ability totreat SUD by substances used.Prescribing capacityProviders reported a range of prescribing capacity forpsychiatric and SUD medications, with some importantlimitations. Mental health prescribing is available at mentalhealth clinics that have a psychiatrist on staff, through anindependently licensed psychiatrist, or through a patient’sprimary care physician. Mental health prescribing is lessavailable at SUD treatment programs unless the programhas a memorandum of understanding with a psychiatricprescriber. MAT is available for methadone at licensedambulatory opioid treatment programs (OTP) and forbuprenorphine at office-based opioid treatment (OBOT)programs from qualified clinicians with X-waivers (whomay practice independently), and at community health,mental health, and SUD clinics.iv, 16Figure 5. Percentage of respondents that reported treating vulnerable populations with co-occurring disorders100%98%100%80%79%80%SUD only86%86%76%MH onlyBoth MH & SUD60%40%20%0%LGBTQ H
co-occurring disorders Figure 6. Prescribing and medication arrangements at provider sites that reported serving patients with co-occurring disorders (n 98) Figure 7. Time to first appointment for MAT for people with co-occurring disorders Figure 8. Time to first outpatient appointment, by language spoken Figure 9.
The Co-Occurring Center for Excellence (COCE), funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), is a leading national resource for the field of co-occurring mental health and substance use . Eating disorders Sleep disorders Impulse-control disorders Adjustment disorders ersonality disorders P Disorders .
uniquely defined as co-occurring disorders (CODs). They may include any combination of at least two mental disorders and substance use disorders identified in the DSM-5. Sometimes co-occurring disorders are referenced as “dual disorders” or as “having a dual diagnosis” (SAMHSA, 2014b). The
Mar 04, 2014 · 2. Substance-induced disorders -- intoxication, withdrawal, and other substance/medication-induced mental disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions,
3. Integrated Assessment for Co-Occurring Disorders People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity.
Co-Occurring Disorders: Integrated Dual Disorders Treatment Implementation Resource Kit DRAFT VERSION 2003 Integrated Dual Disorders Treatment Fidelity Scale This document is intended to help guide you in administering the Integrated Dual Disorders Treatment (IDDT) Fidelity Scale. In this document you will find the following:
“Co-occurring Disorders refer to substance use disorders and mental disorders.” . “The key to effective treatment for clients with dual disorders is the seamless . (2003): “Integrated Treatment for Dual Disorders – A Guide to Effective Practice” The Guilford Press, NY. page xvi, 19)
Guidelines for Effective Integrated Dual Diagnosis Treatment Based on clinical and research experience, a team of experts in co-occurring substance use . A national consensus expert panel was appointed for co-occurring disorders, which issued a consensus report (Managed Care Initiative Panel on Co-Occurring Disorders, 1998).
Alex Rider Facebook page and submit your questions to the author. If you were unable to tune in on the day, the video is available to watch on the National Literacy Trust website and on Alexrider.com. This resource has been created to support primary and secondary practitioners to deliver an exciting transition project, complementing the live event, although not depending on it. It features .
