—by Paul M. Kubek
Fargo, ND—When state officials in the North Dakota Department of Human Services learned about Ohio's success with implementing integrated mental-health and substance-abuse treatment for people with severe mental illness, they did what North Dakotans are prone to do. They set their minds to figuring out how to do it themselves.
There was no bold announcement of their intentions, no fanfare, no press release. They just picked up the phone, asked the consultants and trainers at the Center for Evidence-Based Practices at Case Western Reserve University—and its Substance Abuse and Mental Illness Coordinating Center of Excellence (SAMI CCOE)—in Cleveland for some advice, and made arrangements to come to Ohio for some consultation and a site visit, so they could see for themselves how integrated treatment was being used in a community agency.
What is telling about the Dakotans' quiet, plain-spoken understatement of intention is this: they could have booked a flight for a few policymakers to visit Ohio. Instead, they recruited eight people to make the trip, including program managers and frontline clinicians from Southeast Human Service Center in Fargo who would be the first to implement Integrated Dual Disorder Treatment (IDDT) in their state. Then the crew climbed into two full-sized passenger vans and drove sixteen hours straight, tracing the path of the Great Lakes until they descended into the Ohio River Valley and stopped on the north side of Columbus in Franklin County. That was May 2006.
CHAMPIONS OF INTEGRATED TREATMENT
This past year, the Center for Evidence-Based Practices—and its Ohio SAMI CCOE initiative—presented the "IDDT Champion Award" to Southeast Human Service Center in Fargo for its unwavering commitment to the implementation of Integrated Dual Disorder Treatment (IDDT) in the communities it serves. IDDT is an evidence-based practice that helps improve quality of life and other outcomes for people with co-occurring severe mental illness and substance use disorders. When implemented with fidelity, the IDDT model produces a clinical environment in which social workers, psychiatrists, and other health and human service providers are able to build safe and trusting relationships with people whose severe symptoms of mental illness often impede their ability to interact with others and to manage their health and mental health.
According to Ric Kruszynski, MSSA, LISW, LICDC, director of SAMI consulting and training at the Center for Evidence-Based Practices, the service teams in North Dakota have been so successful with engaging people in treatment and helping them reduce and manage symptoms of both disorders that it is now developing criteria for discharging people from services. Many no longer need the intensive services that IDDT provides.
"Many consumers who receive this model of care were previously under-served or not served at all in their communities," he says. "Individuals now find themselves with hope and a quality of life that they never imagined possible."
IDDT OUTCOMES IN NORTH DAKOTA
Kruszynski has been providing technical assistance to the North Dakota project since its start in 2006. He notes that there are currently 96 consumers in the state receiving IDDT from two service teams. The North Dakota Department of Human Services has collected data on 125 consumers and is currently analyzing data for three cohorts of 49 different people.
- Cohort one: 12 consumers receiving 48 months of IDDT services between January 2007 to May 2011 (see Fig 1)
- Cohort two: 13 consumers receiving 30 months of IDDT services between January 2007 and May 2011
- Cohort three: 24 consumers receiving 12 months of IDDT services between June 2010 and May 2011
The department recently shared some impressive outcomes from all three cohorts, with outcomes for consumers who received four years of IDDT services showing a significant long-term reduction in use of high-cost services, including crisis services, acute and long-term psychiatric hospitalizations, incarcerations, and respite care, as well as a reduction in emergency-room admissions (see Figure 1).
Figure 1: Data for cohort one, which includes 12 consumers receiving 48 months of IDDT services between January 2007 to May 2011.
|Service utilization||Percentage of decrease
from Year 1 to Year 4
in Year 1
in Year 4
|Admissions to emergency room||29 percent decrease||24 admissions||17 admissions|
|Days of acute psychiatric hospitalization||90 percent decrease||97 days||10 days|
|Days of long-term psychiatric hospitalization||70 percent decrease||908 days||268 days|
|Days in crisis unit||40 percent decrease||83 days||50 days|
|Days in respite care||87 percent decrease||94 days||12 days|
|Days incarcerated||98 percent decrease||199 days||3 days|
Source: North Dakota Department of Human Services
Kruszynski attributes much of the success in North Dakota to the buy-in of people at all levels of implementation, including policymakers in the state department, administrators and program managers at Southeast, leaders of the IDDT teams, and service-team members, which include case managers, addictions counselors, psychiatrists, nurses, and employment specialist, among others.
"Their program also has a very active implementation and management team that still meets monthly to monitor progress," Kruszynski adds. "That's almost unheard of. They are five years into implementation, and they still meet monthly. This combination of buy-in and constant communication is what makes them so good. They are able to address and resolve barriers to care efficiently and effectively."
In addition, the management team helps build and expand relationships with community stakeholders, including local housing entities, local law enforcement, and residential treatment programs, as well as with the state's psychiatric hospital. Many of these organizational strategies, Kruszynski points out, are contained in the general organizational index (GOI) of the IDDT fidelity scale, which helps guide the implementation process. Because Southeast pays attention to the GOI and to all the other components of the model, they consistently achieve high fidelity during program reviews.
Southeast is not only bringing the benefits of IDDT to residents in the six-county region that it serves in its corner of the state, but it is also bringing IDDT to other regions as well. Southeast has become the State of North Dakota's go-to resource for IDDT implementation.
"They came here to Ohio to explore an idea that they have turned into a remarkable array of services for their residents," Kruszynski says. "When in North Dakota, you can't help but notice the references to Louis and Clark in restaurants, stores, and landmarks. It's appropriate here, because the good folks at Southeast share that pioneering spirit."
DAKOTA PERSPECTIVE | FROM THE AGENCY
We wanted to share some insights directly from the agency that has been implementing Integrated Dual Disorder Treatment (IDDT) in Fargo, so we asked Jeff Stenseth, MS, assistant regional director at Southeast Human Service Center, to answer a few questions.
Q1: How does IDDT implementation enable clinicians to engage with and develop relationships with clients who, in the past, have been difficult to engage?
JS: Implementing IDDT at this agency has really allowed our clinicians to be much more effective at their jobs. Participating in the pre-implementation consults with the Ohio SAMI CCOE and the site visit to an existing program [in central Ohio in 2006] really helped give us the vision of how IDDT could change our service delivery and help us achieve the desired outcomes that we wanted.
By going through the intensive training process and keeping the focus on the 13 treatment characteristics of IDDT, we have substantially increased our ability to engage a group of individuals who have [had] high rates of "community systems" utilization. In using a stage-based approach to treatment, we have made significant progress in refining both our individual clinical skills and group programming, both of which have a positive impact upon client quality-of-life indicators.
Q2: What has been your biggest lesson learned during implementation? What was the challenge, how did you respond, what has been the outcome?
JS: In order to get through the stages of implementation successfully, we needed a consistent and balanced approach at all levels [e.g., direct service, agency management and administration, state mental health authority]. This is not a "set up a training and start the services" type of strategy; it is more of a process that takes dedicated time and effort to develop. We needed to make sure that we established and maintained the support of leadership (administrative and clinical), that we established a cohesive steering team that meets regularly, and that we selected and supported the clinical staff that were the best fit for this type of practice. We often remind ourselves that this is a marathon and not a sprint and that, with continued dedication and vigilance, both Southeast Human Service Center and the clients we serve will have continued success.
DAKOTA PERSPECTIVE | FROM THE STATE
MORE FROM THE STATE
Andy McLean, MD, MPH, is medical director of the North Dakota Department of Human Services. Read his account of the state's success with implementing Integrated Dual Disorder Treatment (IDDT).
Citation: Andy McLean, MD, MPH (2011). "IDDT: From Dartmouth to Case Western to North Dakota." Community Psychiatrist. Dallas, Texas: American Association of Community Psychiatrists (AACP). October 2011, v25, n2, p9.
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We also wanted to share some insights from the state leadership that has been supporting the implementation process, so we posed a few questions that were answered by Susan H. Wagner, LSW, program administrator at the North Dakota Department of Human Services, Division of Mental Health and Substance Abuse Services.
Q1: How has IDDT helped improve services to people with severe mental illness?
SW: IDDT meets the needs of individuals who, for many reasons, had not been successful in treatment services before. IDDT exemplifies what person-centered services really means. Individuals feel cared about, listened to, and, most importantly, respected by the service team. The ability to establish trust and to make a meaningful connection with the team inspires each individual to set and accomplish goals and to feel better about themselves. This, in turn, has helped reduce the frequency and duration of hospitalization, reduce involvement in the criminal justice system, and reduce mental illness and substance abuse symptomatology. It has also increased stability in housing and has assisted with employment opportunities.
Q2: What has been the biggest lesson learned thus far?
SW: The biggest lesson learned so far is that implementation takes time. We have learned so much from the individuals we strive to help, and they have truly guided and will continue to guide this journey for North Dakota.
Q3: How might this help ongoing implementation efforts in the state?
SW: Ongoing implementation in North Dakota will continue to develop, based upon the needs of the individuals we serve in each region of the state. As we learn more about the various components of IDDT, we are able to assist the regions to identify strengths and challenges and to develop an action plan to guide implementation. We have cultured our own humble "experts" who consistently offer their experiences and knowledge to assist their colleagues across the state.
ABOUT SOUTHEAST HUMAN SERVICES
Southeast Human Service Center in Fargo, North Dakota, is one of eight regional human service centers within the North Dakota Department of Human Services. The center provides a wide range of human services to the residents of six counties in the southeast region of the state, including the City of Fargo, population 105,000. Services include the following:
Regional aging services
County program supervision
| website |
THE NATIONAL SCENE
Integrated Dual Disorder Treatment (IDDT), the evidence-based practice, was developed and continues to be studied by researchers at the Dartmouth Psychiatric Research Center of Dartmouth Medical School in Lebanon, New Hampshire. The researchers include Robert E. Drake, MD, PhD; Kim T. Mueser, PhD; and their colleagues.
The Center for Evidence-Based Practices (CEBP) at Case Western Reserve University—through its Ohio SAMI Coordinating Center of Excellence (CCOE) initiative—has built upon the work of Dr. Drake and his colleagues to facilitate IDDT implementation in 23 states, in numerous communities throughout Ohio's 88 counties, and in several regions of the Netherlands. Through the Center for Evidence-Based Practices, the State of Ohio has participated in the national dissemination of IDDT sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Paul M. Kubek, MA, is director of communications at the Center for Evidence-Based Practices at Case Western Reserve University.