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Behavioral Health Integration Project
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Background
Over the past twenty years, national efforts to address the treatment needs of individuals with co-occurring substance use and mental health disorders have been steadily gaining momentum. A growing body of research has documented the high prevalence of individuals with co-occurring disorders, their difficulty in accessing appropriate treatment in separate substance abuse and mental health systems, and the challenges to recovery when one disorder or the other is left unrecognized and untreated Longstanding systemic barriers which characterize many mental health and substance abuse systems—including separate administrative structures, differing client eligibility criteria, varying professional credentials, and multiple and fragmented funding streams—have all been identified as standing in the way of effectively addressing the treatment needs of this population.
In an effort to overcome these barriers, the Substance Abuse and Mental Health Services Administration (SAMHSA), through its Centers for Substance Abuse Treatment (CSAT) and Mental Health Services (CMHS), created the Co-Occurring State Incentive Grants for the Treatment of Persons with Co-Occurring Substance Related and Mental Disorders (COSIG). The purpose of this new federal grant opportunity was to “develop and enhance the infrastructure of States and their treatment service system” to better serve individuals with co-occurring disorders. Coming on the heals of, and reflecting, SAMHSA’s landmark Report to Congress on Co-Occurring Disorders, the COSIG grants provided states an opportunity to support infrastructure development and capacity building activities around the goals of improved screening, assessment, treatment, training, and evaluation.
Alaska Planning Efforts
In June 2000, Alaska began a multi-year planning effort to improve the integration of mental health and substance abuse treatment for individuals with co-occurring disorders. During this period of time, DHSS (including DMHDD and DADA), AMHB, ABADA, and AMHTA agreed to adopt the Comprehensive, Continuous, Integrated System of Care (CCISC) model for creating statewide systems change.
In the fall of 2003, the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) awarded Alaska a State Incentive Grant for Treatment of Persons with Co-Occurring Substance Related and Mental Disorders (COSIG). Alaska was one of seven states to receive the first round of COSIG grants. Its ambitious application built on the significant work it had already undertaken in the area of co-occurring disorders as well as the opportunity afforded by Governor Murkowski’s recent merger of Alaska’s mental health and substance abuse agencies. The Director of the newly merged Division of Behavioral Health (DBH), William Hogan, laid out the broad project vision in his letter to the field (personal communication, 2004):
“All Alaskans with behavioral health needs will be provided services that are welcoming, accessible, integrated, continuous, and comprehensive, regardless of age, culture, language, or geography, and regardless of whether they have mental health needs, substance abuse disorders, or both. Furthermore, the system of care shall be cost effective and administratively efficient, be designed in a manner that is sensitive to local needs, maximizes consumer, family and provider participation, and has the capacity to continuously improve quality and track outcomes.”
The Alaska COSIG grant application required that the State address the following infrastructure development areas:
• Standardized Screening and Assessment
• Complementary Licensure and Credentialing Requirements
• Service Coordination and Network Building
• Financial Planning
• Information Sharing
The multi-year COSIG grant is the funding mechanism to help make this vision a reality. It funds the activities of Alaska’s Behavioral Health Integration Project (BHIP), working to design and implement an integrated behavioral health system for Alaska at the state and local levels.
The Behavioral Health Integration Project
The Behavioral Health Integration Project’s (BHIP) internal planning group decided at its very first meeting in January 2004 that the COSIG grant would be an opportunity to “think big and broadly” about a new behavioral health system for Alaska. It’s concept for the project included the following:
• Focusing the multi-year work at all levels (top down and bottom up), including the state system, community system, agency/program, clinician, and consumer. The concept was not about changing one program at a time, but about fundamental change at each level.
• Using the Comprehensive, Continuous, Integrated System of Care (CCISC) model for systems re-design developed by Drs. Kenneth Minkoff and Christie Cline, as the project’s organizing framework. CCISC is based on the recognition that clients with co-occurring disorders are an expectation, rather than an exception, and the policies, programs and practices must therefore meet basic standards for “dual diagnosis capability.” A consensus document, or Charter, is the vehicle which outlines the concrete action plan. CCISC also provides a “Toolkit” including instruments to identify strengths and weakness and assess movement toward dual diagnosis capability at the system, program, and clinician levels (COFIT, COMPASS, and CODECAT, respectively).
• Meeting consumer-driven standards of welcoming, accessible, integrated, continuous, and comprehensive. These standards would ultimately be the measure of how well the system was meeting the needs of people with co-occurring disorders.
• Building a successful change process through seven key elements: 1) strong, committed leadership; 2) alignment with organizational mission and goals; 3) consensus by key stakeholders; 4) infrastructure that facilitates recommended change; 5) internal and external communication; 6) training; and 7) information systems to track implementation.
• Adopting Continuous Quality Improvement (CQI) as the driving technology for the change process and moving towards a more collaborative organizational structure at the new Division of Behavioral Health to support the implementation of CQI.