DESCRIPCIÓN DEL PROCESO METALÚRGICO DE LA PLANTA CONCENTRADORA

persons 18 and older in the past year with serious mental illness used an illicit drug. In

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2003, the survey also found that 5.7 million persons ages 18 and over with serious mental illness engaged in binge alcohol use and 1.9 million were heavy drinkers. Overall, the survey showed that about 4.2 million adults aged 18 and older met the medical criteria for both substance abuse and mental illness.”45

At the national level, SAMHSA is conducting research on and trying to support the expansion of programs that treat co-occurring mental health and substance abuse disorders. Information is being developed and distributed in “Tool Kits” on how to implement effective treatment programs for this growing population. Additionally, SAMHSA is working with the CMS (federal Medicaid agency) on how to use existing reimbursement mechanisms for services to people with co-occurring disorders; and convened two National Policy Academies on Co-Occurring Disorders to help states and communities enhance service capacity to this population. Georgia has conducted its own research on treatment of co-occurring disorders and adopted policies to support best practices in services: GEORGIA MHDDAD BEST PRACTICE SUGGESTIONS PRINCIPLES AND STAFF CAPABILITIES FOR DAY SERVICES FOR

ADULTS WITH COOCCURRING DISORDERS46 developed in conjunction with the Technical Assistance Collaborative. The report suggests that treatment for co-occurring disorders be integrated within the treatment plan and that staff should have additional credentials to provide the necessary supports. A full version of the report is attached as APPENDIX VII-1: BEST PRACTICE SUGGESTIONS PRINCIPLES FOR COOCCURRING DISORDERS.

In Georgia there are thousands of individuals that are currently enrolled in services that have a co-occurring mental illness and addictive disease. If the national percentage of 27.3% is applied to the statewide prevalence figures for adults with mental illness (348,040) the total number of individuals with co-occurring disorders is estimated to be 95,014. Additionally, one can examine the number of individuals with co-occurring disorders enrolled in services to understand how many people Georgia is serving. The following table represents the number of individuals with co-occurring mental illness and substance abuse as a primary disability or a secondary disability, broken down by region.

TABLE VII-4: Individuals with Co-Occurring mental illness and substance abuse enrolled in services within FY04

East Central Region

Metro Region North Region Southeast Region Southwest Region West Central Region 5,476 11,626 14,290 9,622 5,688 8,378

Across the state there are 55,080 individuals with co-occurring disorders enrolled in services in FY04.47 These figures can be misleading however due to the subjectivity and definition of substance abuse: sources from the Division of MHDDAD and community providers believe that any consumer having any history of drug use are given a substance abuse diagnosis and would be included in these numbers. Additionally, it is challenging

45 _{http://www.oas.samhsa.gov/nhsda/2k3nsduh/2k3Results.htm}

46 _{http://www.tacinc.org/cms/admin/cms/_uploads/docs/GAbestPrac.pdf} 47 _{Figures were extracted from the EARF reporting system within MHDDAD.}

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to determine what services are being provided to these individuals, as not all substance abuse providers do not use the MHMRIS system to capture encounter and service data. Within the state there are several programs that integrate treatment for mental illness and substance abuse disorders. For the purpose of this report we will focus on several

programs.

GATEWAY

One of the exemplary programs within the state of Georgia treating co-occurring Mental Health and Addictive Disease is the Gateway Dual Diagnosis Community Residential Treatment Program, out of Southwest State Hospital (SWSH). Gateway Dual Diagnosis Program was created from 20 beds of the Regional State Psychiatric Hospital in

Southwest Georgia. It became a community residential program in 1996 and meets the needs of consumers with dual disorders (mental health and addictive diseases).

Gateway’s unique service delivery system interfaces with the service delivery system of the 24 rural counties in the Southwest Region of the state. The program is a model program that offers a multi-model treatment approach that includes conventional psychotherapy, psycho-education, case management, activity therapy, self-help, skill building classes, and training in relapse prevention. Outcome data supports the efficacy of its treatment approach by lowering subsequent hospitalization. Features of the program are listed below:

• A unique treatment model that integrates both psychiatric and substance abuse services and interfaces with community services, including self-help groups and a dual case management system

• Consumers elect program representatives and conduct a daily and nightly group to review issues of the milieu

• Received numerous positive appraisals from consumer groups and accreditation organizations (e.g., JCAHO, CLIP, GAO)

• SWSH received special funding by taking funds out of the hospital’s budget. • Used Dennis Daily’s work from Hazelton catalog, clinical program, since 1996:

education modules on coping with various mental illnesses and addiction, including personality disorders and behaviors that are self-defeating. • Serves Adults (18 years and older)

• The two Single Point of Entry (SPOE) vendors conduct the admissions to the program. SPOEs receive referrals from agencies and all paperwork is gathered within a couple days and approved/denied. People who are in a crisis bed or hospital bed get priority admission status.

Gateway’s outcomes have faired considerably better than those in programs treating just mental illness or addictive diseases. The integrated treatment has a favorable impact on re-hospitalization rates (e.g., lowering such rates) in the rural counties of South Georgia. Additional findings include:

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(entitled “Next Step”) for aftercare has a favorable impact on recovery, especially with the limited resources in a rural catchment area

• Consumer empowerment is an essential component of the Gateway experience; consumers are generally satisfied with the various Gateway services available • Volunteers are a key component of the program’s success

Since the initiation of the Gateway program the staff and administrators have developed several lessons and things to be considered in the development of a rural dual diagnosis program. Issues of importance are:

• Understanding the integrated approach to treatment with rural counties.

• Research data to demonstrate a decrease of State Hospital admissions following dual diagnosis treatment.

• Identify funding streams and available resources to obtain certification for addiction counselors for rural areas.

• Cost containment strategies with oversight by provider (comparison of Gateway’s cost vs. State Hospital’s cost per diem).

• Competence, cross-training and cultural sensitivity of staff who must have knowledge, skills and experience with dual diagnosed consumers from rural communities.

• Development of regional dual diagnosis training and credentialing for rural behavioral health providers. Working with regional colleges to provide training for interns/students and providing professional dual diagnosis training.

• Managed care and utilization review of services to manage costs of providing specialized services through a regional admitting authority. Authority controls approval for admissions.

• Funding stream through redirecting of hospital funding into a community budget. • Explore creative ways to provide services to rural counties, including the creation

of an intensive case management service for the dually diagnosed called “Next Step.”

The staff at Gateway are constantly training staff and trying to stay “cutting edge” with best practices. Other strengths about the program follow:

Hospital advocate is a strong unofficial member of the program and treatment teams.

Gateway staff attempt to determine and address why the program does not work for some

Use of Dialectical Behavior Therapy for those with Borderline Personality Disorder

Building is very different from the rest of the hospital; it “feels” different there. Consumers are given voice in the program and how to make it better.

Alliances are/have been built with all programs and supports, including AA Weekend is typically leisure activities but sometimes family therapy is conducted for those whose family can only come at those days.

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Use and implementation of the GEORGIA MHDDAD – BEST PRACTICE SUGGESTIONS, PRINCIPLES AND STAFF CAPABILITIES FOR DAY SERVICES FOR ADULTS WITH CO-OCCURRING DISORDERS

Gateway does not generate revenue, however it has shown that it is cost-effective and has better outcomes than traditional treatment that does not treat both disorders

simultaneously. The following chart illustrates the differences in cost of care of inpatient mental health and the gateway program.

Table VII-5: FY03 Daily Cost of Care

State Inpatient Adult Mental Health & Gateway Dual Diagnosis

$450.52 $247.58 $152.28 0 100 200 300 400 500

INPT AMH GATEWAY W/ InfraStructure Gateway Without InfraStructure

Double Trouble in Recovery

The self-help movement has been gaining greater recognition for its value in helping people make positive changes and get support. Alcoholics Anonymous (AA) was the first organized self-help program to bring attention to the importance of individuals with similar issues who can provide each other with mutual support and solutions. AA started over 65 years ago and has helped millions of individuals to improve the quality of their lives. Because of the success of AA, many other self help groups have started using the same philosophy of self-help. An example is Double Trouble in Recovery (DTR). DTR is a self-help group based on the twelve steps of AA. DTR is unique because it is a self- help group for those who live with both mental illness and addictive diseases. DTR provides mental health consumers, who have a history of substance abuse, with an environment of acceptance and empathy that may not be available at other traditional 12- step groups that deal only with addictions, such as AA or Narcotics Anonymous (NA). Some mental health consumers may not be accepted or understood at AA or NA because of stigma, and the lack of education about mental health issues among its members. Also, members of AA or NA may feel that because a mental health consumer is taking medication, to remain stable, that the mental health consumer is not clean (without drugs in their system) or sober (in a sound state of mind). Stigma, stereotyping, and insensitive comments can make a person who is dually diagnosed feel disconnected to a group, even though they came to it for support.

Double Trouble in Recovery was introduced to the Atlanta metro area in 1996, for the homeless, so they would have a place to go during the Olympics. DTR was added to the drop-in centers shortly thereafter. Double Trouble originated in three churches in the

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Ponce de Leon area of Atlanta, and became known as the Ponce Project. The Ponce Project is under the umbrella of the Georgia Mental Heath Consumer Network. Since 1997, Double Trouble has grown by leaps and bounds and the project is expanding to include Dekalb County). At this time, there are twenty-three DTR meetings in the Metro Atlanta area, and serves between 900 and 1200 people each month. The facilitators of Double Trouble are also dually diagnosed; implementing the benefit of one dually

diagnosed person helping another. All facilitators have between 3 to 22 years in recovery and are encouraged to take care of their mental health and work on their own personal recovery. Many of the facilitators are in fact former and current participants in the project. The current project director is a graduate of the program while another graduate has been hired to lead a statewide project to educate consumers on the Wellness

Recovery Action Plan and is creating Wellness Communities.

In June of 2004, Georgia State University conducted a survey, on the effect of the Ponce Project on its participants. According to their research, 76% reported they were using substances less, 88% felt the project helped them focus on personal recovery goals, 91% agreed that DTR helped them deal better with stress in their life, 85% agreed they were becoming more stable, 74% felt better able to handle crisis, and 80% reported taking their psychiatric medications more regularly and felt better about themselves. Although DTR is taught in the Certified Peer Specialist training, metro Atlanta remains the only area in Georgia where DTR groups are available in the community.