The authors are affiliated with Twin Valley Behavioral Healthcare, Columbus, Ohio, an inpatient treatment facility of the Ohio Department of Mental Health for approximately 200 civil, forensic, and maximum-security forensic patients.
This article describes the components of the integrated dual diagnosis treatment (IDDT) outpatient services model and discusses how the IDDT outpatient service components and strategies were successfully adapted and implemented in a psychiatric hospital inpatient program. The adaptation and implementation was a small investment because it primarily used existing resources and personnel. However, it yielded a large change in the organizational inpatient structure and improved the treatment culture with co-occurring disorder treatment provisions. It therefore had a significant impact on the patient population and the quality of services overall.
As early as the 1970s, researchers and practitioners became increasingly aware of the necessity for services that would address the varied needs and treatment implications for consumers with the co-occurring disorders of substance abuse and mental illness.1 High percentages of consumers in substance abuse treatment centers were identified with mental illness disorders, and consumers admitted to psychiatric facilities often were identified as having additional substance use disorders.2,3 These findings prompted collaboration, particularly at the national level to consider treatment programs, which would jointly address the co-occurring disorders of substance abuse and mental illness directly.4,5 The New Hampshire–Dartmouth Psychiatric Research Center pioneered an outpatient co-occurring disorders treatment design that integrated multiple components according to the principles of evidence-based mental health practices.6 The resultant design was the IDDT model, which has become widely accepted as an evidence-based best practice.7,8
The IDDT model seeks to improve the quality of life for people with co-occurring severe mental and substance use disorders by integrating substance abuse services with mental health services. This model addresses both disorders at the same time, in the same service organization, and by the same team of treatment providers. The implementation of IDDT facilitates continuous and coordinated service and system adjustments to ensure clinical continuity of care for each consumer.
Research shows that treatment organizations that maintain fidelity to the original design of IDDT achieve and sustain the best outcomes. Successful IDDT programs include 13 defined service components and strategies (discussed below) in order to maintain fidelity to the IDDT model and to produce the positive outcomes that research has shown will occur.9-11 The realization of these IDDT outcomes motivates consumers, family members, service providers, and community stakeholders to maintain a long-term commitment to the model.
The successful establishments of outpatient substance abuse and mental illness co-occurring disorder (COD) treatment programs during the years 2000-2005 resulted in a change of treatment philosophy in the direction of the integration of these co-occurring disorder services into a program of substance abuse mentally ill services, abbreviated as “SAMI” services. There was a substantial increase in co-occurring disorder community-based programs nationwide.12 In 1999, Twin Valley Behavioral Healthcare (TVBH, formerly named Twin Valley Psychiatric Services) was one of the first US inpatient psychiatric facilities to adapt the New Hampshire–Dartmouth Psychiatric Research Center’s outpatient IDDT model to an inpatient environment. TVBH administration was motivated to adopt the IDDT model as a means to manage risk, to decrease recidivism, and to promote cost-effective co-occurring disorder treatment. The TVBH leadership felt that their organization was ready for the shift in perspective, possessed the need for treatment improvements and, therefore, began to adapt the IDDT model.
TVBH is one of 7 Joint Commission Accredited Ohio Department of Mental Health (ODMH) psychiatric hospitals. TVBH’s daily census approximates 100 acute care patients and 130 forensic patients; half of the forensic patients are treated in a separate statewide maximum-security facility. In 2000 the Ohio SAMI Coordinating Center of Excellence (CCOE) was created through an ODMH grant to assist in the statewide implementation of the IDDT model in an outpatient setting and later at all ODMH state psychiatric hospitals.6,11 Since the introduction of the IDDT model to Ohio, the inpatient psychiatric SAMI services at Twin Valley Behavioral Healthcare have consistently been on the forefront of COD treatment developments working closely with various statewide and federal resources in the establishment of high fidelity programs.
The initial TVBH IDDT implementation team recognized that this model would not be effective if put into practice on a single designated dual disorder unit, given the wide scope of services needed. Instead, it was clear that the IDDT model would be best integrated throughout the entire hospital treatment milieu including the acute and long-term forensic maximum-security settings. The TVBH IDDT implementation team recruited and organized clinical leadership and staff from each of the hospital disciplines that had an interest in assessing and treating CODs. These COD treatment leaders, in turn, helped develop the guidelines for the TVBH SAMI integrated services by applying the principles of the IDDT program to an inpatient setting. Each of the IDDT outpatient service components was adapted to meet the needs of the TVBH inpatient setting; these are presented below with a discussion of how these outpatient service components were successfully modified to maintain IDDT fidelity in the TVBH SAMI inpatient program.
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