Comment - zialogic

lnnovative
Strategies
for Behavioral
HealthSystems

Jl.:r:.e23,2006
Summer King
SAMHSA Reports ClearanceOfficer
Room 7-1044
One Choke Cherry Road
Rockville, MD 20857
Re: ProposedCo-occurring Infrastructure Measuresfor COSIG
Dear Ms. King:
We are writing to comment on the above initiative, as referencedin the Federal
Register,volume 71, number 86, pp. 26382-3,datedMay 4,2006.
We are writing from the perspectiveof being very actively involved in the system
infrastructure developmentactivities funded by COSIG, in that we have provided or are
providing direct state,regional, and provider level consultation, technical assistance,and
training in almost all of the COSIG states. With regard to current active consultation
statewide, we are working with Alaska, Louisiana, Maine, oklahoma, Pennsylvania,
Vermont, and Virginia. We have provided extensive consultation in the past in Arizona,
Hawaii, New Mexico, and the District of Columbia, and we have provided targeted
consultation in Arkansas,Missouri, and Texas. ln addition, we are providing similar
statewide consultationscurrently in the following non-COSIG states:Michigan,
Montana, and South Dakota, as well as current extensive regional consultationsin
California and Florida. We have worked extensively as well with Maryland, and are
beginning a statewide and regional project with Wisconsin
Further, in most of the COSIG stateswith which we are working, we were written
in to the grant application, and our participation in the design of the application
contributed to the award of the grant. In addition, we were both members of the CSAT
consensuspanel that produced TIP 42, and Dr. Minkoff co-authoredthe subcommittee
report on co-occurring disordersto the President's New Freedom Commission, and is a
member of the SeniorAdvisory Board to SAMHSA's Co-occurringDisorder Centerof
Excellence(COCE).
In this context we have an in depth view of the actual infrastructure development
activities in each generationofCOSfC awardees,as well as knowledge of the differences
(or lack thereof) between the processof change in non-COSIG statescomparedto
COSIG states.

12231Academy Road NE, #3011313r Albuquerque,NM 87111 o (505) 379-6145Office
[email protected]

Further, in our work, we utilize a SAMHSA recognizedbest practice model for
integrated system development,termed the Comprehensive,Continuous, Integrated
Systemof Care (CCISC), referencedin SAMHSA's Report to Congresson Co-occurring
Disorders (2002). For recent articles on the utilization of CCISC in theseprocesseswe
referencethe following:
1.
Minkoff K & Cline C, "Changing the World: the design and implementation of
comprehensivecontinuous integrated systemsof care for individuals with cooccurring disorders.P sychiatr Clin N.Am 27:727-7 43, 2004
2. Minkoff K & Cline C, "Developing welcoming systemsfor individuals with cooccurring disorders:the role of the comprehensivecontinuous integrated system of
caremodel." J. Dual Diagnosis, I(1):39-64,2005
3. Curie C, Minkoff K, Hutchins, G, and Cline C, "Strategic Implementation of Systems
Change for lndividuals with Mental Health and SubstanceUse Disorders" J. Dual
. Diagnosrs,1(4): 75-95.2005.

With this background,we are writing to expressour seriousconcernsabout the
proposed data collection process,and to urge SAMHSA to seriously re-considerboth the
prooessand content of the proposedmeasurement.Our goal in this processis to assist
SAMHSA in developing a processthat will be reinforcing to the tremendousenergy that
is going on currently in the statesregarding systemtransformation, and will assistin the
development of a partnership betweenthe COSIG statesand SAMHSA that will facilitate
the movement toward system transformation and integrated servicesdevelopment over
time. (The article referencedabove, with Charles Curie as the lead author, describesthe
role of this strategicpartnership at all levels of the systemtransformation process.)
In this regard, there are four major points that we wish to make:
l.

.

The PROCESS of data collection is defined outside the partnershipbetween the
statesand SAMHSA, and outside the emerging partnershipsbetween the states
and their own systems,not just programs, but the intermediary entities that
coordinate behavioral health servicesin many states(e.g counties in
Pennsylvania,Community Service Boards in Virginia). Consequently,it is
outside the state's own infrastructure development activity, skips over the
activities of any significant intermediaries, and asks programs to report
information that may be disconnectedfrom the priorities that the state is working
on with them. To the extent that occurs, it both inhibits the state's ability to
provide SAMHSA with real information on its own infrastructure activities, and
createsa distracting burden for all the levels of the state systeminvolved in that
process. In this regard, what we would recommend is that the data collection be
organized to reflect primarily the collection of information that is managed
through the state's actual infrastractare, as well as any intermediaries that are
participants in the infrastructure of the stote system- (See below).

12231 AcademyRoad NE, #301/313 . Albuquerque,NM 87111 r (505) 379-6145Office
[email protected]

2 . Secondly,the datacollectedis basedon an incorrector misleadingmodel for what
the majority of COSIG statesare doing with regard to infrastructure development.
The original purposeof COSIG was NOT to develop specializedco-occurring
disorder programming, but basedon "co-occurring is an expectation, not an
exception" to createbasic infrastructure capacity in all elements of the system
(each clinician, each program, each subsystem,each state)to provide
appropriately matched interventions for co-occurring clients that present
anywhere in the system.Consequently,the goal is universality of what is termed
"co-occurring
disorder capability" in each type of progrilm. This includes not
only screeningand assessment,but the capacity to deliver an integrated service to
a co-occurring client who is being served in a typical mental health setting or a
typical substanceabusetreatment setting. In this regard, all programs are "cooccurring disorder" programs, and your languageshould reflect this development.
Note that the CCISC framework offers a specific methodology for designing and
implementing universal co-occurring capability, but that all COSIG states,
whether they are using CCISC or not, are trying to implement universal capability
into their infrastructure. In this regard, data collection should not be divided
into umh, sa, and cod" progran s, so much as positioned with language that
says: How does the state communicate with its intermediaries or programs the
following qaestion, and how does it retrieve the information thst is responsive
to the question? "The goal of COSIG k that all programs develop core
capability for co-occurring services. Identify the type of services Jlour program
currently provides, and describeyour vision of how you will become cooccurring capable".

3 . Further, the definitions that are used to describethe different functions are not
fully consistentwith what is happening in the field, and not fully aligned with
definitions that have been already developedand articulated by cocE.
Specifically,the definition of co-occurringdisorder capability is not mentioned;
this is a much more current concept than the "consultation, coordination,
collaboration, integration" continuum that you are using in this request. Those
functions are all componentsof the development of co-occurring capability in an
organization; asking questionsas if they are distinct is not helpful or relevant to
what statesare working on. The definition of screeningwould not correspond
with waiting a month to perform the screeningfunction Further, there is an entire
position paperdescribing"integratedservices",and delineatinghow these
servicescan be provided in any setting, and are distinct from formal "integrated
treatment programs"; the definitions you usefor integrated services (and other
items) should comespondto the cunent COCE deJinitions, and the definition of
co-occurring capability should be included..
4. Finally, as noted in item #1, the specific dataelementsrequestedare not
consistentwith either assessingthe state's acfual infrastructure development, does
not acknowledgethe need to collect the information through counties or
community service boards, and requestsinformation at the program level that is
beyondthe core universaldevelopmentalactivities that COSIG is designedto
12231
Academy
Road
NE,u.ot,.tlniod!,llli',1i,?;-" 87111
t (5o5)
37e-6145
office

promote in stateinfrastructure. In this regard, to help SAMHSA collect
information more relevant to its purpose, as well as more aligned with, and less
burdensometo, the statesand their participating intermediariesand programs, we
woald propose the following for data collection :
Ask the statesthe following:
l. At the statelevel: what definitions have been adoptedfor defining
the population, and for screening,assessment,and integrated
services?
2. At the statelevel: what are the current level of intermediary
(county) and program requirementsfor screening,assessment,and
development of co-occurring capable services?
3. At the state level, what mechanismsare in place to track
participation at the intermediary level and at the program level for
participation in the processof developing routine co-occurring
capability as a feature of system/programinfrastructure? How
many intermediaries/programsare participating in this process?
4. At the statelevel: what mechanismsare in place to facilitate access
to welcoming engagementfor individuals with cod who present
routinely and in crisis? Is there a welcoming policy that addresses
removal of accessbarriers? How much penetration is there of these
policies at the intermediary level, and at the program level? Is there
a statewidemechanism for tracking data for quality improvement
purposesregarding basic accessto care for individuals with cod?
5. At the statelevel: what mechanism is in place to collect
information on what intermediarieslprogramsare providing in
terms of screening?Assessment?Identification of co-occurring
clients? Tracking whether the program is providing appropriately
integrated servicesto the clients?
6. At the statelevel, what data can you currently report, in your data
infrastructure, that says: (If you wish to survey your
intermediariesor programs to obtain this information, pleaselet us
know the methodologyyou will useto do so)
. How many counties/programshave a co-occurring disorder
screeningpolicy?
o How many counties/ progmms have identified a cooccurring disorder screeningprocess?
o How many clients receivea screeningfor cod (as defined
by the county or program)?
o How many clients are screenedpositively (identified as
cod) in the county or program data system?, and
. How many clients receive an appropriate integrated
assessmentand/or service in the county/ program
(depending on what the screeningindicates is needed)?
12231
Academy
Road
NE,n.0,,.,1";d;P,llli',11,?;"M
87111o (505)
37e€145
office

This would be a substantialamount of information, and would make more
sensethan the questionscurrently being asked. If stateswere to passthese
requestsalong to their providers, they would be consistent with what the
statesare actually doing with regard to infrastructure development and
basic data collection, and would require less than 10 data elementsto be
reported.
We want to thank you for your time and consideration of our input. Pleasefeel
free to contact us directly if fi.rther information is required, or for further elaboration of
our comments.We have copied these commentsto the COSIG project managersin the
statesin which we are part of the COSIG implementation process,in order that they are
aware of our input. We look forward to your response.

Respectfullysubmitted,

ChristieA. Cline,MD, MBA, PC
President
[email protected]

Senior SystemsConsultant
[email protected]

12231 AcademyRoad NE, #301/313 r Albuquerque,NM 87111 r (S05)379-6145Office
[email protected]