# Presentation: 254488

## Richard E. Lopez, Ph.D., J.D.

**State Incentive Grants (COSIG) for Treatment of Persons with Co-Occurring Substance Related and Mental Disorders**

## BACKGROUND

_***Consensus***_ There is a growing consensus among key stakeholders about the critical importance of improving services to people with co-occurring disorders and the action*** ***steps that are needed to do so.

## Background Continuation

_***Report***_  SAMHSA released a landmark Report to Congress on Co-occurring Disorders (RTC) on December 2, 2002, _***Opportunity***_ creating a critical opportunity for SAMHSA to provide leadership to support State efforts to improve services for people with co-occurring disorders.

## WHAT COSIG DOES

_***Provides***_ COSIG provides funding to the States to develop or enhance their infrastructure to increase their capacity to provide accessible, effective, comprehensive, coordinated/integrated, and evidence-based treatment services to persons with co-occurring substance abuse and mental disorders.  _***Opportunity***_ COSIG also provides an opportunity to evaluate the feasibility, validity and reliability of the proposed co-occurring performance measures for the future Performance Partnership Grants (PPGs).

## What COSIG Does Continuation

_***Quadrants***_ COSIG will support infrastructure development and services across the continuum of co-occurring disorders from least severe to most severe (i.e., Quadrants I, II, III, and IV of the State Directors’ Conceptual Framework).Under COSIG, SAMHSA’s emphasis is on Quadrants II & III.

## COSIG CONCEPTS

_***Definition***_** **COSIG is built on the following concepts and principles: COSIG uses the definition of co-occurring disorders developed by the consensus panel convened to draft SAMHSA’s Treatment Improvement Protocol (TIP), *Substance Abuse Treatment for Persons with Co-occurring Disorders:***  **People with co-occurring substance abuse and mental disorders are “...individuals who have at least one psychiatric disorder as well as an alcohol or drug use disorder.  While these disorders may interact differently in any one person (e.g., an episode of depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms) at least one disorder of each type can be diagnosed independently of the other.”

## Concepts Continuation

_***Appropriate***_ COSIG is appropriate for States at any level of infrastructure development.  States will not be at a disadvantage either for being at an early stage of development or at a more advanced stage.

## Concepts Continuation

_***History***_ Some States and communities throughout the country already have initiated system-level changes and developed innovative programs that overcome barriers to providing services for individuals of all ages who have co-occurring substance abuse and mental disorders.  The COSIG Grant program reflects the experience of States to date.

## Who Can Apply?

_***Only***_ Only the immediate Office of the Governor of States could apply.  _***State- level***_ State-level agencies are not considered to be part of the immediate Office of the Governor.  This means, for example, that the State Mental Health or Substance Abuse Authorities or other State-level agencies within the Office of the Governor could not apply independently.  _***Limited***_ SAMHSA limited the eligibility to Governors of States because the immediate Office of the Governor has the greatest potential to provide the multi-agency leadership needed to develop the State’s infrastructure/treatment service systems.

## Purpose of the COSIG

_***FY 2003***_ The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT), and Center for Mental Health Services (CMHS), accepted applications for Fiscal Year 2003 grants to develop and enhance the infrastructure of States and their treatment service systems to increase the capacity to provide accessible, effective, comprehensive, coordinated/integrated, and evidence-based treatment services to persons with co-occurring substance abuse and mental health disorders, and their families.
_** **_

## Purpose Continuation

_***Budget***_ It was expected that approximately $6.5 million would be available for 6 to 10 awards in FY 2003. We received 40 applications, and funded 7. The average annual award ranges from $500,000 to $1.1 million in total costs (direct and indirect).  Grantees in years 1-3 will receive up to $1.1 million per year.  Grantees with service pilots will receive up to half of the third year award in the 4th year to phase down the services pilot and up to $100,000 for evaluation in year 5. Grantees without service pilots will receive up to $100,000 for evaluation in both years 4 and 5.

## Purpose Continuation

***Services Pilot*** The program will **allow** (but not require) up to 50% of the grant to be used for services pilots to test the infrastructure enhancements that are being made through the grant.  In other words, these service pilots will help States who choose to implement them to determine whether the enhancements are feasible and whether they are resulting in the intended outcomes.  Patient services are required in a pilot.

## Program Requirements 

_***Capacity Building Goals***_ In developing their COSIG applications, States selected one or more of the capacity building goals enunciated in SAMHSA’s Report to Congress on Co-Occurring Disorders and implemented infrastructure development and enhancement activities (tailored to State needs) that would support the selected goal(s).  Applicants identified measurable outcomes for each goal, established targets, and described how progress would be tracked and measured over the course of the grant. _***PPG***_ _***Measures***_ In addition, all COSIG Grantees were required to report on the proposed co-occurring performance measures for the PPGs and to participate in an evaluation study to determine the feasibility, validity, and reliability of the co-occurring performance measures.

## Program Requirements Continuation-Infrastructure Development 

**Standardized Screening and Assessment**:  A number of screening and assessment instruments exist that can be used to identify and effectively assess the needs of persons with co-occurring disorders.  At present, there is no standard for using these instruments or for ensuring that screening and assessment are even done in existing programs throughout the States.  Adoption of acceptable protocols State-wide can help ensure that the initial objectives of the SAMHSA Report to Congress are achieved.

## Infrastructure Development Continuation

**Complementary Licensure and Credentialing Requirements:  **State licensure and credentialing policies and legal requirements often act as barriers to providing effective integrated services for persons with co-occurring disorders.  Review and revision of these laws and policies are a critical initial step toward improving services and extending effective substance abuse treatment to existing mental health treatment programs and vice versa.

## Infrastructure Development Continuation

**Service Coordination and Network Building:** Conventional boundaries between single-focus agencies impede the clinical progress of persons with co-occurring disorders.  Network building will help States develop more effective linkages across systems of care.  This activity area also includes the development of a permanent State-level coordinating body and assignment of specific “boundary spanning” responsibilities designed to ensure continuous coordination which yields the most efficient use of agency resources and the elimination of service redundancies.

## Infrastructure Development Continuation

**Financial Planning:** Current reimbursement practices inhibit coordination/integration of services and effective treatment for persons with co-occurring disorders.  Mental health and substance abuse services are funded through separate Federal, State, local, and private funding sources.  The goal of comprehensive financial planning is the development of effective and innovative approaches for coordinating funds from these multiple programs to fund seamless services for individuals with co-occurring disorders—while maintaining accountability—and the removal of barriers that inhibit effective resource coordination.

## Program Requirements Continuation

- The capacity building goals in SAMHSA’s Co-Occurring Report to Congress are as follows:
**1     1.Screen** all individuals for the presence of co-occurring disorders;**2.Assess** the level of severity of co-occurring disorders;**3.****Treat** both disorders in a comprehensive and coordinated manner that is seamless to the client and, where feasible, that involves the client’s family.  This may involve consultation/collaboration with other providers, if the provider does not have the ability to offer comprehensive treatment.

## Progam Requirments Continuation

**4.Train** providers to screen, assess, and develop preventive interventions and treatment plans for people who have co-occurring disorders; and 5.**Evaluate** the impact of prevention and treatment services on individuals who have co-occurring disorders and their families.

## Program Requirements Continuation

-  _***Program Phases***_ COSIG program will have two phases: Phase I – The first three years of the grant will focus on infrastructure development/enhancement. Awards will be for up to $1.1 million per year for the first three years. Phase II – An additional 2 years of funding will be provided at a lower level for evaluation and continued collection/reporting of performance data.

## Evaluation/Performance Measurement 

- COSIG grantees will participate in two types of evaluation activity:1)All grantees will participate in an evaluation of the feasibility, validity, and reliability of the proposed co-occurring performance measures for the PPGs, and 2) All grantees will conduct a local evaluation to monitor individual grantee progress towards achieving the goals and outcomes identified in the COSIG application.

## Evaluation/Performance Measurement Continuation

_***PPG***_ .  The co-occurring performance measures are as follows: 1.Percentage of clients (adults and children/adolescents) in mental health and substance abuse programs with symptoms of the corresponding co-occurring problem; 2.Percent of treatment programs that: a.screen for co-occurring disorders; b.assess for co-occurring disorders; and c.provide treatment to clients through collaborative, consultative and integrated models of care.3.Percentage of clients who experience reduced impairment from their co-occurring disorders following treatment.

## Evaluation/Performance Measurement

_***Local ***_All awardees also must conduct a project evaluation to determine the effectiveness of the project in meeting its specific goals and objectives.  The project evaluation should be designed to provide regular feedback to the project to help the project improve services.  The project evaluation must incorporate but should not be limited to co-occurring performance measures described above.

## Evaluation/Performance Measurements

- Because the COSIG projects will differ significantly, no single evaluation plan or design will apply to all applicants.  Experimental or rigorous quasi-experimental evaluation designs are NOT required.  In general, the applicant’s project evaluation plan should include three major components:

## Evaluation/Performance Measurements Continuation

- Implementation fidelity, addressing issues ***such as***:  How closely did implementation match the plan?  What types of deviation from the plan occurred?  What led to the deviations?  What impact did the deviations have on planned intervention and evaluation?Process, addressing issues ***such as***:  What activities, events, and services were supported with COSIG Grant dollars?  Who participated in these activities or received these services?Outcome, addressing issues ***such as***:  What impact did the activities have on the system?  What was the effect of treatment on service participants?  What program/contextual factors were associated with outcomes?  What client factors were associated with outcomes?  How durable were the effects?  How enduring or sustainable were changes in the service system or in clients?

## Evaluation/Performance Measurements Continuation

_***Cross Site Evaluation***_ In addition to these two evaluation requirements, SAMHSA _may_ choose to implement a cross-site evaluation of the COSIG grant program.  If conducted, the cross-site evaluation will be managed through a public/private collaboration.  States will be required to collaborate in the evaluation by attending up to two meetings annually, participating in the development of a cross-site evaluation plan, and by submitting information consistent with the plan.

## 2003 COSIG GRANTEES

**Pennsylvania**
**Missouri**
**Hawaii**
**Texas**

**Alaska**
**Arkansas**
**Louisiana**

## AbstactsPennsylvania's State Incentive Grant #1TI15344-01

- Pennsylvania's Departments of Public Welfare and Health are proposing an initiative to integrate mental health and substance abuse treatment through 1) the construction of a permanent, state level infrastructure using the knowledge and experience gained through MISA pilots at the county level; and 2) pilot enhancement activities that will result in a comprehensive, integrated approach to serving persons with co-occurring disorders throughout the Commonwealth. This project will provide knowledge to the field on the challenges and successes possible for states already engaged in the process of developing new initiatives involving complex boundary spanning activities.

## Abstracts Missouri’s State Incentive Grant #1TI15347-01 

- Missouri will implement infrastructure development and services activities for clients with co-occurring disorders in Quadrants II and III. A Governor-appointed Steering Committee will oversee the project, which will include developing a standardized screening and assessment system; implementing evidence-based treatment practices; and training staff who will pilot the new systems at selected Department of Mental Health-contracted rural and urban sites.

## Abstracts Hawaii's State Incentive Grant #1TI15351-01 

- The collaborative and cooperative efforts of Hawaii's Department of Health, including the Adult Mental Health Division (AMHD) and Alcohol and Drug Abuse Division (ADAD), propose to develop and enhance the capacity and infrastructure of the State of Hawaii's Service system to provide integrated, evidence-based treatment services to people whom have co-occurring substance use and mental health disorders. The grant initiative will be managed through the Office of the Governor, with active participation of the State's Lieutenant Governor, who has agreed to co-chair the project's coordinating committee. This project will also include the establishment of collaborative relations and common agendas with the Departments of Human Services (responsible for the State's Medicare and Medicaid programs) and Public Safety (responsible for the State's criminal justice system). It is expected that this cross-system cooperation will foster the ultimate development of an infrastructure leading to a seamless and comprehensive system of care for people who have co-occurring disorders.

## Abstracts Texas State Incentive Grant#1TI15353-01 

- The Texas COSIG will increase co-occurring capacity by building on existing services, ensuring co-occurring competencies of systems of providers through training, and by conducting an evaluation of the state's current practice for serving clients with co-occurring disorders (referred to as the COPSD Specialist model) to a proposed system methodology (referred to as the COPSD System model) that promotes a "no wrong door" approach to placing clients into integrated services. By evaluating client data from both models to validate co-occurring performance measures and the quadrant framework, Texas can enhance the state's ability to sustain long-term change in the service delivery system to meet the needs of more Texans with co-occurring disorders.

## Abstracts Alaska’s State Incentive Grant #1TI15354-01 

- To improve the identification and treatment of individuals with co-occurring disorders throughout a diverse service delivery system, Alaska has committed to addressing SAMHSA goals of improved screening, assessment, treatment, and training, which will be accomplished through infrastructure development, focusing on staffing competency, credentialing, and licensure; financial planning and reimbursement; and information sharing and data collection. The work will be carried out in fulfillment of a State action plan for the integration of mental health and substance abuse services.

## Abstracts Arkansas’s State Incentive Grant #1TI15360-01 

- To meet the needs of Arkansans dually diagnosed with substance abuse and mental health illness, the State of Arkansas, under the leadership of the Governor and his staff, proposes to institute standardized universal screening and assessment as a first step in its attempt to integrate the presently divided systems of substance abuse and mental health care. SAMHSA funding will also be used to train caregivers from both systems to better recognize co-occurring disorders, and to understand and create treatment plans that address the needs of these individuals. The barriers and facilitators to treatment throughout the process will be systematically evaluated.

## Abstracts Louisiana’s State Incentive Grant #1TI15378-01 

- Louisiana has developed the Louisiana Integrated Treatment Services (LITS) Model for serving persons with co-occurring mental and substance abuse disorders. This model, developed through two SAMHSA Community Action Grants, was successfully piloted in one region of the state and has been adopted for statewide implementation. The COSIG grant will focus on implementation of the LITS Model in the state's remaining regions and on development of statewide infrastructure to support and sustain LITS. Major infrastructure developments will include a) cross agency screening and assessments tools; b) integrated management information and program evaluation systems; c) funding structures that includes new Medicaid funds for substance abuse services, and maximizes current funding to support a broad range of services for people with co-occurring disorders; d) professional licensing standards that support integrated treatment. Regional implementation of LITS will include on-going intensive education, cross training and specialized consultation. Stakeholder involvement will be supported at both the state and local levels through direct partnerships with consumer and community- based mental health and substance abuse organizations. Organizational structure for the COSIG grant will include a state level Coordinating Council with decision- making and oversight responsibilities; 10 regional steering committees; 20 regional LITS specialists, 10 regional LITS facilitators; and a full-time project director. Expert consultants will provide technical assistance throughout the project.

## Thank you