TABLE III: MODEL ELEMENTS, CRITERIA, AND EXPECTED RESULTS FOR SPECIAL SERVICES
Best Practice Model Component
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Criteria for the Best Practice Model Component
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Results to be Expected by Meeting Best Practice Criteria
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Services for individuals with co-
occurring mental illness and
substance abuse
30 percent of people with mental illness
have co-occurring substance abuse. 37
percent of alcohol abusers have mental
illness, and 53 percent of drug abusers
have mental illness. 40 to 80 percent of
individuals seen in mental health
treatment settings have substance
abuse problems, and over 50 percent of
individuals admitted to state psychiatric
hospitals have a history of substance
abuse. Among homeless adults, 50
percent are active substance abusers,
and 30 percent have co-occurring
mental illness and substance abuse.
Co-occurring disorders are major
contributing factors in loss of housing,
treatment non-compliance, emergency
room use, and re-hospitalization. From
these facts it can be seen that dual
diagnosis is the expectation, not the
exception11. Further, when mental
illness and substance abuse diagnoses
co-occur, they both must be treated as
the primary diagnosis, not one or the
other.
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- Dual diagnosis services are fully integrated and
coordinated across outpatient, inpatient, and
community support/residential service settings.
- All integrated service components are
welcoming, accessible, continuous, culturally
competent, and linked to all other necessary
service systems.
- Integrated services recognize that recovery is
not a linear process, but rather one that must
flexibly respond to individual consumer needs
for engagement, self-acceptance, active
treatment, relapse prevention, and maintenance
- abstinence is step-wise, not absolute).
- Integrated assertive community treatment and
intensive case management teams have dual
competencies in mental illness and substance
abuse interventions, and are a primary modality
for the delivery of services for individuals with
co-occurring disorders.
- All components of the public behavioral health
system receive continuous co- and cross
training in assessing and treating co-occurring
disorders.
- All components of the public behavioral health
system have sufficient competencies in dual
diagnosis services to assure effective responses
wherever individuals with co-occurring disorders
present.
- There is coordinated, system-wide planning,
development, and coordination of dual diagnosis
services.
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- Individuals with co-occurring
mental illness and substance
abuse disorders will be more likely
to be engaged in services and to
remain in treatment.
- Consumers with co-occurring
disorders will be more likely to
maintain treatment compliance.
- Consumers with co-occurring
disorders will have greater success
in maintaining community living
and working arrangements, will
use fewer hospital days, and will
have fewer crisis program and
emergency room encounters.
- Local criminal justice systems and
homeless service systems will
have fewer encounters with
individuals with co-occurring
disorders, and will have greater
success in referring such
individuals to the public behavioral
health system.
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Best Practice Model Component
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Criteria for the Best Practice Model Component
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Results to be Expected by Meeting Best Practice Criteria
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Geriatric Mental Health Services
15 to 25 percent of elders in the United
States suffer from significant symptoms
of mental illness. Persons over 65
years of age represent approximately 12
percent of the total population of the
United States, yet they account for over
20 percent of the suicides nationwide.
Despite these statistics, fewer than four
percent of individuals treated in mental
health centers nationwide are over 65.
And, less than 1.5 percent of the direct
costs for treating mental illness in this
country are spent on behalf of elders
living in the community.12
As a proportion of total population,
those over 65 are the fastest growing
group. This is caused by two factors.
First, the substantial burst of population
growth in the late 40s and early 50s (the
baby boomer generation) results in
proportionately higher numbers of
individuals who will turn 65 within the
next 10 to 15 years. Second, average
life expectancies have increased
markedly, going from 68.2 years in 1950
to 74.9 years in 1985. By the year
2025, average life expectancies are
expected to exceed 85 years, and
elders are predicted to comprise over 25
percent of the total population (double
their current proportional representation
in the general population.)13
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- The public behavioral health system works to
assure integration and coordination among
resources important to elders, particularly
primary health care, mental health and
substance abuse treatment, and elder services
such as homemakers, meals-on-wheels, and
visiting nurse services.
- There is coordinated and active outreach to and
engagement of elders, most successfully
conducted by peers.
- The system assures flexibility as opposed to
specialization among service providers. The
collaborating components of the system have an
attitude of "these individuals belong to us"; not
"we don't serve that type of person."
- The system assures provision of a full array of
clinically competent services designed to reduce
institutionalization and to support on-going
community living and integration. These include
mobile services provided in homes and
community centers, in-home services with
integrated health and behavioral health
competencies, and facilitated access to
community social and recreational opportunities.
- There are on-going cooperative efforts to
provide cross training among a variety of
practitioners about depression, substance
abuse, co-occurring dementia, and other related
conditions affecting elders.
- The system cooperates with other service
systems to engage natural community supports
and people most likely to come in contact with
elders, such as the faith community, shop
keepers, transportation providers, postal
services, etc.14
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- Depression, substance abuse, and
other behavioral health issues
among elders will be quickly
identified and successfully
addressed.
- Primary health care physicians will
be better trained in identification of
mental illness and/or substance
abuse, and in pharmacological
procedures and precautions for
elders.
- Linkages to services and
coordination across behavioral
health, primary health, and aging
services will be facilitated.
- The rate of institutionalization
(primarily nursing home-based
care) among elders with behavioral
health needs will be reduced.
- Social indicators of untreated
behavioral issues among elders,
such as isolation, poor nutrition,
spousal abuse, etc. will be
ameliorated and reduced.
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Best Practice Model Component
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Criteria for the Best Practice Model Component
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Results to be Expected by Meeting Best Practice Criteria
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Housing
A recent study by the Consortium for
Citizens with Disabilities found that in
the Phoenix-Mesa Area, a mental health
consumer would need to use 84.4
percent of their $494 monthly SSI check
to rent an efficiency apartment, leaving
them with only $77 a month for all other
household expenses including food15.
To rent a one-bedroom apartment in the
Phoenix Area, a SSI beneficiary would
need to spend 102.2 percent of their
monthly income on rent, leaving with
virtually no other funds. This scenario is
no better in Flagstaff or Tucson, where
the percentages are 92.7 percent and
91.9 percent respectively for a one-
bedroom apartment.
There is widespread agreement that
when housing is permanent and flexible,
individualized support services are
available as needed, people with
serious mental illnesses can achieve
and maintain residential stability in the
community. For persons with mental
illness, supported housing offers a safe,
viable, more affordable alternative that
reaffirms independence and community
living.
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- Access to affordable, safe, and decent
independent housing by consumers is among
the highest priorities of the public behavioral
health system. Living in independent housing of
one's choice is a key ingredient to the
rehabilitation and recovery process.
- The system provides an array of flexible
community services and supports designed to
assist consumers to select and maintain
independent housing in communities of their
choice.
- At the state and regional levels the system has
plans and strategies for increasing access of
consumers to affordable housing and for
increasing the supply of affordable housing for
consumers. The strategies include accessing
mainstream housing resources as well as
specialized resources designed solely for
individuals with disabilities.
- At the state and regional levels the system has
forged strong working relationships with
organizations that fund, develop, and/or manage
affordable independent housing. These
organizations include housing finance agencies,
public housing authorities, and non-profit
organizations dedicated to the production and
management of affordable housing.
- The system provides regular training to
consumer on the rights and responsibilities of
tenancy and on approaches to accessing and
selecting affordable housing. The system also
regularly trains landlords, real estate brokers,
public housing authorities, etc. in the housing
rights and competencies of people with mental
illness, and about the system of services and
supports available in the community to assist
individuals with mental illness to live
successfully in independent housing.
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- The number and proportion of
consumers accessing independent
affordable housing will increase on
a year-to-year basis.
- The length of time that consumers
live in independent housing will
increase substantially.
- Consumer utilization of inpatient
hospitalization and crisis services
will be reduced.
- Incarceration and homelessness
for individuals with mental illness
will be reduced.
- Communities will become more
knowledgeable about and
accepting and supportive of people
with mental illness.
- The over-all supply of affordable
housing available to very low-
income individuals with disabilities
will increase on a year-to-year
basis.
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Best Practice Model Component
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Criteria for the Best Practice Model Component
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Results to be Expected by Meeting Best Practice Criteria
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Employment
A 1972 study found that less than 30
percent of individuals with serious and
persistent illness ever work.16 More
recently, a 1998 study found that less
than 12 percent of persons with
schizophrenia or bi-polar disorder
obtained jobs in the competitive sector,
even after finding training in job-finding
skills.17 Even using "place-then-train"
supported employment approaches,
about 50 percent of persons with
serious mental illness obtain competitive
employment. Only ½ of those who
secure competitive employment remain
employed in the same jobs six months
later.18
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- The public behavioral health system assures
consideration of individuals' interests, abilities,
and goals in selecting jobs. This includes
employment strategies that match individuals'
education and skill levels with employment
opportunities. People with mental illness do not
have to work only in minimum wage, service
sector jobs.
- The system provides early intervention
strategies designed to assist people to return to
work as soon as possible after the onset of a
psychiatric disability.
- The system adopts supported employment
strategies that focus on getting people into the
workplace and then training on the job, rather
than spending time in pre-employment training.
- The system provides of a range of on-going
services and supports to assist people to work
and interact effectively in the workplace.
- The system assures flexibility in work
expectations during periods of acute
exacerbation of the mental illness.
- Supported employment strategies include a
range of work experiences including short term
job tryouts, on the job training, part time jobs,
and other productive activities, including
education and volunteer activities.
- The public behavioral health system provides
sufficient employment opportunities19 for current
and former consumers.
- The system provides multi-disciplinary teams
that blend vocational supports with other clinical
and community supports.20
- The system effectively coordinates behavioral
health resources with vocational rehabilitation
resources to provide continuity of employment
training, placement, and follow-along services.
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- Consumers with serious mental
illness will increase their
participation in competitive
employment of their choice on a
year-to-year basis.
- Consumer income from
competitive employment will
increase substantially.
- Employers will become more
accepting of consumers as valued
and competent employees, which
will result in increased employment
opportunities for individuals with
serious mental illness.
- Consumers maintaining
competitive employment will use
fewer hospital days and have
fewer encounters with the crisis
system.
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11These data were synthesized from the environmental catchment area (ECA) studies, and published articles by Osher, Drake, Test, and Minkoff
12These facts were extracted from a literature review conducted by the American Psychiatric Association, 1998
13Bazelon Center. At Home: Strategies for Serving Older People with Mental Disabilities in the Community. Washington, DC, 1995
14Ibid.
15Priced Out: The Housing Crisis for People with Disabilities. Consortium for Citizens with Disabilities Housing Task Force. Technical Assistance Collaborative, Inc. March 1999.
16Anthony WA, Buell GJ, Sharrett S, et. al. The Efficacy of Psychiatric Rehabilitation Psychological Bulletin 78:447-456, 1972
17Liberman RP and Mintz J. Psychopathology and the Ability to Work Unpublished, June 1998 (Quoted in Wallace CJ, Tauber R, and Wolde J. Teaching Fundamental Workplace Skills to Persons with Serious Mental Illness Psychiatric Services 50(9):1147-1153)
18Drake RE and Becker DR. The Individual Place and Support Model of Supported Employment Psychiatric Services 47:473-475 1996
19Some public behavioral health systems have made the mistake of employing consumers only as "consumer advocates" or representatives. While these roles are necessary and productive, consumers should also be employed as case managers, administrative staff, and any other functions that meet their skills, education level, and choices.
20The above criteria were extracted from a National Technical Assistance Center for Mental Health Planning publication on supported employment published in 1999.
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