Best Practice Model Component Criteria for the Best Practice Model Component Results to be Expected by Meeting Best Practice Criteria

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.

  • 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.
  • 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.
Best Practice Model Component Criteria for the Best Practice Model Component Results to be Expected by Meeting Best Practice Criteria

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

  • 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
  • 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.
Best Practice Model Component Criteria for the Best Practice Model Component Results to be Expected by Meeting Best Practice Criteria


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.

  • 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.
  • 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.
Best Practice Model Component Criteria for the Best Practice Model Component Results to be Expected by Meeting Best Practice Criteria

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

  • 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.
  • 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.

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


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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