It is essential to employ a common language in order to develop consensus on how to address the needs of persons with co-occurring disorders (COD).

*Access: The extent to which an individual who needs care and services is able to receive them. Access is more than having insurance coverage or the ability to pay for services. It is also determined by the availability of services, acceptability of services, cultural appropriateness, location, hours of operation, transportation needs, and cost.

*Accessible Services: Services that are affordable, located nearby, and open during evenings and weekends. Staff is sensitive to and incorporates individual and cultural values. Staff is sensitive to barriers that may keep a person from getting help. An accessible service can handle consumer demand without placing people on a long waiting list.

*Accreditation: An official decision made by a recognized organization that a health plan, network, or other delivery system complies with applicable standards.

ACT: Assertive Community Treatment is a model of intensive, non-office centered client services management, psychiatric care and other supportive services for adults with chronic mental illnesses. The ACT model is also used in serving children with long-term mental illnesses.

Addiction-or mental health-only services: refers to programs that either by choice or for lack of resources cannot accommodate patients who have co-occurring disorders that require ongoing treatment, however stable the illness and however well functioning the patient.

*Alternative Therapy: An alternative approach to mental health care is one that emphasizes the interrelationship between mind, body, and spirit. Although some alternative approaches have a long history, many remain controversial.

*Appropriateness: The extent to which a particular procedure, treatment, test or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to a patient’s or member’s needs.

*Appropriate Services: Designed to meet the specific needs of each individual child and family and usually provided in the child’s community.

*Assessment: A professional review of child and family needs that is done when services are first sought from a caregiver. The assessment of the child includes a review of physical and mental health, intelligence, school performance, family situation, and behavior in the community. The assessment identifies the strengths of the child and family. Together, the caregiver and family decide what kind of treatment and supports, if any, are needed.

*Behavioral Health Care: Continuum of services for individuals at risk of or suffering from mental, addictive, or other behavioral health disorders.

*Behavioral Therapy: Focuses on behavior changing unwanted behaviors through rewards, reinforcements, and desensitization. Often involves the cooperation of others, especially family and close friends, to reinforce a desired behavior.

BH: Behavioral Healthcare

CA: Coordinating Agency

*Case Management: A service that helps people arrange for appropriate services and supports. A case manager coordinates mental health, social work, educational, health, vocational, transportation, advocacy, respite care, and recreational services as needed. The case manager makes sure the changing needs of the child and family are met.

CCISC: Comprehensive Continuous Integrated Systems of Care. It is designed to improve treatment capacity for COD individuals. There are four basic characteristics: system level of change, efficient use of existing resources, incorporation of best practices and integrated treatment philosophy.

CMH: Community Mental Health

CMHSP: Community Mental Health Services Program is a program operated under Chapter 2 of the Michigan Mental Health code. Operated as a county mental health agency, a community mental health organization or a community mental health authority.

*Clinical Psychologist: A professional with a doctoral degree in psychology who specializes in therapy.

*Clinical Social Worker: Health professionals trained in client-centered advocacy that assist clients with information, referral, and direct help in dealing with local, State or Federal government agencies. As a result, they often serve as case managers to help people “navigate the system.” Clinical social workers cannot write prescriptions.

COCE Co-occurring Center for Excellence

COD: Co-Occurring Disorder. Clients said to have COD have one or more substance-related disorders as well as one or more mental disorders. At the individual level, COD exists when at least one disorder of each type can be established independent of the other. Mental health and substance abuse problems may not, at a given point in time, fully meet the criteria for diagnoses in DSM-IV-TR categories. A service definition reflects clinical realities and constraints and/ or programmatically meaningful descriptions of at-risk populations targeted for prevention and early intervention. Some individuals may exhibit symptoms that suggest the existence of COD, but could be transitory (e.g., substance induced mood disorders).

CODE CAT: Co-Occurring Disorders Educational Competency Assessment Tool.

CO-FIT: CCISC Outcome Fidelity Implementation Tool. A system measurement tool of readiness for integration of SA and BH.

Collaboration: is a more formal process of sharing responsibility for treating a person with COD, involving regular and planned communication, sharing of progress reports, or entry into a memorandum of agreement. In a collaborative relationship, different disorders are treated by different providers yet the roles and responsibilities of the providers are clear. The threshold for collaboration relative to consultation is the existence of formal agreements and/ or expectations for continuing contact between providers.

COMPASS: Comorbidity Program Audit and Self-Survey for Behavioral Health Services

Consultation: is a relatively informal process for treating persons with COD, involving two or more service providers and requires the transmission of medical or clinical information. The threshold for consultation relative to minimal coordination is the occurrence of any interaction between providers after the initial referral, including active steps by the referring party to ensure that the referred person enters the recommended.

*Consumer: Any individual who does or could receive health care or services. Includes other ore specialized terms, such as beneficiary, client, customer, eligible member, recipient, or patient.

Co-occurring Disorders- Integrated Dual Diagnosis Treatment (COD-IDDT): refers to program that have either Dual Diagnosis Capable or Dual Diagnosis Enhanced services.

DALI-14: Dartmouth Assessment of Lifestyle Instrument-Modified. (A screening tool)

EBP: Evidence Based Practice. EBBs are service models that research has demonstrated to generate improved consumer outcomes, program outcomes, and service systems outcomes. Research shows that organizations which maintain fidelity to the original design of each EBP achieve and sustain the best outcomes

DDC: Dual Diagnosis Capable

DDE: Dual Diagnosis Enhanced

*Diagnostic Evaluation: The aims of a generally psychiatric evaluation are 1) to establish a psychiatric diagnosis, 2) to collect data sufficient to permit a case formulation, and 3) to develop an initial treatment plan, with particular consideration of any immediate interventions that may be needed to ensure the patient’s safety, or if the evaluation is reassessment of a patient in a long-term treatment, to revise the plan of treatment in accord with new perspectives gained from evaluation.

Dual diagnosis capable: programs are those that address co-occurring mental and substance-related disorders in their policies and procedures, assessment, treatment planning, program content and discharge planning. Program staff are able to address the interaction between mental and substance related disorders and their effect on the patient’s readiness to change as well as relapse and recovery environment issues through individual and group program content.

Dual diagnosis enhanced: programs have a higher level of integration of substance abuse and mental health treatment services. These programs are able to provide unified substance abuse and mental health treatment to clients. Enhanced-level services place their primary focus on the integration of services for mental and substance-related disorders in their staffing, services and program content.

Efficient Use of Existing Resources: One of the four basic characteristics of the CCISC model designed for implementation within the context of current service resources and emphasizes strategies to improve services to ICOPSD within the funding stream, program contract, or service code, rather than requiring blending or braiding of funding streams or duplication services. It provides a template for planning how to obtain and utilize additional resources should they become available, but does not require additional resources, other than resources for planning, technical assistance, and training.

*Enrollee: A person eligible for services from a managed care plan.

* Enrollment: The total number of covered persons in a health plan. Also refers to the process by which a health plan enrolls groups and individuals for membership or the number that do not meet their needs.

ICOPSD: Individuals with co-occurring psychiatric and substance disorders

IDDT: Integrated Dual Diagnosis Treatment

ILSA: Integrated Longitudinal Strength based Assessments

Incorporation of Best Practices: One of the four basic characteristics of the CCISC model recognized by SAMHSA as a best practice for systems implementation for treatment of ICOSPD. An important aspect of CCISC implementation is the incorporation of evidence based and clinical consensus based on best practices for the treatment of all types of ICOPSD throughout the service system.

*Intake/Screening: Services designed to briefly assess the type and degree of a client’s mental health condition to determine whether services are needed and to link him/her to the most appropriate and available service. Services may include interviews, psychological testing, physical exams including speech/hearing, and lab studies.

Integrated Approach: Research has shown that IDDT’s unique integrated approach reduces relapse, duplication of services and costs, and improves continuity of care. IDDT promotes ongoing recovery from mental and substance use disorders through four stages of interaction with consumers and caregivers:
Stage 1: Engagement
Stage 2: Persuasion
Stage 3: Active Treatment
Stage 4: Relapse Prevention

Integrated assessment: consists of gathering information and engaging in a process with the client that enables the provider to establish the presence or absence of co-occurring disorders, determine the client’s readiness for change, identify client strengths or problem areas that may affect the processes of treatment and recovery, and engage the client in the development of an appropriate treatment relationship. The purpose of an assessment is to establish (or rule out) the existence of a clinical disorder or service need and to work with the client to develop a treatment and service plan.

Integrated interventions: are specific treatment strategies or therapeutic techniques in which interventions for all COD diagnoses or symptoms are combined in a single contact or in a series of contacts over time. These can be acute interventions to establish safety, as well as ongoing efforts to foster recovery.

Integrated screening: is the determination of the likelihood that a person has a co-occurring substance use or mental disorder. The purpose is not to establish the presence or specific type of such a disorder but to establish the need for an in-depth assessment. Integrated screening is a formal process that typically is brief and occurs soon after the client presents for services.

Integrated Treatment Philosophy: One of the four basic characteristics of the CCISC model based on implementation of principles of successful treatment intervention that are derived from available research and incorporated into an integrated treatment philosophy that utilizes a common language that makes sense from the perspective of both mental health and substance disorder providers. This model can be used to develop a protocol for individualized treatment matching, that in turn permits matching of particular cohorts of individuals to the comprehensive array of dual diagnosis capable services within the system.

Integration: requires the participation of providers trained in both substance abuse and mental health services to develop a single treatment plan addressing both sets of conditions and the continuing formal interaction and cooperation of these providers in the ongoing reassessment and treatment of the client. The threshold for integration relative to collaboration is the shared responsibility for the development and implementation of a treatment plan that addresses the COD.

IPLT: Improving Practices Leadership Team is aimed at creating system transformation by building capacities of community mental health organizations. The charge of the IPLT is to promote an improved array of services to consumers in the nine county region. Toward this end, the IPLT will: link with the MDCH Evidence Based Practices initiatives; coordinate regional training and technical assistance; oversee PIHP EBP work plans and evaluate the impact of EBPs, promising practices and emerging practices by monitoring outcomes and fidelity to the models; monitor and facilitate implementation of evidence based, promising and emerging practices as part of the bigger picture of systems transformation.

*Local Mental Health Authority: Local organizational entity (usually with some statutory authority) that centrally maintains administrative, clinical, and fiscal authority for a geographically specific and organized system of health care.

*Managed Care: An organized system for delivering comprehensive mental health services that allows the managed care entity to determine what services will be provided to an individual in return for a prearranged financial payment. Generally, managed care controls health care costs and discourages unnecessary hospitalization and overuse of specialists, and the health plan operates under contract to a payer.

NLCMH: Northern Lakes Community Mental Health. NLCMHA provides mental health services in Grand Traverse, Leelanau, Crawford, Roscommon, Missaukee and Wexford counties.

PIHP: Prepaid Inpatient Health Plan

*Practice Guidelines: Systemically developed statements to standardize care and to assist in practitioner and patient decisions about the appropriate health care for specific circumstances. Practice guidelines are usually developed through a process that combines scientific evidence of effectiveness with expert opinion. Practice guidelines are also referred to as clinical criteria, protocols, algorithms, review criteria, and guidelines.

Quadrants of Care and the Integration Continuum:
The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders was cosponsored and facilitated by the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD).
I. Low addiction/low mental illness severity
II. Low addiction/high mental illness
III. High addiction/low mental illness
IV. High addiction/high mental illness

Recovery: consists of gaining information, increasing self-awareness, developing skills for sober living, and following a program of change. It is the process in which people are able to live, work, learn, and participate fully in their communities. When people with COD are in recovery, it is implied that they are abstinent from the substance causing impairment, are able to function despite symptoms of mental illness, and participate in life activities that are meaningful and fulfilling to them.

Relapse: is the return to active substance use in a person with a diagnosed substance use disorder or the return of disabling psychiatric symptoms after a period of remission related to a non addictive mental disorder. Relapse is both an anticipated event in the course of recovery and a process in which warning signs appear prior to an individual’s actual recurrence of impairment.

Remission: refers to the absence of distress or impairment due to a substance use or mental disorder. An individual in remission no longer meets DSM-IV criteria for the previously diagnosed disorder but may benefit from relapse prevention services.

SA: Substance Abuse

SAMHSA: Substance Abuse and Mental Health Services Administration

Serious Emotional Disturbance (SED): persons from birth up to age 18, who currently or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school or community activities.

Serious Mental Illness: persons age 18 and over, whom currently or at anytime during the past year, have had a diagnosable mental, behavioral, or emotional disorder resulting in functional impairment which substantially interferes with or limits one or more major life activities.

SPMI: Severe and Persistent Mental Illness

Stage Wise Interventions: IDDT treatment Model stresses that treatment providers utilize the 4 stages of treatment matched to the stage of change.

Stages of Change:
– Precontemplation: Not yet acknowledging that there is a problem behavior that needs to be changed.
– Contemplation: Acknowledging that there is a problem but not yet ready or sure of wanting to make a change
– Preparation/Determination: Getting ready to change
– Action: Changing behavior
– Maintenance: Maintaining the behavior change
– Relapse: Returning to older behaviors and abandoning the change

Stage of change	Stages of IDDT Treatment	Clinical Focus
Precontemplation	Engagement	Build a relationship with consumer
Contemplation/Preparation	Persuasion	Help engage client find motivation to reduce SA and participate
Action	Active Treatment	Helps motivated consumer develop skills and supports to manage symptoms of both disorders.
Maintenance	Relapse Prevention	Help consumers in stable remission develop and use strategies for maintaining abstinence/recovery

Substance abuse treatment system is used to describe the system of care for substance-related disorders.

Substance abuse/use has come to be used informally to refer to both abuse and dependence. It is defined in the DSM-IV-TR, as a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. Individuals who abuse substances may experience harmful consequences such as:
– Repeated failure to fulfill roles for which they are responsible
– Use in situations that are physically hazardous
– Legal difficulties
– Social and interpersonal problems

Substance dependence: is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. (APA, 2000, p. 192). This maladaptive pattern of substance use includes all the features of abuse and additionally such features as:
– Increased tolerance for the drug, resulting in the need for ever-greater amounts of the substance to achieve the desired effect
– An obsession with securing the drug and with its use
– Persistence in using the drug in the face of serious physical, occupational, social, or psychological problems

Substance-induced disorders: represent the direct result of substance use; their presentation can be clinically identical to other mental disorders. This includes substance intoxication, substance withdrawal, and groups of symptoms that are in excess of those usually associated with the intoxication or withdrawal that is characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention. To meet diagnostic criteria, there must be evidence of substance intoxication or withdrawal, maladaptive behavior, and a temporal relationship between the symptoms and the substance use must be established.

SUD: Substance Use Disorder

System Level Change: One of the four basic characteristics of the CCISC model designed for implementation throughout an entire system of care. All programs are designed to become DDC or DDE programs within the context of existing resources, with a specific assignment to provide services to a particular cohort of individuals with co-occurring disorders. Implementation of the model integrates the use of system change technology with clinical practice technology at the system level, program level, clinical practice level, and clinician competency level to create comprehensive system change.

*Utilization Management: A system of procedures designed to ensure that the services provided to a specific client at a given time are cost-effective, appropriate, and least restrictive.

*Utilization Review: Retrospective analysis of the patterns of service usage in order to determine means for optimizing the value of services provided (minimize cost and maximize effectiveness/appropriateness)

Eight Principles of Treatment for the CCISC:
– Dual diagnosis is an expectation, not an exception;
– All ICOPSD are not the same; the national consensus four quadrant model for categorizing co-occurring disorders can be used as a guide for service planning on the system level;
– Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting; provision of continuous integrated treatment relationships is an evidence based best practice for individuals with the most severe combinations of psychiatric and substance difficulties.
– Case management and are must be balanced with empathic detachment, expectation, contracting, consequences, and contingent learning for each client, and in each service setting;
– When psychiatric and substance disorders coexist, both disorders should be considered primary, and integrated dual (or multiple) primary diagnosis-specific treatment is recommended;
– Both mental illness and addiction can be treated within the philosophical framework of a “disease and recovery model” with parallel phases of recovery in which interventions are not only diagnosis specific, but also specific to phase of recovery and stage of change;
– There is no single correct intervention for ICOPSD; for each individual interventions must be individualized according to quadrant, diagnosis, level of functioning, external constraints or supports, phase of recovery/stage of change, and (in a managed care system) multidimensional assessment of level of care requirements; and
– Clinical outcomes for ICOSPD must also be individualized, based on similar parameters for individualizing treatment interventions.

Twelve Steps for CCISC Implementation:
– Integrated system planning process
– Formal consensus on the CCISC model
– Formal consensus on funding the CCISC model
– Identification of priority populations and locus of responsibility for each
– Development and implementation of program standards
– Structures for intersystem and interprogram care coordination
– Development and implementation of practice guidelines
– Facilitation of identification, welcoming, and accessibility
– Implementation of continuous integrated treatment
– Development of basic dual diagnosis capable competencies for all clinicians
– Implementation of a system wide training plan
– Development of a plan for a comprehensive program array

*definitions from SAMSHA