Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 45
The Comprehensive, Continuous, Integrated System of Care (CCISC) model for organizing services for individuals with co-occurring psychiatric and substance disorders (COPSD) is designed to improve treatment capacity for these individuals in systems of any size and complexity, ranging from entire states or provinces, to regions or counties, networks of agencies, individual complex agencies, or even programs within agencies. The model has the following four basic characteristics:
System level change: The CCISC model is designed for implementation throughout an entire system of care, not just for implementation of individual program or training initiatives.
Efficient use of existing resources: The CCISC model is designed for implementation within the context of current service resources, however scarce, and emphasizes strategies to improve services to individuals with COPSD within the context of each funding stream, program contract, or service code, rather than requiring blending or braiding of funding streams or duplication of services.
Incorporation of best practices: The CCISC model is recognized as a best practice for systems implementation for treatment of persons with COPSD. An important aspect of CCISC implementation is the incorporation of evidence-based and clinical consensus based best practices for the treatment of all types of people with COPSD throughout the service system.
Integrated treatment philosophy The CCISC model is 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.
The eight research-derived and consensus-derived principles that guide the implementation of the CCISC are as follows:
Dual diagnosis is an expectation, not an exception
All people with COPSD are not the same; the national consensus four-quadrant model for categorizing cooccurring disorders1 can be used as a guide for service planning on the system level (see box below)
Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting
Case management and care must be balanced with empathic detachment, expectation, ‘contracting,’ consequences, and ‘contingent learning’ for each client, and in each service setting. (Contingent learning involves specifying consequences for desired or un-desired behaviours for which the client has responsibility; contracting is a means for coming to an agreement for these, as a way to increase the chances for success)
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 (acute stabilization, motivational enhancement [helping a person reach the stage where they are ready to make change], active treatment, relapse prevention, and rehabilitation/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 individuals with COPSD; each individual intervention must be individualized according to quadrant, diagnoses, level of functioning, external constraints or supports, phase of recovery and stage of change
Clinical outcomes for clients with COPSD must also be individualized.
Implementation of the CCISC requires utilization of system change strategies (e.g., continuous quality improvement), in the context of an organized process of strategic planning, to develop the specific elements of the CCISC. The ‘12-step Program for Implementation of a CCISC’ defines this process sequentially, and, in collaboration with Cline, Minkoff has organized a CCISC Implementation Toolkit that promotes the successful accomplishment of many of the specific steps. Implementation of the CCISC occurs incrementally in complex systems, over a period of years, and is characterized by establishment of the following 12 elements:
Integrated system planning process
Implementation of the CCISC requires a system-wide, integrated, strategic planning process that can address the need to create change at every level of the system, ranging from system philosophy, regulations and funding, to program standards and design, to clinical practice and treatment interventions, to clinician competencies and training.
Formal concensus on CCISC model
The system must develop a clear mechanism for articulating the CCISC model, including the principles of treatment and the goals of implementation, developing a formal process for obtaining consensus from all stakeholders, identifying barriers to implementation and an implementation plan, and disseminating this consensus to all providers and consumers within the system.
Formal consensus on funding the model
CCISC implementation involves a formal commitment that each funder will promote integrated treatment within the full range of services provided through its own funding stream.
Identification of priority populations and locus of responsibility for each
Using the four-quadrant model, the system must develop a written plan for identifying priority populations within each quadrant, and locus of responsibility within the service system for welcoming access, assessment, stabilization and integrated continuing care.
Development and implementation of program standards
A crucial element of the CCISC model is the expectation that all programs in the service system must meet basic standards for dual diagnosis capability, whether in the mental health system or the addiction system. In addition, within each system of care, for each program category or level of care, there need to written standards for dual diagnosis enhanced programs.
Structures for intersystem and interprogram care coordination
CCISC implementation involves creating routine structures and mechanisms for addiction programs and providers and mental health programs and providers, as well as representatives from other systems that may participate in this initiative (e.g., corrections) to participate in shared clinical planning for complex cases whose needs cross traditional system boundaries
Development and implementation of practice guideline
CCISC implementation requires system-wide transformation of clinical practice in accordance with the principles of the model. Obtaining input from and building consensus with clinicians prior to final dissemination is highly recommended.
Facilitation of identification, welcoming and accessibility
This requires several specific steps: (1) modification of database capability to facilitate identification, reporting and tracking of clients with COPSD; (2) development of ‘no-wrong-door’ policies that mandate a welcoming approach to people with COPSD; and (3) establishing policies and procedures for universal screening for co-occurring disorders at initial contact throughout the system.
Implementation of continuous integrated treatment
Integrated treatment relationships are a vital component of the CCISC. Implementation requires developing the expectation that primary clinicians in every treatment setting are responsible for developing and implementing an integrated treatment plan in which the client is assisted to follow diagnosis-specific and stage-specific recommendations for each disorder simultaneously.
Development of basic dual diagnosis capable competencies for all clinicians
Creating the expectation of universal competency, including attitudes and values, as well as knowledge and skill, is a significant characteristic of the CCISC model. Competency assessment tools (e.g., CODECAT) can be utilized to facilitate this process. For more information about these tools, see the full text of the CCISC model, and scroll down to find the Implementation Toolkit link.
Implementation of a system-wide training plan
In the CCISC model, training must be ongoing, and tied to achievable competencies in the context of actual job performance. This requires an organized training plan to bring training and supervision to clinicians on site. The most common components of such training plans involve curriculum development and dissemination, mechanisms for training and deploying trainers, career ladders for advanced certification and opportunities for experiential learning.
Development of a plan for a comprehensive program array
The CCISC model requires development of a plan in which each existing program is assigned a specific role or area of competency with regard to provision of dual diagnosis capable or dual diagnosis enhanced service for people with co-occurring disorders, primarily within the context of available resources. Four important areas that must be addressed in each CCISC are:
Evidence-based best practices:There needs to be a specific plan for initiating at least one continuous treatment team (or similar service) for the most seriously impaired individuals with SPMI and substance disorder. This can occur by building dual diagnosis enhancement into an existing intensive case management team.
Peer dual recovery supports:The system must identify at least one dual recovery self-help program (e.g., Dual Recovery Anonymous, Double Trouble in Recovery) and establish a plan to facilitate the creation of these groups throughout the system.
Residential supports and services:The system should begin to plan for a comprehensive range of programs that addresses a variety of residential needs, building initially upon the availability of existing resources through redesigning those services to be more explicitly focused on individuals with COPSD. This range of programs should include:
dual diagnosis capable/enhanced addiction residential treatment (e.g., modified therapeutic community programs)
abstinence-mandated (‘dry’) supported housing for individuals with psychiatric disabilities
abstinence-encouraged (‘damp’) supported housing for individuals with psychiatric disabilities
consumer-choice (‘wet’) supported housing for individuals with psychiatric disabilities at risk of homelessness
Continuum of levels of care: All categories of service for those with COPSD should be available in a range of levels of care, including outpatient services of various levels of intensity, intensive outpatient or day treatment, residential treatment and hospitalization.
CCISC implementation requires a plan that includes attention to each of these areas in a comprehensive service array.
About the Author
Ken is the originator of the CCISC model. He and Dr. Christine Kline are currently consulting with the Vancouver Island Health Authority to implement the model
The following article has been edited for length and includes the key points of the model. To download the full version of the article, including references, and for access to a preview of the CCISC Implementation Toolkit, see www.kenminkoff.com/ccisc.html. For more information on the CCISC implementation activities within the Vancouver Island Health Authority and elsewhere, see the article "A Scan Around BC" p.47 by Mykle Ludvigsen
National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors. (1999) The new conceptual framework for co-occuring mental health and substance use disorders.. Washington, DC: NASMHPD.