Creating the Multidisciplinary Integrated Treatment Team: A CEO`s

Creating the Multidisciplinary
Integrated Treatment Team:
A CEO's Perspective
Supported by an independent educational
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activity.
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financial relationships,
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informed of their
responsibility to disclose
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be discussing off-label
or investigational uses
(any use not approved
by the FDA) of products
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Learning
Objective
1
Evaluate the need for
and benefits of a
multidisciplinary treatment
team for patients with
alcohol dependence
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Learning
Objective
2
Integrate 12-steps
and treatment of
co-occurring disorders
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Learning
Objective
3
Integrate the use of
medications into a
traditional abstinencebased treatment
program
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Creating the Multidisciplinary
Integrated Treatment Team:
A CEO's Perspective
Supported by an independent educational
grant from Cephalon, Inc., and Alkermes, Inc.
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Susan K. Blank, MD
VP Clinical Services
Caron Treatment Centers
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Why Change Is Needed?
Today’s patients and their families are
struggling with serious addictions, cooccurring psychiatric disorders, and often
significant medical comorbidities1,2
Patients and their families need help to
heal their physical, emotional, and spiritual
damage resulting from the disease of
addiction
This healing takes place best within a
multidisciplinary treatment team3
1. Brady KT, et al. Curr Psychiatry Rep 2007;9:374-380.
2. Mannelli P, Pae CU. Curr Psychiatry Rep 2007;9:217-224.
3. SAMHSA. Evidence-Based practices for Co-Occurring Disorders Interventions Adults with Co-Occurring Disorders, 2002. Available at:
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http://www.samhsa.gov/reports/congress2002/chap4iacd.htm.
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Accessed
24, 2008.
Integration
Three Levels
Multidisciplinary treatment team
Integration of 12 steps and treatment
of co-occurring disorders
Integration of the use of medications
into a traditional abstinence-based
treatment program
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Integration: Level 1
Multidisciplinary Treatment Team
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Why a Multidisciplinary Team
Individualized, assessment-driven
treatment planning emphasizes the need to
prioritize and plan for the patient’s needs
over a continuum of care1
Studies have shown that patients with
comorbid psychiatric problems benefit from
professionally delivered psychotherapy,
psychotropic medications, and greater
intensity of structure2
1. Shulman GD. Continuing Care 1994;13:27-33.
2. McLellan AT, McKay JR. Components of Successful Addiction Treatment.
In: Principles of Addiction Medicine, 3rd edition, Graham AW, Schultz
TK, Mayo-Smith MF, Ries RK, Wilford BB (Eds). American Society of
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Addiction
Medicine.
Baltimore: Lippincott Williams & Wilkins. 2007,
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pp.
436-437.
Why Change Is Needed?
Until recently, at Caron, medicine,
nursing, psychology, psychiatry,
chaplains, and research have all been
consulting, “ancillary” services to
treatment units
The “psychology pool” provided evaluations
as requested after doing initial psychological
evaluation
Ancillary services made
“recommendations” to treatment team
rather than assuming more direct
responsibility for each patient’s
treatment
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Challenges
History of Caron as a 12-step
treatment center based on a social
model of treatment
Many disciplines “speaking” different
languages
Addiction counselors speaking the
language of recovery
Psychologists speaking “psycho-babble”
Inertia of any large organization
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Challenges
Fear of Change
Misunderstanding roles
We don’t know what we don’t know
Alumni worried about what will
happen to Caron as a 12-step
program
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A multidisciplinary
approach is key to
successful treatment of
alcohol dependence and
other drug addiction
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Team Members
There is a need to expand the idea of
team members being the only people
currently in the room
The treatment team is everyone and
anyone who has a stake in the
outcome of the patient
The patient is at the center and the
most important member of the team
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Family,
Sponsor
12-Step
Group
Significant
others
Employer
EAP
SAP
Other
members of
assigned unit/
Other Caron
Staff/Rec
Staff
Past
Treatment
Providers
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Spiritual
Staff
Clinical Coordinator
Patient and
Addictions
Counselor
Referral
- Outpatient Rx
- Interventionist
- PCP
Lawyer
and
Legal
System
Nutritionist
Psychology/
Psychiatry
Staff
Medical
Staff/
Doctors &
Nurses
BuckyBall
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Example: Psychologists
Psychologists were
the first group to be
integrated
Asked them to
check their egos at
the door
Trained them
extensively in 12step principles, i.e.
“Joe and Charlie Big
Book Study”1
Asked them to be
vulnerable and
present their own
videotaped sessions
to the weekly peer
group supervision
Asked them to learn
from others
Big steps:
Big results
1. Big Book Study: Alcoholics Anonymous. 4th Chicago Big Book Seminar
TitleSchiller
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marginIL. May 21-23, 1993. Presented by Charlie P (from
at
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Maysville,
AR) and Joe McQ (from Little Rock, AR).
Integration: Level 2
Integration of 12-Step Principles
and Treatment of Patients with
Co-Occurring Disorders
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Issues
Multidisciplinary teams need a
common language
They also need a common evidencebased treatment modality to allow
peer supervision1
Silos must come down
Problems need to be addressed at the
level of most direct responsibility
Expectations must be made clear
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1.
Project
MATCH
Group. J Stud Alcohol 1997:58:7-29.
Common Goal Is Needed
Safety first, for patients, staff, and
the institution1
Excellence in patient care
Continue always to strive to be better
Kindness and compassion for all
1. Lee F. If Disney Ran Your Hospital 9 Things You Would Do
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Differently.
Bozeman, MT: Second River Healthcare Press, 2004,
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27-28.
First Things First
Leadership developed a detailed
written philosophy of treatment
Group supervision was introduced and
practiced for 2 years, using the David
Powell method1
Leadership decided on an evidencebased treatment modality to teach all
members of the team: Motivational
Interviewing2
1. Powell DJ, Brodsky A. Clinical Supervision in Alcohol and Drug Abuse
Counseling: Principles, Models, Methods. San Francisco: Jossey-Bass, 2004.
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margin S. Motivational Interviewing, 2nd Ed. New York: The
2. Miller
WR,
Rollnick
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Guilford
Press,
2002.
The key to success
is teamwork!
The key to successful
teamwork is supervision
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Helps clinicians
address issues of
transference and
counter transference,
which they may have
with their patients
and families
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Powell
DJ,-Brodsky
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Counseling:
Models, Methods. San Francisco: Jossey-Bass, 2004.
Expectations
Treatment Team
We expect each member
of the treatment team to
have a working
understanding of the 12
steps and co-occurring disorders1
Helping our patients understand how to use
12-step meetings, work the steps, understand
sponsorship, and find and define their Higher
Power are the primary objectives of our
treatment philosophy
1. Center for Substance Abuse Treatment. Substance Abuse Treatment for
Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP)
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margin Publication No. (SMA) 05-3922. Rockville, MD: Substance
Series
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Abuse
andmargin
Mental Health Services Administration, 2005.
Expectations
Treatment Team
We expect our treatment
team members to respect
and assist each other in
the delivery of care to our
patients and their families
The addiction counselor is the primary
treatment provider to the patient
Other disciplines work with the patient both
directly and indirectly to accomplish treatment
goals and objectives
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Integration: Level 3
Integration of medication management
into a traditional abstinence-based
program
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History of Treatment Evolution
Caron opened in 1957
as a 12-step
therapeutic
community for
patients with alcohol
dependence
1962, first
psychologist on staff,
Gerald Shulman, MA
In 1964, first MD
came on board to
treat complications of
alcohol dependence,
Robert Denby, MD
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History of Treatment Evolution
Began to treat drug
addiction in 1969
In 1975, Caron opened
the first freestanding
detox unit in USA
1978, began to refer
patients out to local
psychiatrist
First full-time
psychiatrist, Susan K.
Blank, MD, hired in
2007 as VP of Clinical
Services
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Example: Quetiapine
Quetiapine, introduced by
AstraZeneca in 1997
FDA approved quetiapine
to treat depressive
episodes associated with
bipolar disorder, acute
manic episodes
associated with bipolar I
disorder, and
schizophrenia. It is often
prescribed to treat
unapproved off-label
health problems such as
insomnia, depression, and
anxiety
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1.
Pinta
J Psychiatry
2007;164:174.
Caron MDs introduced the
use of quetiapine for the
treatment of anxiety and
insomnia with some staff
resistance
In 2005, initial reports of
abuse coming out of
prisons, 2007 Letter to
the Editor1
In-house study on
Caron’s use of quetiapine
Caron’s Department of
Medicine decided not to
use quetiapine off-label
Example: Long-Acting
Injectable Naltrexone
April 14, 2005, FDA approved
long-acting injectable
naltrexone for the treatment
of alcohol dependence in
patients who are able to
abstain from alcohol in an
outpatient setting prior to
initiation of treatment that is
part of a comprehensive
management program that
includes psychosocial support
Caron’s Board of Directors
accepts recommendations
Caron’s Professional Advisory
Board recommends use
Increased referrals for
anticraving medications to
Medical Department
Multiple staff trainings, with
many questioning the use
within an abstinence-based
program
Questionnaires for patients to
review cravings given weeks
2 and 4 of treatment1
1. Caron has several ongoing research studies re: cravings, such as
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Cravings
and
Menstrual Cycle, Cravings and Spirituality, Cravings thru
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the
Continuum
Lessons Learned
Some changes can be evolutionary,
others must be revolutionary
“Incrementalism is innovation’s worst
enemy” - Nicholas Negroponte
No one likes change
Nothing beats direct observation when
changing culture
The higher up the food chain you are, the
less likely you will hear about a problem
when it would be most easily solved
Hire people who have different skill sets
than
yours
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Lessons Learned
The best ideas come from the line
staff who actually have to do the work
Input from stake holders is vital
Inclusion of staff in the discussions of
change help to generate buy in, even
if their opinion did not win the day
Make sure your vision is clearly
stated, over and over and over again
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Education is a Core Value
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Education
Educate the patient about their
disease1
Big Book and Twelve and Twelve2 are
the basis for our treatment and
recovery plan
Activities that illustrate the concepts
of recovery are most valued:
Ropes course to help patient understand
they can not do it alone
Experiential work at Center for Self
Development for co-dependency issues
1. Recovery for Life. Caron-Comprehensive Addiction Treatment for Life.
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Wernersville,
PA, 2007.
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2.
Alcoholics
Anonymous World Services. New York, NY.
Education
Educate the family about patient’s
disease and their disease1
Family education begins at admission,
or even before
Linking families with families through
our PARENT NETWORK helps to
support and educate them
Family programming is vital to
success
1. Center for Substance Abuse Treatment. Substance Abuse Treatment and
Family Therapy. Treatment Improvement Protocol (TIP) Series, No. 39.
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DHHS
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and
Health Services Administration, 2004.
Education
Educate the community
Community outreach is very
important
SAP (Student Assistance Program) at
Caron in 209 schools, in 9 states
reaching over 35,000 kids, 1700
educators, and over 1600 parents
Taking advantage of our
multidisciplinary team to give lectures
and workshops
Caron. Programs & Services: Student Assistance Programs.
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Available
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Accessed
February
Education
Educate the staff about advances in
treatment1,2
Continuing education is very
important; each staff member has an
individual development plan
Staff have the ability to complete
undergraduate and masters programs
on campus
Grand rounds, national speakers, and
lectures are part of our commitment
to excellence
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1. Project
Research Group. J Stud Alcohol 1998;59:631-639.
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2.
Anton
et al. JAMA 2006;295:2003-2017.
Education
Educate other healthcare providers
Training of family practice residents,
psychiatry residents, and fellows
Full-time psychology interns
Internships for Masters-level clinicians
Research department studying all
aspects of our treatment and
outcomes1
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1. Caron
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webpage.
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