In 2005, preliminary studies were conducted to develop standardized measures of organizational capacity to address psychiatric disorders in addiction treatment programs. The process of instrument development included: review of the scientific literature, consultation with expert panels, development of benchmark items and objective rating scales, and measure refinement based on review by expert consensus and field testing. The methodology is based on health services research fidelity scale development. The measures utilize observational data gathered during a site visit, which are systematically obtained via individual and group interviews, qualitative methods, and document review.
These mixed‐method data are then used to make ratings on a 5‐point scale with specific objective criteria for anchor points. Catalyzed by the positive response to the first instrument (capacity of addiction programs to provide integrated mental health services), a measure to assess the capacity of mental health programs to provide integrated addiction services was developed. Both instruments, supported with Robert Wood Johnson Foundation and SAMHSA funding, are described below.
The result of this initial effort is the Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index, now in version 4.0 (Giard et al, 2012). The DDCAT consists of 35‐items addressing policy, practice and workforce benchmarks for providing integrated services to persons with co‐occurring psychiatric and substance use disorders in addiction treatment settings. Ratings are made on a 5‐point scale ranging from 1 — Addiction Only Services, to 3 — Dual Diagnosis Capable, to 5 — Dual Diagnosis Enhanced. This framework was drawn from the American Association of Addiction Medicine (Patient Placement Criteria, Revised, Second Edition; Mee‐Lee et al, 2001). The DDCAT has been widely adopted by systems and providers across the United States and internationally, and is used to assess system variation and to guide implementation efforts and quality improvement. From version 1.0 through the current version (4.0), the DDCAT has been extensively evaluated for psychometric properties (reliability and validity)(McGovern et al, 2007; McGovern et al 2010).
Precipitated by several statewide efforts to improve services to persons with co‐occurring disorders across both addiction and mental health agencies, a need was identified for a companion or “sister” measure to the DDCAT. This measure would instead be organized to assess mental health agencies on policy, practice and workforce elements for integrated addiction services. Such a measure would need to be based on a similar framework as the DDCAT (35‐items rated on 5‐point scale) and methodology (systematic, observational data). The result was the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) index, now also in version 4.0 (Gotham et al, 2012). The DDCMHT ratings and scoring are based on a similar continuum, but from 1 — Mental Health Only Services, to 3 — Dual Diagnosis Capable, to 5 — Dual Diagnosis Enhanced. The DDCMHT has also been studied for psychometric properties (reliability and validity) and has widely implemented (Gotham et al, 2010; McGovern et al, 2010).
Two newer measures have recently been developed, driven by a convergence of: 1) community and research awareness of the DDCAT and DDCMHT measures; 2) expanding interest in organizational metrics to assess behavioral‐physical health care integration; and 3) the promise of health care reform. Funded in part by SAMHSA, these measures have been designed to assess behavioral and medical care integration bi‐directionally, from the perspective of the medical care setting, as well as the perspective of the behavioral health care setting. These measures are described on the next page.
Most persons with substance use, mental health or co‐occurring mental health and substance use disorders do not seek care in specialty addiction or psychiatric settings. Primary care, emergency departments and hospitals are the most common places for their initial entry into the health care system. These “portals” are at the early stages of developing increased capacity to effectively address behavioral health disorders. The estimates vary as to the level of integration of these efforts (mental health and substance abuse). This variation risks a repeat of the historical and unnatural bifurcation of the specialty care system into addiction or mental health business lines. The Dual Diagnosis Capability in Health Care Settings (DDCHCS) was developed similarly to the DDCAT and DDCHCS, and is now in version 2.3. This measure, consisting of 34 benchmark items, assesses a health care organization’s capacity to address behavioral health disorders (mental health AND substance use), and derives objective ratings on a 5‐point scale from 1‐Health Care Only Services to 3‐ Dual Diagnosis Capable to 5‐ Dual Diagnosis Enhanced. The measure has been utilized in a sample of Federally‐Qualified Health Centers, both to assess variation in capacity and for quality improvement measurement. One study reports on DDCHCS reliability and validity (McGovern et al, 2012 in press). A revised version of the measure is available for application and expanded study.
Persons with behavioral health conditions, substance use and/or psychiatric, have higher rates of medical disease and significantly shorter life expectancies than persons without these conditions. Although behavioral health organizations are not funded to provide medical services, many agencies are developing models of integration or coordination to reduce health care disparities for the patients they serve. In addition to chronic metabolic disease, hypertension, diabetes, obesity and nicotine dependence, persons with behavioral health disorders are at greater risk for HIV/AIDs and Hepatitis C. All of these disorders are clinically‐manageable, but persons with behavioral health disorders are often compromised with primary symptoms and neglect to access or do not continue with medical treatments. As with other frameworks for integration, there has been no objective, standardized measure of medical care capacity for behavioral health settings. Such a measure would enable objective assessments of variation in existing service delivery, but also be used to guide improvements and evidence‐based practice implementation. To meet this need, the Dual Diagnosis Medically‐Integrated Care (DDMICe) has been developed. This measure, currently at version 2.0, consists of 51 benchmark items rated on a scale from 1 — Behavioral Health Only Services, to 3 — Medically‐Integrated Capable, to 5 — Medically‐Integrated Enhanced. In addition to the 51 core DDMICe items and scales, three addendum scales have been developed to specifically measure organizational capacity to address Infectious Diseases, HIV/AIDs and Hepatitis C. These additional scales add 12 benchmark items, and are organized using the Seek, Test, Treat and Retain framework outlined by NIDA (NIDA, 2012). The DDMICe has recently completed feasibility field testing, and has been modified for use in broader study. Psychometric studies of the measure are planned but not yet completed.
Childhood and adolescence are periods when young people encounter multiple, complex, and challenging developmental tasks involving significant changes in biological, social, psychological, and environmental/societal domains. Millions of youth experience serious emotional and substance use disorders. Children and adolescents with co‐occurring mental health and substance use disorders often experience numerous difficulties including behavioral problems, familial and academic challenges, and skill deficits. Developed using methods similar to the adult versions, the Dual Diagnosis Capability in Youth Treatment (DDCYT, working title), addresses the lack of an objective, standard measure to assess the co‐occurring capability of child and adolescent services. The DDCYT consists of seven dimensions and 45 benchmark items, rated on a scale of 1 — Youth Services Only, to 3 — Dual Diagnosis Capable, to 5 — Dual Diagnosis Enhanced. The instrument is designed to explore co‐occurring disorder capability of a program (e.g., outpatient, home‐based, juvenile justice, residential, school behavioral healthcare) that was established to serve the needs of children and adolescents. A toolkit and best practices addendum are being developed to 1) support the individualization of child and adolescent programs from adult programs, 2) assist the development of co‐occurring disorder programs and services for children and adolescents and 3) impact organizational change processes. Pilot testing of the instrument is planned for the fall of 2012.