Improving Care for Co-Occurring Psychological Health and Substance Use Disorders

An Implementation Evaluation of the Co-Occurring Disorders Clinician Training Program

by Kimberly A. Hepner, Lynsay Ayer, Brinda Venkatesh, Carrie M. Farmer

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Research Questions

  1. How is the Co-Occurring Disorders Clinician Training Program (CODP) designed, and what are its goals?
  2. How was the CODP implemented by staff of Navy Substance Abuse Rehabilitation Programs?
  3. What training and materials did Hazelden provide, and what did trainees think of them?
  4. Which elements of Hazelden's program were implemented and sustained at treatment sites, and what helped or hindered successful implementation?
  5. How has the training program affected Navy SARPs' capabilities to provide integrated care?

In the past decade, the number of individuals treated by the MHS for psychological health conditions has grown significantly. Patients with co-occurring psychological health and substance abuse conditions have unique treatment needs, and evidence suggests that integrated treatment for these conditions may be more effective than treating each separately. The Navy's Bureau of Medicine contracted with Hazelden to provide training for clinicians to deliver an evidence-based intervention for treating patients with co-occurring disorders. The Hazelden training, the Co-Occurring Disorders Clinician Training Program (CODP), began in 2008.

RAND evaluated the implementation of the training among Substance Abuse Rehabilitation Program (SARP) personnel to understand the CODP approach and goals, and to describe the training program and materials and trainee perceptions, identify which program elements were implemented and sustained, identify facilitators and barriers to implementation, and describe programs' capabilities to provide integrated care.

This report presents the results and makes recommendations for improving training of SARP personnel. RAND researchers formulated the following recommendations: Develop a training plan, obtain leadership support, plan for staff turnover, provide consultation after training, and evaluate training efforts; ensure that clinician training focuses on materials and skills most relevant to their practice; consider requiring that all service members receiving care from a SARP be screened for substance use and psychological health problems; identify and certify select sites as providing enhanced co-occurring disorders services; and implement measures to assess the quality of care at SARPs.

Key Findings

The Navy supports an evidence-based approach to COD treatment.

  • The Navy wanted SARP staff trained in an evidence-based approach to treatment of co-occurring disorders in its personnel. Staff from a range of installations were sent to Hazelden for training.

Trainees had a positive view of the training.

  • Trainees felt the training met or exceeded expectations and felt confident using program materials. They also identified areas for improvement including increasing opportunities for training and supervision and receiving more guidance in how to tailor program materials.

Program elements were adopted cafeteria style.

  • Trainees tended to use some elements, such as assessment and therapy materials, more than others, such as medication management materials. Trainees aimed to tailor the program to the needs of their clients by selecting portions of the therapy materials.

Quality and support aided program implementation, but poor fit hurt it.

  • The quality of the training and materials, enhanced by good support from leadership, promoted program implementation at SARPs. But where staff or leadership saw less relevance to clients, implementation suffered.

Most SARPs were not providing integrated care for CODs.

  • Treatment at SARPs had an emphasis on addiction only, and most did not provide integrated care for co-occurring disorders.

Recommendations

  • Develop a training plan that specifies how the training will be implemented and sustained, obtain leadership support, plan for staff turnover, provide consultation after training, and evaluate training efforts.
  • Ensure that clinician training focuses on materials and skills that are most relevant to the site's clinical practice.
  • Consider requiring that all service members who receive care from a SARP be screened for both substance use and psychological health problems using validated measures.
  • Identify and certify select sites as providing enhanced services for service members with CODs rather than assuming that all SARPs can provide high-quality care for CODs.
  • Implement measures to assess the quality of care provided at SARPs, including both process and outcome measures.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    The Design and Components of the CODP

  • Chapter Three

    Evaluation Methods

  • Chapter Four

    Description of Survey Participants and SARP Characteristics

  • Chapter Five

    Perceived Utility and Quality of the CODP

  • Chapter Six

    Implementation of the CODP at SARPs Post-Training

  • Chapter Seven

    Facilitators and Barriers to CODP Implementation

  • Chapter Eight

    SARP Capability to Provide Integrated Care for Co-Occurring Disorders

  • Chapter Nine

    Summary and Recommendations

  • Appendix A

    Additional Methodological Details

  • Appendix B

    Key-Informant Discussion Guide

  • Appendix C

    Web Survey

  • Appendix D

    Staff Discussion Guide

This research was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

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