Integrated Aftercare for Co-Occurring Disorders

When a person exits residential treatment for addictions or co-occurring disorders, putting together an effective after-care program can be confusing and overwhelming. CNS provides integrated after-care treatment for patients with co-occurring substance and psychiatric disorders, utilizing a multidisciplinary team. This team includes psychiatrists, physician’s assistants, neuropsychologists, psychotherapists and case coordinators, all working together to provide a whole-person approach to effective maintenance of changes made in residential treatment.

Why Integrated After-Care?

According to Minkoff (2001)/’Treatment success is enhanced by maintaining integrated treatment relationships providing disease management interventions for both disorders continuously across multiple treatment episodes, balancing case management support with detachment and expectation at each point in time.” 1

CNS utilizes Evidence-Based Practices to facilitate and maintain change in persons suffering from cooccurring substance abuse and psychiatric disorders. Our staff utilizes the principles of Motivational Interviewing, Stages of Change, Resiliency and Mindfulness-Based Interventions to provide integrated aftercare for persons with co-occurring psychiatric and substance use disorders.

Upon entering the program, each patient receives a comprehensive assessment of his or her health status, including:

*evaluation of the current status of the substance-use disorder;

*analysis of how these difficulties interfere with your day-to-day functioning (e.g., work, school, relationships);

*a comprehensive psychiatric evaluation;

*an inventory of desired changes;

*analysis of relational and social functioning; and

*comprehensive medical history and physical examination.

Results from this comprehensive assessment guide the individualized treatment plan and services to be provided. Substance use issues and mental health issues are addressed simultaneously. Care is coordinated with the patient’s recently exited residential treatment center in order to better maintain changes and ensure treatment goals are consistent.

Program Specifics

Case coordinators review assessments with each patient and integrate both health and treatment services into an Individual Care Plan. Together, patients and case coordinators plot the treatment course and identify a specific, intrinsically-motivated treatment regimen including: group sessions, individual therapy, ongoing psychiatric care, medical services, educational therapy, exercise programs, and linkages to other supportive services. Case Coordinators meet 1-2 times per week with the patient to identify progress on the individual care plan, celebrate successes in meeting objectives, and address any other needs that have emerged. The Individual Care Plan is updated as needed.

The Integrated Treatment Team meets every 3-4 weeks to monitor patients’ progress, and review treatment goals and outcomes. These Treatment Team meetings occur internally with the CNS Treatment Staff. In order to encourage patients to be an active and dynamic part of the Treatment Team, we also conduct Treatment Team Appointments which fosters collaboration between the patient and the team.

The treatment team works together to help patients:

* increase motivation to make and sustain change;

* address underlying mental or medical issues that may increase the risk of relapse;

* improve overall health and functioning.

Patients leave the CNS program with new tools for developing and maintaining positive relationships, for maintaining the positive changes they have made, for setting achievable goals, and for more fully participating in their family and community.

1 Minkoff, K. Chair. CMHS Managed Care Initiative Panel on Co-occurring Disorders Co- occurring psychiatric and substance disorders in managed care systems: standards of care, practice guidelines, workforce competencies, and training curricula. Center for Mental Health Policy and Services Research. Philadelphia, 1998. Web site: www.med.upenn.edu/cmhpsr