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