Clients with dual diagnoses constitute one of the greatest challenges to mental health and substance abuse systems. The strongest evidence for successful treatment has been on using integrated treatment services, which combine mental health and substance abuse treatment concurrently.1 In this article, we describe CHANGES, an evidence-based program in Oakland, California, specifically designed to engage and treat dually diagnosed individuals in the community.
In response to growing concern that Alameda County had among the highest rates of involuntary commitments and psychiatric hospitalizations in the state, Alameda County Behavioral Health Care Services (ACBHS) developed a plan in 1999 for reorganizing access into ACBHS. The resulting Front Door Project involved more than 100 interviews with community stakeholders and analyzed data covering a two-year period, including 21,000 emergency episodes.
The Front Door Project's report identified a number of system problems, including a lack of treatment for substance-abusing clients with mental illnesses and a lack of ongoing services for many of the highest users of acute psychiatric care. The report concluded that individuals with a mental illness and a substance abuse disorder were not receiving effective services, experienced frequent crises, and relied heavily on psychiatric emergency services, locked subacute inpatient programs, jails, and other county resources.
CHANGES was designed as a joint effort between Telecare Corporation and ACBHS to address these problems. Telecare, based in Alameda, California, is a large provider of mental health services and works in partnership with local, county, state, and other behavioral health organizations to design and provide recovery-focused direct-care services for high-risk individuals.
CHANGES' three main goals are to decrease clients' frequent and inappropriate use of psychiatric emergency and acute care services, decrease overall systems costs, and empower clients to regain control of their lives.
CHANGES began in June 2001, and 240 clients were enrolled within the first two years. CHANGES reaches out to clients 18 years or older, with co-occurring disorders, with three or more psychiatric hospitalizations within two years, and with unsuccessful engagement with the traditional mental health system.
Potential clients come from a variety of sources: other ACBHS service teams, a closed co-occurring disorders day treatment program, a list of the top-100 users of mental health services in the county who are dually diagnosed, and discharges from jail through the California State Mentally Ill Offender Crime Reduction Grant initiative.
CHANGES' components include staged interventions, assertive outreach, motivational interventions, counseling, social support, maintaining a long-term perspective, comprehensiveness, and cultural sensitivity and competence.2 Other components include data-supported decision making, measurement of abstract concepts, and client choice making.
Recovery focus. CHANGES is committed to comprehensive client recovery rather than focusing on illness and disability. CHANGES' recovery focus deemphasizes clients' co-occurring disorders and offers a single holistic approach for recovery of life roles. CHANGES is client-centered rather than provider-centered. By designing services sensitive to clients' individual experiences, perceptions, and needs, clients previously considered “treatment avoidant” become treatment receptive.
CHANGES' structure is based on Prochaska and DiClemente's Stages of Change model.3 Three types of teams serve clients according to their Stage of Change: the Outreach Team for individuals in the precontemplation and early contemplation stages; Service Teams for clients in the contemplation, preparation, or action stages; and a Self-Help component for clients in the maintenance stage.
Two Service Teams—the Assertive Community Treatment (ACT) Team and the Intensive Case Management (ICM) Team— provide psychiatric evaluation and treatment, medication support, crisis intervention, stage-appropriate motivational interventions, case management, and community-living skills development.
The ACT Team, with a 1:10 staff-to-client ratio, serves clients experiencing the greatest problem complexity and who need intense or frequent services. The ICM Team, with a 1:20 staff-to-client ratio, serves less complex clients. Additionally, on-call response is available to all clients 24/7.
The Self-Help component provides clients in recovery with a gathering place and access to staff and groups—including a Wellness Recovery Action Plan (WRAP) group led by a mental health consumer and a Relapse Prevention group. Telecare staff also work with clients on learning choice-making skills as an essential part of recovery, helping them understand that the choices they make can bring them what they want, or can bring them harm.
Data focus. Telecare created a data-supported decision-making component to place information at CHANGES' core. Assessment tools capture client information. Clients use reports to make decisions, discuss trends, reinforce successful choice making, and consider other life choices. Staff uses the reports to identify effective approaches, and leadership uses them to continually improve CHANGES' focus.
Clinical risk is measured using Telecare's assessment tools covering seven critical domains: suicide, violence, self-neglect, barriers to medical services, communicable diseases, victimization, and child/abuse neglect. Two additional assessments measure primary contributors to risk: alcohol and other drug use, and problems following a psychiatric medication plan.