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DDCAT Scale

Dual Diagnosis Capability in Addiction Treatment

The Dual Diagnosis Capability in Addiction Treatment (DDCAT) is an instrument that assesses a providers’ ability to provide co-occurring disorder (COD) services. Currently, twenty states are using the DDCAT to guide the development of standardized treatment services for individuals with  COD. The instrument, developed by Mark P. McGovern, Ph.D. of Dartmouth University, is endorsed by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration. There is also a version that is adapted for mental health programs, the Dual Diagnosis Treatment Capability in Mental Health Treatment (DDCMHT) instrument. The DDCAT instruments were validated in substance abuse treatment, mental health treatment, primary care and general medical settings.

 

 DDCAT Rating Scale

 

 

 Variable

1AOS

2

3DDC

4

5DDE

                                             

  I. Program Structure

 

Primary focus of agency as stated in the mission statement (If program has mission, consider program mission).

 

Addiction only.

 

Primary focus is addiction, co-occurring disorders are treated.

 

Primary focus on persons with co-occurring disorders

 

B

Organizational certification and licensure.

 

Permits only addiction treatment.

Has no actual barrier, but staff report there to be certification or licensure barriers.

Has no barrier to providing mental health treatment or treating co-occurring disorders within the context of addiction treatment.

 

Is certified and/or licensed to provide both

 

C

Coordination and collaboration with addiction services

 

No document of formal coordination or collaboration. Meets the SAMHSA definition of minimal Coordination.

Vague, undocumented, or informal relationship with mental health agency, or consulting with a staff member from that agency. Meets the SAMHSA definition of Consultation.

Formalized and documented coordination or collaboration with mental health agency. Meets the SAMHSA definition of Collaboration.

Formalized coordination and collaboration, and the availability of case management staff, or staff exchange programs (variably used). Meets the SAMHSA definition of Collaboration and has some informal components consistent with Integration.

Most services are integrated within the existing program, or routine use of case management staff or staff exchange programs. Meets the SAMHSA definition of Integration

 

D

Financial incentives.

 

 

Can only bill for addiction treatments or bill for persons with substance use disorders.

Could bill for either service type if substance use disorder is primary, but staff report there to be barriers. –OR– Partial reimbursement for mental health services available.

Can bill for either service type; however, a substance use disorder must be primary.

 

Can bill for addiction or mental health treatments, or their combination and/or integration

   II.   Program Milieu


A

Routine expectation of and welcome to treatment for both disorders.

 

Program expects substance use disorders only; refers or deflects persons with mental health disorders or symptoms.

 

 

Documented to expect substance use disorders only (e.g., admission criteria, target population), but has informal procedure to allow some persons with mental health disorders to be admitted.

Focus is on substance use disorders, but accepts mental health disorders by routine and if mild and relatively stable as reflected in program documentation.

Program formally defined like DDC but clinicians and program informally expect and treat co-occurring disorders regardless of severity, not well documented.

Clinicians and program expect and treat co-occurring disorders regardless of severity, well documented.


B

 Display and distribution of literature and patient educational materials.

 

Addiction or peer support (e.g., AA) only.

Available for both disorders but not routinely offered or formally available.

Routinely available for both mental health and substance use disorders in waiting areas, patient orientation materials and family visits, but distribution is less for mental health disorders.

Routinely available for both mental health and substance use disorders with equivalent distribution.

Routinely and equivalently available for both disorders and for the interaction between mental health and substance use disorders.

   II.   Clinical Process: Assessment

 

A

Routine screening methods for mental health symptoms

 

Pre-admission screening based on patient self-report. Decision based on clinician inference from patient presentation or by history.

Pre-admission screening for symptom and treatment history, current medications, suicide/homicide history prior to admission.

Routine set of standard interview questions for mental health using a generic framework, e.g., ASAM-PPC (Dimension III) or “Biopsychosocial” data collection.

Screen for mental health symptoms using standardized or formal instruments with established psychometric properties.

Screen using standardized or formal instruments for both mental health and substance use disorders with established psychometric properties.

 

B

Routine

assessment if screened positive for mental health symptoms.

Assessment for mental health disorders is not recorded in records.

Assessment for mental health disorders occurs for some patients, but is not routine or is variable by clinician.

Assessment for mental health disorders is present, formal, standardized, and documented in 50- 69% of the records.

Assessment for mental health disorders is present, formal, standardized, and documented in 70-89% of the records.

Assessment for mental health disorders is formal, standardized, and integrated with assessment for substance use symptoms, and documented in at least 90% of the records.


C

Mental health and substance use diagnoses made and documented.

 

Mental health diagnoses are neither made nor recorded in records.

Mental health diagnostic impressions or past treatment records are present in records but the program does not have a routine process for making and documenting mental health diagnoses.

The program has a mechanism for providing diagnostic services in a timely manner. Mental health diagnoses are documented in 50-69% of the records.

The program has a mechanism for providing routine, timely diagnostic services. Mental health diagnoses are documented in 70- 89% of the records.

Comprehensive diagnostic services are provided in a timely manner. Mental health diagnoses are documented in at least 90% of the records.

 

D

Mental  and substance

use history reflected in medical record

 

Collection of substance use disorder history only.

Standard form collects substance use disorder history only. Mental health history collected inconsistently.

Routine documentation of both mental health and substance use disorder history in record in narrative section.

Specific section in record dedicated to history and chronology of both disorders.

Specific section in record devoted to history and chronology of both disorders and the interaction between them is examined temporally.

 

E

III Program acceptance

B   based on mental health symptom acuity: low, moderate, high

 

Admits persons with no to low acuity.

 

Admits persons in program with low to moderate acuity, but who are primarily stable.

 

Admits persons in program with moderate to high acuity, including those unstable in their mental health disorder.


F

III   Program acceptance based on severity and persistence of mental health disability: low, moderate, high.

 

Admits persons in program with no to low severity and persistence of mental health disability.

 

Admits persons in program with low to moderate severity and persistence of mental health disability.

 

Admits persons in program with moderate to high severity and persistence of mental health disability.

 

G

III    Stage-wise  assessment.

 

Not assessed or documented.

 

Assessed and documented variably by individual clinician.

Clinician assessed and routinely documented, focused on substance use motivation.

Formal measure used and routinely documented but focusing on substance use motivation only.

Formal measure used and routinely documented, focus on both substance use and mental health motivation

  IV. Clinical Process: Treatment

 

A

Treatment plans

 

Address addiction only (mental health not listed).

Variable by individual clinician, i.e., plans vaguely or only sometimes address co-occurring mental health disorders.

Plans routinely address both disorders although substance use disorders addressed as primary, mental health as secondary with generic interventions.

Plans routinely address substance use and mental health disorders; equivalent focus on both disorders; some individualized detail is variably observed.

Plans routinely address both disorders equivalently and in specific detail; interventions in addition to medication are used to address mental health disorders.

 

B

IV   Assess and monitor interactive courses of both disorders.

 

No documentation of progress with mental health disorders.

Variable reports of progress on mental health disorder by individual clinicians.

Routine clinical focus in narrative (treatment plan review or progress note) on mental health disorder change; description tends to be generic.

Treatment monitoring and documentation reflecting equivalent in-depth focus on both disorders is available but variably used.

Treatment monitoring and documentation routinely reflects clear, detailed, and systematic focus on change in both substance use and mental health disorders.


C

      mental health emergencies and crisis management

No guidelines conveyed in any manner.

Verbally conveyed in-house guidelines.

Documented guidelines: Referral or collaborations (to local mental health agency or emergency department).

Variable use of documented guidelines, formal risk assessment tools, and advance directives for mental health crisis and substance use relapse.

Routine capability, or a process to ascertain risk with ongoing use of substances and/or severity of mental health symptoms;

 

D

IV  Stage-wise treatment.

 

Not assessed or explicit in treatment plan.

Stage of change or motivation documented variably by individual clinician intreatment plan.

Stage of change or motivation routinely incorporated into individualized plan, but no specific stage-wise treatments.

Stage of change or motivation routinely incorporated into individualized plan; general awareness of adjusting treatments by substance use stage or motivation only.

Stage of change or motivation routinely incorporated into individualized plan; formally prescribed and delivered stage-wise treatments for both substance use and mental health disorders.

 

 

E

IV   Policies and procedures for evaluation, management, monitoring and compliance.

Patients on medication routinely not accepted. No capacities to monitor, guide prescribing or provide psychotropic medications during treatment.

Certain types of medication are not acceptable, or patient must have own supply for entire treatment episode. Some capacity to monitor psychotropic medications.

Present, coordinated medication policies. Some access to prescriber for psychotropic medications and policies to guide prescribing are provided. Monitoring of the medication is largely provided by the prescriber.

Clear standards and routine for medication prescriber who is also a staff member. Routine access to prescriber and guidelines for prescribing in place. The prescriber may periodically consult with other staff regarding medication plan and recruit other staff to assist with medication monitoring.

Clear standards and routine for medication prescriber who is also a staff member. Full access to prescriber and guidelines for prescribing in place. The prescriber is on the treatment team and the entire team can assist with monitoring

 

F

IV  Specialized interventions with mental health content.

 

Not addressed in program content.

Based on judgment by individual clinician; variable penetration into routine services.

In program format as generalized intervention (e.g., stress management) with penetration into routine services. Routine clinician adaptation of an evidence-based addiction treatment (e.g., MI, CBT, Twelve-Step Facilitation).

Some specialized interventions by specifically trained clinicians in addition to routine generalized interventions.

Routine mental health symptom management groups; individual therapies focused on specific disorders; systematic adaptation of an evidence-based addiction treatment (e.g., MI, CBT, Twelve-Step Facilitation).

 

G

Education about mental health disorders, treatment, and interaction with substance abuse disorders

 

Not offered.

Generic content, offered variably or by clinician judgment.

Generic content, routinely delivered in individual and/or group formats.

Specific content for specific co-morbidities; variably offered in individual and/or group formats.

Specific content for specific co-morbidities; routinely offered in individual and/or group formats


H

Family education and support

 

For substance use disorders only, or no family education at all.

Variably or by clinician judgment.

Mental health disorders routinely, but informally incorporated into family education or support sessions. Available as needed.

Generic family group on site on substance use and mental health disorders, variably offered. Structured group with more routine accessibility.

Routine and systematic co-occurring disorders family group integrated into standard program format. Accessed by families of the majority of patients with co-occurring disorders.

 

 

I

IV  Specialized interventions to facilitate use of peer support groups in planning or during treatment.

 

No interventions used to facilitate use of either addiction or mental health peer support.

Used variably or infrequently by individual clinicians for individual patients, mostly for facilitation to addiction peer support groups.

Generic format on site, but no specific or intentional facilitation based on mental health disorders. More routine facilitation to addiction peer support groups (e.g., AA, NA).

Variable facilitation targeting specific co-occurring needs, intended to engage patients in addiction peer support groups or groups specific to both disorders (e.g., DRA, DTR).

Routine facilitation targeting specific co-occurring needs, intended to engage patients in addiction peer support groups or groups specific to both disorders (e.g., DRA, DTR).

 

J

IV  Availability of peer recovery supports for patients with co-occurring disorders.

 

Not present, or if present not recommended.

Off site, recommended variably.

Off site and facilitated with contact persons or informal matching with peer supports in the community, some co-occurring focus.

Off site, integrated into plan, and routinely documented with co-occurring focus.

On site, facilitated and integrated into program (e.g., alumni groups); routinely used and documented with co-occurring focus.

  V.  Continuity of Care

 

A

Co-occurring disorder addressed in discharge planning process

 

Not addressed.

Variably addressed by individual clinicians.

Co-occurring disorders systematically addressed as secondary in planning process for off site referral.

Some capacity (less than 80% of the time) to plan for integrated follow-up, i.e., equivalently address both substance use and mental health disorders as a priority.

Both disorders seen as primary, with confirmed plans for on-site follow-up, or documented arrangements for off-site follow-up; at least 80% of the time.

 

B

Capacity to maintain treatment continuity.

 

No mechanism for managing ongoing care of mental health needs when addiction treatment program is completed.

No formal protocol to manage mental health needs once program is completed, but some individual clinicians may provide extended care until appropriate linkage takes place. Variable documentation.

No formal protocol to manage mental health needs once program is completed, but when indicated, most individual clinicians provide extended care until appropriate linkage takes place. Routine documentation.

Formal protocol to manage mental health needs indefinitely, but variable documentation that this is routinely practiced, typically within the same program or agency.

Formal protocol to manage mental health needs indefinitely and consistent documentation that this is routinely practiced, typically within the same program or agency.

 

C

V    Focus on ongoing recovery issues for both disorders.

 

Not observed.

Individual clinician determined.

Routine focus is on recovery from addiction; mental health symptoms are viewed as potential relapse issues only.

 

Routine focus on addiction recovery and mental health management and recovery; both seen as primary and ongoing

 

D

V   Specialized interventions to facilitate use of community-based peer support groups during discharge planning.

 

No interventions made to facilitate use of either addiction or mental health peer support groups upon discharge.

Used variably or infrequently by individual clinicians for individual patients, mostly for facilitation to addiction peer support groups upon discharge.

Generic, but no specific or intentional facilitation based on mental health disorders. More routine facilitation to addiction peer support groups (e.g., AA, NA) upon discharge.

Assertive linkages and interventions variably made targeting specific co-occurring needs to facilitate use of addiction peer support groups or groups specific to both disorders (e.g., DRA, DTR) upon discharge.

Assertive linkages and interventions routinely made targeting specific co-occurring needs to facilitate use of addiction peer support groups or groups specific to both disorders (e.g., DRA, DTR) upon discharge.

 

 

E

Sufficient supply and compliance plan for medications is documented.

 

No medications in plan.

Variable or undocumented availability of 30- day or supply to next appointment off-site.

Routine 30-day or supply to next appointment off-site. Prescription and confirmed appointment documented.

Maintains medication management in program/agency until admission to next level of care at different provider (e.g., 45-90 days). Prescription and confirmed admission documented.

Maintains medication management in program with provider.

  VI. Staffing

 

A

Psychiatrist or other physician or prescriber of psychotropic medications.

 

No formal relationship with a prescriber for this program.

Consultant or contractor off site.

Consultant or contractor on site.

Staff member, present on site for clinical matters only.

Staff member, present on site for clinical, supervision, treatment team, and/or administration.

 

B

On-site clinical staff members with mental health licensure, certification, competency, or substantive experience.

 

Program has no staff who are licensed as mental health professionals or have had substantial experience sufficient to establish competence in mental health treatment.

1-24% of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment.

25-33% of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment.

34-49% of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment.

50% or more of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment.

 

C

Access to mental health  clinical supervision or consultation.

 

No access.

Consultant or contractor off site, variably provided.

Provided as needed or variably on site by consultant, contractor or staff member.

Routinely provided on site by staff member.

Routinely provided on site by staff member and focuses on in-depth learning.

 

 

D

Case review, staffing or utilization review procedures emphasize and support co-occurring disorder treatment.

 

Not conducted.

Variable, by off site consultant, undocumented.

Documented, on site, and as needed coverage of co-occurring issues.

Documented, routine, but not systematic coverage of co-occurring issues.

Documented, routine, and systematic coverage of co-occurring issues.

 

 

E

Peer/Alumni supports are available with co-occurring disorders.

 

Not available.

Available, with co-occurring disorders, but as part of the community. Variably referred by individual clinicians.

Available, with co-occurring disorders, but as part of the community. Routine referrals made through clinician relationships or more formal connections such as peer support service groups (e.g., AA Hospital and Institutional committees or NAMI).

Available on site, with co-occurring disorders, either as paid staff, volunteers, or program alumni. Variable referrals made.

Available on site, with co-occurring disorders, either as paid staff, volunteers, or program alumni. Routine referrals made.

   VII. Training

 

A

VII All staff members have basic training in attitudes, prevalence, common signs and symptoms, detection and triage for co-occurring disorders.

 

No staff have basic training (0% trained).

Variably trained, no systematic agency training plan or individual staff member election (1-24% of staff trained).

Certain staff trained, encouraged by management and with systematic training plan (25-50% of staff trained).

Many staff trained and monitored by agency strategic training plan (51-79% of staff trained).

Most staff trained and periodically monitored by agency strategic training plan (80% or more of staff trained).

 

B

VI   Clinical staff members have advanced specialized training in integrated psychosocial or pharmacological treatment of persons with co-occurring disorders

 

No clinical staff have advanced training (0% trained).

Variably trained, no systematic agency training plan or individual staff member election (1-24% of clinical staff trained).

Certain staff trained, encouraged by management and with systematic training plan (25- 50% of clinical staff trained).

Many staff trained and monitored by agency strategic training plan (51- 79% of clinical staff trained).

Most staff trained and periodically monitored by agency strategic training plan (80% or more of clinical staff trained).