Comorbidity treatment service model evaluation

Service system elements II (practices)

Page last updated: August 2009

This domain has a focus on service system elements in regard to various practices, and includes the subdomains 'appropriate' treatment, clear care/treatment plans, use of referral/communication/feedback for others involved in clients' care, client self-management post-treatment, and treatment cost.

'Appropriate' treatment
Clear care/treatment plans
Use of referral/communication/feedback for others involved in clients' care
Client self-management post-treatment

'Appropriate' treatment

Findings for this sub-domain relate to service system management models employed by the surveyed services, continuous quality improvement, and possible changes to the service's treatment model and/or service structure to improve treatment outcomes.

Service system management models

Three general service system management models for comorbidity treatment have been described in the literature (Ries, 1993):
  • Sequential (or serial) treatment models: Individuals are treated by one system (AOD or MH) and then by the other. For example, a person with comorbid mental health and substance use issues receives mental health treatment from the MH sector, then referral is made to the AOD sector for the treatment of substance use issues—if the substance use issues have not resolved with MH treatment. Treatments are given one after the other, not at the same time. One disorder is usually considered primary and receives priority attention.

  • Parallel treatment models: Individuals are treated concurrently by both the AOD and MH sectors. That is, mental health and substance use issues are addressed at the same time, by different specialists, in different service settings. There may or may not be some level of communication between providers.

  • Integrated treatment models: Individuals receive coordinated treatment for both mental health and substance use problems. Integration is usually understood to be at the clinical level with treatment provided by a single treatment agency or clinician. However, in some literature, particularly policy documents, the integrated treatment model is described at the system or services level with coordination maintained across different service settings.Top of page
There are distinct differences between a number of the integrated models, such as client/program level integration, service/system level integration, and single-sector integration. Further, although not a service system management model, the no wrong door approach is a guiding principle that can be used within a number of service delivery models (e.g. Clark et al., 2008; Croton, 2005). Observance of this principle will impact on service system management and service delivery.

In the literature, integrated treatment models are said to: improve access by ensuring MH and AOD services are available in the same setting; improve individualisation and clinical relevance of treatment (Drake, O'Neal, & Wallach, 2008; Mueser, Noordsy, Drake, & Fox, 2003); overcome problems of fragmented or contradictory treatment; avoid difficulties associated with clients' negotiation of treatment programs across different systems; and limit the financial burden associated with multiple providers (Donald, Dower, & Kavanagh, 2005). It is for these reasons that integrated treatment models are often considered to be superior to sequential or parallel service delivery models.

When asked about models of service provision, the majority of surveyed services reported integrated treatment (n=12), five reported parallel treatment and four serial/sequential treatment. One service noted that 'this varies according to the client's needs and the expertise of the clinician involved', but that the service is 'striving towards the provision of integrated treatment'. Similarly, another respondent noted that the service uses 'all of these based on the individual client's needs and skills of the primary clinician'. One of the services using integrated treatment commented that parallel treatment is also used 'depending on severity of client's mental health condition'. Another service using integrated treatment commented that the goal is:

to assist all [regional] AOD & MH services to achieve the provision of Integrated Treatment as defined in the Victorian dual diagnosis policy; that is, INTEGRATED TREATMENT = EITHER one clinician or agency provides treatment of both disorders OR staff of separate agencies work together to agree and implement an Individual Treatment Plan. This integration needs to continue beyond acute intervention and through recovery by way of formal interaction and cooperation between agencies in reassessing and treating the client.
Serial/sequential treatment was used by combined services and not at all by AOD services, while parallel treatment was used more frequently by AOD services. See table 28 below for more detail.

Table 28: Models of service provision

Response frequency AOD serviceResponse frequency combined service
Serial/sequential treatment
Parallel treatment
Integrated treatment
Not applicable, because we do not accept clients with both AOD and MH problems/disorders

Note: more than one option could be selected

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Continuous quality improvement

As continuous quality improvement (CQI) programs are thought to bring about substantial and sustained improvement in the quality of care, the survey included a question about CQI programs. Fourteen services reported that they had a CQI program in place, and one respondent noted that the service is in the process of choosing a quality improvement provider. The three services that reported not having a CQI program are small services. The CQI providers/programs that were nominated included the following:
  • Quality Improvement & Community Services Accreditation (QICSA) (n=4)
  • Quality Management System (QMS) (n=3)
  • Quality Improvement Council (QIC) for core in A & D standards
  • Australian General Practice Accreditation Limited (AGPAL)
  • Western Australian Network of Alcohol & other Drug Sector Quality Framework
  • External national standards audit
  • An established quality improvement committee with staff, external providers, and consumers, as well as quality assurance policies
  • Dual Diagnosis Capability in Addiction Treatment (DDCAT)
  • Australian Quality Training Framework (AQTF)
  • Quality Framework.
Some services nominated more than one CQI program, while two did not provide information on the type of CQI program used.

Possible improvements

Respondents were also asked what changes could be made to their service's treatment model and/or service structure to improve treatment outcomes. Sixteen services made suggestions, with some of these offering several ideas for improvement. Suggestions related mainly to the areas of partnerships, training, data collection, and resources.

Working towards integrated service treatment and improved partnerships with other providers intra- and inter-sectoral (e.g. housing and employment, 'community involvement especially from the CALD communities') was considered desirable. Better and more training opportunities (in particular stronger emphasis on comorbid issues and 'ongoing capacity building through DD role modelling and consultation'), supervision, and research (e.g. 'more effective partnerships with universities') were also mentioned. In regard to data collection, respondents wanted to improve data collection, implement outcome measures, and document their successes. Increased resources were listed, in particular the following:
  • More resources for aftercare, and 'follow up care programs, particularly in outback communities are very sparse and therefore government funding might be well placed into developing community services with a specific view on comorbidity support workers'.
  • Medical support, 'a free psychiatrist, who is interested in comorbidity'.
  • 'Separate funding for management infrastructure'.
  • Increased staffing resources, such as 'more money to employ a nurse for the large comorbid outclient group'.
  • Provision of wider range of treatment options.
  • Prevention/early intervention initiatives.
  • 'Review of government benchmarks for NGO treatment servicing so that we're not scrambling for money all the time'.
Other changes referred to 'being more proactive in regard to mental health issues' and 'greater access to families and caregivers'.
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Clear care/treatment plans

It could be argued that clear plans are essential in the treatment of clients with complex problems, in particular when client care involves more than one service provider. The majority of surveyed services reported that clients have individual treatment plans. Two small AOD services noted that they do not develop individual treatment plans, and another small AOD service stated that some clients have treatment plans (see table 29 below).

Nearly all surveyed services reported that they always involve clients and sometimes involve other providers in the development of treatment plans (see table 30 below). One service which reported always involving other providers commented that 'case coordination is key in our work with young people'. Other services noted that carers can be involved if clients consent, 'only with more severe, comorbid clients are the carers involved', or that sometimes family meetings occur. Further, respondents suggested that for 'court-mandated clients, providers are involved', and 'case conferences occur for more complex cases where multiple services are involved'.

All services who use individual treatment plans communicate these to the client and/or carer. Some agencies noted that treatment plans are negotiated with the client, or that the client decides who has access to the treatment plan. Two services also provide treatment plans to the referring GP. Another agency reported that 'clients and carers must sign their treatment plan (however, sometimes no carer is involved)'. See table 31 below.

Table 29: Using individual treatment plans

Table 29 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

Response frequency of using individual treatment plans:
  • Yes, all clients - 12
  • Yes, most clients - 2
  • Yes, some clients - 1
  • No - 2

Table 30: Who is involved in the development of treatment plans

Table 30 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

Response frequency of whether clients, carers and other providers are involved in the development of treatment plans:
  • Yes, clients are always involved - 15
  • Yes, carers are sometimes involved - 15
  • Yes, other providers are sometimes involved - 14
  • Yes, clients are sometimes involved - 1
  • Yes, other providers are always involved - 1
  • Yes, carers are always involved - 0
  • No - 0

Table 31: Communication of treatment plans

Table 31 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

Response frequency of treatment plans are communicated to the client and carer:
  • Yes, to the client - 10
  • Yes, to client and carer - 6
  • Not applicable because we don't have treatment plans - 1
  • Yes, to the carer - 0
  • No - 0

Note: One service reported not having individual treatment plans, but also reported communicating treatment plans to the client.

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Use of referral/communication/feedback for others involved in clients' care

Respondents were asked whether they provide feedback to referral sources. Six noted that they always report back, nine stated that they report back sometimes, and three noted that they do not report back. However, of the latter, one service commented that 'GPs they always get a follow-up correspondence', while another noted that feedback is not provided 'unless it is part of a contract the client has "agreed" to; for example, with ... the criminal justice system'. One respondent (who chose two options) stated that feedback is always provided to 'mandated and diversion clients', and sometimes to GPs. Three services noted that provision of feedback is only provided with informed consent from the client (with the exception of court mandated clients). See table 32 below.

Table 32: Provision of feedback to referring services

Table 32 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

Response frequency of provision of feedback referring services:
  • Yes, always - 6
  • Yes, sometimes - 9
  • No - 3

Note: Response frequencies do not add up to 17 because one respondent chose two options.

Client self-management post-treatment

Respondents were asked about the availability of care after clients have been discharged from the service or program. Thirteen services reported that they support clients in self-management after discharge from the program/service. Three services noted that self-management or self-care skills are taught as part of the treatment. Three residential services commented that their outreach program supports clients after discharge.

The after-discharge support that is provided comprises teaching of skills (e.g. relaxation techniques, CBT28 techniques to deal with negative thoughts, problem-solving strategies), provision of information material, and availability of services on a needs basis or as part of aftercare (e.g. support groups). The types of services available to clients after treatment vary. They include home visits, individual counselling, an eight-week post-withdrawal group, post-withdrawal support worker, family counsellor, intensive playgroup, supported accommodation, phone link, drop-in options, transport, monthly support groups, links to job preparation, day programs. Some services provide comprehensive support after discharge from treatment, as described in the following comment:

Provide crisis care, ongoing counselling and support for up to two years, link clients into public/private health services for ongoing care, being available for check-ins/support as needed. Promoting community connectedness is a main priority, through activities etc. The more severe residential clients leave treatment with five TAFE certificates and are linked in with employment services, which assists them with gaining employment. We provide a crisis response; for example, step up–back into treatment for a short period, followed by review of treatment plan and then step them back down (into community/supported accommodation).
It was noted that the availability of supportive counselling and support groups is 'not bad' in suburban areas, but 'remote communities [are] not so pleasant or resource rich'.

Further, respondents were asked whether they consider the care available after discharge to be sufficient. Seven thought it sufficient, while 10 respondents indicated that it is insufficient. The latter were then asked what other supports were needed. Four respondents expressed a need for more staff to proactively follow up clients. Further suggestions included more resources for self-help groups, mentoring, 'more support counselling staff at the coalsites—regional towns and remote communities', and 'we would love to have a greater time with clients referred to us but due to demand for AOD services specifically we have to have time limited interventions'. One Indigenous service noted the following: 'probably more structure AND building client expectation that the Centre programme continues after leaving the Centre'.
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When asked for details about treatment costs, the majority of survey respondents did not provide any figures. Five respondents provided details of treatment cost. A residential service reported a cost of $24,350 per bed for a three-month stay, while another (Indigenous) residential service quoted a cost per enrolment of $10,760, regardless of how long clients stay. A large youth service detailed costs as follows: outreach $1,700 per episode; residential withdrawal $7,016, residential rehabilitation $30,000; day program $1,200; home-based withdrawal $1,500. A community-based outpatient service indicated that the cost of an episode of care is approximately $1,294. A large Victorian service suggested that 'DHS publishes cost per episode of treatment (as per website). For MH clinicians [the] cost [is] roughly $90,000 and [they] have a case load of 20 with throughput of approx. 40 annually'. Several respondents stated that they have not costed the treatments provided. For example, one respondent provided the following comment: 'The cost to clients is free. To work out the different costs to different treatments is too onerous to try as we have many different units and treatments'.

Respondents were also asked to describe the processes for monitoring cost. Monitoring of treatment delivery cost was reported to involve financial reporting (and service delivery reporting) as required by funding bodies, external financial auditing, and/or regular (monthly or quarterly) budget reports. However, five services reported that no monitoring of treatment cost occurs. Presumably, this can be interpreted as no monitoring other than that required by funding bodies.


28 Cognitive Behaviour Therapy

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