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South Dakota: Changing Systems with Integrated Treatment for Co-Occurring Disorders
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How do substance use issues relate to mental illness? How can we best meet the needs of people who experience both?” This is one of many important questions that agencies and service providers across the state of South Dakota are asking themselves as they work together to transform services for people who experience co-occurring psychiatric and substance use issues. Amy Iversen-Pollreisz, the Director of the Division of Mental Health, speaks about collaborative efforts to impact systemic change.

Amy Iversen-Pollreisz is the Director of the Division of Mental Health for the state of South Dakota. She began her career in counseling, and quickly learned that she wanted to create change at the systems level. Amy is working with leaders, service providers, communities, and people who experience mental illness, substance use, and homelessness to create systems transformation across the state. “I wanted to insure that people seeking services from the state system get what they need, when they need it,” shares Amy.

The work of transforming systems to provide people with effective services began with small conversations and a series of priorities within the Division of Mental Health. They established three focus areas, including: recovery-oriented services for adults with severe mental illness, systems of care development for children with serious emotional disorders, and integrated treatment services for individuals with co-occurring disorders.

Improving integrated treatment for people with co-occurring disorders was a clear priority for the state. “Six years ago the Department of Human Services, which includes both the Divisions of Mental Health and Alcohol & Drug Abuse, started organizing around the clear need for integrated treatment for people who experience co-occurring disorders. Internally, we understood that we could do a better job,” says Amy.

At the time they had no grant funding to support the work. They sought out guidance from experts on co-occurring disorders, Dr. Ken Minkoff and Dr. Christy Cline. In the meantime, South Dakota was awarded a Co-Occurring State Incentive Grant (COSIG) from SAMHSA. COSIG provides funding at the state level to develop or enhance programs in order to provide accessible, effective, comprehensive, integrated, and evidence-based treatment services to people who experience co-occurring substance abuse and mental disorders.

The COSIG grant gave the state the funding they needed to advance this work. In addition, nine out of 11 of the state’s mental health centers have received Projects for Assistance in Transition from Homelessness (PATH) technical assistance grants from SAMHSA. South Dakota has been able to leverage all of this funding to provide more effective services. “PATH- funded staff are integral to this work. They are adopting all of the values we are addressing with Ken Minkoff and Christy Cline,” says Amy. “Every agency is asking: How do substance use issues relate to mental illness? How can we best meet the needs of people who experience both?”

“We started with community mental health centers, substance use providers, and the state psychiatric hospital,” explains Amy, “knowing that this was about more than one system.” The group worked together on a consensus statement, and earned buy-in from providers relatively quickly. The group recognized that people have complex needs. They could see that people were getting bounced around the system and wanted to work together to change this deficit in the system.

Since developing a consensus statement, they have focused on identifying and fostering “change agents.” These are people working in the community system as direct service providers who can come together on a quarterly basis to receive training in The Comprehensive, Continuous, Integrated System of Care (CCISC) model. CCISC organizes services for individuals with co-occurring psychiatric and substance use disorders and is designed to improve treatment capacity for these individuals in systems of any size and complexity. Change agents return to their agencies and train their colleagues in this best practices model.

To create change, relationship building is essential. Amy offers that it is critical that people who are receiving services feel that providers are establishing authentic relationships. Part of this work for providers has been to examine whether or not they are being welcoming.

“This goes beyond ‘are we friendly?’ Being welcoming means that when someone comes through the door we are using an individualized, strength-based model. It means, for example, that we are welcoming a person who is intoxicated, rather than saying, ‘you are difficult, come back when you are sober,’” says Amy. Much of this hinges on consistent policies and processes across agencies, but it also has to do with values and attitudes.

“Change takes a long time and we are changing attitudes. Agencies really need to examine and challenge old ideas and values and to focus in on what makes a person complex. If we can’t get this part down, then how do we do the rest?” says Amy. She sees that the most important changes begin with each individual. “You change what you have the ability to change and that starts with yourself,” says Amy. Because people leave and policies remain, Amy explains that the Division of Mental Health and partners have developed important self-assessment tools around values and principles. They have policies and procedures that describe what it means in a very detailed way, for example what it means to be welcoming.

Taking this work a step further, South Dakota has formed the Partners in Transformation Committee that includes stakeholders from throughout the system of care. The next step is to expand their work into additional systems. Amy is meeting with leaders in Child Welfare, Education, Corrections and other systems that are integral to building consistent practices across the state in order to build sustainability.

“We will continue to move in this direction to seek quality improvement. Our work and expectations will continue because we are focused on sustainability,” says Amy.

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