Integrated Treatment for Co-Occurring Disorders (ITCD) in Community Psychiatric Rehabilitation Programs

PURPOSE: This rule sets forth standards and regulations for the provision of ITCD in community psychiatric rehabilitation programs (CPR) for adults. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) ITCD is integrating substance use disorder treatment with community psychiatric rehabilitation for individuals with cooccurring psychiatric and substance use disorders. ITCD is a practice based on evidence and research for individuals with serious mental illness and substance use disorders. (2) Organizations certified or deemed certified by the department as CPR programs may offer further specialized treatment for co-occurring psychiatric and substance use disorders and shall use the Integrated Treatment for Co-Occurring Disorders: The Evidence resource KIT published in 2010 by the U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Publication No. SMA-08-4366, Rockville, MD 20009. This publication may be downloaded at https://store. samhsa.gov/product/Integrated-Treatment-for-Co-OccurringDisorders-Evidence-Based-Practices-EBP-KIT/SMA08-4367. The resource KIT incorporated by reference with this rulemaking does not include any later amendments or additions. (3) The agency shall have policies approved by the governing body as defined in 9 CSR 10-7.090 that are consistent with the provision of effective evidence-based interventions to guide the co-occurring services and be consistent with the ITCD model of treatment. (4) Admission Criteria. Persons meeting criteria for ITCD must meet admission criteria as defined in 9 CSR 30-4.005 and must have a co-occurring substance use disorder. (A) Individuals shall receive screening for both mental health and substance use disorders. (B) If individuals present with both mental health and substance use identified service needs, the individuals shall receive an integrated assessment identifying service needs as well as stage of readiness for change. (5) Personnel and Staff Development. ITCD shall be delivered by a multidisciplinary team responsible for coordinating a comprehensive array of services available to the individual through CPR with the amount and frequency of service commensurate with the individual’s assessed need. (A) The multidisciplinary team shall include but is not limited to the following: 1. A physician/physician extender (physician extender includes licensed assistant physician, physician assistant, psychiatric resident, psychiatric pharmacist, and advanced practice registered nurse (APRN); 2. A registered professional nurse (RN); 3. A qualified mental health professional (QMHP); 4. Additional staff sufficient to provide community support and retain the responsibility for acquisition of appropriate housing and employment services; 5. A qualified co-occurring disorders specialist is defined as a person who demonstrates substantial knowledge and skill regarding substance use disorders by being one (1) of the following: A. A physician or QMHP in Missouri or an individual who meets the applicable training and credentialing required by the Missouri Credentialing Board for any of the following accreditations (Qualified Addiction Professional): (I) Certified Alcohol and Drug Counselor (CADC); (II) Certified Reciprocal Alcohol and Drug Counselor (CRADC); (III) Certified Reciprocal Advanced Alcohol and Drug Counselor (CRAADC); (IV) Certified Criminal Justice Addictions Professional (CCJP); (V) Registered Alcohol Drug Counselor-Provisional (RADC-P); (VI) Registered Alcohol Drug Counselor (RADC); (VII) Co-Occurring Disorders Professional (CCDP); or (VIII) Co-Occurring Disorders Professional-Diplomat (CCDP-D); and B. The QMHP or QAP shall also have one (1) year of training or supervised experience in substance use disorder treatment. If they have less than one (1) year of experience in providing co-occurring disorder treatment, they shall be actively acquiring twenty-four (24) hours of training in cooccurring disorders content and receive supervision from experienced co-occurring disorders staff as approved by the department. (B) The multidisciplinary treatment team shall meet regularly to discuss each individual’s progress and goals and provide insights and advice to one another. (C) Multidisciplinary team members shall receive ongoing training in ITCD and have a training plan that addresses specific ITCD criteria, including co-occurring disorders, motivational interviewing, stage-wise treatment, cognitive behavioral interventions, and substance use disorders treatment. (D) The number of integrated treatment teams is determined by the needs and number of individuals being supported. (E) Only qualified staff shall provide integrated treatment for co-occurring disorder services. Qualified staff for each service are— 1. Individual counseling, group counseling, and assessment, a QMHP, or a QAP who meets the co-occurring counselor competency requirements established by the department; and 2. Group psychosocial rehabilitation services, eligible providers shall have documented education and experience related to the topic presented and either be, or be supervised by, a QMHP or QAP who meets co-occurring counselor competency requirements established by the department. (6) Treatment. (A) ITCD shall be delivered according to the ITCD model and criteria specified by the department. Services are time unlimited with the intensity modified according to level of need and degree of recovery; include outreach efforts and interventions to promote physical health, especially related to substance use; and target specific services to individuals who do not respond to treatment. (B) In addition to eligible CPR services, integrated treatment for co-occurring disorder services include the following: 1. Co-occurring individual counseling. A structured goal-oriented therapeutic process in which an individual interacts with a counselor in accordance with the individual’s treatment plan in order to resolve problems related to the individual’s documented mental and substance use disorders that interfere with functioning. Individual co-occurring counseling involves the use of practices such as motivational interviewing, cognitive behavioral therapy, harm reduction, and relapse prevention. Individual co-occurring counseling may include interaction with one (1) or more members of the individual’s family or other natural supports for the purpose of assessment or supporting the individual’s recovery; 2. Co-occurring group counseling. Goal-oriented therapeutic interaction among a counselor and two (2) or more individuals as specified in individual treatment plans designed to promote individual self-understanding, self-esteem, and resolution of personal problems related to the individual’s documented mental disorders and substance use disorders through personal disclosure and interpersonal interaction among group members. Group size shall not exceed ten (10) individuals; 3. Co-occurring group psychosocial rehabilitation services. Informational and experiential services designed to assist individuals, family members, and others identified by the individual as a primary natural support, in the management of the substance use and mental health disorders. Services are delivered through systematic, structured, didactic methods to increase knowledge of mental illnesses and substance use disorders. This includes integrating affective and cognitive aspects in order to enable the individuals receiving services, family members, and other natural supports to cope with the illness and understand the importance of their individual plan of care. The primary goal is to restore lost functioning and promote reintegration and recovery through knowledge of one’s disease, symptoms, understanding of the precursors to crisis, crisis planning, community resources, recovery management, and medication action, interaction, and side effects. Group size shall not exceed twenty (20) individuals; 4. Co-occurring assessment supplement. Individuals who present with both substance use and mental health identified service needs must receive additional assessments to document the co-occurring disorders and assess the interaction of the cooccurring disorders over time; 5. The agency shall arrange for referrals for withdrawal management/detoxification or hospitalization services when appropriate; 6. The agency shall provide housing and vocational services consistent with the ITCD model; and 7. Other services as appropriate. (C) Staff shall help individuals in the engagement and persuasion stages recognize the consequences of their substance use, resolve ambivalence related to their addiction, and introduce them to self-help principles. Individuals in the active treatment or relapse prevention stage shall receive cooccurring individual and/or group counseling and be assisted in connecting with self-help programs in the community. (D) Families and other natural supports shall receive education and, as appropriate, be involved in counseling. (7) Records. (A) An integrated treatment plan shall be developed by the multi-disciplinary team, including input from the integrated treatment specialist, and shall include participation of the individual receiving services. (B) The treatment plan shall address mental health and substance use disorder treatment strategies that involve building both skills and supports for recovery. (C) Interventions shall be consistent with, and determined by, the individual’s identified stage of treatment. (8) Performance Improvement. The agency’s performance improvement plan shall include monitoring its compliance with the ITCD program model and identifying and measuring satisfaction and outcomes of individuals served. Fidelity improvement shall be included as part of the agency’s overall performance improvement efforts. (9) The team shall participate in fidelity reviews and fidelity improvement activities conducted by the department. AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* Original rule filed Sept. 2, 2008, effective April 30, 2009. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.