The Comprehensive Continuous Integrated System of Care (CCISC) process (Minkoff & Cline, 2004, 2005) is a vision-driven system “transformation” process for redesigning behavioral health and other related service delivery systems to be organized at every level (policy, program, procedure, and practice)—within whatever resources are available—to be more about the needs of the individuals and families needing services, and values that reflect welcoming, empowered, helpful partnerships throughout the system. The ultimate goal of CCISC is to help develop a system of care that is welcoming, recovery-oriented, integrated, trauma-informed, and culturally competent in order to most effectively meet the needs of individuals and families with multiple co-occurring conditions of all types (mental health, substance abuse, medical, cognitive, housing, legal, parenting, etc.) and help them to make progress to achieve the happiest, most hopeful, and productive lives they possibly can.
In a CCISC process, every program and every person delivering clinical care engages in a quality improvement process—in partnership with each other, with system leadership, and with individuals and families who are receiving services—to become welcoming, recovery- or resiliency-oriented, and co-occurring-capable. Every aspect of clinical service delivery is organized on the assumption that the next person or family entering service will have multiple co-occurring conditions, and will need to be welcomed for care, inspired with hope, and engaged in a partnership to address each and every one of those conditions in order to achieve the vision and hope of recovery.
The Four Basic Characteristics of the Comprehensive, Continuous, Integrated System of Care Model (CCISC)
The CCISC model for organizing services for people and families with co-occurring psychiatric and substance disorders is designed to improve treatment capacity for these individuals in systems of any size and complexity, ranging from entire states to regions or counties, networks of agencies, individual complex agencies, or even programs within agencies. The model has the following four basic characteristics:
The CCISC model is designed for implementation throughout an entire system of care, not just for implementation of individual program or training initiatives. All programs are designed to become co-occurring capable (or enhanced) programs, generally within the context of existing resources, with a specific assignment to provide services to a particular cohort of individuals with co-occurring issues. Implementation of the model integrates the use of system change technology with clinical practice technology at the system, program, clinical practice, and clinician competency levels to create comprehensive system change.
Efficient Use of Existing Resources
The CCISC model is designed for implementation within the context of current service resources, however scarce, and emphasizes strategies to improve services to people and families with co-occurring conditions within the context of each funding stream, program contract, or service code, rather than requiring blending or braiding of funding streams or duplication of services. It provides a template for planning how to obtain and use additional resources should they become available, but does not require additional resources, other than resources for planning, technical assistance, and training.
Incorporation of Best Practices
The CCISC model is recognized by SAMHSA as a best practice for systems implementation for treatment of people and families with co-occurring conditions. An important aspect of CCISC implementation is the incorporation of evidence-based and clinical-consensus-based best practices for the treatment of all types of people and families with co-occurring conditions within the service system.
Integrated Treatment Philosophy
The CCISC model is based on implementation of principles of successful treatment intervention that are derived from available research and incorporated into an integrated treatment philosophy that uses a common language that makes sense from the perspective of both mental health and substance disorder providers. This model can be used to develop a protocol for individualized treatment-matching that in turn permits matching of particular cohorts of individuals to the comprehensive array of co-occurring-capable services within the system.
This model is based on the following eight clinical consensus best practice principles (Minkoff and Cline, 2004, 2005) which espouse an integrated recovery philosophy that makes sense from the perspective of both the mental health system and the substance disorder treatment system.
Principle 1. Co-occurring issues and conditions are an expectation, not an exception.
This expectation must be included in every aspect of system planning, program design, clinical policy and procedure, and clinical competency, as well as incorporated in a welcoming manner in every clinical contact, to promote access to care and accurate screening and identification of individuals and families with multiple co-occurring issues.
Principle 2. The foundation of a recovery partnership is an empathic, hopeful, integrated, strength-based relationship.
Within this partnership, integrated longitudinal strength-based assessment, intervention, support, and continuity of care promote step-by-step community-based learning for each issue or condition.
Principle 3. All people with co-occurring conditions are not the same, so different parts of the system have responsibility to provide co-occurring-capable services for different populations.
Assignment of responsibility for provision of such relationships can be determined using the four-quadrant national consensus model for system-level planning, based on high and low severity of the psychiatric and substance disorder.
Principle 4. When co-occurring issues and conditions are present, each issue or condition is considered to be primary.
The best-practice intervention is integrated dual or multiple primary treatment, in which each condition or issue receives appropriately-matched intervention at the same time.
Principle 5. Recovery involves moving through stages of change and phases of recovery for each co-occurring condition or issue.
Mental illness and substance dependence (as well as other conditions, such as medical disorders, trauma, and homelessness) are examples of chronic biopsychosocial conditions that can be understood using a disease and recovery (or condition and recovery) model. Each condition has parallel phases of recovery (acute stabilization, engagement and motivational enhancement, prolonged stabilization and relapse prevention, rehabilitation and growth) and stages of change. For each condition or issue, interventions and outcomes must be matched to stage of change and phase of recovery.
Principle 6. Progress occurs through adequately supported, adequately rewarded skill-based learning for each co-occurring condition or issue.
For each co-occurring condition or issue, treatment involves getting an accurate set of recommendations for that issue, and then learning the skills (self-management skills and skills for accessing professional, peer, or family support) in order to follow those recommendations successfully over time. In order to promote learning, the right balance of care or support with contingencies and expectations must be in place for each condition, and contingencies must be applied with recognition that reward is much more effective in promoting learning than negative consequences.
Principle 7. Recovery plans, interventions, and outcomes must be individualized. Consequently, there is no one correct dual-diagnosis program or intervention for everyone.
For each individual or family, integrated treatment interventions and outcomes must be individualized according to their hopeful goals; their specific diagnoses, conditions, or issues; and the phase of recovery, stage of change, strengths, skills, and available contingencies for each condition.
Principle 8. CCISC is designed so that all policies, procedures, practices, programs, and clinicians become welcoming, recovery- or resiliency-oriented, and co-occurring-capable.
Each program has a different job, and programs partner to help each other succeed with their own complex populations. The goal is that each individual or family is routinely welcomed into empathic, hopeful, integrated relationships, in which each co-occurring issue or condition is identified, and engaged in a continuing process of adequately supported, adequately rewarded, strength-based, stage-matched, skill-based, community-based learning for each condition, in order to help the individual or family make progress toward achieving their recovery goals.
Co-occurring Capability Resources
Resources for agencies/programs, clinicians, and system implementation teams developing co-occurring capability or competency can be found here. The steps are based on the principles above, and can be initiated by anyone to organize progress within the scope of mission, job category, and resources.