SUTS Conference 2018: Reaching the “Unreachable” with Co-Occurring Education Groups

Across the nation, 60 million adults aren’t receiving adequate primary care, 33% of adults with serious mental illness aren’t receiving any mental health services, and 90% of people with substance use conditions aren’t receiving any care for their substance use.

Yet individuals with co-occurring SMI and substance use are often among the highest utilizers in their systems of care. At Telecare, these co-occurring conditions are very prevalent: 70% of our clients are also dealing with substance use. The majority of these individuals do not recognize that their substance use is affecting their health and wellness, aren’t currently considering treatment, and aren’t considering a change in their use of substances. 

In August 2018, Telecare’s Vice President of Operations, David Heffron, and Director of Special Projects - Substance Use Treatment Services (SUTS), Scott Madover, presented at the Substance Use Disorder Statewide Conference put on by the California Department of Health Care Services. We are pleased to share their presentation, “Reaching the Unreachable: Engaging People with SUTS in Pre-Contemplation Phase,” and their ingredients for success below.

Download a PDF of the Presentation

Click the image above to download a pdf of our suts presentation

Click the image above to download a pdf of our suts presentation

Reaching the Unreachable: Engaging People with SUTS in Pre-Contemplation Phase

So how do we help people who not yet ready for change? How can improve health and wellness — when a person does not recognize the impact of substance use in their life?

We begin from a place of curiosity, conversation, information, and engagement — for staff and clients — and we cultivate an environment where change might be possible.

As part of Telecare’s Whole Person Care initiative, we developed and launched a curriculum called Co-Occurring Education Groups (COEG). The 16-week curriculum is intended to address the shared challenges providers and systems face: reaching the “unreachable” through respect, engagement, education, and ongoing support.

COEG Basic Framework

Each session in the 16-week curriculum covers a different topic of discussion: from understanding addiction, to recognizing triggers, to reflecting on one's hopes and goals. In some of Telecare’s programs, groups are offered weekly; in others, groups are offered several times a week. Each group is moderated by a trained staff member and takes 60 to 90 minutes to complete. Due to Telecare’s many types of programs, the curriculum was designed to supplement — not replace — the regular clinical services that a program already delivers. Likewise, the curriculum does not contain service-line specific information, therefore, almost any program can use the materials. The groups are open, so new participants can join a group at any time. This flexible drop-in format gives individuals ownership over their future.

Ingredients for Success

  • Keep on going

  • Teach it all

  • Share the facilitation

  • Stick to the script

  • Be prepared

  • Include everyone

  • Educate and explore

  • Show respect and non-judgment

  • Keep groups open

  • Schedule groups regularly

More Information

Brochures & Information

COEG Resources

The Power of Hope: How Peer Services Provide Living Examples of Recovery

Erin "Wesa" Arthur is a PSC III Substance Abuse Specialist at Telecare’s Santa Maria ACT program.

Wesa specializes in addiction and co-occurring conditions among members and helps them through psychoeducation, assists in detox treatment, and conducts general case management. She uses harm reduction, the RCCS, and shares her story to instill hope.

"That is why I am so passionate about recovery and the work that I do—I’ve been there," said Wesa. "I have 28 years of sobriety and I am living with a mental illness and co-occurring disorders. I think that it helps clients when I open up with them about my own experiences."

Having the ability to have the challenging conversation surrounding substance use in a non-judgmental fashion is key for building trust and hope among our clients. "I think there is so much doubt that many people who are struggling with co-occurring disorders face and that it is something that is destined to hinder them, and that’s not true," Wesa said. "Like anything in recovery, it’s a process and it’s unique to every individual."

This year, Telecare has been expanding and improving the way we inform our staff about co-occurring disorders. With our online learning portal, we are now able to offer staff training sessions on substance use that they can access at any time to help with their understanding of dual diagnosis among clients and how to start conversations around these topics. More than 70% of Telecare programs successfully completed COEG facilitator training and launched COEG groups for the people they serve.

Wesa had the opportunity to share her own experiences when COEG was first being developed. "I feel so strongly that until someone is clean and sober, it’s extremely difficult to treat the psychiatric disorder,” she said. "Substance use can have such an impact on mental health symptoms. To provide adequate treatment for people who have a co-occurring disorder, you have to take the time to understand how the two are affected by one another."

Today, Wesa continues her interest in psychology and writes about her experience. Her recovery journey is a reminder to those she works with that anything is possible.

"People gave up on me when I was diagnosed with bipolar disorder, and I proved them wrong," she said. "The thing I love is being able to instill hope and show them by example that anything is possible. And I love the clients. I absolutely love the clients we serve."

SUTS Telemedicine Detox Pilot

Recovering from addiction can be an extremely stigmatizing and isolating experience for many of our clients. Telecare recently conducted a pilot on Telemedicine Detoxification (Tele-Detox) to see if we could help clients overcome this isolation, while getting the right treatment support at their own pace, in the safety of their own home or within a program.

“Tele-Detox is detox treatment provided via live video calls at the convenience of where our clients are,” said Scott Madover, Director for Specialty Product Services, Substance Use Treatment Services (SUTS). “Through this online process, clients can get connected with an addiction physician who can walk them through their detox, answer any of their questions, and prescribe medications so that their substance use withdrawal symptoms can be as mild as possible.”

The nine-month pilot started June 2016 and was conducted at our CHANGES program in Oakland, CA. CHANGES is Telecare’s first co-occurring program and has been instrumental in helping Telecare identify effective and collaborative ways to treat co-occurring substance use disorders. CHANGES clients receive both mental health and substance use services, but in this program, are not required to be abstinent. Staff encourage clients to reduce their substance intake through a harm reduction model and can refer clients to more robust inpatient detox services.

The Tele-Detox program came about because we wanted to help clients overcome the isolation of addiction recovery, while getting the right treatment support at their own pace, in the safety of their own home or within a program.

The Tele-Detox approach is promising because it supports these goals, as well as offers other system benefits. It’s less expensive than inpatient detox, enables clients to start the detox process faster because it does not require waiting for an available inpatient bed, and alleviates pressures on those inpatient beds for people who need inpatient care the most.

Through the Tele-Detox process, clients are screened and connected with an addiction physician through Clinics On Demand. Clients are loaned a personal computer or a tablet if they do not already have one, a blood pressure cuff, and a finger oxygen device. The blood pressure and finger oxygen devices connect automatically and wirelessly with a monitoring system at Clinics On Demand.

Clients who participated in the demo had regularly scheduled telephone visits with physicians and clinical staff to discuss progress, address concerns, resolve problems, and refer to higher level of care if needed. CHANGES staff could contact the client’s physician to report any change of condition they observe during the detox treatment. Once detox treatment was completed, CHANGES staff would help and support clients in their chosen Intensive Outpatient Programming (IOP) treatment in addition to the services at CHANGES.

“Although the turnout for the pilot program was modest, the support and encouragement clients received by participating really helped them understand their addiction,” Scott said. “As a company, we are looking to continue to have the opportunity to build expertise within Telecare around substance use for our staff.”

Michelle Norris worked on the Tele-Detox program pilot when she was a Personal Service Coordinator II at CHANGES. As someone with lived experience herself, she knows that there is a lot of stigma surrounding addiction, and that having more personalized access to help can make taking those first steps towards recovery a little easier.

“There's still a lot of misconceptions around addiction, like the thought that people could just stop if they wanted to,” she said. “You know what? If I could've stopped, I would have, but I couldn't until I got more education. Having the right education and being provided the steps you need to take to help the client is so important because recovery can be a lot harder than you think.”  

Michelle uses the experience from her own recovery to help guide others on their journey. She is now a Licensed Clinical Social Worker (LSCW) at Telecare’s Villa Fairmont Mental Health Rehabilitation Center.

SUTS: Expanding Treatment at Telecare

Our Plan for Building Skills, Staff, Practices & Programming

In January 2017, Telecare finalized a three-year plan to enrich and expand our substance use treatment services (SUTS) capabilities, with a specific focus on people who have a serious mental illness (SMI) and co-occurring substance use issues.

"Traditional substance use agencies are not necessarily prepared to serve people who have SMI," said Faith Richie, SVP of Development. "We have a 50-year history of working with SMI and complex needs and in the last few years, have made major steps forward in our ability to recruit, retain and support licensed staff, particularly psychiatrists, through our TLC Physician Services Organization. This will make it easier for us to step into more direct SUDS care, deliver Medication Assisted Treatment, and meet all of the site certification and staff licensing requirements to do this work and do it well." 

We are pleased to introduce the highlights of this plan here and will continue to share enhancements and updates as we move forward in this work.

Ultimately, we need to provide dedicated programming that combines mental health and substance use services directly to our clients in our programs. We believe that by doing that, we can better close the gap and help our clients holistically move forward in recovery – and dramatically improve their lives.
— Scott Madover, Director for Specialty Product Services, Substance Use Treatment Services (SUTS)

Overarching Goals

Our vision for our SUTS plan is ambitious. We want to:

  • Increase quality of care

  • Increase access to care

  • Increase strategies for effective care

  • Reduce the stigma of care

  • Nurture a safe space for change

  • Create many options and avenues for clients to make positive behavioral change

  • Enable staff and clients to work proactively and collaboratively toward recovery

SUTS Plan at a Glance


What's New in SUTS

Director of SUTS: Scott Madover

To help us better address co-occurring conditions company-wide, we appointed Scott Madover, Ph.D., to take on the role of Telecare’s Director for Specialty Product Services, Substance Use Treatment Services (SUTS).

"We knew we really needed to focus on substance use, and ensure that we were capable and doing our very best to meet those needs. We thought the best way to do that was to hire a dedicated leader, and that's Scott Madover," said Faith Richie, SVP of Development at Telecare.

In addition to working with the Development and Operations departments at Telecare to create plans for how co-occurring programming could better serve our clients, Scott will also assist with Telecare’s planning efforts so that our services are aligned with parity requirements and SUTS funding in multiple states. He will also ensure that Co-Occurring Education Groups (COEG) curriculum is available at all our product types, and recommend new standards for our existing programs so that they are co-occurring capable.

Scott’s clinical training and program leadership experience coupled with his wealth of knowledge in co-occurring disorders positions him very well for this role.

Before accepting his role as the new SUTS Director, Scott has helped lead many of Telecare’s integrated care efforts, including the development and roll out of COEG, our first company-wide substance use education program, and the design and implementation of Telecare’s first pay for success program. He also helped design and oversee the CHANGES program, our first program specifically designed to support people with co-occurring mental illness/substance use needs. Scott has also served as Regional Director of Operations in the Bay Area. 

Keep Going on the Road to Recovery

Telecare’s CHANGES program in East Oakland, CA, offers co-occurring services to individuals who are diagnosed with mental health and substance use issues, and who are also frequent users of emergency psychiatric care. The staff there are supportive and patient—they understand that recovery is far from a neat process.

Jordan Boehler, Team Leader at CHANGES, has shared a story about Sasha, a member who is learning about the highs and lows of recovery, and, most importantly, to never give up.  

Sasha and Jordan

Sasha and Jordan

Beginning the Journey

When Sasha moved to Alameda County from San Francisco two years ago to flee an eviction, she brought some of her roommates and all of her cats with her. She, like her roommates, struggled with daily heroin, alcohol, and cocaine use. Heroin allowed her to temporarily ignore the pain in her right hand, now completely numb from carpal tunnel syndrome. Alcohol drowned out the depression and the guilt for the choices she made that had landed her in this financially-strained, drug-filled situation again. Cocaine helped her focus on her job, and helped keep her awake. She used to be a nurse, working full-time in a hospital. She felt she had become nothing, with nothing to show for it.

Her roommates’ addictions, like her own, were sustained by part-time employment. Sasha was a home health aide and while she was in significant debt, she didn’t hold her roommates accountable for their financial obligations and never squeezed them for rent. Chaos became the status quo. People—some she knew, some she didn’t—coming and going 24 hours a day made the house seem more like a multi-service center than a residence. Nights were filled with anguish and no sleep, and turned into days with occasional violence and recuperation from the drug use the night before. On top of the guilt, shame, pain, and loneliness Sasha felt, her financial burden continued to pile up to the point where she felt that there was no way out. She wanted to kill herself again—she had tried three times before—and was quickly running out of options. It was at this point when the Oakland Community Support Center referred Sasha to CHANGES.

After completing an intake on the Intensive Case Management (ICM) team, Sasha was connected with a staff therapist to address her depression and suicidal ideation. She consistently met with both her therapist and her case manager every week. She and her therapist developed a strong therapeutic rapport and would go on walks together or to get coffee at Philz. She engaged actively in Cognitive Behavioral Therapy (CBT) exercises to stop and evaluate the negative automatic thoughts, mindfulness activities to ground herself in times of emotional distress, and Recovery-Centered Clinical System exercises to address individual problems as they came up.

Slowly, as Sasha practiced these techniques, she began to apply them without external prompting or conscious effort—replacing the unhealthy habits of her past. Her mood improved and she acknowledged that while her suicidal thoughts remained, they were less distressing. Over a period of months, Sasha grew more confident in her ability to make decisions that she wouldn’t be ashamed of afterwards: she didn’t take in an old friend that she knew she couldn’t care for, she began asking for rent, and she continued to check in weekly with her CHANGES case manager. She began to put her own wellness first over the dependent needs of her roommates and she began to set boundaries with them.

Additionally, Sasha attended orientation at Sparkpoint at Eastmont Mall for debt management and financial assistance. She connected with a personal care provider at PATH Lifelong Medical Center and finally got surgery for carpal tunnel syndrome in her right wrist. She signed up at the methadone clinic with a roommate and attended daily. Things seemed to be looking up, and for a month or two all was well. This was her first time off of IV-heroin in more than 10 years.

Pushing Through Relapse

These changes, however, were hard to maintain. Due to the absence of heroin and the presence of ongoing stress, Sasha’s cocaine and alcohol use both increased. Dealing with the debt and the consistent interpersonal issues with her roommates was taking its toll and she felt she was again without anywhere to turn. While she continued to attend the methadone clinic each morning with one of her roommates, her appointment attendance both at Sparkpoint and at CHANGES declined significantly. She didn’t return calls. Her debt increased. She grew angrier with herself, guiltier, and more fed up with her roommates. Finally, when she had to put down one of her cats because she couldn’t afford the veterinary care, she called her therapist at CHANGES and reconnected. She was lost, felt guilty and suicidal, and needed help.

Recently, she participated in the Clinics on Demand Tele Detox pilot at CHANGES to detox from her daily alcohol use. After seven days of healthy, successful, in-home detox, she is no longer drinking and has been tapering off her daily cocaine use with the help of the CHANGES psychiatrist and Strattera, a non-stimulant based medication designed to help her focus. She no longer reports any suicidal thoughts, and has been successfully navigating her interpersonal relationships with healthy boundaries. She is increasing her hours as a home health aide, and her sights are currently set on restoring her license to practice as a nurse. While she knows she still has a long way to go, she is proud of how far she has come with the help of CHANGES.

This is what recovery looks like.

Educating Others on How to Facilitate Hope

This month, Telecare presented at the 2016 National Conference on Addiction Disorders (NCAD) in downtown Denver, CO, from August 18-21. The conference provided educational sessions for professionals working in addiction prevention, treatment, and management.
"How to Reach the Unreachable: Engaging People with SUDs in Pre-Contemplation Phase" was presented by Scott Madover, Regional Director, David Heffron, Vice President of Operations, and Shannon Mong, Director of Innovation Initiatives.

The presentation aimed to educate others on how Co-Occurring Education Groups (COEG) encourages individuals to make healthier lifestyle choices by identifying what inspires and motivates them, instead of solely focusing on their substance use.

“Participants were very interested to hear how Telecare measured participants' hopefulness and found, not surprisingly, that individuals who have higher levels of hope tend to attend more sessions,” Shannon said. To emphasize this point, Scott and David invited 11 attendees to join in a mock session, where they engaged in the "Hopes and Dreams" lesson of the curriculum.

“People were particularly curious about the curriculum’s harm-reduction approach and were asking if the curriculum is available for use outside of Telecare,” Shannon said. “Given the number of people asking us to share the COEG system, I guess our next step is figure out how to do just that!"

You can email Shannon Mong, Scott Madover, or David Heffron for more information about their presentation. 

COEG Measurement Tools:

We gathered feedback and outcomes in three ways: written feedback forms, which are provided at the end of each session for facilitators and participants; participant completion of two SAMHSA screenings (AUDIT for alcohol use and DAST for drug use), at the beginning and end of their involvement in the education sessions; and in-person debriefing held for program leadership and group facilitators, once all sessions were completed. 

These screenings and measurements help us establish a baseline for identifying issues, track and evaluate progress, and help foster conversations. 

SAMHSA recommends the use of screening to identify clients who are experiencing issues related to their substance use and/or who are using substances at a level at a hazardous or harmful level. The AUDIT and DAST assess client’s self-reported information about substance use, both measures can easily be scored by any health care provider.

AUDIT (Alcohol Use Disorders Identification Test) "is a 10-item questionnaire that screens for hazardous or harmful alcohol consumption. Developed by the World Health Organization (WHO), the test correctly classifies 95% of people into either alcoholics or non-alcoholics. The AUDIT is particularly suitable for use in primary care settings and has been used with a variety of populations and cultural groups," according to the Integrated Behavioral Health Toolkit, California.

DAST-10 (Drug Abuse Screen Test) "is a 10-item, yes/no self-report instrument that has been condensed from the 28-item DAST and should take less than eight minutes to complete. Designed to provide a brief instrument for clinical screening and treatment evaluation and can be used with adults and older youth,” according to the Integrated Behavioral Health Toolkit, California.

Links to info about Screening Tools (including AUDIT and DAST):

Why is COEG Promising?

Beyond these promising preliminary findings, the Co-Occurring Education Group has other design attributes that can benefit clients and systems of care:

For Clients:

  • COEG is an open curriculum, where participants can join or leave whenever they choose.

  • It is respectful. There is no one right or wrong way to make changes in life.

  • Participants are given tools and resources to use and take steps on their own.

  • Session structure creates a respectful and empowering environment for change.

  • The sessions start a conversation, which often continues after a group ends.

For Systems of Care:

  • The educational program is replicable and scalable. The COEG Start-Up Toolkit and training can be implemented without astronomical costs.

  • A variety of line staff can lead the groups. The COEG program includes online and in-person training for facilitators and leaders and the Facilitator Guide provides a word-for-word script to run each session. This means facilitators do not need to be licensed in either behavioral health or substance use.

  • People who have previously been in early stages of readiness for change can empower themselves to move toward more active readiness.

  • Curriculum integrates SAMHSA videos and materials on addiction and recovery.

  • The topics and materials appeal to the people we serve.

  • The program is a recovery-centered approach which is client-centered and driven by an individual's hopes and dreams (integrating Telecare’s Recovery Centered Clinical System).

"What we're doing at Telecare is establishing relationships. I think that’s the key to our success." said Scott Madover, Regional Director of Operations. “Something that Telecare does well is engage people about their hopes and dreams. We find a vision that clients can look at and say, 'That's what I want.' They might not reach that hope and dream, but there are a lot of steps that they do reach which will help people feel satisfied and better about themselves. Everyone has to have not just a goal, but a hope of what could be different in their life." 

COEG Overview

The Co-Occurring Education Groups (COEG) program is a part of Telecare’s larger effort to provide integrated “whole person” care for our clients. To do this, we focus on three fronts: physical health, behavioral health, and substance use.

The COEG program integrates materials from Telecare’s Recovery-Centered Clinical System and SAMHSA. This educational curriculum is heavily focused on Motivational Interviewing and the stages of change, and is designed to help educate those with co-occurring conditions learn about substance use and its impact on mental and physical health. It’s neither forced nor required, and people do not attend the groups as "treatment." People attend the groups because they are curious, want information, and have been invited.  We invite ALL clients to participate (not just those that staff have identified as having problems associated with substance use), through an engaging promotional campaign.

"Typical treatment services are effective for people who have decided they need to make a change in their lives around drug and alcohol use – and sometimes for those who have been mandated to treatment because they have gotten in trouble with the law," said David Heffron, Vice President of Operations. "However these groups provide an alternative for people who don’t think they need or want treatment. Information can be a powerful intervention for people who aren’t yet thinking of making a change."

The COEG was designed and developed at Telecare by David Heffron (Top), Shannon Mong, Director of Innovation Initiatives, and Scott Madover, Regional Director of Operations, with the input and feedback of clients, staff, and leaders at all levels in the organization. Their aim was to combine substance use and mental health services into a single, accessible approach.

"We were thinking about how to intervene with people who haven’t made the decision they want to address their substance use," said Shannon. "We knew that for someone to move from 'No, Not Me' (pre-contemplation) to thinking, ‘Well, maybe I am using substances in an unhealthy way’ takes quite a bit of internal change. It starts with a change in someone’s thoughts and feelings, that can lead to a change in attitude, which then may lead to a change in behavior. Since education is an important first step, we decided to create and pilot our own curriculum to see if the group learning would help people identify healthier choices they were personally interested in making."

The COEG program consists of 16 unique sessions. Each session covers a different topic of discussion: from understanding addiction, to recognizing triggers, to reflecting on one's hopes and goals. In some programs, groups are offered weekly; in others, groups are offered several times a week. Each group is moderated by a trained staff member and takes 60 to 90 minutes to complete. Due to the fact that Telecare has so many types of programs, the curriculum was designed to supplement, not replace, the regular clinical services that a program already delivers. Likewise, the curriculum does not contain service-line specific information, therefore, almost any program can use the materials. The groups are open, so new participants can join a group at any time. This flexible drop-in format gives individuals ownership over their future.

Although the curriculum is very structured, the group facilitators don’t tell people what to do. Instead, the groups provide information people may have heard before and the facilitators ask them questions to encourage their own thinking. "I think our job is to engage and develop relationships with our clients, to accept them where they are and to partner with them," Scott said. "Treatment is not the goal of the program. Instead the goal is for each person to gain information that is pertinent for them, which will lead them to make more effective choices and result in better outcomes for their lives. This approach is consistent with a harm reduction model."

How Do You Connect with People that are Hard to Reach? 

The COEG goes beyond just providing information. It creates a place where people can be heard and appreciated in a non-judgmental, non-shaming way. The trust that emerges in the groups offers people a way to tackle the very difficult process of change. Said Scott, "I would want someone to do the same for me."