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A NIATx Virtual Walk Through to Promote Integrated Care for Co-occurring Mental Health and Substance Use Conditions

Authored By: 
Mat RoosaLCSW-R

Information provided in this post comes from technical assistance provided by the Great Lakes ATTC in Manitowoc County, WI.

Providers throughout the Great Lakes region and across the county have been making steady gains toward integrated mental health and substance use care. Providers have come to understand that co-occurring conditions (COD) are more the norm than the exception. People with serious substance use conditions typically experience some substantial mental health symptoms such as anxiety or depression. People with mental illness often use a range of substances. 

An array of tools and practice models exist for evaluating care systems, delivering dual diagnosis assessments and providing integrated care. Recently The Great Lakes ATTC added simple and useful tools to this list.

Manitowoc County, Wisconsin sought technical assistance from the Great Lakes ATTC and MHTTC to support their efforts to enhance the level of integrated care in their clinic. In addition to providing trainings for COD care and for Contingency Management, we introduced the Manitowoc team to NIATx tools to support this effort.

The Walk Through and Flow Chart remain two of the core NIATx tools used to understand the care experience through the eyes of the customer, and document the work flow Typically, the Walk Through is done as a role play exercise by program staff who then draw a Flow Chart of the experience.

Example of a basic swim lane diagram with an identified starting point followed linearly by guiding arrows and subsequent steps and concluding at an identified ending point.

The Swim Lane Diagram is another common tool used to track a process. This tool is often used to show how the process moves between people or departments that are represented like the lanes of a swimming pool.

Sometimes people combine these two tools into a swim lane flow chart, which documents the process flow, with an emphasis on the movement of the process between people or systems.

To understand the Manitowoc process flow related to integrated care, the ATTC team decided to use this swim lane flow chart approach in conducting a virtual walk through, or “talk through of the experience of clients of the clinic related to integrated care concerns.

A simple swim lane diagram was constructed with a middle starting lane, and a mental health (MH) and substance use (SU) lane on either side.

An example of a basic swim lane diagram with a top lane labeled "MH," a bottom lane labeled "SU," and a middle lane where the integrated process steps of both the top and bottom lanes would be represented.

The plan was to then talk through the Manitowoc client experience from initial intake through admission and commencement of treatment. The process would be documented with boxes and arrows, as in a typical flow chart. These boxes and arrows would “switch lanes” whenever the client experience reflected movement into MH-specific or SU-specific activities. A perfectly integrated process would show as a linear flow chart that stayed in the centered lane.

An example of a swim lane flow chart diagram with a top lane labeled "MH," a bottom lane labeled "SU," and a middle lane where all steps of a process flow chart are displayed. When an entire process is charted in the middle lane, this indicates the process is perfectly integrated.

Conversely, a process lacking in integration would show a rapid departure from the center lane with parallel processes in the MH and SU lanes, and/or a movement back and forth between the lanes.

An example of a swim lane flow chart diagram showing process steps moving between the top and bottom lane into the middle lane and back to outer lanes again. The movement between lanes indicates a non-integrated process that may be subject to redundancy and inefficiencies.

This simple visualization was designed to show the frequency of departures from the integrated care lane, and the redundant processes that might result in inefficiencies.

This integrated care swim lane flow chart was used with the Manitowoc team to document their current clinic process. This exercise revealed that the Manitowoc clinic process was primarily integrated. It also showed some small but substantial ways that the clinic can enhance the workflow to more fully integrate the client experience.

In addition to comprehensive tools designed for assessing care integration (e.g., the DDCAT Index), this variation of a NIATx classic can quickly reveal opportunities for change and improvement of integrated care.

Learn more by completing the free, on-demand online courseNIATx Change Leader Academy: Rapid-Cycle Testing for Teams available on

Mat Roosa, LCSW-R

Photo of Mat Roosa, LCSW-R

Mat Roosa, LCSW-R

Mat Roosa is a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant and trainer in the areas of process improvement, evidence-based practices implementation, and organizational development and planning. Mat’s experience also includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human services agency administration.

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The opinions expressed herein are the views of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, CSAT or the ATTC Network. No official support or endorsement of DHHS, SAMHSA, or CSAT for the opinions of authors presented in this e-publication is intended or should be inferred.