Integrated Care and Substance Abuse Treatment Services: What Are The Issues?

1. Integrated Care and Substance Abuse Treatment Services:What Are The Issues? Mady Chalk, Ph.D. MSW The Chalk Group MD Behavioral Health Conference May, 2012

2. Paradigms ….… INTEGRATION

3. New words/phrases for today • Work at the top of your license • Interprofessional, transprofessional teams • High reliability organization • Five A’s • Six T’s • Teams know what each other do and monitor each others performance so they can backfillat a moment’s notice

4. Background:Integrated Care • PC/MH/SA interwoven • MH/SA less burdensome to PC • Treatment gap reduced • Access easier • Decreased stigma • Feasible • Cost effective • PC/MH/SA separate silos • Information rarely shared • Confidentiality • Cultures and pace quite different • Payment and parity

5. Forces for Integration • Increased recognition of issues related to co-occurring MH/SA disorders • Increased awareness of the role substance use plays in the treatment and management of other chronic conditions • Increased use of disease management for all chronic health disorders • Development of evidence based practices for SUDs treatment in primary care: SBI, medication assisted treatment • Health reform, including MH/SA parity

6. Forces for Integration: Continually growing evidence of co-morbidity and costs • SA increases risk for hypertension (x2) to congestive heart failure (x9), pneumonia (x12)*. • Inhalant use among 12-17 and depression. • Pts in chemical dependency program 18 X more likely to have major psychosis, 15X depression, 9x anxiety disorder. • HIV pts with SA more likely to be non-adherent. • Medicaid pts with SA more likely to be readmitted to hospital within 30 days. • Increased rate of complications with hip replacement. • Pts treated with alcoholism meds had fewer detox, alcohol related inpatient days and ER visits. • High cost Medicaid recipients with HIV; Avg annual cost $157,000; 40% for treatment comorbidities, MH/SA most common. • SA patients with SA related medical disorders, cost savings in integrated treatment. * Narcotic addiction

7. Washington State Estimates: Health reform, Medicaid expansion and increased treatment demand N=381,300 53% N=21,042 N=23,974 N= 159,000 Estimate based on 2008 State Pop Survey Disability lifeline and ADATSA Clients SFY 2009

8. Models of Integrated Care Target population, provider and service capacity, financing, regulatory restrictions

9. Five A’s • Assess: Systematic routine assessment • Advise: BH issues important to health care • Agree: Patient/clinician common ground • Assist: Self-management/problem solving/coping skills/recovery support/referrals • Arrange: 1 month follow-up after initial intervention with successively longer intervals as needed Whitlock, EP, Orleans CT, Pender N, Allan J. (2002) Evaluating Primary Care Behavioral Counseling Interventions, Am J Prev Med 2002, 22:267-284

10. Six “T” Barriers Other barriers to integration: Geographic (often not co-located) Financial (funding streams and payments) Organizational (difficulty sharing information and expertise) Cultural (provider focused rather than patient focused) VanHook S, Harris SK, Brooks T, CareyP, Kossack R, Kulig J, Knight JR, New England Partnership for Substance Abuse Researcj. J Adolesc Health, 2007, 40:456-61; Druss BG, Newcomer,

11. Barriers to Medication Assisted Treatment • Acceptance by SUD treatment field? • Insufficient time: multiple needs • Physician competence and comfort • Lack of training in medical school • Exposure to active untreated persons • Limited number of role models • Pharmacotherapies for addiction seen as more difficult than other meds • Not wanting patients in clinic offices and waiting rooms

12. From here….To there • Can’t just drop existing forms of practice into primary care. • Shift from focus on the individual to focus on the target population • Use brief, focused interventions • Facilitate patient self management, care management as part of comprehensive treatment • Credentialing - e.g., credentials needed for reimbursement by Medicaid • Multiple payers though total funding may remain the same • Education/training /supervision need to be improved • After hours coverage • IT

13. Workforce • Insufficient in number now; may get worse • Uneven preparation • ??? preparation in understanding addictions and substance use treatment approaches • ??? Preparation to work in a health/disease model • ??? Preparation to have work driven by data • ??? preparation to work in integrated health care environments • Different environmental cultures, workflow • Team skills

14. Enhanced Skill Set • Evidenced based practices • Interpersonal skills: • Communication • Conflict resolution • Teamwork • Quality Improvement Skills • Use of data to drive changes in practice • Technology competence • Understanding performance and accountability metrics

15. State GovernmentCounselor Requirements Kerwin ME, Walker-Smith K, Kirby KC. Comparative analysis of state requirements for the training of substance abuse and mental health counselors. JSAT, 2006 30:173-181.

16. MH/SA Counseling Course Requirements

17. High Reliability Organizations and Teamwork • High Reliability Organizations ( HRO’s) Operate in complex, hazardous environments making few mistakes over long periods of time, but consequences of mistakes are serious. • IOM’s Report on Safety: To Err is Human Need for enhanced team work to improve safety and quality • Health care teams: Distinct roles, interdependent tasks, common goal: improve health of patient

18. Effective Teams • Team leadership • Back-up behavior • Mutual performance monitoring • Communication adaptability • Shared mental models • Mutual trust • Team Orientation Baker, DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations, Health Services Research, 2006, 41:1576-1598.

19. New Roles In Integrated Care • Health Educator • Behavioral Health Specialist • Expanded Care Manager • Consultation-Liaison—It’s Back • Community Health Worker • Patient Navigator

20. Dissemination: A major challenge All SBIRT is not created equal • Practices randomized to condition • Written guidelines 39% • Outreach training 74% BUT • Training and telephone support 71% Written guidelines screened/intervened less often than outreach training and training with telephone support, but written guidelines displayed least error. • Greater need for training in screening has been noted in those with less field experience and among nurses and social workers. KanerE, Lock C, Heather N, McNamee P, Bond S. Promoting brief alcohol intervention by nurses in primary care: a cluster randmoized controlled trial. Patient Education and Counseling, 2003, 51:277-284. Vanderbilt, J, Hall MN, Shaffer HJ, Higgins-Biddle JC. Assessing substance abuse treatment provider training needs: screening skills. JSAT, 14:16

21. Evidence Based Training and Dissemination • Expert led intensive workshops, followed by clinical supervision may lead to greater success in adoption of motivational interviewing. (Martino et al, 2007) • Two critical success factors for team training: facilitate application of teamwork skills on-the-job and measure the effectiveness of the team training program. (Salas et al, 2009) • Comparison of conventional and integrated training models in community settings suggest that medical residents trained in integrated settings are more likely to consult or plan treatment with a BH provider and report that their training prepares them to manage BH issues in their practice. (Garfunckel et al., 2011)

22. Financing • Capitated whole payments (MCO’s. HMO’s, PCHC) • Cost reimbursement: FQHC’s • Ambulatory care groups • Consultation/coordination reimbursement • Defined programs • Team/network payments • Layered with FFS FIX • Same day restrictions • Lowest cost provider at top of license • Facilitate billing changes • Push for universality among all payers

23. Key Elements: • Adequate training in SUD’s and complex team interactions • SUD counselors necessary competencies and meaningful certification/licensure • Broad and high quality adoption of SBIRT and Medication- Assisted Treatment • Evidence-Based training methods for evidence based practices and team competencies with follow-up.

24. Successful Integration • Clinical/administrative champion • Culture shift • Value outcome orientation • Cross disciplinary training and accountability • Use of care managers • Consolidated/articulated clinical records systems • Multi-disease total population focus • Active and respectful coordination of co-located interdisciplinary clinical services • Clinical, organizational and financial support* • Capacity and implementation monitoring/evaluation Kathol RG, Butler M, McAlpine DD, KaneRL. Barriers to physical and mental condition integrated service delivery. Psychosomatic Med 2010 72:511-8

25. THANK YOU For more information contact: Mady Chalk, Ph.D., MSW mchalk40@gmail.com