Integration of Mental Health, Substance Abuse, and Primary Care Presented by Dianne Sceranka, RN

1. Integration of Mental Health, Substance Abuse, and Primary Care Presented by Dianne Sceranka, RN Veronica Camacho, LCSW And Daniel Peters, Alcohol and Drug Counselor

2. Integrated Healthcare Team Dianne Sceranka, RN Clinic Manager, Integrated Healthcare Veronica Camacho, LCSW Jose Herrera, SW /Case Manager Daniel Peters, Certified Alcohol and Drug Counselor

3. Overview of Integrationin the County of San Bernardino Project started in 2007 Second site and Alcohol and Drug added 2010 Departments involved: Behavioral Health Public Health Arrowhead Regional Medical Center

4. Services Provided • Brief Solution Focused Therapy • Targeted Case Management • Linkage to community resources and benefits • Trauma Resiliency Model • Substance Abuse Counseling and Linkage to Treatment • Comprehensive Pain Management

5. Model Used Warm Handoff from Physical Healthcare Provider to a member of the Integrated Healthcare Team • Preferred method • Any Provider • Establishes a relationship Paper referrals

6. Important Components • Relationship Building to promote the warm handoff concept Team Members Providers and the Team Members Clinic Staff and the Team

7. Communication • Weekly Team Meetings with case discussions • Problem solving and utilization of the skills provided by each discipline • Provide feedback to Providers-can be written or verbal

8. Development of Teamwork • Addition of second site with focus on Primary Care • Addition of Alcohol and Drug Services to a Program providing Mental Health Services • Awareness of the capabilities of the Team Members • Willingness to cross over traditional boundaries

9. The Problem • Prescription Drugs • Opiate prescriptions up nearly 50% from 2000 to 2009 • Emergency-room visits, due to prescription drug overdose, rose 500% from 2005 to 2010. (WSJ, Sec D1, 7-5-11) • The numbers keep increasing while a plateau or decrease is not in sight – yet!

10. The Right Question Dr. Niren Raval has asked the right question: “How do we help our patients: • To not escalate doses, • To reduce usage, and • To taper off opioids in nonmalignant pain?” (Dr. Raval is an active Primary Care Provider fully engaged with the Integrated Services at the McKee Family Clinic)

11. The Answer • A female patient receiving adequate dosage of pain medication for lower back trauma ~ • Complaining that her pain was just as bad as in the beginning ~ • Seeking higher dose of pain medication from Doctor ~ • Claims: smoking marijuana helps with the pain ~ • Patient disclosing chaos in her life revealed lack of coping skills ~

12. The patient was adequately dosed for her lower back trauma at the existing dosage, however, • The lower back pain had caused unresolved emotional pain to ‘come back to life’. • This unresolved emotional pain became added to her body pain. • This additional pain was thought to be increasing pain from the original trauma thus requiring an increase in pain medication.

13. The Patient Was Informed • That her pain medications were at the proper levels, and • That her body trauma had activated her unresolved emotional pain, thus mingling them together. • That these two different pain sources require two different treatment approaches – medical and emotional. • That by adding counseling / therapy for the emotional component, along with medical treatment, the pain quotient can be reduced.

14. Comprehensive Pain Management • Many patients that are properly treated with pain medications, seek higher levels to deal with “a pain that won’t go away.” • Over time, if dosage levels are increased, the patient develops a tolerance and can become addicted. • The awakened emotional pain appears to express itself through the point of the traumatic injury. This causes the patient to believe the dosage of pain medication needs increasing.

15. This “pain that will not go away” is the awakened emotional pain that exacerbates the original body trauma pain. • Pain medications are designed to treat body pain, not emotional pain. As this service evolved, we added an intervention to address the underlying, unresolved emotional trauma - TRM

16. Trauma Resiliency Model • We integrated this important tool when addressing chronic pain. • “TRM is a skill based intervention focused on stabilizing, reducing and/or preventing the symptoms of traumatic stress.” Developed by TRI (Trauma Resiliency Institute) founders Elaine Miller-Karas and Laurie Leitch.

17. The Goal To work with patient and PCP to; • Not escalate doses • Reduce usage • Tapper off opioids in those with nonmalignant pain by using newly learned coping skills combined with resources of the Integration Team, the patient has a stable platform for recovery

18. Each Case is Individualized • Although there appears to be general features common to most CPM patients, it is important to individualize treatment. • There is not a ‘one-size-fits-all’ answer.

19. Coordinated Services • The CPM patient may receive counseling from the Clinical Therapist or Drug & Alcohol Counselor • Service is determined at the time of screening • Drug Counselor: Counseling dealing with any pain medication due to the potential for abuse / dependence. • Also addressing any life issues normally addressed in traditional treatment settings.

20. Therapist screens, provides care and referral to a higher level of care – if indicated. • The Case Manager acts on any CM needs of the patient. • This CPM is a Wrap Around service for the patient.

21. Program Development Goals • Create a system of blended funding Prevention and Early Intervention MAA/Medi-Cal Funds available through Healthcare Reform • Performance Measures and Outcomes Monitoring

22. Questions? • Contact information: Dianne Sceranka, RN Clinic Manager (909)382-3150 dsceranka@dbh.sbcounty.gov