Presented by: H. Westley Clark, M.D.

1. Presented by: H. Westley Clark, M.D. COD Initiatives at SAMHSA

3. Linking Healthcare and Substance Use Disorders Services: Implications for the Addiction Treatment Field H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services 6th Annual COSIG Grantee Meeting Bethesda, MD  June 28, 2010

4. Past Month Alcohol Use - 2008 Any Use: 52% (129 million) Binge Use: 23% (58 million) Heavy Use: 7% (17 million) (Current, Binge, and Heavy Use estimates are similar to those in 2007) 4 4 4 Source: NSDUH 2008

5. Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2008 Source: NSDUH, 2008

6. Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2008 Felt They Needed Treatment and Did Not Make an Effort Did Not Feel They Needed Treatment (766,000) 95.2% 1.1% (19.8 Million) Felt They Needed Treatment and Did Make an Effort (233,000) 20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use Source: NSDUH 2008

7. Substance Dependence or Abuse among Adults Aged 18 or Older, by Serious Mental Illness in the Past Year: 2008 2.5 Million Adults have Co-Occurring SMI and Substance Use Disorder Source: SAMHSA NSDUH 2008

8. Treatment Admissions: Psychiatric & Substance Abuse Problems Admissions to treatment reporting psychiatric problems in addition to substance abuse problems more than doubled between 1992 and 2007. Source: SAMHSA Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to 2007

9. Past Year Mental Health Care and Treatment for Substance Use Problems among Adults (18+) with Both Serious Mental Illness and a Substance Use Disorder: 2008 Despite the rise in treatment admissions for co-occurring disorders, the percentage of those seeking treatment for both mental health and substance use disorders is still small. Both Mental Health Care & Treatment for Substance Use Problems 45.2% 11.4% Mental Health Care Only 3.7% Treatment for Substance use Problems Only 39.5% No Treatment Note: The percentages add to less than 100% due to rounding. Source: NSDUH 2008

10. Treatment Challenges for Co-occurring Disorders • Mental health services tend not to be well prepared to deal with patients having both mental health and substance abuse problems. • Often only one of the two problems is identified. • If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them. • Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders. Source: National Alliance on Mental Illness, retrieved 06/21/10 from http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049

11. Outpatient Mental Health Services - 2008 17 Million adults (18+ years) seen for outpatient MH treatment/ counseling: 4.2 million seen by Primary Care Source: 2008 NSDUH

12. Substance Abuse Treatment in 2008 7.5 Million adults (12+ years) seen for substance abuse treatment: 1.7 million seen by Primary Care Source: 2008 NSDUH

13. Community Health Centers • Health Resources and Services Administration (HRSA) supported Health Centers provide comprehensive, primary health care services to underserved communities & vulnerable populations. • In 2007, 1080 Community Health Centers (CHC) reported seeing 17 million patients. • Mental health services were provided to 677,213, and substance abuse services to 92,406 – approximately 4% of total patients receiving services. Source: HRSA National Total Summary Data, Retrieved 6/24/2010 from http://hrsa.gov/data-statistics/health-center-data/NationalData

14. Community Health Centers (cont’d) • 2.8% of CHC staff are mental health personnel; 0.7% are substance abuse treatment professionals. • CHCs reported an average of 4.5 encounters for patients with alchol related disorders, • 6.8 encounters for those with other substance related disorders, • 3 encounters for those with depression and other mood disorders • 2.3 encounters for anxiety disorders, including PTSD • 3.1 encounters for ADD Behavior Disorders, and • 3 encounters for other mental disorders (including mental retardation • Were patients linked to other services/organizations? Source: HRSA National Total Summary Data, Retrieved 6/24/2010 from http://hrsa.gov/data-statistics/health-center-data/NationalData

15. What Should the Role of CHCs Be In Integrated Care? • What should the role of CHCs be, given staffing levels? • Are COSIGS linking with CHCs?

16. Benefits of “Linking” Primary and Behavioral Health Care • Improved cross-disciplinary knowledge/understanding • Shared priorities/initiatives • Better integrated management (less siloing) • Braided/blended funding streams • Integrated/linked health information technology (HIT) • Integrated, co-located service delivery • Consolidated reporting of client outcomes

17. Integrated Health Care Integrated health care: • Creates a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for achieving optimal health throughout the life span. • Shifts the focus of the health care system toward efficient, evidence-based practice, prevention, wellness, and patient-centered care, creating a more personalized, predictive, and participatory health care experience. Source: Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit (2009) Institute of Medicine (IOM), Retrieved from http://www.iom.edu/Reports/2009/Integrative-Medicine-Health-Public.aspx

18. The Cost Benefit of Integrated Care • Individuals with co-occurring substance abuse/medical problems randomized to integrated care had significantly lower total medical costs than those in independent care. • Following SA treatment, inpatient and emergency room costs decline by approximately 35% and 39% respectively.¹ • Total medical costs per patient per month decline from $431 to $200.² • One state study found that treatment lead to a decrease in Medicaid costs of about 5% over a 5-year period.³ • Treatment for Medicaid patients in a comprehensive HMO reduced medical costs by 30% per treatment member.4 ¹ Parthasarathy, S. et al. (2001) J Stud Alcohol. 62(1): 89-97 ² Parthasarathy, S. et al. (2003) Med Care. 41(3): 357-367 ³ Luchasnky, B. et al. (1997) Cost Savings in Medicaid Medical Expenses [Briefing Paper] Olympia, WA: Research & Data Analysis, Dept. of Social & Health Svcs.4 Walter, L.J. et al. (2005) J Behav Health Serv Res. July-Sep. 32(3): 253-263

19. Barriers to Integrated Care • Delivery System Design • Physical separation of services, fragmented communication, language differences between systems • Financing • Siloed payment & reporting systems, competition for scarce resources • Legal/Regulatory • HIPAA and confidentiality rules, conflicting mandates at federal, state & local levels, categorical program requirements Source: Report of the California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (2009, October 22) [PowerPoint Slides] Retrieved from http://www.ibhp.org/index.php?section=news&subsection=show_news_details&news_id=80

20. Barriers to Integrated Care (cont’d.) • Workforce • Feared loss of identity and priority • Lack of cross-training • Shortage of providers, need for cultural competence/linguistic capacity • Health Information Technology • Lack of common IT systems, electronic health records (EHRs) often unable to support multi-system information Source: Report of the California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (2009, October 22) [PowerPoint Slides] Retrieved from http://www.ibhp.org/index.php?section=news&subsection=show_news_details&news_id=80

21. Steps to Improve Primary and Behavioral Health Care Linkage • Recognize benefits and inevitability of improved linkage. • Improve collaboration and cross-training, especially primary care identification of patients with and at risk for substance use disorders. • Focus on holistic health, including prevention and recovery. • Better integrate funding, including federal grants. • Co-locate service delivery where possible. • Enhance referral relationships.

22. Recovery-oriented Systems of Care (ROSC) Approach Outcomes Evidence-Based Practice Employment/ Education Systems of Care Business Community Addictions Reduced Criminal Involvement Cost Effectiveness Child Welfare Services & Supports Mental Health Peer Support Alcohol/Drug Tribes/Tribal Organizations Housing/ Transportation Mental Health Primary Care Community Individual Family Child Care Housing Health Care Wellness Recovery Financial Mutual Aid Vocational Employment Educational Education Stability in Housing Community Coalitions Perception Of Care DoD & Veterans Affairs Indian Health Service Spiritual Civic Organizations Legal Case Mgt Criminal Justice Private Health Care Abstinence Retention Bureau of Indian Affairs Organized Recovery Community Human Services Access/Capacity Social Connectedness Health Ongoing Systems Improvement

23. Federal Efforts to Integrate Primary and Behavioral Health Care 15

24. Affordable Care ActInteragency Collaborative Efforts

25. Other Affordable Care Act BH/PC Integration Efforts

26. Other Affordable Care Act BH/PC Integration Efforts (cont’d.)

27. Other Affordable Care Act BH/PC Integration Efforts (cont’d.)

28. HHS Behavioral Health Integration • HHS Interdepartmental Behavioral Health Committee • SAMHSA/HRSA Collaboration, e.g., National Health Service Corps and MAT • Health Reform regulations/CMS • Expanding and integrating SBIRT services • Medical residency curriculum development (SBIRT) • Health information technology development/ONC

29. Collaboration/Integration within SAMHSA 21

30. SAMHSA’s Strategic Initiatives • SAMHSA’s strategic initiatives focus on behavioral health and crosscut the Centers. • The goal is to improve lives and capitalize on emerging opportunities, align resources, and create a consistent message. • They are works in progress that will continue to benefit from public input and reflect the concepts of open government.

31. SAMHSA’s Strategic Initiatives • Prevention of Substance Abuse & Mental Illness • Trauma and Justice • Military Families – Active, Guard, Reserve, and Veteran • Health Insurance Reform Implementation • Housing and Homelessness • Jobs and the Economy • Health Information Technology for Behavioral Health Providers • Behavioral Health Workforce – In Primary and Specialty Care Settings • Data Quality and Outcomes – Demonstrating Results • Public Awareness and Support

32. Enhanced Collaboration within SAMHSA • Close integration of work as part of SAMHSA-wide behavioral health approach • Cross-unit collaboration on 10 Strategic Initiatives • More jointly funded grant programs (braided funding) • Better integration of substance abuse and mental health within other efforts (Recovery Month, TIPS, data systems, etc.)

33. SAMHSA Braided Funding • Resources from two or more programs used to support single program effort (RFA) • 2010 example: mental health “placed based” Community Resilience and Recovery (CRRI) grants combined with SA treatment drug court funds • Funds must maintain separate identities • Co-project officers from contributing sources • Emphasis on comprehensive behavioral health will require increased collaboration at local level.

34. Jointly-Funded/Managed Programs 2010 • Community Resilience and Recovery Initiative, $4.2M (CMHS and CSAT) • Training/TA Center for Primary and Behavioral Health Integration, $2M (SAMHSA and HRSA) • Adult Drug Courts, $10M (SAMHSA and DOJ) 2011 • Substance Abuse and Mental Health SBIRT, $15M (CMHS and CSAT) • Integration of behavioral health into FQHCs, $25M (HRSA, VA, SAMHSA) • Others expected for 2011

35. Summary • This is a critical time for the future of all federal health programs, including behavioral health. • Health care reform and other initiatives will inevitably result in primary and behavioral health integration. • It is essential to begin now to foster enhanced linkages. • Emphasis will continue to be on improved system efficiency and performance within a patient/client centered, holistic approach.

36. Thank you.