The Valley Specialty Center – part of the Santa Clara Valley Health & Hospital System

1. The Valley Specialty Center – part of the Santa Clara Valley Health & Hospital System

2. Santa Clara Valley Health and Hospital System Department of Alcohol & Drug ServicesIntegrated Care Projects Update

3. Santa Clara County—Quick Facts • Population: 1.8 million (larger than SF) • White 37% • Asian 30% • Hispanic 26% • Black 3% • Foreign Born: 40% (One of 10 U.S. counties where more than 50% of residents speak a language other than English at home) • Income: $75K median, 10th in US, but . . . . • < $25K 13% • $25-45K 15% • $45-100K 37% • > $100K 35% 28% of families earn less than local poverty threshold

4. Governance and Organization Voters Board of Supervisors Health and Hospital Committee Santa Clara Valley Health and Hospital System Valley Medical Center Drug & Alcohol Public Health Mental Health Valley Health Plan

5. Department in Santa Clara Valley Health and Hospital System • Safety-net system for County of Santa Clara • VMC has 574 licensed beds • 9 Valley Health Center Clinics • 3 Urgent Care Clinics • 17 Network Neighborhood Clinics

7. One in four Santa Clara County Residents are served by SCVMC • Greater than 220,000 unduplicated patient count (increase of 60% in 10 years) • Busy Emergency Department (24 beds) seeing 70,000 visits • 700,000 Ambulatory Clinic visits yearly

9. Two projects were initiated in 2010 that incorporated the core components of screening, brief intervention treatment, and referral (SBIRT). • Moorpark Medical Home: A pilot project within one of three similar primary care settings that will demonstrate that when substance abuse services are integrated with primary medical care both medical and substance use outcomes are improved. • Alexian Integrated Care Project: Integrate the DADS addiction medicine division with the Valley Health Homeless primary care program at Alexian. DADS is also planning to conduct pilot studies on an array of various addiction medicines in addition to those being used for opioid addiction. These would include naltrexone, acamprosate, odansetron, topiramate, and disulfiram.

10. Project Goals As a result of both initiatives, DADS is planning to see: medical and substance use problems both show better improvements when treated in an integrated way; patient compliance with their medical care plan and substance abuse treatment plan will improve; a decrease in over-utilization of limited medical services; and demonstrated cost offsets and savings through the health system as a result

11. Partnership Development Process • Moorpark Medical Home • Regular planning meetings were held in order to co-develop the logistics with medical clinical staff. • Screener form development processes occurred to integrate into the medical system • Securing permanent office space for the addiction specialist • Selection of a screening test and a substantial training for the medical staff on the importance of routine screening for SUDs in all patients. CAGE-AID is the screening tool being used. • Addressing 42 CFR issues that can impede integration

12. CAGE-AID QUESTIONNAIRE • Patient Name _____________________________ Date of Visit __________________ • When thinking about drug use, including illegal drug use and the use of prescription drugs other than prescribed, • Questions Yes No • Have you ever felt you ought to cut down on your drinking or drug use? • Have people annoyed you by criticizing your drinking or drug use? • Have you felt bad or guilty about your drinking or drug use? • Have you ever had a drink or used drugs first thing in the morning to • steady your nerves or to get rid of a hangover (eye-opener)? • Reviewed By: _____________________________ Date: __________________ • Disposition:

13. Moorpark Patient Flow Through Primary Care and Referral SCREENING Administering the CAGE-AID: Screen all patients for SUDs using the CAGE-AID. Patients can self administer the screen, although be mindful of language/reading concerns. Offer assistance. Inform patients that this is now being asked of all patients in order to help accomplish their healthcare goals Place completed screen in patient chart for physician review in exam room CAGE-AID Action Steps: Physicianreviews results of positive screen with pt and clarify/confirm quantity, frequency, and duration of use. Score 1: Possible SUD. Physician reviews and discusses w/ pt Score 2: Probable SUDs or at-risk use. Physician reviews and discusses w/ pt and refers for assessment Score >2: Suspected high SUDs. Physician reviews and discusses w/ pt and refers for assessment Patient education about use and medical dx Explain how health problems can be caused by or exacerbated by drug/EtOH use. Monitor and review use patterns at f/u visits Assessment and ASAM level of care (LOC) placement. If LOC 0.5 - 1.0, use brief intervention/brief tx on site at Moorpark If LOC > 1, consider referral to DADS system of care At-risk use unchanged or increasing, refer for Brief Intervention/Brief Tx (ASAM 0.5—1.0) Brief intervention unsuccessful Refer to treatment admission in DADS (ASAM > 1) Pt refuses treatment Successful brief intervention (may need to be repeated as circumstances change). Motivation interviewing and watchful waiting Continued follow-up and relapse prevention for SUDs

14. MOORPARK DADS REFERRAL FORM Pt alt contact #______________ CAGE-AID score____________ Referring physician (please print)_________________________ Date of referral______________ PCP (if different from referring provider above):_________________________________________ Referring Clinic:______ Moorpark Care Team Reason for Referral (check all that apply): ___Worsening of patient’s medical condition (s) due to ongoing substance abuse ___Difficulty adhering to treatment plan due to substance or prescription abuse ___New relapse/near-relapse of substance abuse, request help connecting to programs ___Obtain prior and/or current treatment plan from substance abuse program ___Request assistance communicating with treatment program ___Other: Chronic conditions: Current meds (list here or attach printout from ELMR): FAX TO DADS LCSW:_For DADS use: Please circle: Date form rcvd:___/____/____ Y N DADS release form attached 1st attempt contact pt__/__/___ 2nd attempt contact pt_ _/__/__

15. Outcomes • Moorpark Medical Home • DADS established a data dashboard to document outcomes compared to the non-medical home settings. • Measures include: # of patients, % SUD screened, % assessed and diagnosed, % received patient education and brief intervention, % referred to DADS for treatment, % referred to the continuous recovery model post treatment and the number active in post treatment. Preventative Care and Patient Satisfaction will also be measured.

16. SANTA CLARA COUNTY • DEPARTMENT OF ALCOHOL & DRUG SERVICES DASHBOARD • Data collected continuously but reported on a quarterly basis • Bi-monthly Report # ____ From ______ to ______ • CLINICAL QUALITY: • Addiction Care Preventive Care • # of pts Tobacco education • % screened for SUDs Information given pts • % referred for assessment TB test • % pt education or Brief Intervention • # Referral to SUD tx • PATIENT EXPERIENCE: • Patient Satisfaction • Pt satisfaction survey: Overall quality of care - % rated as “excellent” • Chronic disease Self-Efficacy Scales

17. Partnership Development Process • Alexian Integrated Care Project • Regular planning meetings were held in order to co-develop the logistics with medical clinical staff. • Addressing 42 CFR issues that can impede integration • Minor construction needed to assist integrating both programs and an increase in patient capacity

18. Outcomes • Alexian Integrated Care Project • Based in part on the Primary Care Behavioral Health model, the Alexian Health Clinic is a fully integrated model where behavioral health is a routine part of the medical care. • Effective collaboration for the Alexian Health Clinic and the Valley Health Homeless Project (VHHP) will improve the quality of care for patients of both programs and will include: • Increased accessibility to needed care through patient referrals (i.e. methadone patients needing primary medical care , VHHP Suboxone patients needing transition to methadone, etc.); • Consultations by Addiction Medicine staff with VHHP and vice versa to patients in common;

19. Outcomes • Alexian Integrated Care Project • In-service trainings on addiction medicine including screening, MI and addiction clinical practice; • VHHP/AMT participation in regular case conference meetings (42 CFR federal confidentiality guidelines restrictions would apply); • Patient education series on substance abuse, co-occurring medical conditions, preventive health care, and medical comorbidities provided; • VHHP representative in weekly AMT clinic management team

20. Barriers • Moorpark Medical Home • Time and place to conduct screening and brief intervention is problematic. • MDs can’t do the full SBIRT, but they can do SRT (screening, referral to treatment). Therefore, it is essential to bring in support behavioral health staff to conduct the pieces in between. • To save some time, patients can complete the CAGE-AID on their own and the MD can review it with them during the exam. • There are no data fields to capture patient information for SUDs in current medical databases. 42 CFR can be a barrier to accomplish this. • During the process of selecting or modifying electronic medical records, and/or modifying procedures stay compliant with privacy regulations, it is important to manually collect data as soon as possible. • Selecting the data measures and collecting data remains challenging (both projects)

21. Plans for Sustainability • Moorpark Medical Home and the Alexian Integrated Care Project • Test out a billing system using LCSW staff who can bill FQHC for Medi-Cal clients.  This is a very high reimbursement rate that may support the full cost of the SUD staff.  • If cost savings can be identified as a result of integrating and treating SUDs, such as reduction in hospitalizations or use of ED for medical care, this would help justify the investment in Tx of SUDs.   • Integration, if successful, identifies that primary care settings are the appropriate place to identify and initiate treatment for SUDs, and this will shift responsibility to the primary care system, thus increasing the likelihood that the services will continue.  If they see value, and recognize their responsibility, they may decide they own it.   • As we get increased Medi-Cal reimbursement from the MCE waiver, and ultimately from health care reform in 2014, the SUD services may have their own reimbursement stream.

22. Project Contacts: Mark Stanford, Ph.D. Division Director DADS Addiction Medicine Division (408) 885-4078 Kakoli Banarjee, Ph.D. DADS research and Development (408) 792-5683