How Behavioral Health Organizations Can Positively Impact Communities Effected by Prescription Drug Abuse

1. How Behavioral Health Organizations Can Positively Impact Communities Effected by Prescription Drug Abuse Doug Leonardo, LCSW Executive Director Tracey Kaly, LMHC Clinical Services Manager

2. Learning Objectives • Learn about state/local prescription drug abuse data related to mortality rates, neonatal abstinence syndrome and pain clinic monitoring. • Learn a minimum of 3 ways a behavioral health center can support their local community. • Learn some of the steps needed to develop an integrated care model to provide behavioral health services onsite in specialty care sites (e.g.; pain management clinics, health clinics, primary care offices and hospitals).  

3. Agenda • Who We Are • State and Local Data Trends • Supporting Your Local Community • Building an Integrated Care Model

4. Who We Are • BayCare - large community-based non profit health care system in Florida • Located in Tampa Bay Region • Network of hospitals and outpatient facilities • 22,000 team members • We are the behavioral health service provider for the BayCare Health System • Full continuum of adult and children's behavioral health services • Services provided in 5 counties in Tampa Bay area

5. Addiction • …a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing the development and manifestations. It is characterized by behaviors that include one or more of the following: • Impaired control over drug use • Compulsive use • Continued use despite harm • Craving • (American Society of Addiction Medicine, 2001)

6. State Data 10 Year Trend Upward in Prescription Drug Abuse

7. State Data Overdoses – Opiates and Benzo’s Florida counties with high rates of opiate overdoses Florida counties with high rates of benzodiazepine overdoses

8. State Data Hospitalizations and Emergency Department Visits for Unintentional Rx Drug Poisonings Source: Agency for Health Care Administration Emergency Department and Inpatient Hospital Datasets

9. Oxycodone Suspected Suicides 326% Increase January 20, 2011 Florida Poison Information Center Tampa

10. Oxycodone Cases 264% Increase January 20, 2011 Florida Poison Information Center Tampa

11. State Data Drug Overdose Deaths 2003 - 2009 • Death rates for all substances increased with the exception • of heroin and cocaine. Heroin decreased 62.2% Cocaine decreased 10.8% • Death rates for prescription drugs increased 84.2%. • 7.3 to 13.4 per 100,000 • Substance specific death rates. • Oxycodone rose 264.6% • Alprazolam rose 233.8% • Methadone rose 79.2% • Ethanol rose 81.4% • Source : MMWR July 8, 2011/60 (26);869-872

12. Prescription Drug Monitoring Program (PDMP) • Florida lacked a system for monitoring drug prescriptions until Governor Scott signed a bill into law on June 3, 2011; • The law strengthens reporting requirements to a prescription drug database, increases penalties for overprescribing, tracks wholesale distribution of specific controlled substances, bans most doctors who prescribe narcotics from dispensing them and provides funding to support law enforcement and state prosecutor efforts; • Attorney General Pam Bondi has made prescription drug abuse her top priority; • 98 of the top 100 doctors dispensing Oxycodone nationally are in Florida – concentrated in the Miami, Tampa and Orlando regions.

13. Prescription Drug Monitoring Program (PDMP) • The state of Florida has established a program that will improve patient quality of care and reduce controlled prescription drug abuse and diversion. • The PDMP will reduce the chances for patients to repeatedly and illegally divert prescription drugs. • Overall the program will dramatically reduce doctor and pharmacy shopping.

14. Local Data - Pasco County Prescription Drug Abuse Becomes Priority • Parents began calling local substance abuse coalition (ASAP) to get involved; • Legislators asking for community members to get involved; • Law enforcement was highlighting the prescription drug related crimes: (impaired driving, stolen property, drug trafficking, pill mills, etc.); • Detoxification unit seeing unprecedented number of admissions for prescription drug dependency (specifically females aged 18 to 40); • FYSAS indicated increase in prescription drug use by students; • Pill mills and drug trafficking arrests increased significantly in Pasco County; • Pain Management practitioner reached out to local provider and coalition to become part of the solution.

15. Local Data - Pasco County Lethal Level of Drug Present at Death According to the Medical Examiner, there were 103 deaths from Oxycodone alone in 2010. District 6, which consists of both Pasco and Pinellas Counties identified higher amounts of prescription drugs tracked by the Medical Examiner at the time of death then any other district in the State of Florida. Primary drug of choice is Oxycontin (30 mg), followed by Xanax. Pasco County is higher than Pinellas County in per capita drug-related deaths. Primary route of delivery; crushing and inhaling, followed by an equal amount of oral and injection. Approximately 80% obtain from “friends” who sell off the streets and approximately 20% steal from a parent or family member who is prescribed.

16. Local Data Pasco County Pasco County has the Highest Rates of Diagnoses of Newborn withdrawal per 1000 live births in the State of Florida. Source: DCF Pinellas and Pasco Counties ranked 1 and 2 respectively in the state of Florida for the number of substance exposed newborns. Pasco saw a 2,840% increase from 5 in 2005 to 147 in 2010 and nearly doubled the from 2009 to 2010 (75 to 147 respectively). Data obtained from the Florida Agency for Health Care Administration (AHCA)

17. Local Data - Pasco County • 63.2% of the 399 women ages 18 - 40 (child bearing age) that entered treatment, reported a prescription drug as their primary drug of choice in Pasco County (BayCare Behavioral Health 2009 - 2010). • 4.1% of Pasco County high school students report past 30-day use of prescription pain relievers (2010, Florida Youth Substance Abuse Survey). • In 2008 in Pasco County, there were 159 ER visits for an Opioid related incident. There were 86 overdoses of Benzodiazepine and 20 overdoses involving other tranquilizers (2008 Agency for Healthcare Administration). • The number of female inmates in Pasco Sheriff’s County jails that are pregnant and have substance abuse problems with prescription drugs is increasing. • 59% of Pasco residents feel that there is not enough enforcement of prescription drugs (2010 Pasco Alcohol Policy and Prescription Drug Use Survey).

18. Supporting Your Local Community:What Can I Do As a Provider? • Gather data to prioritize the public health problem related to prescription drugs; • Start a local Initiative with rapid action planning; • Join learning collaboratives and list serves; • Leverage grants and other funding initiatives; • Educate policy makers, funders, providers, individuals, families and communities about the public health issue and advocate for policies to reduce morbidity and mortality rates; • Explore with local community the recovery supports for supportive housing, activities of daily living, phone outreach, peer mentors, recovery coaches wellness centers, etc.; • Focus on what happens BEFORE and AFTER primary treatment with greater emphasis on the physical, social and cultural environment in which recovery succeeds or fails;

19. Supporting Your Local Community:What We Did as a Provider • Leverage collaborative initiatives to combat epidemic (coalition’s, stakeholders, specialty clinics, legislators, law enforcement, etc.). • Frame your system of care with a focus on integrated carepartnerships (FQHC, health clinics, primary care, specialty care clinics, hospitals, emergency departments, etc.);

20. Collaborative Initiatives • In 2010 we created a Prescription Drug Initiative to address the growing number of individuals seeking treatment for prescription drug use, increased deaths related to prescription drug use, increased substance exposed newborns and the increased number of unauthorized pain management clinics in Pasco County. • Focus was to review, research and make recommendations on how to address the increasing prescription drug problems within our community. • Committee was composed of law enforcement, treatment providers, parents, judiciary, pain clinics and community partners. • One of the recommendations from that effort was the development of a proposed innovative project to assist Pasco County in the epidemic fight against prescription drug use. • The proposed project would harness six environmental strategies that would bring about community change that was adopted as a useful framework by the Community Anti-Drug Coalitions of America (CADCA). • Provide Information - Enhance Skills - Provide Support - Change Consequences • Change Physical Design - Enhance Access

21. Collaborative Initiatives

22. Collaborative Initiatives • Sample Description of Activities • Provide Information • Community Forums, Marchman Act training, prescription drug tool kits and social norms marketing campaign, etc. • Enhance Skills • Prescriber training, parent and youth summit, student and faculty training, motivational interview training, screening and intervention training, community education, etc. • Provide Support • Prescription drug information line, medication disposal pill drop boxes, Rx drug safes, etc. • Change Consequences • Pain clinic best practices, pain clinic compliance, pain clinic drug screenings, enhance drug court Ambassador Program, etc. • Change Physical Design • Intelligence Led Policing enforcement activities, Take Back events, etc. • Enhance Access • Outreach, care management, community education, substance abuse screening tools, expanded treatment capacity, etc.

23. Integrated Care Partnerships • “Integrated care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their medical care providers.” • “It allows patients to feel that, for almost any • problem, they have come to the right place.” • Alexander Blount, Ed.D.

24. Why do Integrated Care? • To strengthen collaboration between behavioral health and health care; • To reduce cost and utilization factors; • To improve outcomes, access to care and engagement; • To integrate population based care into system redesign; • To prepare for payment reform and overall system redesign; • Because with reform primary care and behavioral health services must be available in all clinical settings; • Because behavioral health settings must have streamlined access to medical services; • Because all healthcare settings must have care coordination capability in the continuum based on case mix and severity; • Because it is the right thing to do.

25. How do I get started?Building an Integrated Model Establish administrative and clinical leadership “buy-in”; Create a sense of urgency; Establish an Integrated Care Initiative; Complete an environmental scan - readiness assessment; Benchmark the perception of healthcare professionals regarding integration; Design and deploy strategically (PCP, FQHC, Hospitals, ED, Pain Clinics, etc.); Identify and address funding/financial barriers; Develop and revise business modeling/practices; Seek partners who bring needed expertise or consultation; Commit on transformation from volume to value.

26. Qualities of an Integrated Model • Culturally competent • Stepped care approach • Shortened sessions • Condensed treatment pathways • Multiple delivery formats

27. Benefits of an Integrated Model More likely to keep appointments Treat person where they feel comfortable Focus on preventative care Offset medical cost On site behavioral services available Better communication Better outcomes Mind/body connection Whole person approach

28. Measure, Measure, Measure • Develop metrics (satisfaction, efficacy, productivity, cost, access, utilization, capacity, health indicators, etc.)

29. Not one size fits all (cultural tailoring, developing common language, variance in population based needs, training, etc.); Quality outcomes and measurement are vital (future pay structure, integrated record, reliable data, etc.); Care management/coordination imperative (break down silos, use skills with care management, cross train, home based practice, patient education coaching, focus on raising health of population, etc.); Payment alignment and reimbursement is challenging (transforming from fee for service model to delivering model of brief care, internal and external barriers, minimal current state flexibility, minimal consultation reimbursement/care management/ telephone contact, pursuit of cost offset not immediate, etc.); Access and the ability to ramp immediately based on the unmet demand by primary care is urgent (physician demands, access to care, multiple primary sites, psychiatric evaluation requests, etc.); Changing the system of care is essential (finding the right staff, brief stepped care approach, pathway driven model, limited short sessions with focus on triage, group preventive care with focus on at risk patient, linkage to specialty care clinics for diversion of high risk patients, emphasis on early identification, etc.); Key Findings and Challenges ofIntegrated Care

30. Key Findings and Challenges of Integrated Care Cultural competencies are critical (recognizing differences, assessments/screenings/interventions are appropriate, linkage to community support services, etc.); Sustainability is crucial. Data and Outcomes (integrated electronic health record, measurement moving from encounters to overall health outcomes, increased productivity for physicians, patient/family satisfaction will be driver of long term market differentiation, change in care being based on managing health of population. physician satisfaction, quality of life increased, identifying and documenting added values, payment for those of us that deliver, etc.).

31. Four Level Integration Model Staff Model Integration Level 4 Deep Integration Co-Located Level 3 Basic Integration Co-Located Level 2 Basic Collaboration At-a-Distance Level 1

32. ACCESS Staff Model Integration Single Site One Reception One Visit for All Needs Specialty Care Referrals Deep Integration Co-Located Single Site Same Reception Warm Handoff Referral Specialty Care Referrals Basic Integration Co-Located Single Site Separate Reception On Site Paper Referral Basic Collaboration At-a-Distance Separate Sites 2 Front Doors Referral to BH Clinic

33. Staff Model Integration SERVICES 1 Prescriber 1 Treatment Plan Fully Integrated Licensed Clinician in Staff Model 1 Treatment Team Patient Prevention - Wellness Groups Integrated Care Manager On Site In Home Clinical Services Available Integrated Appointment with PC Deep Integration Co-Located 2 Prescribers with On Site Psych. Consult 2 Treatment Plans with Integrated Goals Licensed Clinician On Site Multi Disciplinary Treatment Team Staffing Patient Prevention Groups Same Day Appt. as Primary Appointment Referrals Made to Case Management Basic Integration Co-Located Basic Collaboration At-a-Distance 2 Prescribers with Psych. Phone Consult 2 Treatment Plans with Information Sharing Licensed Clinician On Site Informal On Site Staffing Patient Prevention Materials Distributed Scheduled Appointments for BH On Site 2 Prescribers 2 Separate Treatment Plans Licensed Clinician At A Distance Phone Consultation for Staffing

34. VALUE ADDED PRACTICES Staff Model Integration Integrated Clinical/Critical Pathways Brief Therapy Model and SBIRT Model Motivational Interviewing Care Management Model Care Manager Conducts Screenings Team Monitoring Health Conditions Psychiatric Training Patient Centered Medical Home Manage Multiple Chronic Conditions Deep Integration Co-Located Basic Integration Co-Located Integrated Clinical Pathways Brief Therapy and SBIRT Model (4-8 sessions) Motivational Interviewing On Site Clinician Conducts Screenings Joint Monitoring Health Conditions Psychiatric Training Basic Collaboration At-a-Distance Specialized Clinical Pathways Brief Therapy Model (15 - 30 minute sessions) Motivational Interviewing Screening Tools On Site (e.g. PHQ9, CAGE) Traditional Clinical Pathways Traditional Therapy Models Motivational Interviewing

35. Try to avoid this……

36. What’s Next?

37. QUESTIONS • Contact Information • Doug Leonardo, LCSW • Tracey Kaly, LMHC • BayCare Behavioral Health • 8132 King Helie Blvd. • New Port Richey, Florida 34653 • douglas.leonardo@baycare.org • tracey.kaly@baycare.org