Developing a Bidirectional Integrated Care System to Treat Dual Diagnosis

1. Developing a Bidirectional Integrated Care System to Treat Dual Diagnosis Center of Excellence for Integrated Care Cathy M. Hudgins, Ph.D., LPC, LMFT

2. “Do I contradict myself. Very well, I contradict myself. (I am large. I contain multitudes).” • Walt Whitman, 1855

3. The Mind/Behavioral Body Connection • What common issues are related to your clients’ MH/SA? • What factors impede adherence and recovery? • What parts of your client’s whole-person health are outside of your scope of practice? • What do you want and need to know about the other parts of your client’s whole-person health to fully address the whole person in front of you? • How you can help other providers understand the whole-person needs of your client?

4. What is Integrated Care? • Assumes that health is a shared community responsibility and can be achieved through the dissolution of barriers that result in silo-style service provision (Mauer & Jarvis, 2010). • Mental health and medical care providers work together to coordinate the detection, treatment, and follow-up of both the physical and mental health needs of their patients. • Strategic framework stressing team-based care that supports individuals in their whole-person health needs and goals. • Meets the Triple Aim.

5. Whole-Person Care • The majority of people have comorbid mental health and medical problems but donot receive care consistent with established practice guidelines (Institute of Medicine, 2006). • Developing an interdisciplinary cadre of health care providersthat work with patients and their loved ones can ensure that whole-person, evidence-based care is the standard of care (Kaslow et al., 2007).

6. Treating the Whole Person • Physical Health • Emotional/Behavioral Health • Oral Health • Spiritual • Social/Community • Others?

7. The Whole-Person Community Context

8. Why Integrate? • Behavioral health issues affect quality of life • SMI population die at younger ages(25 years less than average life expectancy) than people with non-major mental illness diagnoses (Lutterman et al., 2003). • SMI population less likely to be linked to a primary care home (Collins et al., 2010).

9. Why Integrated Care? ANNUAL MEDICAL COSTS FOR ADULTS Without MHWith MH • All adults $1,913 $3,545 • Heart Condition $4,697 $6919 • High BP $3,481 $5492 • Asthma $2,908 $4,028 • Diabetes $4,172 $5559 Robert Graham Center for Policy Studies in Family Medicine and Primary Care, March, 2008. Information from US DHHS 2002 and 2003 MEPS AHRQ

10. Bidirectional Integrated Care • Bidirectional Integrated Care involves placing primary health care providers into specialty mental health settings. • Levels of bidirectional integration are also on a continuum. • Primary Care services do not replace the need for more intensive, specialty care. The focus is on targeted medical issues for the population in the setting (Mauer & Jarvis, 2010).

11. Benefits of Bidirectional Integration Research shows benefits ranging from: • Lowered long-term healthcare costs; • Decreased outpatient costs; • Dramatic reductions in Emergency Department visits; • Reduced costs to treat high-cost, high-risk patients; • Reduction in inpatient cost, reduction in ER cost, and reduction in total medical cost for substance abuse patients; • Significantly higher abstinence rates for substance abuse patients; • Significantly increased rates and number of visits to medical providers and reduced likelihood of ER use; • Significantly improved quality of most routine preventive services; • Increased receipt of recommended preventive services, and • Increased patient work productivity and reduction in work absenteeism. (Collins et al., 2010; Mauer& Jarvis, 2010)

12. Additional Rationales for Bidirectional Integration • Completes the continuum of care. • Focuses on lifting the barriers to gaining access or receiving primary care services, including the impediments related to negotiating complex health systems. • Bridges the division between physical and mental health, patient-centered care, which calls for “meeting people where they are.” • Traditional primary care settings may not be perceived as a welcoming place to those with mental and behavioral health diagnosis, resulting in poor access and poor health outcomes. • Addresses ineffective referral methods that do not work and that easily disrupt care. (Collins et al., 2010; Mauer & Jarvis, 2010)

13. Common Goals for Bidirectional Integrated Care • Recognition and treatment of medical disorders that exacerbate/interact with psychosocial problems; • Early detection of “at risk” clients, with the aim of preventing further physical deterioration; • Prevention of relapse or morbidity in conditions that tend to recur over time; • Prevention and management of addiction to pain medicine or other medications prescribed to address physical symptoms;

14. Common Goals, cont’d • Prevention and management of work and/or functional disability related to whole-health problems; • Efficient and effective treatment and management of clients with chronic health problems; • Efficiently moving clients into appropriate medical or mental health specialty care when indicated. (Open Door, 2005)

15. Co-occurring Medical and MH/SA Disorders • Gastrointestinal Disorders • Cardiovascular Disorders • Hematologic Disorders • Pulmonary Disorders (Other Than Infectious) • Neurologic System • Infectious Diseases • Other Conditions (SAHMSA, 2006)

16. Disease Model of Addiction • The disease model reflects the progression of the disorder. • At a certain point, the addict loses control over the use (compulsion) • Not a moral choice/not a character flaw (Moral model) • The idea that one may never use again on any level (relapse) • Could be used as an excuse (one of the criticisms) • Relevance of this model • Helps the treatment provider determine the severity and intervention • Helps the addict’s family, friends, coworkers, etc. better understand the progressive nature of the disease and reduces blame and hurt

17. DSM 5 Diagnosis • DSM 5 diagnosis criteria reflects a progression of use. • Usefulness • Challenges • Flexibility • DSM 5 no longer identifies abuse and dependence as distinct disorders – they are identified on a continuum. • Contemporary medical diagnosis criterion is unilateral and should be combined with other factors, such as those included in the DSM to determine the nature of the use and the type of treatment required (Borges, et al., 2010).

18. Individualized Assessment Criteria • The criteria for substance abuse and dependence diagnosis should be individualized • Tolerance • Withdrawal • Social/interpersonal consequences • Culture, age, gender, and other contextual factors • Identification requires a more comprehensive, whole-person view (biopsychosocial model of assessment). • Biological • Psychological • Cognitive • Social • Interpersonal • Developmental

19. Making this Work • Unified whole-person care definition and vision • Policy change on all system levels • Need for cross-training and technical support • Collaborative data collection and analysis to support change • Development of community collaboration and partnerships to address issues outside of the Integrated Care scope of practice • TEAMWORK!!!! • Think outside of your silo – reject the status quo!

20. Teamwork is Key Two Teams (may include some or many of the same members*): • Program Implementation Team • Clinical Team Possible Members*: • PCPs • BHPs • Practice Manager • Nursing Staff • Care Manager/coordinator • Receptionist/support staff • Medical records staff • Risk Management Officer • Others?

21. Needs for Integrated Care in NC North Carolina’s health system is built to meet the needs of the high moderate to severe needs population. • Result: Gap in care for those with emerging or moderate to mild healthcare needs. • Result: Patients with moderate to mild issues divert needed resources away those with the high-moderate to severe issues. Many MH/SA have difficulty navigating and feeling welcome in traditional healthcare settings. • One solution: Integrated Care provides continuity of care in a stigma-free environment for those who need brief, focused treatment for mild to moderate healthcare needs.

22. Concerns and Issues Related to Integrating • Finding referrals for SMI/Chronic SA Populations for more intensive healthcare • Ethical Issues • Scope of the healthcare services • Paradigm Shift • Culture Shift • Others?

23. Who We Are • North Carolina Foundation for Advanced Programs • http://www.ncfahp.org/ • Center of Excellence for Integrated Care • (ICARE) http://www.ncfahp.org/nc-center-of-excellence.aspx Staff: Cathy M. Hudgins, Ph.D., LMFT, LPC -- Director Christine Borst, Ph.D., LMFT -- Clinical Coordinator Maria Dover, M.S., LMFT -- Pediatric Program Manager Peter Rives, M.S. -- Consultant Eric Christian, M.S., LPC -- Consultant

24. Center of Excellence for Integrated Care (ICARE) Who we are: The Center is a multidisciplinary group of experts assembled to promote, support, develop, sustain, and improve local, regional and statewide Integrated Care (IC) efforts.

25. Center of Excellence for Integrated Care (ICARE) What we do: • Consult and provide technical assistance services to support and advance IC services in all types of healthcare and mental health settings. • Present IC information related to best practices to local, state, national stakeholders. • Research and develop resources to facilitate efficient and sustainable whole-person, IC systems. • Maintain an up-to-date clearinghouse of the IC existing and evolving resources, literature and research to support evolving systems.

26. Questions?

27. References • Borges, G., Ye, Y., Bond, J., Cherpitel, C., Cremonte, M., Moskalewicz, J., Swiatkiewicz, G., & Rubio-Stipec, M. (2010). The dimensionality of alcohol use disorders and alcohol consumption from a cross-national perspective. Addiction, 105, 240-254. • Collins, C., Hewson, D., Munger, R., & Wade, T. (2010). Evolving models of behavioral health integration in primary care. Retrieved from http://www.integratedprimarycare.com/Milbank%20Integrated%20Care%20Report.pdf • Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions. Washington, DC: National Academies Press. • Kaslow, N. J., Bollini, A. M., Druss, B., Glueckauf, R. L., Goldfrank, L. R., Kelleher, K. J., ... & Zeltzer, L. (2007). Health care for the whole person: Research update. Professional Psychology: Research and Practice, 38, 278. • Lutterman, T., Ganju, V., Schacht, L., Monihan, K., & Huddle, M. (2003). Sixteen state study on mental health performance measures Rockville: Center for Mental Health Services. Substance Abuse and Mental Health Services Administration. • Mauer, B., & Jarvis, D.(2010). The business case for bidirectional integrated care. Retrieved from http://www.thenationalcouncil.org/galleries/policy-file/CiMH%20Business%20Case%20for%20Integration%206-30-2010%20Final.pdf • Open Door Community Health Center (2005). Open door community health center’s behavioral health program. Retrieved on March 10, 2010 from http://www.opendoorhealth.com/resourceguide.php. • Substance Abuse and Mental Health Services Administration (US). (2006). SAHMSA Treatment Improvement Protocol (TIP) Series, No. 45. Rockville, MD: Center for Substance Abuse Treatment. • Whitman, W. (1860). Leaves of grass. Boston, MA: George C. Rand & Avery.