Integrating Mental Health, Substance Use Disorder, and - UCLA ...

Integrating Mental Health,Substance Use Disorder, andPrimary Care Services:An OverviewHoward Padwa, Ph.D.University of California, Los AngelesIntegrated Substance Abuse ProgramsOctober 26, 20111

Overview• What is integration and why is it important?• The integration of mental health (MH) andsubstance use disorder (SUD) treatmentservices to serve the needs of clients with cooccurringdisorders (COD).• The integration of MH, SUD, and CODservices (“behavioral health”) with primarycare (PC).2

Our Current Health SystemPrimaryCareSUDMH3

Our Current Health System• The burden of coordinating care and meeting theservice needs of the population “should rest onthe system, not on the families or consumerswho are already struggling because of a seriousillness”President’s New Freedom Commission, 2003• Goal is go from a system where services aresystem centered to one where they are clientcentered.4

What Integration Can DoSUDPrimaryCareIntegrated CareMH6

Why integrate services for mentalhealth and substance usedisorders?• SUDs are much more common amongindividuals with mental health problems.Total populationMH diagnosis6.5%Serious MentalIllness% of population with a diagnosable SUD19.7%25.7%SAMHSA, 20107

Why Integrate Services for mentalhealth and substance usedisorders?• Mental health disorders are more prevalentamong individuals with SUDs.SAMHSA, 20108

Why Integrate Services formental health and substance usedisorders?• 25-50% of people in the mental health systemhas a co-occurring substance use disorder.• 50-75% of people in the substance use disordertreatment system have a co-occurring mentalhealth disorder.CSAT, 20059

Why Integrate Services formental health and substance usedisorders?• Mental health and substance use problemscomplicate each other.• Individuals with COD are more than five times aslikely to be hospitalized as people with just amental health disorder.• They are more than twenty times as likely to behospitalized than individuals with just substanceuse disorders.CSAT, 200510

Why Integrate Services for mentalhealth and substance usedisorders?Where people with COD receive services11

What can integration of MH andSUD services do?• Improve access to both mental health andsubstance abuse services• Make interventions more focused on clientneeds.• Transfer the burden of coordinating treatmentfrom the client to the system.Drake et al., 200812

What are the ways that MH andSUD services are integrated?MH/SUDConsultationMH/SUDCoordinationFullIntegrationIntegration of servicesNASMHPD-NASADAD, 199913

What are the ways that MH andSUD services are integrated?• Informal relationshipsbetween providers.MH/SUDConsultation• Referrals/linkages toproviders of other specialty.• Consultation generally onidentification of clientneeds, engagement,prevention, and earlyintervention.14

What are the ways that MH andSUD services are integrated?• Formalized relationshipsbetween providers.MH/SUDCoordination• Discuss specific clients,usually requires clientauthorization.• More clinically integrated,with providers working as ateam.15

What are the ways that MH andSUD services are integrated?• Services for bothdisorders provided in sameprogram.FullIntegration• Services given byintegrated team.• Expertise in providingservices for MH, SUD, andCOD.16

Where should integrated servicesbe provided?Severity of SU DisorderMauer, 2006Severity of MH Disorder17

What are the key elements ofintegrated services for clients withco-occurring disorders?• Program Structure• Program Environment• Clinical Assessment• Clinical Treatment• Continuity of Care• Staffing• Training• Can be evaluated using the DDC instruments,http://cooccurring.org/public/research_ddcat.page18

Integrating Mental Health andSubstance Use DisorderServices with Primary CareSUDPrimaryCareIntegrated CareMH19

To Reach the UnservedWhere people with COD receive services20

To Reach the Unserved• Many people with mental health andsubstance use disorders present forservices in medical settings.• Issues related to co-occurring disorders oftenbring people in to primary care.• When a mental health issue comes up, peopleare much more likely to go to primary carethan to a mental health specialist.IBHP, 200921

To Reach the Unserved• Primary care is the MH/SUD system for asmuch as 63% of the US population.Kessler and Stafford, 200822

Why Should We Integrate?http://kevinspear.com/tag/single-panel-cartoon/page/2/23

To Treat the Whole Person• To improve clients’ physical health• Individuals with SMI are more likely developproblems with diabetes, and cardiovascular,respiratory, and infectious disease.• Toxic effects and behavioral risks associatedwith substance use disorders (SUDs) lead toincreased risk of injury and illness.24

To Treat the Whole Person• On average, people with SMI die as muchas 25 years earlier than the rest of thepopulation .NASMHPD, 2006• Individuals with co-occurring disorders diean average of 34.5 years earlier.ODHHS, 200825

Why Integrate with Primary Care?• Because mental health and substance abuseproblems are among the leading sources ofdisease burden. (USDHHS 1999)ILLNESS CATEGORY% OF BURDENIschemic heart disease 9.0%Unipolar major depression 6.8%Cardiovascular disease 5.0%Alcohol use 4.7%Road traffic accidents 4.4%26

Why Integrate with Primary Care?• According to The US Preventive Task Force:• Alcohol screening and interventions can reducedisease burden as much as preventive servicesfor colorectal cancer and hypertension.• Depression screening can reduce it as much asosteoporosis screening and cholesterolscreening/treatment.Maciosek et al, 200627

Why Integrate with Primary Care?• Because research shows that physical healthproblems and behavioral problems oftenexacerbate each other.28

Why Integrate With Primary Care?MindsMH/SUDCareBodiesPrimaryCare29

Why Should We Integrate withPrimary Care?• To Improve Outcomes• MH: Integration can improve physical, mental,emotional, and social functioning.Unutzer et al., 2001; Druss et al., 2010• SU: Integration can reduce alcohol/drugconsumption, improve physical and mental health,and reduce utilization of inpatient and emergencyservices.Madras et al, 2009; Weisner et al, 2001; Parthasarathay et al, 200330

Why Should We Integrate withPrimary Care?• Integrating mental healthand substance usetreatment services withprimary care can cut costs.Butler et al, 2008Parthasarathy et al, 2003• Not effectively integratingcould lead to an extra $300billion in health costs eachyear nationwide.Mauer and Jarvis, 2010 31

What are the ways that MH/SUDand primary care services can beintegrated?CoordinatedBH/PC ServicesCo-locatedBH/PC ServicesIntegratedBH/PC ServicesIntegration of servicesMinimalIntegrationBasicIntegrationat aDistanceBasicIntegrationOn-SiteClosePartiallyIntegratedServicesFullyIntegratedServicesCollins et al., 201032

What are the ways that MH/SUDand primary care services can beintegrated?• BH and PC providers work in separate systems, butin same facility.• Co-located BH providers handle psychosocialaspects of care in PC: assessment, brief counselingand treatment, and referrals.• Co-located medical providers provide services in BHsettings.PCPCBasic Integration On-SiteReferral andLinkageMH/SUDMH/SUD35

What are the ways that MH/SUDand primary care services can beintegrated?Close Partially Integrated Services• BH and PC providers work in the same facility, andhave some common systems (scheduling, medicalrecords)• Better communication and service collaboration.• BH care manager works with PC providers to developand implement integrated treatment plan.PCPartiallyIntegratedServicesMH/SUD36

What are the ways that MH/SUDand primary care services can beintegrated?Fully Integrated Services• BH and PC providers work in the same facility, underthe same system, and as part of the same team.• Client may experience BH treatment as part ofregular medical care.• BH and PC providers regularly consult on client care,can see clients together at the same time.PCFullyIntegratedServicesMH/SUD37

Integrated Care IsNot One Size Fits AllBehavioral Health Risk/StatusMauer, 2006Physical Health Risk/Status38

Integrated Care IsNot One Size Fits All…especially for clients with co-occurring disorders.39

There are some barriers tointegrating with primary care• “Integrated behavioral/primary care is like apomegranate: overwhelmingly people saythey like it, but few buy it.”Cummings, 200940

Barriers to Integrated Care41

Barriers to Integrated Care• Financing• Siloed funding• Medi-Cal restrictions on same day billing• Scarcity of resources42

Barriers to Integrated Care• Documentation• Different systems have differentdocumentation requirements.• HIPAA and 42 CFR can make sharing clientinformation more difficult43

Barriers to Integrated Care• Partnering with Primary Care• Many PC providers do not know much aboutmental health and substance abuse disorders—still carry stigma.• Primary care is a very hectic environment – they44don’t have time to add more to their plate.

Potential Solutions to Barriers• Financing: Start small, use flexible funds(grants/foundations, MHSA, etc.)• Documentation: With client approval, canshare information• Partnering with Primary Care: Show thatintegration is a win-win, identify“champions” within primary care.45

REFERENCES• Butler M, Kane RL, McAlpine D, et al. Integration of Mental Health/Substance Abuse and Primary Care.Evidence Report/Technology Assessment No. 173. Rockville, MD: Agency for Healthcare Research andQuality, 2008.• Center for Substance Abuse Treatment (CSAT). Changing the Conversation: Improving Substance AbuseTreatment. The National Treatment Improvement Plan. Rockville, MD: Center for Substance AbuseTreatment, 2000.• Center for Substance Abuse Treatment, Substance Abuse Treatment for Persons with Co-OccurringDisorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3922.Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.• Collins C, Hewson DL, Munger R et al. Evolving Models of Behavioral Health Integration in Primary Care.New York, NY: Milbank Memorial Fund, 2010.• Cummings NA, O’Donohue WT, Cummings JL. The Financial Dimension of Integrated Behavioral/PrimaryCare. J Clin Pscyhol Med Settings 2009;16:31-34.• Drake RE, O’Neal EL, Wallach MA. A systematic review of psychosocial research on psychosocialinterventions for people with co-occurring severe mental and substance use disorders. Journal ofSubstance Abuse Treatment. 2008;34(1):123-128.• Druss BG. Improving general medical care for persons with mental and addictive disorders: systematicreview. Gen Hosp Psych 2006;28(2):145-153.• Druss BG. A Randomized Trial of Medical Care Management for Community Mental Health Settings: thePrimary Care Access, Referral, and Evaluation (PCARE) Study. Am J Psychiatry 2010;167:151-159.• Integrated Behavioral Health Project (IBHP) Partners in Health: Primary Care/County Mental HealthCollaboration. Tool Kit. 2009.• Kessler R and Stafford D. Primary Care Is the De Facto Mental Health System. Collab Med Case Stud.2008;1:9-21.• Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) forillicit drug and alcohol use at multiple healthcare sites: Comparison at intake and six months later. Drug andAlcohol Dependence. 2009;99(1-3):280-295.• Mauer BJ. Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-BasedPractices. National Council for Community Behavioral Healthcare 46

REFERENCES• Mauer BJ, Jarvis D. The Business Case for Bidirectional Integrated Care: Mental Health and Substance UseServices in Primary Care Settings and Primary Care Services in Specialty Mental Health and Substance UseSettings. http://www.cimh.org/LinkClick.aspx?fileticket=FBCYbhoBeg8%3d&tabid=489• Maciosek MV, Coffield AB, Edwards NM, et al. Priorities among effective clinical preventive services: Resultsof a systematic review and analysis. American Journal of Preventive Medicine. 2006 Jul; 31(1):52-61.• National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council.Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: NASMHPD, 2006.• National Association of State Mental Health Program Directors (NASMHPD) and National Association ofAlcohol and Drug Abuse Directors (NASDADAD). National Dialogue on Co-Occurring Mental Health andSubstance Abuse Disorders. Washington, D.C.: NASMHPD and NASADAD: 1999.• Oregon Department of Health and Human Services (ODHHS), Addiction and Mental Health Division. 2008.Measuring Premature Mortality among Oregonians, 2008.http://www.oregon.gov/OHA/addiction/publications/msur_pre_mort_6_2008.pdf?ga=t• Parthasarathy S, Mertens JM, Moore C, Weisner C. Utilization and cost impact of integrating substance abusetreatment and primary care. Med Care. 2003;41(3):357-367.• President’s New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental HealthCare in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.• Substance Abuse and Mental Health Administration (SAMHSA). 2002. Report to Congress on the Preventionand Treatment of Co-Occurring Substance Abuse Disorder and Mental Disorders.• Substance Abuse and Mental Health Administration (SAMHSA). Results from the 2009 National Survey onDrug Use and Health: Mental Health Findings (Office of Applied Studies, NSDUH Series H-39, HHSPublication No. SMA 10-4609). Rockville, MD: Substance Abuse and Mental Health Administration, 2010.• Unutzer J, et al. Collaborative Care Management of Late-Life Depression in the Primary Care Setting: ARandomized Control Trial. JAMA. 2002;288(22):2836-2845.• U.S. Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General.Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental HealthServices Administration, Center for Mental Helath Services, National Institutions of Health, National Instituteof Mental Health, 1999.• Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addictiontreatment: a randomized control trial. JAMA 2001;286(14):1715-1723.

SAN MATEO COUNTYHEALTH SYSTEMMOVING TOWARDINTEGRATED CAREStephen G. Kaplan, DirectorSMC Behavioral Health & Recovery Services

What Consumers & Family MembersWant and Need• ACCESS TO CARE• ACCOUNTABILITY• WHOLE‐PERSON CARE• CONTINUITY• COORDINATION & INTEGRATION• PERSON & FAMILY‐CENTERED CAREOregon Standards and Measures for Patient Centered Primary Care Homes

What Consumers & Family MembersWant and Need• Recovery Based• Wellness Focused• Family Inclusion• Cultural Inclusion and CulturalHumilityIntegration of Mental Health, Substance Use, and Primary Care Services. Embracing our Values from a Client and Family MemberPerspective. Cal MEND, CIMH 2011

What the National Data Tells Us• MediCaid Beneficiaries• Highest adjusted odds for HEARTDISEASE, ASTHMA, GASTROINTESTINALDISORDERS & RESPIRATORY DISORDERS• Americans with SMI‐on average‐die @ 53yrs of age• Healthcare costs SMI/MH greater due tountreated health conditions2002 Massachusetts MediCaid StudyThe Business Case for Bidirectional Care, CIMH 2009

Costly Physical ConditionsAges 22 ­ 6425%20%21.4%Mental Health Services Users Ages 22 through 64All Medicaid Beneficiaries Ages 22 through 6415%14.3%10%5%5.3% 5.0% 5.2%3.5% 3.4% 3.3%3.2% 3.2%2.0% 2.0% 2.2% 1.9%0%Any CostlyPhysicalConditionDiabetes Cardiovascular Renal Gastrointestinal Pulmonary CancerSource: Medicaid Analytic eXtract (MAX), 2003, 13 states

What ACA Requires• Mental health and substance use treatmentas essential benefit• Health homes• SUD/MH in chronic disease preventioninitiatives• Expand Medicaid coverage to all Americansbelow 133 percent of the federal povertylevel

MediCaid Waiver Opportunity• Bridge to Health Care Reform• Uninsured to insured• SU and MH services• Federal Financial Participation• BH and Primary CareIntegrations

The Local Data Story• HPSM/BHRS/SMMC DATA CROSSWALK• Of 70,000 patients in SMC 9.7% were served by both physicaland behavioral health care• 46% were high cost patients w/behavioral health needs• 27% were MediCal population w/behavioral health needs• Providing BH services to people with chronic conditionscontributes to lower health costs• Local study confirmed lost years of life• 40% SUD clients were uninsured & eligible MCE

San Mateo County Health SystemFinancial OfficerStrategic OperationsAdministrationHealth OfficerPolicy and PlanningCorrectional Health ServicesSan Mateo Medical CenterBehavioral Healthand Recovery ServicesAging and Adult Services11/2/2011Family Health ServicesCommunity Health

A Consensus Policy• Clinical policy• Shared responsibilities• Fiscal policy• Mutual outcomes

SU and MH Integration Story• CCISC (MHSA and AOD $)• Behavioral Health and Recovery Services• MHSARC• Change agents• Administrative integration• Service Level• Integrated access• Psychiatry‐ Medical Director oversight, psychiatrist at SUsights• Day of Partnering• SU into Adult Resource Management• SU Children/Youth Case Management

SU and MH Integration Story• Policy• Charter Document• Welcoming Policy• Standards of Care• Medications• Relapse• Funding• SDMC certification SU sites• MHSA co‐occurring• Workforce Development/Training

BHRS and Primary Care• Four quadrants• Interface team• Nurse practioner at Regional Clinics• S B I R T *• ACCESS to care planning – policy priority• CalMend• Total wellness• DSRIP outcome

Continuing Challenges• Cultural Alignment• Capacity• Right Response Right Place Right Time• Health Homes• Person Centered Care

Final Comments• CLIENTS’ LIVES VS. THE BUREAUCRACY• STIGMA & DISCRIMINATION• ALLISON’S STORY

Eighth Statewide Conference onCo-Occurring Disorders:Treatment of Substance Use, MentalHealth, and Primary Care Disorders inthe Era of Health ReformOctober 26-27, 2011

Integrated …Lily AlvarezBehavioral Health System AdministratorKern County Mental Health

Spoken Goals• Universal screening• Brief interventions• Technology via health registries

Unspoken Goals• Develop a value for the SAS• Develop the blood pressure cuff forSUD• Close the gap between primarycare and specialty care• Demonstrate how to overcomesecurity and privacy issues• Building capacity for 2014

What is the Model?• Universal screening• Brief consultation in the examroom• Brief interventions• Integrated case conferencing• Using data to monitor progress

Anticipated Barriers andProposed Solutions• Being in the forefront; creating alearning environment• Competition; monthly providermeetings• Physician involvement; contractualrequirements for case conferencing• New practice standards; technologytransfer through events

Current Barriers• Fear of recognizing the SUDpatient• Filing in the medical record• Charting in the medical record

Health Information Exchange• 42 CFR Part 2 requires:Individual consentSpecificityProhibits re-disclosure• Between primary care and specialtyDiagnosisLab resultsMedications

UCLA and Evaluation• Baseline with DDCAT• The pipeline using i2i• Perceptions and attitudes

Preliminary Results• Prevalence of depression• Prevalence of thought disorders• Prevalence of alcohol and drug