Advances in the Treatment of Addiction: Shifting the Treatment Paradigm Again

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Disproportionate Impact on Persons with MI/SUDs. 20.4% SMI and 18.2% other mental disorder are uninsured, compared to 11.4% w/o mental disorder111 million Americans covered by group commercial insurance; 29 million covered by state/local governments98% of policies cover MH

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Advances in the Treatment of Addiction: Shifting the Treatment Paradigm Again

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1. Advances in the Treatment of Addiction: Shifting the Treatment Paradigm Again Thomas E. Freese, Ph.D. UCLA Integrated Substance Abuse Programs

2. Disproportionate Impact on Persons with MI/SUDs 20.4% SMI and 18.2% other mental disorder are uninsured, compared to 11.4% w/o mental disorder 111 million Americans covered by group commercial insurance; 29 million covered by state/local governments 98% of policies cover MH & 92% cover SA but with unequal coverage and/or processes MI/SUD are usually pre-existing conditions when seeking coverage 3 million (16.3%) full-time workers w/o health insurance needed substance use treatment in past year (SAMHSA national survey), particularly among 18-25 year olds (24.4%) & males (19.2%)

3. Disproportionate Cost Implications - 1 Medical costs of persons w/co-morbid physical & BH disorders 5% of population accounted for almost 50% of total costs due to chronic conditions & multiple co-morbidities, severe mental illness, and services that are fragmented among multiple providers Costs for persons w/ these illnesses are disproportionately high and services are increasingly provided in integrated settings 20.3% of MH spending is in general medical settings 23.2% of mental health spending is for psychotropic drugs (2007)

4. Health Insurance Reform Goals President’s Principles: More stability & security for those who have insurance Affordable coverage options for those who do not Lower costs for families, businesses, and governments

6. 20.9 Million People Need But Do Not Receive Treatment For Illicit Drug or Alcohol Use The majority of people 12 years and older who have a diagnosable substance use disorder are not on the radar screen of healthcare professionals. This population may be unaware that they have a diagnosable substance use disorder or be aware, but do not feel they need help. In both cases, intervention is an effective public health response and may prevent progression to dependency. Intervention may also positively impact other health conditions and unhealthy behaviors. The majority of people 12 years and older who have a diagnosable substance use disorder are not on the radar screen of healthcare professionals. This population may be unaware that they have a diagnosable substance use disorder or be aware, but do not feel they need help. In both cases, intervention is an effective public health response and may prevent progression to dependency. Intervention may also positively impact other health conditions and unhealthy behaviors.

9. It’s time for another paradigm shift… Specialty treatment system will need to be able to bill for individual services Specialty treatment system will need to respond to patient choice A whole new group of patients will enter the system through the health care system The healthcare system will be able to provide some of our services

10. Workforce integration issues

11. There is quite a bit of overlap among the various healthcare and counseling professions with addiction specialty services. All of the disciplines shown have sub-specialty credentialing for addiction services. The numbers of persons who are currently certified in addiction sub-specialties are current as of this September 2010, with a few entities not reporting their most current data. American Society of Addiction Medicine (ASAM) ASAM, with approximately 3,200 members, is a specialty medical society founded in the early 1950’s, to serve to educate, advocate and promote research in addictions. The ASAM-developed certification program has certified more than 3,800 candidates who are graduates of accredited medical schools, hold a valid state license, submit three letters of recommendation from fellow physicians, and pass a rigorous day-long examination. American Academy of Addiction Psychiatrists (AAAP) AAAP, started in 1985, has a membership of about 1,200 psychiatrists whose interests are to promote quality addiction treatment, strive for excellence in clinical practice, and disseminate information about addictions. The organization publishes the American Journal on Addictions. International Nurses Society on Addictions (IntNSA) IntNSA is a group of nurses that has members in every state and a number of countries overseas.  IntNSA has a certification program with two levels of credentials, the Certified Addictions Registered Nurse (CARN) and the CARN-Advanced Practice (CARN-AP).  To be eligible for the CARN, a nurse must have a minimum of three years of experience as an RN and must have worked 4,000 hours (equivalent of two years) in the addictions field within the past five years. To be qualified for the CARN-AP, the candidate must possess or be eligible for the CARN, have a master’s degree, and have 500 hours of supervised work in addictions treatment. Association of Social Workers (NASW), a large membership organization, offers a specialty certificate - the Certified-Clinical Alcohol, Tobacco and Other Drugs Social Worker (C-CATODSW) certificate requires that a candidate be a member of NASW; have an MSW degree from an accredited school; have 180 hours of education specifically in alcohol, tobacco and other drugs; have  3,000 hours (two years) of supervised post MSW paid supervised experience; have 3,000 hours (two years) of  supervised post-MSW experience working in alcohol, tobacco and other drug field; have an evaluation from an approved supervisor; and have references from a colleague. Social workers are an integral part of the addiction treatment workforce. Some may be dually credentialed in their respective state as both a licensed social worker and as a certified addiction counselor; however, many do not seek the addiction counseling credential. Nurses Nurses in the addictions field work in methadone maintenance programs, other outpatient programs, and residential and inpatient settings. In addition, there is an organization of nurses who specialize in treating addictions. International Nurses Society on Addictions (IntNSA) IntNSA is a group of nurses that has members in every state and a number of countries overseas.  IntNSA has a certification program with two levels of credentials, the Certified Addictions Registered Nurse (CARN) and the CARN-Advanced Practice (CARN-AP).  To be eligible for the CARN, a nurse must have a minimum of three years of experience as an RN and must have worked 4,000 hours (equivalent of two years) in the addictions field within the past five years. In addition, candidates must pass a written examination.  To be qualified for the CARN-AP, the candidate must possess or be eligible for the CARN, have a master’s degree, and have 500 hours of supervised work in addictions treatment. The American Psychology Association (APA) also offers a special certificate in substance use disorders.  The Proficiency Certificate in Substance Use Disorders is for licensed, independent practitioners who provide health services in psychology.  It requires passing a three-hour, 150 multiple choice exam, letters of recommendation from a fellow psychologist, and at least three years of work providing psychological services, with at least one year in addiction treatment. There is quite a bit of overlap among the various healthcare and counseling professions with addiction specialty services. All of the disciplines shown have sub-specialty credentialing for addiction services. The numbers of persons who are currently certified in addiction sub-specialties are current as of this September 2010, with a few entities not reporting their most current data. American Society of Addiction Medicine (ASAM) ASAM, with approximately 3,200 members, is a specialty medical society founded in the early 1950’s, to serve to educate, advocate and promote research in addictions. The ASAM-developed certification program has certified more than 3,800 candidates who are graduates of accredited medical schools, hold a valid state license, submit three letters of recommendation from fellow physicians, and pass a rigorous day-long examination. American Academy of Addiction Psychiatrists (AAAP) AAAP, started in 1985, has a membership of about 1,200 psychiatrists whose interests are to promote quality addiction treatment, strive for excellence in clinical practice, and disseminate information about addictions. The organization publishes the American Journal on Addictions. International Nurses Society on Addictions (IntNSA) IntNSA is a group of nurses that has members in every state and a number of countries overseas.  IntNSA has a certification program with two levels of credentials, the Certified Addictions Registered Nurse (CARN) and the CARN-Advanced Practice (CARN-AP).  To be eligible for the CARN, a nurse must have a minimum of three years of experience as an RN and must have worked 4,000 hours (equivalent of two years) in the addictions field within the past five years. To be qualified for the CARN-AP, the candidate must possess or be eligible for the CARN, have a master’s degree, and have 500 hours of supervised work in addictions treatment. Association of Social Workers (NASW), a large membership organization, offers a specialty certificate - the Certified-Clinical Alcohol, Tobacco and Other Drugs Social Worker (C-CATODSW) certificate requires that a candidate be a member of NASW; have an MSW degree from an accredited school; have 180 hours of education specifically in alcohol, tobacco and other drugs; have  3,000 hours (two years) of supervised post MSW paid supervised experience; have 3,000 hours (two years) of  supervised post-MSW experience working in alcohol, tobacco and other drug field; have an evaluation from an approved supervisor; and have references from a colleague. Social workers are an integral part of the addiction treatment workforce. Some may be dually credentialed in their respective state as both a licensed social worker and as a certified addiction counselor; however, many do not seek the addiction counseling credential. Nurses Nurses in the addictions field work in methadone maintenance programs, other outpatient programs, and residential and inpatient settings. In addition, there is an organization of nurses who specialize in treating addictions. International Nurses Society on Addictions (IntNSA) IntNSA is a group of nurses that has members in every state and a number of countries overseas.  IntNSA has a certification program with two levels of credentials, the Certified Addictions Registered Nurse (CARN) and the CARN-Advanced Practice (CARN-AP).  To be eligible for the CARN, a nurse must have a minimum of three years of experience as an RN and must have worked 4,000 hours (equivalent of two years) in the addictions field within the past five years. In addition, candidates must pass a written examination.  To be qualified for the CARN-AP, the candidate must possess or be eligible for the CARN, have a master’s degree, and have 500 hours of supervised work in addictions treatment. The American Psychology Association (APA) also offers a special certificate in substance use disorders.  The Proficiency Certificate in Substance Use Disorders is for licensed, independent practitioners who provide health services in psychology.  It requires passing a three-hour, 150 multiple choice exam, letters of recommendation from a fellow psychologist, and at least three years of work providing psychological services, with at least one year in addiction treatment.

12. Differing practice styles Differing practice cultures and language Difficulty in matching provider skills with patient needs Heavy reliance on physician services Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services Provider/practice barriers

13. Lack of recognition of provider limitations Lack of MH knowledge in PC providers and lack of health knowledge in BH providers Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context Differing coding and billing systems Provider resistance Provider/practice barriers

14. Licensure and scope of practice is set at the state level - many variations in laws and professional regulations/certification standards Varying standards across disciplines governing the types of services that can provided and the extent to which clinicians can practice independently in different settings Confidentiality laws and sharing of case information can be affected (HIPPA, CFR 42) Regulatory, licensure, and scope of practice barriers

15. FINANCIAL BARRIERS Payors have strict requirements of who can bill for what service Increase in Medicaid necessitates provider and workforce capability to bill this payor Payment for health/recovery coaches and use of peers is slow to emerge Allowances for payment for services in new job classifications areas, such as Care Managers While many of the reasons for integrating behavioral health and primary care are clinical, many of the reasons for continued fragmentation are financial. Despite the creation of new billing codes for behavioral health issues, the difficulty of getting reimbursed for providing behavioral health services in a primary care setting is one of the chief barriers to integration. While many of the reasons for integrating behavioral health and primary care are clinical, many of the reasons for continued fragmentation are financial. Despite the creation of new billing codes for behavioral health issues, the difficulty of getting reimbursed for providing behavioral health services in a primary care setting is one of the chief barriers to integration.

16. There are many similarities in workforce issues between primary health and behavioral health. There are many similarities in workforce issues between primary health and behavioral health.

17. Overall: Essential Workforce Skills The acute shortage of both behavioral health and primary care providers in many areas makes the provision of care, particularly integrated services, difficult. This problem is compounded by the fact that both primary care and behavioral health providers often are not trained or educated about how to work in an integrated setting, resulting in a disconnect between the two cultures of care. There is a common set of essential Skills that can help to enable people to perform tasks required by their jobs as well as adapt to change. The acute shortage of both behavioral health and primary care providers in many areas makes the provision of care, particularly integrated services, difficult. This problem is compounded by the fact that both primary care and behavioral health providers often are not trained or educated about how to work in an integrated setting, resulting in a disconnect between the two cultures of care. There is a common set of essential Skills that can help to enable people to perform tasks required by their jobs as well as adapt to change.

18. Behavioral Health Practice Models: Workforce implications Behavioral Health Practice Models: Workforce implications

19. What is “Primary Care Integration”? Primary care integration is the collaboration between SUD service providers and primary care providers (e.g., FQHC’s, CHC’s) Collaboration can take many forms along a continuum* Minimal collaboration: SUD providers and primary care providers work in separate facilities, have separate systems, and communicate sporadically Basic collaboration at a distance: Primary care and SUD providers have separate systems at separate sites, but engage in period communication about shared patients Basic collaboration on-site: SUD and primary care providers have separate systems but share the same facility Close collaboration in a partly integrated system: SUD providers and primary care providers share the same facility and have some systems in common, such as scheduling appointments or medical records. Physical proximity allows for regular face-to-face communication among SUD and primary care providers. Close collaboration in a fully integrated system: The SUD provider and primary care provider are part of the same team. The patient experiences the mental health treatment as part of his or her regular primary care. Coordination between specialty care and primary care clinics Co-location of screening, intervention and/or SUD treatment with primary care services, either in a primary care or an SUD treatment setting Full integration of primary care and SUD screening, intervention, and/or treatment services in either a primary care or an SUD treatment setting, including records and documentationMinimal collaboration: SUD providers and primary care providers work in separate facilities, have separate systems, and communicate sporadically Basic collaboration at a distance: Primary care and SUD providers have separate systems at separate sites, but engage in period communication about shared patients Basic collaboration on-site: SUD and primary care providers have separate systems but share the same facility Close collaboration in a partly integrated system: SUD providers and primary care providers share the same facility and have some systems in common, such as scheduling appointments or medical records. Physical proximity allows for regular face-to-face communication among SUD and primary care providers. Close collaboration in a fully integrated system: The SUD provider and primary care provider are part of the same team. The patient experiences the mental health treatment as part of his or her regular primary care. Coordination between specialty care and primary care clinics Co-location of screening, intervention and/or SUD treatment with primary care services, either in a primary care or an SUD treatment setting Full integration of primary care and SUD screening, intervention, and/or treatment services in either a primary care or an SUD treatment setting, including records and documentation

20. Mental health (MH) providers and primary care (PC) providers: work in separate facilities, have separate systems, and communicate sporadically. minimal

21. PC and BH providers have separate systems at separate sites, but now engage in periodic communication about shared patients. Communication occurs typically by email, telephone or letter. Improved coordination is a step forward compared to completely disconnected systems. Basic AT A DISTANCE

22. Mental health and primary care professionals have separate systems but share the same facility. Proximity allows for more communication, but each provider remains in his or her own professional culture. BASIC ON-SITE

23. MH professionals and PC providers share the same facility have some systems in common, such as scheduling appointments or medical records. Physical proximity allows for regular face-to-face communication among providers. There is a sense of being part of a larger team in which each professional appreciates his or her role in working together to treat a shared patient. CLOSE PARTIALLY INTEGRATED

24. The MH provider and PC provider are part of the same team. The patient experiences the mental health treatment as part of his or her regular primary care. CLOSE – FULLY INTEGRATED

25. Regulatory issues including credentialing and licensing State laws/rules regarding licensure of mental health and substance abuse facilities – each with workforce requirements to deliver care State laws/regulations about scope of practice –govern types of services that can provided and the extent to which clinicians can practice independently in different settings Levels of risk and responsibility depend upon the level of integration The use of paraprofessionals—common in the behavioral health setting—can be difficult to reimburse in a primary care site. Integration: workforce considerations

26. Improved Collaboration between Separate Providers Medical-provided Behavioral Health Care Co-location Disease management Models of integration The Millbank Memorial Fund (Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care) identified eight practice models that represent qualitatively different ways of integrating care (see pages 46-51 for full summary table). 1. Improved Collaboration Between Separate Providers • Collaboration: Minimal -separate facilities with separate systems, sporadic communication • Private practices with active referral linkages; care managers, specialty BH providers • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 2. Behavioral Health Care Rendered by Medical Providers • Collaboration: basic-separate facilities and systems, periodic communication about shared patients • Private practices with active referral linkages; Physician or other medical professionals with consultative support from BH specialist • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 3. Co-Located Behavioral Health Services • Collaboration: basic-on-site with separate systems, greater communication • HMO settings, clinics that employ therapists or care managers; therapists and specialty BH clinicians • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 4. Disease Management • Close collaboration in partially integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care managers • Best use: Provider , through billing or partnership, is able to sustain a more integrated model 5: Reverse Co-location (Primary Care in BH Settings) • Close collaboration in partly integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care mgrs; traditional BH team members and medical professionals • Populations: patients with both high physical/behavioral needs • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 6: Unified Primary Care & Behavioral Health • Close collaboration in fully integrated system: shared facility and systems, providers are part of same team • Setting/Behavioral health provider - Large practices and medical systems; Psychiatrists and therapists • Populations: patients with high behavioral/physical health needs • Best use: When PMPM or capitated financing is available; provider can access codes necessary to fund all key elements in a fully integrated model The Millbank Memorial Fund (Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care) identified eight practice models that represent qualitatively different ways of integrating care (see pages 46-51 for full summary table). 1. Improved Collaboration Between Separate Providers • Collaboration: Minimal -separate facilities with separate systems, sporadic communication • Private practices with active referral linkages; care managers, specialty BH providers • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 2. Behavioral Health Care Rendered by Medical Providers • Collaboration: basic-separate facilities and systems, periodic communication about shared patients • Private practices with active referral linkages; Physician or other medical professionals with consultative support from BH specialist • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 3. Co-Located Behavioral Health Services • Collaboration: basic-on-site with separate systems, greater communication • HMO settings, clinics that employ therapists or care managers; therapists and specialty BH clinicians • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 4. Disease Management • Close collaboration in partially integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care managers • Best use: Provider , through billing or partnership, is able to sustain a more integrated model 5: Reverse Co-location (Primary Care in BH Settings) • Close collaboration in partly integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care mgrs; traditional BH team members and medical professionals • Populations: patients with both high physical/behavioral needs • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 6: Unified Primary Care & Behavioral Health • Close collaboration in fully integrated system: shared facility and systems, providers are part of same team • Setting/Behavioral health provider - Large practices and medical systems; Psychiatrists and therapists • Populations: patients with high behavioral/physical health needs • Best use: When PMPM or capitated financing is available; provider can access codes necessary to fund all key elements in a fully integrated model

27. Reverse Co-location (PC co-located in BH settings) Unified Primary Care and Behavioral Health Primary Care Behavioral Health Hybrid Collaborative System of Care Models of integration The Millbank Memorial Fund (Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care) identified eight practice models that represent qualitatively different ways of integrating care (see pages 46-51 for full summary table). 1. Improved Collaboration Between Separate Providers • Collaboration: Minimal -separate facilities with separate systems, sporadic communication • Private practices with active referral linkages; care managers, specialty BH providers • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 2. Behavioral Health Care Rendered by Medical Providers • Collaboration: basic-separate facilities and systems, periodic communication about shared patients • Private practices with active referral linkages; Physician or other medical professionals with consultative support from BH specialist • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 3. Co-Located Behavioral Health Services • Collaboration: basic-on-site with separate systems, greater communication • HMO settings, clinics that employ therapists or care managers; therapists and specialty BH clinicians • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 4. Disease Management • Close collaboration in partially integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care managers • Best use: Provider , through billing or partnership, is able to sustain a more integrated model 5: Reverse Co-location (Primary Care in BH Settings) • Close collaboration in partly integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care mgrs; traditional BH team members and medical professionals • Populations: patients with both high physical/behavioral needs • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 6: Unified Primary Care & Behavioral Health • Close collaboration in fully integrated system: shared facility and systems, providers are part of same team • Setting/Behavioral health provider - Large practices and medical systems; Psychiatrists and therapists • Populations: patients with high behavioral/physical health needs • Best use: When PMPM or capitated financing is available; provider can access codes necessary to fund all key elements in a fully integrated model The Millbank Memorial Fund (Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care) identified eight practice models that represent qualitatively different ways of integrating care (see pages 46-51 for full summary table). 1. Improved Collaboration Between Separate Providers • Collaboration: Minimal -separate facilities with separate systems, sporadic communication • Private practices with active referral linkages; care managers, specialty BH providers • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 2. Behavioral Health Care Rendered by Medical Providers • Collaboration: basic-separate facilities and systems, periodic communication about shared patients • Private practices with active referral linkages; Physician or other medical professionals with consultative support from BH specialist • Populations: low BH needs • Best use: When reimbursement structure does not support integrated model 3. Co-Located Behavioral Health Services • Collaboration: basic-on-site with separate systems, greater communication • HMO settings, clinics that employ therapists or care managers; therapists and specialty BH clinicians • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 4. Disease Management • Close collaboration in partially integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care managers • Best use: Provider , through billing or partnership, is able to sustain a more integrated model 5: Reverse Co-location (Primary Care in BH Settings) • Close collaboration in partly integrated system: shared facility with some shared systems, regular communication • Setting/Behavioral health provider –HMO settings, medical clinics that employ therapists or care mgrs; traditional BH team members and medical professionals • Populations: patients with both high physical/behavioral needs • Best use: Provider, through billing or partnerships, is able to sustain a more integrated model 6: Unified Primary Care & Behavioral Health • Close collaboration in fully integrated system: shared facility and systems, providers are part of same team • Setting/Behavioral health provider - Large practices and medical systems; Psychiatrists and therapists • Populations: patients with high behavioral/physical health needs • Best use: When PMPM or capitated financing is available; provider can access codes necessary to fund all key elements in a fully integrated model

28.

29. A key partner… The Federally Qualified Health Centers (FQHCs)

30. What are FQHCs? Federally Qualified Health Centers (FQHCs), designation provided to BPHC grantees (HRSA) under Section 330 Public Health Service Act Private non-profit or public free-standing clinics serving designated MUAs or MUPs. One of few Federal programs for primary care to the non-institutionalized population Must meet additional requirements in order to participate in BPHC Health Center program 30

31. Types of “Health Centers” Terminology used interchangeably but confusing: “federally qualified health centers (FQHCs)”, “health centers”, “community-based health clinics”, “community health centers (CHCs) Several types of FQHCs in the health center program: Community Health Centers Migrant Health Centers Healthcare for the Homeless Program Public Housing Program FQHC look-alikes Others- clinics operated by IHS or tribal authorities, school-based health clinics, nurse-led clinics 82% of BPHC Section 330 grant funding were CHC health center grants 82% of BPHC Section 330 grant funding were CHC health center grants

32. BPHC Health Center Program Requirements (Health Services) Basic health services (primary and preventive care) Ensure access to comprehensive health and social services (e.g. substance abuse and mental health) Agreements for hospital referral (e.g. admitting privileges) Additional services may be critical depending upon population (e.g. occupational health for migrant workers) Includes substance abuse and mental health services to varying extents Required of FQHCs, see that the goal of many of these requirements is to reduce barriers Submit annually visit and clnical performance measures for the UDSIncludes substance abuse and mental health services to varying extents Required of FQHCs, see that the goal of many of these requirements is to reduce barriers Submit annually visit and clnical performance measures for the UDS

33. BPHC Health Center Program Requirements (Additional Key Requirements) Provide enabling services (e.g. transportation, translation, in-house pharmacy) Provide services regardless of ability to pay (sliding scale) Accessible hours of operation Continuous quality improvement Community and patient representation on Board Reporting requirements (e.g. UDS) Includes substance abuse and mental health services to varying extents Required of FQHCs, see that the goal of many of these requirements is to reduce barriers Submit annually visit and clnical performance measures for the UDSIncludes substance abuse and mental health services to varying extents Required of FQHCs, see that the goal of many of these requirements is to reduce barriers Submit annually visit and clnical performance measures for the UDS

34. Benefits of FQHC designation BPHC grant funding (20% of funding sources) Additional grant funding opportunities only open to FQHCs (e.g. Health Disparities Collaborative) Cost-based Medicare reimbursement and Medicaid prospective payment system Prescription drug discount Malpractice coverage Federal loan guarantees for capital projects NHSC site, although soon can qualify as own ambulatory care teaching site

35. FQHCs in California Who do FQHCs serve 113 clinic corporations with 1,049 sites 3.7 million patients served 53% of state’s population below 100% of Federal Poverty Level (FPL) and 26% below 200% 15% of state’s uninsured residents served 46% of total revenues from Medi-Cal 1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.

36. The Role of FQHCs in Providing SUD services New funds will allow for construction of new FQHCs expanded behavioral health services a dramatic increase in the number of newly insured Medicaid patients who receive services from FQHCs. 15 million more people are expected to be eligible for Medicaid by 2019 1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.

37. Evidence shows that increases in funding to FQHCs result in an increase in the provision of behavioral health services. Federal government boosted financial support to FQHCs between 2002 and 2007 the number of FQHCs increased 43% the number of FQHCs providing SUD services increased 58%. newly funded FQHCs were no more likely than previously funded FQHCs to provide behavioral health care.   1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.

38. Evidence shows that increases in funding to FQHCs result in an increase in the provision of behavioral health services. Over half (51%) of FQHCs providing some type of SUD service. there are no data describe what services are delivered or how they are delivered 77% of FQHCs provide mental health services it is not clear why this proportion of FQHCs have not also incorporated SUD services.  1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.1,080 grantees nationwide in 2008 with 8,176 sites. 113 grantees in California with 1,049 sites. Illinois is the next closest with 36 grantees and 570 sites and New York with 50 grantees and 508 sites.

39. New opportunities ahead

40. Transformation of organizational cultures Expand diversity of providers (e.g., culture, language) and assure culturally competent service delivery Define future roles (care manager, navigator, coach, health educator, others) for peers/family partners) and develop methods to recruit, train and certify them in these roles Areas for workforce advocacy Workforce is a challenging issue. Some issues, such as those related to academic training and scope of practice, are heavily laden with strong interest group perspectives that are difficult to evaluate (and overcome). As implied by the ideas in the federal legislation, the skills needed to work on a collaborative, multidisciplinary healthcare team are not generally part of academic training for clinicians, and the success of person-centered healthcare homes will depend on bridging the cultural differences between primary care and MH/SU practitioners.   Training and technical assistance for the current workforce as well as those in the academic pipeline is required. As federal, state and local initiatives and financing for workforce development move forward, the following issues should be incorporated into those processes. Current job roles may need to be redefined, but new, future roles will have to be identified and created.Workforce is a challenging issue. Some issues, such as those related to academic training and scope of practice, are heavily laden with strong interest group perspectives that are difficult to evaluate (and overcome). As implied by the ideas in the federal legislation, the skills needed to work on a collaborative, multidisciplinary healthcare team are not generally part of academic training for clinicians, and the success of person-centered healthcare homes will depend on bridging the cultural differences between primary care and MH/SU practitioners.   Training and technical assistance for the current workforce as well as those in the academic pipeline is required. As federal, state and local initiatives and financing for workforce development move forward, the following issues should be incorporated into those processes. Current job roles may need to be redefined, but new, future roles will have to be identified and created.

41. Identify a set of shared core competencies train current staff as well as those in the educational pipeline Engage all community partners for local PC/MH/SA workforce plans Seek adjustments in clinical training programs and academic curricula to support collaborative/integrated practice Areas for workforce advocacy Workforce is a challenging issue. Some issues, such as those related to academic training and scope of practice, are heavily laden with strong interest group perspectives that are difficult to evaluate (and overcome). As implied by the ideas in the federal legislation, the skills needed to work on a collaborative, multidisciplinary healthcare team are not generally part of academic training for clinicians, and the success of person-centered healthcare homes will depend on bridging the cultural differences between primary care and MH/SU practitioners.   Training and technical assistance for the current workforce as well as those in the academic pipeline is required. As federal, state and local initiatives and financing for workforce development move forward, the following issues should be incorporated into those processes. Current job roles may need to be redefined, but new, future roles will have to be identified and created.Workforce is a challenging issue. Some issues, such as those related to academic training and scope of practice, are heavily laden with strong interest group perspectives that are difficult to evaluate (and overcome). As implied by the ideas in the federal legislation, the skills needed to work on a collaborative, multidisciplinary healthcare team are not generally part of academic training for clinicians, and the success of person-centered healthcare homes will depend on bridging the cultural differences between primary care and MH/SU practitioners.   Training and technical assistance for the current workforce as well as those in the academic pipeline is required. As federal, state and local initiatives and financing for workforce development move forward, the following issues should be incorporated into those processes. Current job roles may need to be redefined, but new, future roles will have to be identified and created.

42. Care Manager/BHC Educates the individual about depression/other conditions Supports medication therapy prescribed by the PCP Coaches individuals in behavioral activation Offers a brief counseling Monitors symptoms for treatment response Completes a relapse prevention plan with each individual Consulting Mental Health Expert Caseload consultation for care manager and PCP (population-based) Diagnostic consultation on difficult cases Recommendations for additional treatment and referral according to evidence-based guidelines Two New team members

43. As the treatment of substance use disorders (SUDs) moves to the world of healthcare services……………………… A wide range of SUDs will be addressed, not just the most severe. Patients will be viewed as respected healthcare consumers. Treatments will need evidence of effectiveness Treatment will be accountable. Patients will have choice about treatment types and goals.

44. A diverse set of treatments will be used for a diverse set of patients Screening and Brief Interventions Brief Treatments SUD treatment delivered in MD offices and primary care settings SUD treatment will be delivered together with mental health services. Evidence-based treatments will be used Outpatient services will be increasing combined with needed social services and housing alternatives.

45. Evidence-based Treatments: Medications Opiate Addiction: Methadone, Buprenorphine, Naltrexone Alcohol: Naltrexone, Vivatrol, Campral, Ondansetron Nicotine: Nicotine replacement, Varenicline

46. Evidence-based Treatments: Behavioral Approaches Brief Interventions Brief Treatments for cannabis and other problem use disorders Motivational Interviewing Motivational Incentives Cognitive Behavioral Therapy Combination Therapies (Community reinforcement approach, Matrix model, Family therapies)

47. Consumer Improvement Strategies Integration of SUD screening and treatment into mainstream healthcare settings. Increasing focus on consumer satisfaction and consumer perception of care Increasing use to strategies to increase consumer access to care and appreciation of care (eg. NIATx) Increasing measurement of service effectiveness and greater provider accountability

48. One example of why this is so difficult…

49. Physician Management of Opioid Addiction Qualitative analysis of interviews with illicit drug-using patients and their physicians and direct observation of patient care interactions Inpatient medical service of an urban teaching hospital (6/97-12/97)

50. Physician Management of Opioid Addiction: Themes 1. Physician Fear of Deception Physicians question the “legitimacy” of need for opioid prescriptions (“drug seeking” patient vs. legitimate need). “When the patient is always seeking, there is a sort of a tone, always complaining and always trying to get more. It’s that seeking behavior that puts you off, regardless of what’s going on, it just puts you off.” -Junior Medical Resident

51. Physician Management of Opioid Addiction: Themes 2. No Standard Approach The evaluation and treatment of pain and withdrawal is extremely variable among physicians and from patient to patient. There is no common approach nor are there clearly articulated standards. “The last time, they took me to the operating room, put me to sleep, gave me pain meds, and I was in and out in two days.. . .This crew was hard! It’s like the Civil War. ‘He’s a trooper, get out the saw’. . .’” -Patient w/ Multiple Encounters

52. Physician Management of Opioid Addiction: Themes 3. Patient Fear of Mistreatment Patients are fearful they will be punished for their drug use by poor medical care. “I mentioned that I would need methadone, and I heard one of them chuckle. . .in a negative, condescending way. You’re very sensitive because you expect problems getting adequate pain management because you have a history of drug abuse. . .He showed me that he was actually in the opposite corner, across the ring from me.” -Patient

53. Physician Management of Opioid Addiction: Conclusions Physicians and drug-using patients display mutual mistrust. Physicians’ clinical inconsistency, avoidance behaviors and fear of deception, problematically interact with patients’ fear of mistreatment and stigma. Medical education should focus greater attention on addiction medicine and pain management.

54. Treatment of SUDs: Changes Ahead SUD Treatment will increasingly become a part of the healthcare system and less an extension of the criminal justice system. Treatments will be required to “attract” patients based on their effectiveness, convenience and patient acceptability, rather than relying on patient coercion. Scientific evidence and treatment accountabilty will play increasingly important roles.

55. Allows state Medicaid programs to establish medical homes for those with chronic illnesses –MH/SUD prevention and treatment among those with chronic illnesses Grants for school-based health clinics to provide MH/SUD assessments, crisis intervention, treatment, and referral Grants to community MH programs for co-locating primary and specialty care services Establishes the CLASS Program – voluntary, self-funded long-term care insurance program for people currently employed – flexible funds for support services to people with disabilities, including Mental illness Affordable care act – Behavioral health

56. SUPPORT FOR WORKFORCE DEVELOPMENT Funding for residencies for behavioral health included with other disciplines (HRSA) Loan repayment programs Push towards more national certification standards and re-licensure/re-certification TRAINING & RESEARCH Increased patient-centered health research Training grants for behavioral health workforce Training on MH/SUD for Primary Care Extender Affordable care act – Behavioral health

57. Potential Benefits of Linking Primary Care (PC) and Substance Abuse (SA) Services Patient Perspective Facilitates access to SA treatment and PC Improves substance abuse severity and medical problems Increases patient satisfaction with health care Societal perspective Reduces health care costs Diminishes duplication of services Improves health outcomes

58. Preparing field (states, providers, consumers, families) Capacity to provide mental health and substance use services (workforce) Accessing and developing strategies to improve infrastructure (data, HIT) Facilitating linkage with primary care and other providers Providing enrollment information Reviewing current block grant spending to focus on recovery and support services not paid for through Medicaid or commercial insurance Current SAMHSA initiatives

59. Providing workforce development to addiction service providers through the ATTC Network www.attcnetwork.org Grants for screening and brief interventions (SBIRT) for primary care National Technical Assistance Center for Primary Care and Behavioral Health Integration (SAMHSA/HRSA). Current SAMHSA initiatives

60. Similar challenges exist in the health and behavioral health workforces Behavioral health workforce is complex with much state level variation, particularly for the addiction workforce Achieving integration will require attention to barriers and development of current, essential workforce skills Workforce-related risks and responsibilities will vary depending upon which integration model is selected Future holds many opportunities to advocate for our respective workforces and advance workforce development through financial and technical assistance means. Take away points

61. More Training Coming

62. Thank you

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