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

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

5. Distribution of Alcohol (or Drug) Problems Specialized Treatment Brief Intervention Prevention

6. 20.9 Million People Need But Do Not Receive Treatment For Illicit Drug or Alcohol Use Did not feel that they needed treatment Felt that they needed Tx, but made no effort Felt that they needed Tx, and did made an effort Source: SAMHSA, 2007 National Survey on Drug Use and Health (Sept 2008).

7. Distribution of Alcohol (or Drug) Problems 2.3 Million 22.2 Million ??????

8. Current Funding Sources Current Tx System HCR Funding Sources Residential Block Grant MediCal Medical System Outpatient Detox Insurance SUD services OTP MediCal Insurance Self pay Recovery Support Self pay Block Grant

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. Practitioners Specializing in Addiction Treatment through Various Certification or Certificate Programs (9/2010)

12. Provider/practice barriers • 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

13. Provider/practice barriers • 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

14. Regulatory, licensure, and scope of practice barriers • 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)

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

17. Overall: Essential Workforce Skills Borkan, J. (2009). Workforce Training for PCMH: What are We doing to Equip the Team?

18. 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 BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt Coordinated Co-located Integrated *Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.

20. minimal • Mental health (MH) providers and primary care (PC) providers: • work in separate facilities, • have separate systems, and • communicate sporadically. MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt

21. Basic AT A DISTANCE • 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. MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt

22. BASIC ON-SITE • 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. MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt

23. CLOSE PARTIALLY INTEGRATED • 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. MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt

24. CLOSE – FULLY INTEGRATED • 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. MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt

25. Integration: workforce considerations • 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.

26. Models of integration • Improved Collaboration between Separate Providers • Medical-provided Behavioral Health Care • Co-location • Disease management MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care

27. Models of integration • Reverse Co-location (PC co-located in BH settings) • Unified Primary Care and Behavioral Health • Primary Care Behavioral Health • Hybrid Collaborative System of Care MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care

28. Where Do You Begin? • All healthcare is local. Working out the details of who does what, for what levels of MH/SA services requires engaging local partnerships to: • Decide your integration goals • Determine how you want to achieve those goals • Understand your regulations that govern facility licensure and professional scopes of practice for MH/SA services • Examine current and projected needs for your workforce • Determine payor issues

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

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

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)

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)

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

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

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.  

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. 

39. New opportunities ahead

40. Areas for workforce advocacy • 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

41. Areas for workforce advocacy • 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

42. Two New team members Care Manager/BHC 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 • 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 Mauer, B. (2009). Behavioral Health/Primary Care Integration and The Person-Centered Healthcare Home

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) Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. J Gen Intern Med. 2002;17:327-333.

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