The Integration of Behavioral Health and Primary Care

1. National Center for Primary Care Morehouse School of Medicine The Integration of Behavioral Health and Primary Care George Rust, MD, MPH, FAAFP, FACPMFather of Dan & Christina, Husband of Cindy,Professor of Family Medicine and Director, National Center for Primary Care

2. National Center for Primary Care at Morehouse School of Medicine Promoting Excellence in Community-Oriented Primary Health Care and Optimal Health Outcomes for all Americans

3. What Is Primary Care? • CFirst Contact Care • CComprehensive • CContinuous • CCoordinated • CContext of Family & Community

4. What Is Primary Care? • Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Institute of Medicine, 1996

5. Primary Care is Relational Care Personalismo y ConfianzaTrump Evidence-Based Medical Advice

6. Behavioral Health Physical Health • “Baseball is 90% mental -- the other half is physical." -- Yogi Berra

7. Partnerships on Behavioral Health in Primary Care Federal Partners Senior Workgroup Satcher Health Leadership Institute Carter Center National Center for Primary Care Rollins School of Public Health Southeast Regional Clinicians’ Network

8. WHO Global Burden of Disease All Behavioral Health -- Mental Illness, Suicide, Alcohol, & Drug Use = 21.6% Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: World Health Organization and the World Bank, Harvard University Press, 1996. www.who.int/msa/mnh/ems/dalys/intro.htm

9. Depression in Primary Care • Survey of 1898 patients in 88 primary care practices • Patients meeting DSM criteria for depression w/in past 30 days • 21.7% of women • 12.7% of men Rowe MG. Correlates of Depression in Primary Care. Journal of Family Practice, 1995.

10. Why Primary Care? 18% Prevalence of Alcohol Abuse or Dependence in Primary Care McQuade et al; Detecting symptoms of alcohol abuse in primary care. Archives of Family Medicine, 2000.

11. Screening vs. Readiness to Change • 7 VA Clinics --36% screened positive for alcohol misuse Readiness to Change in Primary Care Patients Who Screened Positive for Alcohol MisuseWilliams et al. Ann Fam Med 2006;4:213-220.

12. Is Primary Care Failing? • “About 70 percent of the population sees one of the 255,173 primary care physicians at least once every two years.” BUT: • “94 percent of primary care physicians failed to include substance abuse among the five diagnoses they offered when presented with early symptoms of alcohol abuse in an adult patient.” • “Most patients (53.7 percent) said their primary care physician did nothing about their substance abuse: • 43 percent said their physician never diagnosed it • 10.7 percent believe their physician knew about their addiction and did nothing about it.” Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. CASA- National Center on Addiction & Substance Abuse at Columbia University, April 2000.

13. Usual Care = Sub-Optimal Care • Fail to screen / detect • Fail to diagnose • Fail to treat • Fail to treat adequately • Fail to treat to remission

14. “Typical” Primary Care Patient • A1C (Diabetes) • BP (Hypertension) • Cholesterol /LDL • Depression • Plus – Osteoarthritis / Pain Mgt (Self-medicating with sister’s Vicodin) • Plus – Social ComplexitiesHusband unemployed, now drinking heavily; teens caught up in juvenile justice system. D

15. Co-morbidities Abound! • He’s just one patient, how bad could it be??? • Diabetes • Arthritis • COPD • CHF • Stroke • Pneumonia • Cancer • Depression • Alcohol / substance abuse * 21 ER Visits * 139 hospital bed-days

16. Mental Health Co-Morbidities in the Disabled Medicaid Population

17. Complex Co-Morbidities • Among disabled Medicaid patients with HTN: • 60% have at least 3 other serious physical conditions (on a billed claim within the past year) • 26.7% have a mental health diagnosis • 17.6 % have a substance use disorder diagnosis • 36.5% have either a mental health or substance use disorder diagnosis • 9.8% have both a mental health and a substance use disorder diagnosis

18. Prescription Drug Abuse • 15.1 million Americans admit abusing prescription drugs • The number of people who admit abusing controlled prescription drugs increased from 7.8 million in 1992 to 15.1 million in 2003. • In 2003, 2.3 million teens between the ages of 12 and 17 (9.3 percent) admitted abusing a prescription drug in the past year; 83 percent of them admitted abusing opioids. • In 2002, controlled prescription drugs accounted for 23 percent of all drug-related emergency department mentions in the U.S • -- Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. (July 2005); CASA – The National Center on Addiction and Substance Abuse at Columbia University

19. Pain Management vs Opioid Addiction You are now entering . . . Achieve Adequate Pain Control Prevent Prescription Drug Addiction . . . the No-Win Zone!

20. Strategies to Address At-Risk Substance Use and SUDs in Primary Care Setting • Screening • Brief Intervention • Motivational Interviewing • Referral • Care Management • Medication-Assisted Recovery • Recovery-Oriented Systems of Care

21. Primary Care without A Team Approach Preventive Services = 7.4 hrs / day Chronic Dz (well-controlled panel) = 3.5 hrs/day Chronic Dz (poorly-controlled panel) = 10.6 hrs/day Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005 May-Jun;3(3):209-14.

22. Screening in Primary Care CAGE CAGE-AID AUDIT-C ASSIST DAST CRAFFT PHQ-9 Hamilton-D GAD-7 Beck Anxiety Inventory HITS (domestic violence) Epworth Sleepiness Scale

23. Screening & Brief Intervention in Primary Care • AHRQ Evidence Review does recommend alcohol screening & brief intervention • After primary care brief, multi-contact interventions, patients reduced average drinks per week by 13%–34% and increased the proportion drinking at moderate or safe levels by 10%–19% compared with controls. BUT, . . . the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. Whitlock EP, Green CA, Polen MR, Berg A, Klein J, Siu A, Orleans CT. Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 Mar.

24. Brief Intervention -- FRAMES • Feedback • “I am specifically concerned about your substance use because…” • Responsibility • “What you do with your substance use is up to you.” • Advice • “In my medical opinion, you can best minimize your health risks by…” • Menu • “What do you think would work for you if you decided to make a change?” • Empathy • “It is not easy to change.” • Self-Efficacy • “I can see that you are a strong person.”

25. Primary Care Needs the Partnership with Behavioral Health !!!

26. http://pcpcc.net/files/pcmhpurchasersummary.pdf

27. Does the Mental Health Sector Need More Primary Care? • 25-year survival deficit -- Schizophrenia Excess Mortality • 28% due to  suicide • 12% due to  accidents • 60% due to  everything else • S Brown. Excess mortality of schizophrenia. A meta-analysis The British Journal of Psychiatry 171: 502-508 (1997)

28. Uncoordinated Care – When We Just Don’t Talk • Jane Doe -- 37 y/o F w/ Bipolar Disorder • Lithium (Lithobid®) • Aripiprazole (Abilify®) • Divalproex Sodium (Depakote®) • Jane Doe – 37 y/o fertile female smoker with HTN & two-weeks of productive cough • Azithromycin (Zithromax Z-Pack®) • ACE + HCTZ (Vaseretic®) • OCP’s (Yaz®) • Bupropion (Zyban® or Wellbutrin®)

29. Three-Way Integration – Mental Health, Substance Abuse, & Primary Care • 40 percent of those with an alcohol use disorder also had an independent mood disorder and 60 percent of those with a drug use disorder had an independent mood disorder (Grant, Stinson, Dawson, Chou, Dufour, Compton, et al., 2004). • Integrated treatment for both problems is the standard of care for clients with substance abuse and depressive symptoms or any co-occurring mental disorder. • TIP 48:Managing Depressive Symptoms in Substance Abuse Clients during Early Recovery. SAMHSA/CSAT Treatment Improvement Protocol Series; 2008.

30. Clinical Scenarios • PRIMARY CARE • Diabetic patient with depression • Insomnia patient using increasing doses of Xanax® • CHF patient who self-treats PTSD with alcohol • Chronic back pain patient develops opioid addiction • SUBSTANCE ABUSE TREATMENT • Alcohol patient in detox with HTN and chest pain • Sickle cell patient with heroin addiction has painful crisis • Obese, smoking diabetic worried that he is addicted to the Darvocet® he takes for neuropathic pain. • MENTAL HEALTH • Schizophrenia patientgains 100 lbs and develops diabetes • Bipolar patient on lithium has hypothyroidism and high blood pressure

31. Status Quo = Fragmentation • Silos: • Public health • Medical care • Behavioral Health • Mental health • Substance Abuse • Faith Communities • Employers • Legislators policymakers • Payors / Funders

32. How’s that workin’ for ya???

33. Choices Real People Make

34. Roles for Primary Care in Specialty Substance Abuse Treatment Setting • Screening for Medical Co-Morbidities • Treatment of Co-Morbid Medical Conditions • Asthma/COPD, Blood Pressure, Diabetes, etc. • Coordination / Care Management with Medical Specialty Providers • Infectious Disease (HIV-AIDS, Hepatitis C, Tuberculosis) • Gastroenterology / Hepatology(Liver Failure, Cirrhosis, Hepatitis) • Coordination / Care Management with Mental Health Specialty Providers

35. Can Primary Care Improve SA Treatment Effectiveness? • Survey of 2878 patients in 52 treatment programs • At 12-month follow-up, patients who attended programs with on-site primary medical care (compared with patients who attended programs with no primary medical care) experienced : • Significantly less addiction severity • No significant difference in medical severity . • Referral to off-site primary care exerted no detectable effects on either addiction severity or medical severity. Friedmann PD, Zhang Z, Hendrickson J, Stein MD, Gerstein DR. Effect of primary medical care on addiction and medical severity in substance abuse treatment programs. J Gen Intern Med. 2003 Jan;18(1):1-8.

36. Primary Care Impact on SA Treatment • DESIGN: Randomized controlled trial conducted between April 1997 and December 1998. • SETTING AND PATIENTS: Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif. • INTERVENTIONS: Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA. 2001 Oct 10;286(14):1715-23.

37. Impact on Outcomes • RESULTS: • Both groups showed improvement on all drug and alcohol measures. • Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18). • Patients with SA-related medical conditions (SAMCs) were more likely to be abstinent in the integrated care group than the independent care group(69% vs 55%, P =.006; odds ratio [OR], 1.90) • This was true for both those with medical (OR, 3.38) and psychiatric (OR, 2.10) SAMCs.

38. Four-Quadrant Model (~2004)

39. Four-Quadrant Clinical Integration Model (~2010) --National Council, B. Mauer Mental Health / Substance Use Complexity

40. Continuum of Integration

41. INTEGRATING APPROPRIATE SERVICES FOR SUBSTANCE USE CONDITIONS IN HEALTH CARE SETTINGS An Issue Brief on Lessons Learned and Challenges Ahead 2010 http://www.niatx.net/pdf/ARC/Integrating_Appropriate-Services_TRI.pdf

42. Coordinated Care • Tracking & Confirmation of Referrals & Follow-up • Sharing of Medical Records • Sharing of Prescribing Changes & Medication Lists • Inter-Operable Electronic Health Records • Mutual Participation in Effective Health Information Exchange

43. Collaborative Care • All of the Above plus . . . • Team-Based Case Conferences • Frequent Interaction on Therapeutic Strategy • Patient-Centered, Shared Decision-Making • Shared Care Management • Joint Decision-Making on Medication Changes • Frequent, secure communication by phone, e-mail, & videoconferencing

44. Continuum of Integration

45. National Collaborations • http://www.niatx.net/Content/ContentPage.aspx?PNID=4&NID=245

46. Baby Steps • NIATx / NACHC Collaborative

47. NIATx Resource Links http://www.niatx.net/Content/ContentPage.aspx?NID=249#skip3

48. Resources

49. Review of Evidence (& Best-Practices)

50. “Best-Practices” Integrating Behavioral Health & Primary Care • Cherokee Health System