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

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advances in the treatment of addiction shifting the treatment paradigm again

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

Thomas E. Freese, Ph.D.

UCLA Integrated Substance Abuse Programs

disproportionate impact on persons with mi suds
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%)

disproportionate cost implications 1
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)

health insurance reform goals
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

slide5

Distribution of Alcohol (or Drug) Problems

Specialized

Treatment

Brief

Intervention

Prevention

20 9 million people need but do not receive treatment for illicit drug or alcohol use
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).

slide7

Distribution of Alcohol (or Drug) Problems

2.3 Million

22.2 Million

??????

slide8

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

it s time for another paradigm shift
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
slide11

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

provider practice barriers
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
provider practice barriers1
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
regulatory licensure and scope of practice barriers
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)
slide15

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
overall essential workforce skills
Overall: Essential Workforce Skills

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

what is primary care integration
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.

minimal
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

basic at a distance
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

basic on site
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

close partially integrated
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

close fully integrated
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

integration workforce considerations
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.
models of integration
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

models of integration1
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

slide28

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
a key partner

A key partner…

The Federally Qualified Health Centers(FQHCs)

what are fqhcs
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
types of health centers
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
bphc health center program requirements health services
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)
bphc health center program requirements additional key requirements
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)
benefits of fqhc designation
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
fqhcs in california
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
the role of fqhcs in providing sud services
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
slide37
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.  
slide38
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. 
areas for workforce advocacy
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
areas for workforce advocacy1
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
two new team members
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

as the treatment of substance use disorders suds moves to the world of healthcare services
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.

a diverse set of treatments will be used for a diverse set of patients
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.
evidence based treatments medications
Evidence-based Treatments: Medications
  • Opiate Addiction: Methadone, Buprenorphine, Naltrexone
  • Alcohol: Naltrexone, Vivatrol, Campral, Ondansetron
  • Nicotine: Nicotine replacement, Varenicline
evidence based treatments behavioral approaches
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)
consumer improvement strategies
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
physician management of opioid addiction
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.

physician management of opioid addiction themes
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

physician management of opioid addiction themes1
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

physician management of opioid addiction themes2
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

physician management of opioid addiction conclusions
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.
treatment of suds changes ahead
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.

affordable care act behavioral health
Affordable care act – Behavioral health
  • 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

Hyde, P. (2010). Behavioral Health 2010: Challenges & Opportunities

affordable care act behavioral health1
Affordable care act – Behavioral health

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

Hyde, P. (2010). Behavioral Health 2010: Challenges & Opportunities

potential benefits of linking primary care pc and substance abuse sa services
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

Samet JH, Friedmann P, Saitz R. Arch Intern Med. 2001; 161: 85-91.

current samhsa initiatives
Current SAMHSA initiatives
  • 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 initiatives1
Current SAMHSA initiatives
  • 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).

take away points
Take away points
  • 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.
more training coming
More Training Coming
  • SAVE THE DATE
  • And
  • PRE-REGISTER for $50
  • Tuesday, November 16, 2010 TehamaCounty
  • Thursday, November 18, 2010 Los Angeles County
  • Wednesday, December 1, 2010 Merced County
  • Tuesday December 7, 2010 Alameda County
thank you
Thank you
  • Thomas E. Freese, Ph.D.
  • tfreese@mednet.ucla.edu
  • www.psattc.org www.uclaisap.org
    • “Be kind, for everyone you meet is fighting a great battle.”
    • Philo of Alexandria