Increasing opportunities for effective REFERRAL AND TREATMENT

1. Increasing opportunities for effectiveREFERRAL AND TREATMENT Center for Community Collaboration Department of Psychology University of Maryland, Baltimore County March 22, 2010

2. Today’s Objectives • Overview of SBIRT • Introduction of Referral and Treatment as a decision-making process • Review the skills and knowledge important for effective referral and treatment • Self-Assessment of agency RT processes • Provide additional SBIRT implementation tools • Brainstorm ideas to enhance SBIRT processes

3. SBIRT:A National Initiative • SAMHSA’s Screening, Brief Intervention, Referral and Treatment (SBIRT) cooperative agreements • Boards and federal agencies have taken a major interest in SBIRT (JACHO; ACOG) • American College of Surgeons’ Committee on Trauma • Federation of State Medical Boards • Accreditation Council for Continuing Medical Education

4. SBIRT • Goal: Improved treatment and treatment integration for various medical and behavioral risks Referral &Treatment Brief Intervention Screening

5. SBIRT Core Components “[Referral to treatment] is an imperative component of SBIRT as it ensures access to the appropriate level of care” (SAMHSA, 2009)

6. SBIRT • The Problem: Fragmented, uncoordinated services are ineffective for treatment of mental illness and substance abuse co-occurring disorders (COD) common among persons living with HIV/AIDS. • There is a movement towards integrated, client-centered services for individuals with COD and HIV. • Screening, assessment, and treatment planning make up the three crucial elements that guide integrated care.

7. SBIRT Process Center for Substance Abuse Treatment. Screening, Assessment, and Treatment Planning for Persons With Co-Occurring Disorders. COCE Overview Paper 2. DHHS Publication No. (SMA) 07-4164 Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007.

8. Decision-Making Process • Referral and treatment as a decision-making process • Step 1: Identifying the Problem • Screening • Knowledge of comorbidities • Step 2: Assessing the Problem and the Need • Severity index, decision-trees, readiness to change • Levels of care and treatment options • Step 3: Adequacy of Referral • Internal vs External Referral • Communication Style to enhance engagement • Step 4: Feedback and Follow-up • Treatment Planning and Service Authorization • Close the Loop

9. Step 1: Identifying the Problem • Tools for Problem Identification • Screening information (Roundtable Part 1 Binder) • Validated tools • Formal vs. Informal • Knowledge of comorbidities • What are co-occurring disorders (COD)? • Common CODs among persons living with HIV/AIDS • Interactions between mental health, substance abuse, and HIV/AIDS medications, access, and adherence

10. Co-Occurring Disorders • The clients we serve often include individuals with mental health, substance abuse, and HIV needs • The term co-occurring disorders (COD) refers to simultaneous substance-related and mental disorders. • Clients said to have COD have one or more substance-related disorders as well as one or more mental health disorder.

11. Examples of COD • Schizophrenia • Bipolar affective disorders • Major depression • PTSD • Anxiety disorders • Mild depressive disorders • Mild organic syndromes • (e.g. head injuries) • Eating disorders • Anti-social personality disorder • Borderline personality disorders The following mental health disorders are most often associated with substance abuse disorders:

12. Statistics of COD 4.2 million American adults are currently suffering from serious mental illness and a substance use disorder ³ Illicit drug use is more than twice as high among individuals with a serious mental illness than among those without ³ 20% of individuals with substance use disorder have at least one mood disorder; 18% have at least one anxiety disorder ¹ 29% of individuals with a current alcohol use disorder and 48% of those with a drug use disorder have at least one personality disorder ² Over 80% of individuals with COD do not perceive a need for treatment of both problems ³ _____________________________________________________ ¹ 2001-02 NESARC data ² 2004 Kids Count Data Book, Annie E. Casey foundation. www.kidscount.org ³ 2003 NSDUH data

13. HIV & COD • Most common mental health disorders for individuals with HIV are depression and anxiety. • Receiving an HIV diagnosis can produce intense emotional reactions including shock, fear, anger, sadness, hopelessness, denial and suicidal ideation. • Depression is twice as common in individuals with HIV as in the general population • Substance use, very common among those with HIV, can complicate mental health problems by increasing levels of distress, interfering with treatment adherence, and leading to impairment in thinking and memory. • HIV, as well as some medications used to treat the virus, can directly affect the brain causing impairments to memory and cognition.

14. Identifying COD • People with COD and HIV often face discrimination, stigma, and blame. • It is important to educate providers in COD to decrease stigma and improve identification of the problem(s). • Challenges in identifying and treating COD include: • Varying severity and interactions among disorders • Need for cultural competence and sensitivity • Need for improved COD resources for behavioral health systems (e.g. integrated dual diagnosis treatment) • Need for coordination between state and local agencies providing services to individuals with COD • Further assessment is needed beyond the initial screening

15. Case Example: James is a 44-year old African American male entering HIV treatment for the first time. During intake, scores on the SAMISS indicate a positive screen for nonprescription use of prescription drugs and possible mental health problems. • What would you initially? • Agency-specific decision-trees • The construction of "decision trees” helps to identify where and how to start mental health and substance abuse treatment and when to refer out…

16. Sample Decision Tree

17. Step 2: Assessing the Problem and the Need (CAMH, 2006)

18. Step 2: Assessing the Problem and the Need • Knowledge of severity of the problem, history, and evidence-based treatment options • Tools for Assessment (Samples provided in binder) • Severity index (e.g., ASAM, DSM criteria) • Additional Biopsychosocial Assessment • History of problems, treatment, and patient strengths • Readiness to Change for each problem • Information about evidence-based practices for each problem • Agency-specific referral guide

19. (SAMHSA, 2006)

20. Center for Substance Abuse Treatment. Screening, Assessment, and Treatment Planning for Persons With Co-Occurring Disorders. COCE Overview Paper 2. DHHS Publication No. (SMA) 07-4164 Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007.

21. Evidence-Based Practices • Those treatment practices that have demonstrated empirical evidence for effectiveness and can be considered best-practices: • Gold Standard • Research findings from randomized, controlled clinical trials • Next Best • Research findings from quasi-experimental studies using randomization • Weak Design • Open clinical trials coupled with expert-based clinical observations

22. Evidence-Based Practices • Integrated Treatment for COD • Drake et al. (1998) reviewed 36 research studies on the effectiveness of integrated treatment in mental health settings for people with COD. • Found that: “Integrated treatment, especially when delivered for 18 months or longer, resulted in significant reductions in substance abuse, and, in some cases, in substantial rates of remission, as well as in reductions in hospital use and/or improvements in other outcomes.” • Effective integrated and comprehensive treatment begins with enhanced motivation and engagement strategies.

23. Evidence-Based Practices • Treatment strategies with evidence for improved treatment engagement include: • Motivational Interventions • Cognitive/Behavioral Approaches • Modified Therapeutic Communities • Assertive Community Treatment (ACT) • Intensive Case Management • Contingency Management • Medications • Suboxone/buprenorphine for opioid dependence • Combinded psychoactive meds and therapy

24. Mental health and Adherence • Although specific SBIRT recommendations for mental health are currently lacking, studies show that treatment for mental health problems among those with HIV predict improvements in a variety of life areas, including adherence to medications. • Springer, Chen, and Altice (2009): • Among 89 HIV-infected drug users enrolled in a clinical trial, 58 (63%) met criteria for major depressive disorder. • Improvements in depression with treatment were associated with: • Higher self-efficacy • Having housing • Remaining abstinent from illicit drugs • Improvements in CD4 count • Adherence to prescribed antiretroviral therapy • “Improvements in depressive symptoms could occur with improvement of alterable factors that are associated with strengthening adherence such as linkages to case management, mental health and substance abuse treatment services as well as through enhancement of social stabilization factors through social support and supportive housing" (p. 976) • Up-to-date resources for mental health treatments for persons with HIV/AIDS are available at http://mentalhealthaids.samhsa.gov/

25. Comprehensive Drug Abuse Treatment (NIDA, 2009)

26. Case Example: Assessment with James confirms DSM opioid dependence and major depression. His medical and psychosocial challenges include hypertension and homelessness and strengths include the attainment of a GED and maintaining close family contacts. On readiness rulers, James rated himself a 2 of 10 for quitting heroin and a 7 of 10 for improving his mood. • What would be your referral decision? • How has this changed from your initial response? • What would be your referral decision based on the information gathered in Step 2? • How has it changed from your initial decision?

27. Sample Decision Tree

28. Step 3: Adequacy of the Referral • Communication styles that impact treatment engagement and adherence: • Hot Handoff • Matching patient to provider, aiding in Direct contact, Meet-n-greet • Warm Handoff • May match patient to provider, indirect notification to provider (e.g., note in chart, electronic message) • Cold Handoff • No notification to provider, requires self-activated referral by patient

29. Step 3: Adequacy of the Referral • External referrals can involve more extensive processes to improve likelihood that patient will engage in treatment: • Locating and contacting services • Developing a referral process that is timely, appropriate, well-monitored, and client-centered • Identifying appropriate referral outsources • Identifying appropriate time for referral based on agency abilities and client readiness

30. Referral Practices • Assess client referral needs • Plan the referral • Help client access referral services • Document referral • Feedback and Follow-up

31. Step 4: Feedback & Follow-Up • Internal Referral: Treatment Planning • Use of MI principles, assessment information, client readiness, and COD knowledge to create client-centered plans • Discriminating between long- and short-term treatment goals • Techniques for enhancing treatment planning (e.g., Fit Circles, Genograms, Strengths and Needs Planners) • Communication between providers • Documentation, chart flags, notification of missed and attended appointments

32. Step 4: Feedback & Follow-Up • External Referral: Service Authorization and Tracking • Using MI to encourage client initiative and follow-through in the referral process • Developing a process to ensure that referrals are well-monitored • Up-to-date external contact information • Fax referrals and other streamlined referral methods • Service Authorization that complies with confidentiality requirements of both HIPAA and CRF

33. Ensure high quality referral services • Education and support of staff members • Provider coordination and collaboration • Referral resources that are up-to-date and easy to navigate

34. HIPAA • The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and its regulations (the "Privacy Rule" and the "Security Rule") protect the privacy of an individual’s health information and govern the way certain health care providers and benefits plans collect, maintain, use and disclose protected health information (“PHI”).

35. Intent of 42 CFR • To ensure that a client seeking or using services for alcohol or drug use is not made more vulnerable due to the availability of his or her client or medical record.

36. 42 CFR • When communicating with other agencies, keep this regulations in mind: • 42 CFR covers information that identifies or can be used to identify a person as an alcohol or drug abuser, or a recipient of alcohol or drug abuse diagnosis, referral, or treatment services. • HIPAA must be used to determine what is individually identifiable information that is related to patients in substance use services.

37. 42 CFR + HIV/AIDS Specific provisions for HIV test results • Providers may only release test results as permitted under Health and Safety Code §81.103. • In general, permitted disclosures are limited to those relating to disease reporting, treatment, and notification of exposed individual. • Test results include statements that a person has or has not been tested and statements that a person is positive, negative, or high risk. • All other disclosures of HIV test results require written authorization from the client.

38. Interaction between HIPPA + 42 CFR • HIPAA allows, but does not require, programs to make disclosures to other healthcare providers without authorization. • 42 CFR prohibits disclosure unless there is authorization, court order, or the disclosure is done with out revealing PHI. • These requirements need not be a barrier to collaborative care between agencies, with the use of clear documentation and consent forms.

39. CCC Treatment and Referral Framework

40. CCC Core Framework

41. Conclusion • Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a decision-making process that: • Streamlines problem identification and treatment planning • Brings clients closer to their own treatment goals • Improves integration of treatment services • Recognizes the complexities of COD • Treats service coordination as an ongoing process of follow-up and quality improvement

42. References Barrowclough C, Haddock G, Tarrier N, et al (2001). Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. American Journal of Psychiatry, 158, 1706-1713. Center for Substance Abuse Treatment. Definitions and Terms Relating to Co-Occurring Disorders. COCE Overview Paper 1. DHHS Publication No. (SMA) 07-4163 Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007. Center for Substance Abuse Treatment. Screening, Assessment, and Treatment Planning for Persons With Co-Occurring Disorders. COCE Overview Paper 2. DHHS Publication No. (SMA) 07-4164 Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007. Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders. Treatment Improvement Protocol (TIP) Series 42. (DHHS Publication No. SMA 05-3992). Rockville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration. (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194). Rockville, MD. Wright, D. (2004). State Estimates of Substance Use from the 2002 National Survey on Drug Use and Health (DHHS Publication No. SMA 04-3907, NSDUH Series H- 23). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

43. Today’s Roundtable • Break for Lunch • Please enjoy this time to meet with colleagues and review the contents of your binder • Discussion • Evaluation and Closing • Thank you from the CCC Team!