Download Santa Clara County Initiatives - UCLA Integrated Substance Abuse

The Valley Specialty Center – part of the
Santa Clara Valley Health & Hospital System
Santa Clara Valley Health and Hospital System
Department of Alcohol & Drug Services
Integrated Care Projects Update
Santa Clara County—Quick Facts
• Population: 1.8 million (larger than SF)
White
Asian
Hispanic
Black
37%
30%
26%
3%
• Foreign Born: 40% (One of 10 U.S. counties
where more than 50% of residents speak a language
other than English at home)
• Income: $75K median, 10th in US, but . . . .
< $25K
$25-45K
$45-100K
> $100K
13%
15%
37%
35%
28% of families
earn less than local
poverty threshold
Governance and Organization
Voters
Board of Supervisors
Health and Hospital Committee
Santa Clara Valley Health and Hospital System
Drug &
Alcohol
Public
Health
Mental
Health
Valley
Health
Plan
Valley
Medical
Center
 Department in Santa Clara Valley Health
and Hospital System
 Safety-net system for County of Santa Clara
 VMC has 574 licensed beds
 9 Valley Health Center Clinics
 3 Urgent Care Clinics
 17 Network Neighborhood Clinics
 One in four Santa Clara County Residents are
served by SCVMC
 Greater than 220,000 unduplicated patient count
(increase of 60% in 10 years)
 Busy Emergency Department (24 beds) seeing
70,000 visits
 700,000 Ambulatory Clinic visits yearly
Two projects were initiated in 2010 that incorporated the
core components of screening, brief intervention treatment,
and referral (SBIRT).
Moorpark Medical Home: A pilot project within one of three
similar primary care settings that will demonstrate that when
substance abuse services are integrated with primary medical care
both medical and substance use outcomes are improved.
Alexian Integrated Care Project: Integrate the DADS addiction
medicine division with the Valley Health Homeless primary care
program at Alexian. DADS is also planning to conduct pilot
studies on an array of various addiction medicines in addition to
those being used for opioid addiction. These would include
naltrexone, acamprosate, odansetron, topiramate, and disulfiram.
Project Goals
As a result of both initiatives, DADS is planning to see:
1) medical and substance use problems both show better
improvements when treated in an integrated way;
2) patient compliance with their medical care plan and
substance abuse treatment plan will improve;
3) a decrease in over-utilization of limited medical
services; and
4) demonstrated cost offsets and savings through the
health system as a result
Partnership Development Process
Moorpark Medical Home
• Regular planning meetings were held in order to co-develop
the logistics with medical clinical staff.
• Screener form development processes occurred to integrate
into the medical system
• Securing permanent office space for the addiction specialist
• Selection of a screening test and a substantial training for the
medical staff on the importance of routine screening for SUDs
in all patients. CAGE-AID is the screening tool being used.
• Addressing 42 CFR issues that can impede integration
CAGE-AID QUESTIONNAIRE
Patient Name _____________________________ Date of Visit __________________
When thinking about drug use, including illegal drug use and the use of prescription drugs other than
prescribed,
Questions
Yes
Have you ever felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to
steady your nerves or to get rid of a hangover (eye-opener)?
Reviewed By: _____________________________
Disposition:
Date: __________________
No
Moorpark Patient Flow Through Primary Care and Referral
SCREENING
Administering the CAGE-AID:
Screen all patients for SUDs using the CAGE-AID.
Patients can self administer the screen, although be mindful of language/reading concerns. Offer assistance.
Inform patients that this is now being asked of all patients in order to help accomplish their healthcare goals
Place completed screen in patient chart for physician review in exam room
CAGE-AID Action Steps: Physician reviews results of positive screen with pt and clarify/confirm quantity, frequency, and duration of use.
Score 1: Possible SUD.
Physician reviews and discusses w/ pt
Patient education about use and medical dx
Explain how health problems can be caused by
or exacerbated by drug/EtOH use.
Score 2: Probable SUDs or at-risk use.
Physician reviews and discusses w/ pt and
refers for assessment
At-risk use
unchanged or
increasing, refer for
Score >2: Suspected high SUDs.
Physician reviews and discusses w/ pt and
refers for assessment
Assessment and ASAM level of care (LOC) placement.
If LOC 0.5 - 1.0, use brief intervention/brief tx on site at Moorpark
If LOC > 1, consider referral to DADS system of care
Monitor and review use patterns at f/u visits
Brief Intervention/Brief Tx
(ASAM 0.5—1.0)
Brief intervention unsuccessful
Pt refuses treatment
Refer to treatment admission in
DADS
(ASAM > 1)
Successful brief intervention (may need to be
repeated as circumstances change).
Motivation interviewing
and watchful waiting
Continued follow-up and relapse
prevention for SUDs
MOORPARK DADS REFERRAL FORM
Pt alt contact #______________
CAGE-AID score____________
Referring physician (please print)_________________________ Date of referral______________
PCP (if different from referring provider above):_________________________________________
Referring Clinic:______ Moorpark Care Team
Reason for Referral (check all that apply):
___Worsening of patient’s medical condition (s) due to ongoing substance abuse
___Difficulty adhering to treatment plan due to substance or prescription abuse
___New relapse/near-relapse of substance abuse, request help connecting to programs
___Obtain prior and/or current treatment plan from substance abuse program
___Request assistance communicating with treatment program
___Other:
Chronic conditions:
Current meds (list here or attach printout from ELMR):
FAX TO DADS LCSW:_
For DADS use:
Please circle:
Y
N
Date form rcvd:___/____/____
1st attempt contact pt__/__/___
nd
2 attempt contact pt_ _/__/__
DADS release form attached
Outcomes
Moorpark Medical Home
DADS established a data dashboard to document outcomes
compared to the non-medical home settings.
Measures include: # of patients, % SUD screened, % assessed
and diagnosed, % received patient education and brief
intervention, % referred to DADS for treatment, % referred to
the continuous recovery model post treatment and the number
active in post treatment. Preventative Care and Patient
Satisfaction will also be measured.
SANTA CLARA COUNTY
DEPARTMENT OF ALCOHOL & DRUG SERVICES DASHBOARD
Data collected continuously but reported on a quarterly basis
Bi-monthly Report # ____ From ______ to ______
CLINICAL QUALITY:
Addiction Care
• # of pts
• % screened for SUDs
• % referred for assessment
• % pt education or Brief Intervention
• # Referral to SUD tx
Preventive Care
Tobacco education
Information given pts
TB test
PATIENT EXPERIENCE:
Patient Satisfaction
• Pt satisfaction survey: Overall quality of care - % rated as “excellent”
• Chronic disease Self-Efficacy Scales
Partnership Development Process
Alexian Integrated Care Project
• Regular planning meetings were held in order to codevelop the logistics with medical clinical staff.
• Addressing 42 CFR issues that can impede
integration
• Minor construction needed to assist integrating both
programs and an increase in patient capacity
Outcomes
Alexian Integrated Care Project
Based in part on the Primary Care Behavioral Health model,
the Alexian Health Clinic is a fully integrated model where
behavioral health is a routine part of the medical care.
Effective collaboration for the Alexian Health Clinic and the Valley
Health Homeless Project (VHHP) will improve the quality of care for
patients of both programs and will include:
• Increased accessibility to needed care through patient referrals (i.e.
methadone patients needing primary medical care , VHHP Suboxone
patients needing transition to methadone, etc.);
• Consultations by Addiction Medicine staff with VHHP and vice
versa to patients in common;
Outcomes
Alexian Integrated Care Project
• In-service trainings on addiction medicine including screening, MI
and addiction clinical practice;
• VHHP/AMT participation in regular case conference meetings (42
CFR federal confidentiality guidelines restrictions would apply);
• Patient education series on substance abuse, co-occurring medical
conditions, preventive health care, and medical comorbidities
provided;
• VHHP representative in weekly AMT clinic management team
Barriers
Moorpark Medical Home
• Time and place to conduct screening and brief intervention is
problematic.
• MDs can’t do the full SBIRT, but they can do SRT (screening, referral to
treatment). Therefore, it is essential to bring in support behavioral health
staff to conduct the pieces in between.
• To save some time, patients can complete the CAGE-AID on their own
and the MD can review it with them during the exam.
• There are no data fields to capture patient information for SUDs in
current medical databases. 42 CFR can be a barrier to accomplish this.
• During the process of selecting or modifying electronic medical records,
and/or modifying procedures stay compliant with privacy regulations, it is
important to manually collect data as soon as possible.
• Selecting the data measures and collecting data remains challenging (both
projects)
Plans for Sustainability
Moorpark Medical Home and the Alexian Integrated Care Project
1) Test out a billing system using LCSW staff who can bill FQHC for Medi-Cal
clients. This is a very high reimbursement rate that may support the full cost
of the SUD staff.
2) If cost savings can be identified as a result of integrating and treating SUDs,
such as reduction in hospitalizations or use of ED for medical care, this
would help justify the investment in Tx of SUDs.
3) Integration, if successful, identifies that primary care settings are the
appropriate place to identify and initiate treatment for SUDs, and this will
shift responsibility to the primary care system, thus increasing the likelihood
that the services will continue. If they see value, and recognize their
responsibility, they may decide they own it.
4) As we get increased Medi-Cal reimbursement from the MCE waiver, and
ultimately from health care reform in 2014, the SUD services may have their
own reimbursement stream.
Project Contacts:
Mark Stanford, Ph.D. Division Director
DADS Addiction Medicine Division
(408) 885-4078
Kakoli Banarjee, Ph.D.
DADS research and Development
(408) 792-5683