Download Minutes/Summary - UCLA Integrated Substance Abuse Programs

SUMMARY REPORT
MEETING 15
Date:
Time:
Hosts:
Topic:
Wednesday, August 22, 2012
1:15PM – 2:45PM
UCLA Integrated Substance Abuse Programs (ISAP) & CA
Dept. of Alcohol and Drug Programs (ADP)
Integration in the Field: County Initiatives (Riverside County,
Merced County and Los Angeles)
Presenters: -- Elizabeth Schaper
UCLA ISAP
-- Karen Kane
Riverside County
-- Manuel Jimenez
Merced County
-- Loretta Denering
Los Angeles County
Review of ILC Meeting 14
UCLA ISAP
The fourteenth ILC meeting, conducted on June 27, 2012, focused on the
growing prescription drug abuse problem. Special thanks to Beth Rutkowski who
gave a very informative presentation and responded to questions posed from
meeting attendees. Thank you all for your participation.
Logistics
 Summary and materials discussed from the previous ILC meetings are
available at http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html. Subsequent meeting materials will continue to be
posted on this site.
 The next ILC meeting will be held during CADPAAC on September 26,
2012 from 11:00AM to 12:00PM. Darren Urada from UCLA will be
presenting.
 All further meetings are scheduled to be held at 11:00AM (PST) on the 4th
Wednesday of every month, unless otherwise noted.
ILC Meeting 15 Topic:
Integration in the Field: County Initiatives (Riverside County, Merced
County and Los Angeles)
Topic Introduction – Elizabeth Schaper, UCLA ISAP
 The topic for today’s learning collaborative is to hear about the integration
activities taking place in Riverside, Merced and Los Angeles County. We
thank Karen Kane, Manuel Jimenez, and Loretta Denering for being willing
to share their work and hope this will be a learning opportunity for those in
the audience but also for the speakers. Questions and troubleshooting
among the group are encouraged.
Integration Introduction
Elizabeth Schaper, UCLA ISAP
Summary
 Areas of focus
o Provide background and discuss the importance of behavioral healthcare
integration
 Facilitate understanding the key elements to moving toward integrated
care
o Describe three CA counties’ models of integration
 Share practical strategies to integrating substance use, mental health,
and/or primary care
 Why is integrated care important?
o 27% of the population will experience a mental health or addictive disorder
problem annually
o Research findings consistently suggest that most people who seek
behavioral healthcare do so from their primary care providers
o Healthcare reform will result in an influx of patients with newly acquired
SUD and MH treatment benefits seeking care in PC settings
 What is “integrated healthcare”?
 The collaboration of mental healthcare (MH), substance use disorder
(SUD) treatment, and primary healthcare (PC) service providers to
address a patient’s needs holistically and concurrently
o Collaboration takes many forms along a continuum. Integration is more a
process than a thing, a journey than a destination —it takes time, and it
usually happens gradually. This continuum illustrates the steps
organizations take as they integrate:
 Coordinated services: are given by separate medical and behavioral
health providers, and in separate settings.
 Co-located services: occur where medical and behavioral health
providers work separately, but in the same location.
 Fully integrated service: occurs where medical and behavioral health
providers are not only co-located, but they work together as a team to
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provide care that addresses both the physical and behavioral health
needs of their clients concurrently.
o Integration of services also follows a continuum
 Minimal Integration
 Basic Integration at a Distance
 Basic Integration On-Site
 Close Partially-Integrated Services
 Fully Integrated Services
Where can integrated care occur?
o Primary care settings
o Community health centers
o Federally qualified health centers
o Emergency rooms/trauma centers
o Prenatal clinics/OB-Gyn offices
o Medical specialty settings for diabetes, liver and kidney disease,
transplant programs
o Pediatric clinics
o College health centers
o Mental healthcare settings
o Substance abuse treatment centers
What are the key elements to successful integrated care?
o Mission Integration – providers across disciplines embracing a common
goal
 Getting all the staff, regardless of discipline, ideologically together,
embracing the importance of meeting a patient’s needs holistically.
This would be reflected in a mission statement that highlights the
treatment of behavioral health problems as part of the program’s
overall improved health goals for patients
o Physical Integration – medical and behavioral health providers working in
the same immediate area
 i.e. How close BH and PC service delivery are
o Clinical Integration – seamlessly connecting clinical activities of PC and
BH providers
 How well clinic day-to-day operations facilitate connections between
BH and PC care, for example the use of warm hand offs between
providers for same-day contact.
o Operations Integration – PC and BH providers practicing within a shared
infrastructure
 using the same billing sheets, sharing waiting areas and entrances for
patients, imposing no role restrictions on support staff
o Information Integration – PC and BH provider sharing clinically relevant
information in real time
 adhering to information sharing guidelines under HIPAA and 42 CFR,
Part 2, which allow for the sharing of information on a “need to know”
basis, allowing all providers access to patient information pertinent to
the delivery of integrated care; document the histories and interaction
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of physical health, mental health and substance abuse disorders in one
patient record, provided proper consent is obtained
o Financial and Resource Integration – financing integrated services using
a blended pot of health care and mental health care resources
What barriers can we anticipate to successful integration?
o Differing priorities: For patients with mental health and substance use
disorders, there are many challenges and issues that need urgent
attention. It can be difficult to coordinate them all in one treatment plan.
o Different philosophies: Different providers come from different
orientations. For example, some substance abuse counselors may want
abstinence from drugs to be the goal of treatment, whereas many PC
clinicians prefer harm reduction. Also, some medical providers may want
to focus services on treating symptoms of disease, while behavioral health
may be more interested in changing clients’ behavior. Differences in
approach can make coordination difficult.
o Differences in training: Medical providers may not be trained or
comfortable dealing with MH/SUD issues, and vice versa. Stigma
regarding MHD and SUD can also hinder integration.
o Funding: As mentioned earlier, though grantees have more flexibility,
lack of specific BH funding streams make it difficult to integrate care. In
many systems it is difficult for a physician to be reimbursed for behavioral
health screenings or brief interventions.
o Documentation: Different funding sources require different paperwork,
which can become overwhelming. Also mentioned before, there are
different systems in place to protect patients’ private health information. At
times privacy restrictions can be a barrier to the sharing of information that
is needed to integrate services.
Riverside County
Karen Kane
Program Administrator
Substance Abuse Services
Department of Mental Health
Summary
Three programs offering integrated services in Riverside were described.
1. Mental Health Services Integrated within Rubidoux Public Health Clinic
(FQHC-Look Alike):
o After months of planning, this integrated Public Health Clinic started
last week in Rubidoux (just west of the City of Riverside).
o This is a grant funded project, FQHC status was denied. They expect
to get FQHC approval in the future.
o Licensed Staff were needed for the program; hired two bi-lingual
MFT’s. They could not find LCSW’s.
o Psychiatrist started last Friday - three days/week (20 hours total).
o It was clear during the planning process that the doctors did not
understand what mental health (MH) providers do.
o The program was created because their co-occurring disorders (COD)
clients are dying at an average age of 48 years.
o Many mentally ill individuals show signs of untreated health issues.
o The goal was to identify and link MH clients to physical health care.
o They also want to link physical health clients to mental health care,
including prevention, e.g., post-partum depression information and
education for pregnant women.
o The Local MH Clinic identified those mental health consumers in the
Public health catchment area;
-who had two or more physical health problems and who
were not engaged with a primary health care provider and
-who needed management of integrated health problems.
o Most of the clients served within the Mental Health Clinic were eligible
for Medi-Cal.
o Some MH clients did not want to move to a Public Health Clinic for
services.
o The CRAFT tool was used to screen patients for substance use. The
MH clinicians were trained in using the tool. Patients receiving a
certain score were referred to substance abuse treatment services.
o The MH Clinician sees clients in an exam room in the public health
clinic. Nurses from other doctors bring clients to the MH clinician if a
doctor is prescribing a psychotropic drug. If there is an acute crisis,
the clinician and/or psychiatrist will see someone immediately if they
are available.
o The program is tracking all services provided during the grant period
so they can figure out how to bill under available funding later. They
are learning how to do this so they will be prepared for 2014.
o The grant from Riverside Health Foundation covers; Psychiatrist time,
Nurse Practitioner time at Blaine St Clinic, and limited amount of
physical health set-up costs. The plan was to bill Medi-Cal for lab
services.
o Charts are fully integrated at this site.
o They have learned that the medical model at the Public Health clinic is
very different from the MH model. They are two different work styles
and languages. This has required patience, tolerance, and openness
in order to merge the two cultures. Dysfunction existed in each
system. “We know we have it – we just don’t talk about it. We don’t
know all the hidden rules in the other the system.”
2. Blaine Street Mental Health Clinic:
o Public Health provided a Nurse Practitioner (NP) who was bi-lingual
and experienced in Public Health to work in the MH clinic.
o They set up a primary health care exam room – the NP described the
equipment needs.
o It cost $35K for equipment & supplies- this was more than expected.
o They needed to have a lab room for supplies and to collect specimens.
This required specialized equipment including: a phlebotomy chair,
more refrigerators, urine test cart, microscopes, slides, ear scopes, etc.
o The focus was on basic physical health care prevention and education
services; birth control, STD education & testing, women’s reproductive
health care (for women age 40 and older).
o The NP had to get to know the MH clients and they needed to get to
know her. It was critical to establish that relationship.
o MH staff tended to screen out too many clients initially.
o MH clients have high rate of obesity, cancer, high blood pressure, and
diabetes. The clients need onsite services.
o NP has a good way of talking to the clients; provides education and
advocacy, which is necessary to provide coordinated care.
o In the first two weeks of the added emphasis on physical health care
there were two medical crises identified that the employees had not
been aware of that required referral to the Emergency Room.
o NP’s first approach was to teach the MH nurses about phlebotomy,
about how to approach clients, etc. This increased their comfort level.
The MH staff became more comfortable with physical health issues.
o Clients did not want to switch to the new service initially. Clinicians
found introducing the clients to the NP in the hall helpful – to allow an
interaction. Once they met the NP, they were very likely to keep the
next appointment. The NP is very skillful at developing a relationship,
very caring.
o The clinic is keeping the charts separate (one for MH and one for
physical health); but the two are kept together – so they can both be
pulled when the clinician or doctor sees the client. Both are used at
the same time.
3. Suboxone Treatment with Primary Care Physician
o Drug Manufacturer’s Protocol:
 requires three months of Suboxone, on a step-down basis,
 plus 3 months of simultaneous substance abuse counseling,
 followed by one month of Naltrexone, if needed.
o County Requires 4 month outpatient substance abuse treatment program.
o Procedure in place:
 Doctor identifies Drug Medi-Cal eligible clients in his private practice.
 Doctor writes script that patient takes to a specific pharmacy.
 Pharmacist calls the doctor prior to filling script for verification from the
doctor that client is obtaining substance abuse treatment.
 Doctor’s nurse checks with substance abuse clinic weekly to see if
patient is keeping appointments. Sometimes, if there are problems,
nurse visits clients at the treatment site.
 Pharmacist calls the doctor to approve refill of Rx for each additional
30 days.
 The doctor, pharmacist, and treatment center are working together.
o Outcomes:
 Treated 8 clients;
 3 clients have completed the program.
 No drop outs.
 Only problem was a Registered Nurse who had trouble attending
groups. She had an attitude problem. She is about to graduate.
 One graduate completed our Perinatal program, graduated and is
now a Peer Support Specialist. She has cleared all past legal
issues, and plans to become a volunteer for our department.
o Drugs clients were using:
1)Oxycontin and
2) Norcos
Merced County
Manuel Jimenez, MA, MFT
Alcohol & Drug Program Administrator
Summary
 Community Outreach Program Engagement and Education (COPE)
o The focus of COPE is to reach the underserved and racial disparate
populations throughout Merced County
o The primary focus is the development and continual engagement of
collaborative system that relies on community based organizations.
o COPE has further enhanced services by collaboration with agency
partners, law enforcement, and other departments.
 COPE clinicians partner with primary health clinics:
o Livingston Medical Group—Hilmar Medical Group
o Dos Palos Rural Health Center
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Merced County serves about 256,000 clients. The County is beginning to
co-locate services within two family friendly FQHC’s (the Livingston
Medical Group and Family Care).
o They will do screenings and refer patients (utilizing warm hand-offs).
o The Family Care clinic is an alcohol and other drug (AOD) provider.
o Currently they will be co-locating services (with plans to move into the
FQHC facilities).
Family Care
o Master Agreement with Mercy Medical Center
o SAMHSA Substance Abuse Counselor
Livingston—Hilmar Medical Group
o MOU—formalize structure
o Blue Shield Grant—California Inst. for Mental Health
o Total Integration
Integration with other FQHCs
o Castle Family Health Centers
o Golden Valley Health Centers
Merced County has staff co-located on site at a primary care facility to
work with physicians, nurses and their patients.
o About seven to eight months ago they received the support of their
psychiatrists to integrate into rural clinics.
o The AOD counselor is at the clinic 20 hours per week.
The program is using a Behavioral Health Screening Tool (it is much like
the La Clinica form) and they have trained the physicians on how to use it.
o The front desk staff gives out the screening tool to all patients seen in
primary care.
The MH and substance use forms that they use are not in patient medical
records. The charts are kept separate.
The procedure being implemented is as follows:
o The patient is given the screening form
o The physician reviews it
o Patients that need follow-up are flagged
o The AOD counselor is paged and the physician provides a warm handoff
Sometimes the patient speaks with the AOD counselor in the exam room
or they are taken into the counselor’s office.
Patients provide consent to release information.
The goal is to provide small groups at the clinic (group therapy and psycheducation groups) in the future.
It’s been a long process to get the staff on board. The staff at the clinic
was used to referring out for AOD services.
A considerable amount of time has been spent training the physicians on
the signs/symptoms of substance use and how to use the screening tool.
The County also has probation co-located with the children and adult AOD
judicial team- this provides a one stop shop for clients to see their
probation officers before or after their treatment appointments.
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Mental health and AOD staff are co-located at juvenile hall to provide AOD
and MH services and facilitate a warm hand off when clients are released
to community.
Los Angeles County
Loretta Denering
Summary
Telepsychiatry for Patients with Co-morbid Psychiatric and Substance Use
Disorders
 Telemedicine: “the practice of health care delivery, diagnosis, consultation,
treatment and transfer of medical data and interactive tools using audio, video
and/or data communication with a patient at a location remote from the
provider.”
o Telepsychiatry/Telemental Health is a potentially important application of
telemedicine (Rost et al., 2002).
o Telepsychiatry has been practiced within the University of California (UC)
system since the late 1990’s and since 1996 UC Davis has provided over
5000 clinical consultations and has been awarded 10+ grants in this area.
 Telepsychiatry allows the psychiatrist to meet with and monitor patients via a
secured web-based application.
o Telepsychiatry is accomplished though the use of special software and/or
a freestanding mobile cart that includes a computer connect to the
Internet, a camera and a microphone.
o Studies thus far have demonstrated comparable levels of efficacy
compared to routine live clinical visits
 Targeting Unmet Needs
 Research suggests that 33%-50% of patients in substance use
disorder (SUD) rehabilitation programs often have co-morbid
psychiatric problems (Drake et al., 2007).
 Very few rehabilitation programs (and even fewer rural programs) have
on-site psychiatrists (Hilty, 2008).
o This project started in April 2011 is an innovative partnership between
UCLA ISAP, the Los Angeles County Department of Public Health and the
Los Angeles County Department of Health Services.
 Telepsychiatry services are provided for patients admitted to the
County operated Antelope Valley Rehabilitation Center (AVRC) in
Acton, CA.
 Background: UCLA/AVRC Telepsychiatry program
o The AVRC is located in the high desert of LA County where access to
psychiatric services is limited due to the remoteness of the facility.
o Currently, UCLA provides psychiatric care to patients one day/week (4
hours).
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o Patients with severe and persistent mental illness (SPMI) and are eligible
for services via the LA County Department of Mental Health (DMH) are
transported to a DMH-operated clinic in Palmdale.
o Patients in this project all have a DSM-IV-R SUD plus significant
psychiatric co-morbidity, but do not qualify as (SPMI).
UCLA/AVRC Telepsychiatry Protocol
1. Patients are identified by the AVRC psychologist or LCSW as
appropriate to receive telepsychiatry services.
2. Patients complete telemedicine information sheet, telemedicine
consent form, and multi-consortium consent form. AVRC staff faxes via
a secure line and mails hard copies to UCLA Neuropsychiatric
Hospital.
3. Patient registration is processed and UCLA medical record numbers
are issued.
4. Registration information is forwarded via secure line to ISAP
psychiatrist.
5. AVRC mails copies of patients’ clinical information directly to ISAP
psychiatrist.
6. ISAP psychiatrist conducts the session and completes dictations which
are stored with the patients’ UCLA patient record.
7. Copies are sent via a secure line to the medical personnel at the Acton
facility for placement in the patient’s AVRC file.
8. Prescriptions are written by the UCLA psychiatrist and filled at a local
Acton pharmacy.
Clinical Activities To Date
o As of August 1, 2012: 120 unique patients have been registered and 106
have had at least 1 session.
o 71 diagnosed with Major Depressive Disorder (MDD)
o 5 diagnosed with Bipolar Mood Disorder
o 38 diagnosed with Anxiety Disorders (Generalized Anxiety Disorder and
Panic Disorder)
o 6 diagnosed with Psychotic Disorders (Drug-induced psychosis vs.
Schizophrenia)
o Using a low-cost medication formulary, psychotropic medications are
prescribed.
So far, this project has resulted in a number of positive outcomes including: a
reduced barrier to access for those in remote areas and an increase in
efficiency for the AVRC and UCLA systems.
o Next Steps
1. We hope that improved mental health outcomes will be noted as a
result of the continuous care.
2. Other potential benefits include opportunities for enhanced cultural
competency (i.e. increased interaction with traditionally underserved
ethnic groups).
3. A report will be written in the next year to discuss SUD and mental
health outcomes and results of the satisfaction survey.
Closing Remarks – Elizabeth Schaper, UCLA ISAP
 Thanks again to Karen Kane, Manuel Jimenez, and Loretta Denering for
sharing today. It is always helpful to hear from the people actually working
on integrated care. Thank you for volunteering your time and sharing with
the group.
 The next ILC Meeting is scheduled on Wednesday, September 26, 2012
at 11am.
 Please remember to reference the website which holds all information and
materials disseminated from the ILC: http://www.uclaisap.org/AffordableCare-Act/html/learning-collaborative/index.html.
APPENDIX 1 – ATTENDEES
Presentation was held during the ADP Training Conference on August 22,
2012 in Sacramento, California.
APPENDIX 2 – AGENDA AND RELEVANT MATERIALS
 Introductions
1. Karen Kane – Riverside County
2. Manuel Jimenez – Merced County
3. Loretta Denering – Los Angeles County
 Topic discussion – Integration in the Field: County Initiatives (Riverside
County, Merced County and Los Angeles)
 Q and A
MATERIALS FOR THIS MEETING
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PPT Presentation – Elizabeth Schaper, Manual Jimenez, Loretta Denering
Copies of materials can be found at UCLA ISAP’s ACA Resources Website:
http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html.