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Session # Pre-conference
Models of Integration:
Pre-Conference Workshop
Jeff Reiter, PhD, ABPP
Lori Raney, MD
Stephen A. Wyatt, DO
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships
during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Determine the difference between these approaches to
integration
• Identify the core concepts and practice elements of each
integrated care approach
• Discuss how each model is applied, the populations they serve,
and the challenges associated witih the implementation and
sustainability of each
Bibliography / Reference
1Gaskin,
D. & Patrick, R. (2012). The economic costs of pain in the United States. The Journal of Pain, 13(8) 715-724.
2Babor, T. F., Higgens-Biddle, J. C. (2001) Brief intervention for hazardous and harmful drinking: A manual for use in primary care. World Health Organization,
Department of Mental Health and Substance Dependence.
3U.S.
Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Retrieved from http://www.drugabuse.gov/relatedtopics/medical-consequences-drug-abuse
4Mclellan,
A., Lewis, D., O‘Brien, C., & Kleber, H. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes
evaluation. Journal of American Medical Association, 284(13), 1689-1695.
5Madras,
B., Compton, W., Avula, D., Stegbauer, T., Stein, J., & Clark, H. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and
alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1-3), 280-295.
6Bernstein,
J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and
heroin use. Drug and Alcohol Dependence, 77(1), 49-59.
7Bernstein,
E., Edwards, E., Dorfman, D., Heeren, T., Bliss, C., & Bernstein, J. (2009). Screening and brief intervention to reduce marijuana use among youth and
young adults in a pediatric emergency department. Academic Emergency Medicine, 16(11), 1174-1185.
8Zahradnik,
A., Otto, C., Crackau, B., Löhrmann, I., Bischof, G., John, U., & Rumpf, H. (2009). Randomized controlled trial of a brief intervention for problematic
prescription drug use in non-treatment-seeking patients. Addiction, 104(1), 109-117.
9Madras,
B., Compton, W., Avula, D., Stegbauer, T., Stein, J., & Clark, H. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and
alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1-3), 280-295.
10Miller,
P. (2006). Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol and Alcoholism, 41(3), 306-310.
Complete reference list available upon request
The Primary Care
Behavioral Health
(PCBH) Model
JEFF REITER, PHD, ABPP
SW EDISH MEDICAL GROUP
ARIZONA STATE UNIVERSITY DBH
MOUNTAINVIEW CONSULTING GROUP
Overview of the PCBH Model
Overview
◦ Team-based primary care approach to managing
behaviorally-influenced health conditions
Goal
◦ Improve the efficiency and effectiveness of primary
care in general
Provider
◦ Behavioral Health Consultant (BHC)
Key Features
“GATHER”
Generalist
◦ All ages, any behaviorally-influenced condition
Accessible
◦ Goal of same-day access
Team-based
◦ Shared clinic space, resources, EHR
Key Features (cont’d)
High volume
◦ Large percentage of population
Educator
◦ Improve the behavioral care milieu
Routine
◦ Regular part of care for certain conditions (via
pathway)
Key Strategies
Flexible, brief visits
◦ Generally 15-30 minutes
Consultant model
◦ Extend and support the PCP
◦ Follow-up:
◦
◦
◦
◦
Until starting to improve and clear plan in place
PCP then continues treatment
BHC re-engaged as needed over time
Patients not improving are referred, if possible
Assumptions
About primary care
◦ PC is powerful if done well
◦ But…behavioral issues inhibit PC’s potential
◦ Well-supported PC is best place for most behav tx
About the goal of intervention
◦ Small improvement in risk factors across population can produce large
benefit to population
◦ Must work through the PCP
Assumptions (cont’d)
About the change process
◦
◦
◦
◦
◦
◦
Timing and context can be huge drivers of change
Routinized team-based care allows for brief visits
Functional change drives emotional change
Behavior change is a lifelong process (not dz)
Mental and physical health are one and the same
Change can occur quickly, even in long-term habits
Goals
Goals are the same as primary care’s goals:
◦ Accessibility
◦ Integration/Coordination of care
◦ Meet the vast majority of health care needs
◦ Longitudinal care
◦ Care in the context of family and community
Key Attributes
What types of problems are addressed?
◦ Any behaviorally-influenced condition
What level of problem chronicity is addressed?
◦ Preventive, acute, chronic
Which age groups are treated?
◦ Any age
Who drives the behavioral care?
◦ PCP owns care; BHC assists, extends
Key Attributes (cont’d)
What is the productivity goal?
◦ High population penetration
When is BH involvement ended?
◦ When improvement is noted; re-engaged as needed
What is the role for care-tracking?
◦ Minimal, not routinely done
How accessible is the BH provider?
◦ On-demand
Key Attributes (cont’d)
What BH provider skill level is needed?
◦ Generalist/broad – typically higher training
What type of population-based strategy is used?
◦ Whole population rather than a specific group
What is the primary intervention goal?
◦ Skill-building/Functional improvement
What are the performance measures/metrics?
• Functional measures
The
Collaborative
Care Model
Lori Raney, MD
Principal, Health Management Associates
16
History: Collaborative Care
Wayne Katon, MD
1950-2015
17
Definition of Collaborative
Care
Collaborative Care is a specific type of integrated care that
operationalizes the principles of the chronic care model to
improve access to evidence based mental health treatments
for primary care patients.
Collaborative Care is:
◦
◦
◦
◦
“TEMP”
Team-driven collaboration and Patient-centered
Evidence-based and practice-tested care
Measurement-guided treatment to target
Population-focused
◦ Accountable care
http://aims.uw.edu
Sweet” Spot for the
Collaborative Care Model
None
Mild
Moderate
Severe
Target
Population
Issues with depression and substance abuse must be preempted, rather than treated once advanced.
Goal is to detect early and apply early interventions to prevent
from getting more severe
21
Collaborative Team Approach
22
The Collaborative
Care Model
Effective
Collaboration
Informed,
Activated Patient
Measurement-guided
Treat to Target
PRACTICE
SUPPORT
Psychiatric
Consultation
PCP supported by
Behavioral Health
Care Manager
Caseload-focused
Registry review
Training
Doubles Effectiveness of Care
for Depression
50 % or greater improvement in depression at 12 months
Usual Care
70
Co-located
Therapist
IMPACT
60
50
40
%
30
20
10
0
1
2
3
4
5
6
7
8
Participating Organizations
Unützer et al., JAMA 2002
How Well Does It Work For
Other Disorders?
Evidence Base Established
Emerging Evidence
•
•
•
•
•
•
•
•
•
Depression
- Adolescent Depression
- Depression, Diabetes and Heart
Disease
- Depression and Cancer
- Depression in Women’s Health
- Depression and HIV - HITIDES
Anxiety
Post Traumatic Stress Disorder
Chronic Pain
Dementia
Post Concussion in Adolescents
Substance Use Disorders
ADHD
Bipolar Disorder
School-based health centers
Specialty clinics (esp OB),
Pediatrics
Building More Effective Models:
Collaborative Care
Research Evidence Over 80 Randomized Controlled Trials
Cochrane meta analysis: Collaborative care for people with
depression and anxiety. Archer J et al. 2012: 79 RCTs.
• Community Preventive Services Task Force. Recommendation from the
community preventive services task force for use of collaborative care for the
management of depressive disorders. Am J Prev Med. 2012; 42(5):521-524: 69
RCTs.
• Gilbody S. et al. Archives of Internal Medicine; Dec 2006: Collaborative care (CC)
for depression in primary care (US and Europe): 37 RCTs.
Collaborative care is consistently more effective
than care as usual.
Experimenting with Delivery:
Telemedicine
Telemedicine-based team:
• Nurse care manager phone
• Pharmacist – phone
• Psychologist – CBT televideo
• Psychiatrist – televideo if did
not respond to trial to 2
antidepressants
• Weekly – whole team met to
make recommendations
Fortney, Pyne et al Am J Psychiatry 2013; 170:414–425
Business Case: Reduces Health
Care Costs
Intervention
group cost in
$
Usual care
group cost in
$
Difference in
$
522
0
522
661
558
767
-210
7,284
6,942
7,636
-694
Other outpatient costs
14,306
14,160
14,456
-296
Inpatient medical costs
8,452
7,179
9,757
-2578
114
61
169
-108
Cost Category
4-year
costs in
$
IMPACT program cost
Outpatient mental health costs
Pharmacy costs
Inpatient mental health /
substance abuse costs
Total health care cost
31,082
29,422
32,785
-$3363
Unützer et al., Am J Managed Care 2008.
Savings
ROI
$6 : $1
VALIDATED SCREENING AND
MEASUREMENT TOOLS
PHQ 9 > 9





< 5 – none/remission
5 - mild
10 - moderate
15- moderate severe
20 - severe
GAD 7, Vanderbilt, PCL, risky drinking,
SCARED, etc
30
30
© 2016 American Psychiatric Association. All rights reserved.
BHPs/Care Managers
31
32
REGISTRIES TO TRACK
PROGRESS, OUTREACH AND
Caseload Overview INREACH
© University of Washington
FREE UW AIMS Excel® Registry (https://aims.uw.edu/resource-library/patienttracking-spreadsheet-example-data )
Allows proactive engagement ( “no one falls through the cracks”)
and treatment adjustment
33
© 2016 American Psychiatric Association. All rights reserved.
Things That Are Measured
Get Better
• HAM-D 50% or <8
• Paroxetine and
mirtazapine
• Greater response
• Shorter time to
response
• More treatment
adjustments (44 vs
23)
• Higher doses
antidepressants
• Similar drop out, side
effects
Quo T, Correll, et al. American Journal of Psychiatry, 172 (10), Oct, 2015
34
MBC
35
Measurement-Based Care (MBC)
Concepts
Process:
Systematic administration of symptom
rating scales – use huddle or registry
Frequently applied
NOT a substitute for clinical judgement
Patient rated scales are equivalent to
clinician rated scales
Primary Gains
Secondary Gains: Aggregate data for
◦ Professional development at the
provider level – MACRA
◦ Quality improvement at the clinic level
◦ Inform reimbursement at the health
system level
Ineffective Approaches:
One-time screening
Assessing symptoms infrequently
Feeding back outcomes outside the
Use of the results to drive clinical decision context of the clinical encounter
making at the patient level
Use to overcome clinical inertia
Fortney et al Psych Serv Sept 2016
36
Psychiatric Provider: Force
Multiplier of CoCM
Prioritizing Cases in the Registry
AIMS Center 2011, http://aims.uw.edu/
Psychiatric Consultants
Supporting Teams
Care
Manager/BHP 1
Care Manager/BHP 4
Care
Manager/BHP 3
Care Manager/BHP 2
50-80 patients/caseload
2 hrs psych/week/ care manager
= ~ 600 patients with oversite at one time
39
Technology Enabled
Behavioral Health Care
Patient Guided
PCP Consultation
Case-based
Learning
Embedde
d
In EHR.
Timely
informatio
n at the
point of
care
Didactic,
Case
presentatio
ns – to the
“spokes”
from
experts at
the “Hub”
Collaborative Care Model Virtual Visit
Online Tasking
and
consultatio
n
For
specific
cases
Psychiatric
consultatio
n readily
available
Pediatric
Assess
Lines
(PALs)
Offsite,
Make treatment
Recommendati
ons
For PCP
Virtua
l visit
Performance Measures:
Accountability
Process Metrics:
◦
◦
◦
◦
◦
Percent of patients screened for depression
Percent with follow-up with case manager within 2 weeks
Percent not improving that received case review and psychiatric recommendations
Percent treatment plan changed based on advice
Percent not improving referred to specialty BH
Outcome Metrics
◦ Percent with 50% reduction PHQ-9
◦ Percent reaching remission (PHQ-9 < 5 ) NQF 710 and 711
Satisfaction – patient and provider
Functional –work, school
Utilization/Cost
◦ ED visits, 30 day readmits, overall cost
New CPT Codes for
Collaborative Care
GPPP1 - Initial Month
GPPP2 - Subsequent Months
GPPP3 – Additional Time
GPPPX – Other Integration (not CoCM)
44
Summary of Key Required
Tasks
◦ Outreach to and engagement in treatment of a patient directed
by the treating physician or other qualified health care
professional;
◦ Initial and continued assessment of the patient, including
administration of validated rating scales, with the
development of an individualized treatment plan;
◦ Provision of brief interventions using evidence-based
techniques such as behavioral activation, motivational
interviewing, and other focused treatment strategies.
◦ Tracking patient follow-up and progress using the registry,
with appropriate documentation;
◦ Participation in weekly caseload consultation with the
psychiatric consultant;
45
BLENDED MODEL - BEST
OF BOTH
• Team-driven collaboration that is patient-centered,
immediate access in primary care for health behaviors,
life stressors, crises, stress-related physical symptoms,
ineffective patterns of health care utilization
Evidence-based, practice-tested
◦ Mental health and substance use disorders
◦ Evidence-based behavioral interventions
Measurement based care (MBC)
◦ Treat to defined targets
Population- based
◦ Track a subgroup with registry as a standard practice
◦ Caseload review with psychiatric
consultant to address
46
patients who are not progressing
46
© 2016 American Psychiatric Association. All rights reserved.
Pitch it to a Payer
Robust evidence base
Know what works
ROI $6:1
P4P study with good results
Performance measures you can hold me
accountable for
CPT codes could be billed starting Jan 2017
for Medicare
47
Lori Raney, MD
[email protected]
Video: Daniel’s Story
https://aims.uw.edu/daniels-story-introduction-collaborative-care
49
GPPP1 – Initial
Collaborative Management
Initial psychiatric collaborative care management, first 70 minutes in the first
calendar month of behavioral health care manager activities, in consultation
with a psychiatric consultant, and directed by the treating physician or other
qualified health care professional, with the following required elements:
◦ Outreach to and engagement in treatment of a patient directed by the treating
physician or other qualified health care professional;
◦ Initial assessment of the patient, including administration of validated rating scales,
with the development of an individualized treatment plan;
◦ Review by the psychiatric consultant with modifications of the plan if
recommended;
◦ Entering patient in a registry and tracking patient follow-up and progress using the
registry, with appropriate documentation, and participation in weekly caseload
consultation with the psychiatric consultant; and
◦ Provision of brief interventions using evidence-based techniques such as
behavioral activation, motivational interviewing, and other focused treatment
strategies.
50
GPPP2 – Subsequent
Months
Subsequent psychiatric collaborative care management, first 60 minutes in a
subsequent month of behavioral health care manager activities, in
consultation with a psychiatric consultant, and directed by the treating
physician or other qualified health care professional, with the following
required elements:
◦ Tracking patient follow-up and progress using the registry, with appropriate
documentation;
◦ Participation in weekly caseload consultation with the psychiatric consultant;
◦ Ongoing collaboration with and coordination of the patient's mental health care with
the treating physician or other qualified health care professional and any other
treating mental health providers;
◦ Additional review of progress and recommendations for changes in treatment, as
indicated, including medications, based on recommendations provided by the
psychiatric consultant;
◦ Provision of brief interventions using evidence-based techniques such as
behavioral activation, motivational interviewing, and other focused treatment
strategies;
◦ Monitoring of patient outcomes using validated rating scales; and relapse
prevention planning with patients as they achieve remission of symptoms and/or
other treatment goals and are prepared for discharge from active treatment.
51
GPPP3 – Additional
Time/GPPPX
Initial or subsequent psychiatric collaborative care management,
each additional 30 minutes in a calendar month of behavioral
health care manager activities, in consultation with a psychiatric
consultant, and directed by the treating physician or other qualified
health care professional (List separately in addition to code for
primary procedure) (Use GPPP3 in conjunction with GPPP1,
GPPP2).
Behavioral Health Integration Code not Specific to CoCM
GPPPX: Care management services for behavioral health conditions,
at least 20 minutes of clinical staff time, directed by a physician or
other qualified health care professional time, per calendar month. (for
other models of integration)
52
The SBIRT (Screening, Brief
Intervention, and Referral to
Treatment) Model
S T E P H E N A . W YAT T, D O
MEDICAL DIRECTOR, ADDICTION MEDICINE
B E H AV I O R A L H E A LT H S E R V I C E
C A R O L I N A S H E A LT H C A R E S Y S T E M
Why Is SBIRT Important?
• Unhealthy and unsafe alcohol and drug use
are major preventable public health problems
resulting in more than 100,000 deaths each
year.
• The cost to society is more than $600 billion
annually.
54
Harms Related to Hazardous Alcohol and
Substance Use
Increases the risk for:
•
•
Noncompliance and adverse interactions with
prescribed medication
Illness/injury/trauma/poisoning
Mental health consequences (e.g., anxiety,
depression)
Increased absenteeism and injuries in the workplace
•
Social problems (job loss, homelessness, crime)
•
•
55
Substance Use Disorders Are Similar to
Other Chronic Illnesses
Less than 30 percent of
patients adhere to
prescribed medications and
diet or behavioral changes.
There is a 50 percent
recurrence rate.
Substance use problems
should be insured,
monitored, treated, and
evaluated like other chronic
diseases.
Hypertension
Diabetes
Asthma
Addiction
56
Rankings of Preventive Services
National Commission on Prevention Priorities
25 USPSTF-recommended services ranked by:
Clinically preventable burden (CPB) How much disease, injury, and death would be prevented
if services were delivered to all targeted individuals?
Cost-effectiveness (CE) - return on investment How many dollars would be saved for each dollar spent?
Maciosek, Am J Prev Med 2006; Solberg, Am J Prev Med 2008;
http://www.prevent.org/content/view/43/71
57
Rankings of
Preventive Services
#
Service
CPB
CE
1
Aspirin - Men - 40+, Women 50+
5
5
2
Childhood immunizations
5
5
3
Smoking cessation
5
5
4
Alcohol screening &
intervention
4
5
5
Colorectal cancer screening
4
4
6
Hypertension screening &
treatment
5
3
7
Influenza immunization
4
4
8
Vision screening - 65+
3
5
*1 = lowest; 5 = highest
Maciosek, Am J Prev Med 2006; Solberg, Am J Prev Med 2008;
http://www.prevent.org/content/view/43/71
58
Screening, Brief Intervention,
and Referral to Treatment
SBIRT
SBIRT: The Three Components
• Screening: Screen patients for high-risk or
dependent drinking and drug use.
• Brief Intervention: Have a conversation to
motivate patients who screen positive to
consider healthier decisions (e.g., cutting back,
quitting, or seeking further assessment).
• Referral to Treatment: Link patients to
resources when appropriate.
60
SBIRT Defined
• Screening, Brief Intervention, and Referral to
Treatment (SBIRT) is a comprehensive, integrated,
public health approach to the delivery of early
intervention and treatment services.
• Primary care centers, hospitals, and other
community settings provide excellent opportunities
for early intervention with patients who are at risk
for substance use and to identify patients with
substance use disorders.
61
Making a Measurable Difference
•
Since 2003, SAMHSA has supported SBIRT programs
with good evidence that screening in primary care
identifies patients with at-risk drinking patterns.
•
Outcome data confirm a 40 percent reduction in harmful
use of alcohol by those drinking at risky levels and a 55
percent reduction in negative social consequences.
•
Outcome data also demonstrate positive benefits for
reduced illicit substance use.
62
Illicit Drugs and Prescription Medication
•
Limited but promising
•
Cocaine and heroin
•
•
•
More likely to be abstinent (both drugs)
Significant reductions in hair sample drug levels (cocaine
only)
Marijuana in youth and young adults
•
•
•
More likely to be abstinent for past 30 days (12-month
results)
Greater reduction in days used
Less likely to have been high
63
Rationale for Universal
Screening
• Drinking and drug use are common.
• Drinking and drug use can increase the risk for
health problems, safety risks, and a host of other
issues.
• Drinking and drug use often go undetected.
• People are more open to change than you might
expect.
64
Begin with:
Do you sometimes drink beer,
wine, or other alcoholic beverages?
 No
(“Why not?”)
 Yes
65
Screening for Harmful Alcohol Use:
Single question screen
(www.niaaa.nih.gov/guide)
AUDIT (Alcohol Use Disorders Identification
Test)
(www.who.org)
66
Screening for Harmful Alcohol Use:
During the last year, how many times
have you had __ or more drinks:
• 5 for men
• 4 for women
• 4 if > 65
Positive screen is 1 or more times.
82%
Sensitivity
79% Specificity (unhealthy use)
Smith, PC, et.al., J Gen Int Med, 2010
(www.niaaa.nih.gov/guide)
67
NIAAA Guidelines
Men
◦ Not more than 14 drinks in a week
◦ Not more than 4 drinks at a single setting
Women
◦ Not more than 7 drinks in a week
◦ Not more than 3 drinks at a single setting
A standard drink is 14grams of or alcohol
◦ 12 oz beer
◦ 5 oz wine
◦ 1.5 oz liquor
68
WHAT’S A STANDARD DRINK?
What’s a Standard Drink?
• In the U.S., a standard drink is any
drink that contains about 14 grams
of pure alcohol (about 0.6 fluid ounces
or 1.2 tablespoons).
69
U.S. Adult Drinking Patterns
and Their Significance
Never exceed daily or weekly limits:
2/3 of this group either abstain or drink < 12 drinks/yr
Prevalence of alcohol use disorder:
< 1 in 100
Exceed only daily limit:
>8/10 less than once/week
Prevalence of alcohol use disorder:
Exceed both daily and weekly limits:
8/10 exceed the daily limit at least once/wk
Prevalence of alcohol use disorder:
72%
16%
1 in 5
10%
1 in 2
NIAAA, 2005
70
The Spectrum of Alcohol Use.
Saitz, R. N Engl J Med 2005;352:596-607
71
AUDIT – Alcohol Use Disorders
Identification Test
Developed by the WHO
10 Questions
Valid across cultures, Sens/spec varies w/population.
Takes 5 minutes
Positive score: >7 for men up to 60 yo
• >4 for women, adolescents, men > 60.
Reinert, DF, Allen JP. Alcohol Clin Exp Res. 26(2):272-279, 2002
www.niaaa.nih.gov/guide
72
ALCOHOL USE DISORDERS
IDENTIFICATION TEST (AUDIT)
1. How often do you have a drink
containing alcohol?1
7. How often during the last year have
you had a feeling of guilt or remorse after
drinking?
2. How many drinks containing alcohol do
you have on a typical day when you are
8. How often during the last year have
drinking?1
you been unable to remember what
happened the night before because you had
been drinking?
3. How often do you have six or more
drinks on one occasion?
9. Have you or someone else been
injured as a result of your drinking?
4. How often during the last year have
you found that you were not able to stop
drinking once you had started?
10. Has a relative or friend, or a doctor or
other health worker been concerned about
your drinking or suggested you cut down?
5. How often during the last year have
you failed to do what was normally
expected from you because of drinking?
6. How often during the last year have
you needed a first drink in the morning to
get yourself going after a heavy drinking
session?
73
ONE Question Screen for Drug
Abuse in Primary Care
How many times in the past year have you used an
illegal drug or used a prescription medication for a
non-medical reason?
◦ A response of > 1 is considered positive.
◦ 100% sensitive, 74% specific for a drug use disorder
◦ Similar sensitivity and specificity to DAST-10
Smith, PC, et.al., Arch Int Med, 170:1155-1160, 2010
74
Alcohol, Smoking and Substance
Involvement Screening Test
(ASSIST)
In your life, which of the following substances have you ever used?
In the past three months, how often have you used the substances you
mentioned?
During the past three months, how often have you
had a strong desire or urge to use?
During the past three months, how often has your use of led to health, social,
legal or financial problems?
During the past three months, how often have you failed to do what was
normally expected of you because of your use of?
Has a friend or relative or anyone else ever expressed concern about your
use of Have you ever tried and failed to control, cut down or stop using?
Have you ever used any drug by injection?
http://www.who.int/substance_abuse/activities/assist_v3_english.pdf?ua=1
75
Summary: Screening for Harmful
Alcohol and Drug Use
1. Screen everyone.
2. Use validated screening tools.
3. Provide nonjudgmental feedback with their
results.
4. For positive screens: Proceed to Brief
Intervention
76
Brief Intervention (BI)
Brief Intervention Pathways
No substance use disorder: conduct brief
intervention, provide follow-up and ongoing care
Patients with possible substance use disorder:
◦ conduct brief intervention,
◦ offer menu of additional support options,
◦ negotiate a plan that may include referral
78
Patients Are Open to Discussing Their
Substance Use to Help Their Health
•
Ninety percent of surveyed patients said they would give
an honest answer if asked about their drinking.
•
Over 90 percent of surveyed patients reported that their
primary care physician should ask about their drinking
and advise cutting down if it is affecting their health.
•
Eighty-six percent of patients disagreed that they would
be embarrassed if asked to discuss their drinking
patterns.
•
Seventy-eight percent of patients disagreed that they
would be annoyed if asked about their drinking.
79
Brief Interventions
80
Steps of the Brief
Interventions:
1.
Raise the Question
2.
Provide Feedback
3.
Enhance Motivation
4.
Negotiate a Plan
D`Onofrio, et al., 2005
82
Steps of the Brief Intervention
Raise the Question
83
Steps of the Brief Intervention
Provide Feedback
84
Steps of the Brief Intervention
Enhance Motivation
Steps of the Brief Intervention
Negotiate a Plan
86
IV
III
II
87
Other Factors Behind
Recommending Abstention
• Prior history of alcohol or
substance dependence
• Pregnancy
• Medications
• Serious mental illness,
medical condition
88
Offer a Menu of Options: Ask
Permission
“Many patients at your risk level find they do
better with more support. Could I share with
you some of the things that have helped
some of my other patients?”
89
Referral to
Treatment
Menu of Options
Medication: (naltrexone, acamprosate, or disulfiram for alcohol;
buprenorphine or methadone for opioids)
Self-help/support group (e.g., AA/NA, Celebrate Recovery, Smart
Recovery, etc.)
Individual counseling (brief treatment)
Formal substance use treatment programs
92
MI Principles for Making
Treatment Referral
Respect patient’s autonomy— “Any decision
you make is entirely up to you”
Make every effort to help patients make
contact with treatment providers while they
are still in your office (“warm handoff”)
93
Colorado SBIRT Initiative in
Integration
Federal Grant assistance from the Substance Abuse
and Mental – 2006
SBIRT was implemented in 22 settings in 12 different
sites throughout Colorado and screens more than
3,000 people each month in these settings.
Six-month follow-up interviews:
◦ patients screened:
◦ alcohol use fell by 51 percent
◦ and overall illegal drug use fell by 36 percent
Absence of evidence for
dependent drinking
Alcohol screening and BI has efficacy in primary care for
unhealthy alcohol use
There is no evidence for efficacy among those with very heavy
use or dependence.
Screening identifies both dependent and non-dependent
unhealthy use,
Absence of evidence for the efficacy of BI with alcohol dependent
pateints raises questions of efficiency for SBIRT.
The finding also highlights the need to develop new approaches.
Saitz R, etal, Drug Alcohol Rev. 2010 November ; 29(6): 631–
640. doi:10.1111/j.1465-3362.2010.00217.
Selected References
Helping Patients Who Drink Too Much, A Clinician’s
Guide, 2005 Edition, US Department of Health and Human
Services, NIH Publication No. 07-3769,
www.niaaa.nih.gov/guide
(excellent video cases and written materials)
For patients: Rethinking Drinking.niaaa.nih.gov
• www.alcoholscreening.org
• www.drugscreening.org
96
References
1Gaskin,
D. & Patrick, R. (2012). The economic costs of pain in the United States. The Journal of Pain, 13(8) 715-724.
T. F., Higgens-Biddle, J. C. (2001) Brief intervention for hazardous and harmful drinking: A manual for use in
primary care. World Health Organization, Department of Mental Health and Substance Dependence.
3U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse.
Retrieved from http://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse
4Mclellan, A., Lewis, D., O‘Brien, C., & Kleber, H. (2000). Drug dependence, a chronic medical illness: Implications for
treatment, insurance, and outcomes evaluation. Journal of American Medical Association, 284(13), 1689-1695.
5Madras, B., Compton, W., Avula, D., Stegbauer, T., Stein, J., & Clark, H. (2009). Screening, brief interventions, referral to
treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later.
Drug and Alcohol Dependence, 99(1-3), 280-295.
6Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., & Hingson, R. (2005). Brief motivational
intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77(1), 49-59.
7Bernstein, E., Edwards, E., Dorfman, D., Heeren, T., Bliss, C., & Bernstein, J. (2009). Screening and brief intervention to
reduce marijuana use among youth and young adults in a pediatric emergency department. Academic Emergency
Medicine, 16(11), 1174-1185.
8Zahradnik, A., Otto, C., Crackau, B., Löhrmann, I., Bischof, G., John, U., & Rumpf, H. (2009). Randomized controlled trial
of a brief intervention for problematic prescription drug use in non-treatment-seeking patients. Addiction, 104(1), 109117.
9Madras, B., Compton, W., Avula, D., Stegbauer, T., Stein, J., & Clark, H. (2009). Screening, brief interventions, referral to
treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later.
Drug and Alcohol Dependence, 99(1-3), 280-295.
10Miller, P. (2006). Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians.
Alcohol and Alcoholism, 41(3), 306-310.
2Babor,
97
Bidirectional
Integrated Care
L O R I R A N E Y, M D
P R I N C I PA L , H E A LT H M A N A G E M E N T A S S O C I AT E S
Bidirectional Integrated Care
Why primary care services to mental
health populations?
•High rates of physical illness
in mentally ill
•Premature mortality
•Low quality of medical care
to patients with mental
illness
•Costly physically ill with
mental illness – “High
Utilizers”
•Access problems
100
Premature Mortality in Adults with
Schizophrenia
101
JAMA Psychiatry. 2015;72(12):1172-1181.
doi:10.1001/jamapsychiatry.2015.1737.
Predicting Cardiovascular Risk in SMI
Osborn et al, JAMA Psych, 2015 72(2): 143-51.
Rates of Non-Treatment
NASRALLA, ET AL SCHIZOPHRENIA
RESEARCH 2006
APA/AMP 2014: PRIMARY CARE SKILLS FOR
PSYCHIATRISTS
What’s Been Tried?
PCARE
PBHCI
2703 Health Homes- Missouri and DC
NEW:
◦ HOME
◦ CCBHC
◦ Psychiatrist’s changing responsibility?
104
PCARE: Primary Care Access,
Referral and Evaluation
RCT, Atlanta, GA: 407 SMI over 1 year
Usual Care
Intervention Group
Preventive Services
21.8%
57.8%
Cardiometabolic
Interventions
27.7%
34.9%
Have Primary Care
Provider
51.9%
71.2%
Framingham Risk
Index
9.8%
6.9%
Druss BG, et al. Am J Psychiatry. 2010;167(2):151-159
PCARE: Care Management
Roles
RN/LCSW
Facilitates patient engagement
Identification and targeting of high-risk individuals
Monitoring of health status and adherence – tracking
outcomes in registries
Staff and patient education
Development of treatment guidelines
Individualized planning with patients
Tracks care transitions
Adaptations
https://dmh.mo.gov/docs/mentalillness/prnov13.pdf
Scharf et al Psych Serv 2013
HOME Study
108
Model Programs Generally
Contain 3 Major Components:
Kern J in Integrated Care: Working at the Interface of Primary Care and Behavioral Health, L Raney
editor, American Psychiatric Publishing, 2014
109
Registry for Tracking and
Analyzing
Primary Care Onsite
Psychiatric
Provider
PCP
Care
Manager
Case
Manager
New Team
Members
Patient
Other Behavioral Health Clinicians
Substance Treatment, Wellness Coach
Vocational Rehabilitation
Core Team
Consultative Model with Primary Care
PCP/Consultant
PCP
Nurse
Care
Manager
New
Team
Members
PCP
Offsite
Psychiatrist
Case
Manager
Core Team
Patient
Other Behavioral Health Clinicians,
Substance Tx, Vocational Rehabilitation
Other Community Resources
Other
Resource
Integrating Primary Care Into Behavioral Health
Settings: What Works For Individuals with
Serious Mental Illness - Millbank Report 2014
The use of fully integrated systems or enhancing
collaboration through care management enhances
outcomes
The interventions required additional staffing, training
and support of care managers
Cost savings is not clear but early reports from Health
Home model is this will be effective
Integrated data and population health tracking
Gerrity, et al: Integrating Primary Care Into
Behavioral Health
113
Settings: What Works For Individuals with Serious Mental Illness
Millbank Memorial Fund, NY, 2014
CCBHC: Metabolic Quality Metrics
CCBHC
BMI
Control high blood
pressure
Tobacco screen and
cessation
STATE
REQUIREMENTS
Diabetes screening
schizophrenia and bipolar
disorder on SGAs
Diabetes care for SMI with
poor control HbA1c>9
Cardiovascular health
screening SMI
Health monitoring for SMI
and cardiovascular disease
SAMHSA Quality Measures 2016
Psychiatrists Addressing Health of Patients
with Mental Illness
Courses at APA meetings
Online CME on APA website
Prevention in Psychiatry –
McCarron et al, American
Psychiatric Publishing 2014
What Is the Psychiatrist’s Role?
Do No Harm: Minimizing metabolic effects of psychotropic
medications
Know Harm: Screening for cardiometabolic risk factors – APA/ADA
Guidelines
Counsel: for lifestyle issues - tobacco, obesity, diet
Treat: some basic medical conditions
Lead: teams – psychiatrists uniquely trained in both worlds
Adapted from Ben Druss, MD, MPH, 2010.
.
116
Domain
Spectrum
Action
1
Nature of
Problem
Routine
Urgent
Emergent
2
Access to
Care
Poor/Ref
uses
Inconsiste
nt
Good
3
Medical
Training,
MedicoLegal
Scope
Sufficient,
Covered
Insufficient, Not
Covered
4
System
Capacity
of BHO
Adequate
Systems in
Place, Monitoring
and Follow-Up
Limited
Systematic
Capacity
5
Patient
Preferenc
e
Prefers BHO,
Psychiatrist
Prefers
Traditional
Primary Care
Psych Manages with PCP Support
Emergent
Referral
Refer to
PCP,
Triage
Barriers
to
Access
to Care
Vanderlip, Raney AJP 2016
Pitch it to a Payer
Cost savings with Missouri model
Better rates of screening for cardiovascular
disease
118
Continuum of Services and How
Patients Cycle Through
Lori Raney, MD
[email protected]
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