Download How Behavioral Health Organizations can Positively Impact

How Behavioral Health
Organizations Can Positively
Impact Communities Effected by
Prescription Drug Abuse
Doug Leonardo, LCSW
Executive Director
Tracey Kaly, LMHC
Clinical Services Manager
Learning Objectives
1)
Learn about state/local prescription drug abuse data
related to mortality rates, neonatal abstinence
syndrome and pain clinic monitoring.
2)
Learn a minimum of 3 ways a behavioral health center
can support their local community.
3)
Learn some of the steps needed to develop an
integrated care model to provide behavioral health
services onsite in specialty care sites (e.g.; pain
management clinics, health clinics, primary care
offices and hospitals).
Agenda
1) Who We Are
2) State and Local
Data Trends
3) Supporting Your
Local Community
4) Building an
Integrated
Care Model
Who We Are
• BayCare - large community-based non profit health
care system in Florida
• Located in Tampa Bay Region
• Network of hospitals and outpatient facilities
• 22,000 team members
• We are the behavioral health service provider for the
BayCare Health System
• Full continuum of adult and children's behavioral
health services
• Services provided in 5 counties in Tampa Bay area
Addiction
…a primary, chronic, neurobiological disease, with
genetic, psychosocial, and environmental factors
influencing the development and manifestations. It
is characterized by behaviors that include one or
more of the following:
– Impaired control over drug use
– Compulsive use
– Continued use despite harm
– Craving
(American Society of Addiction Medicine, 2001)
State Data
10 Year Trend Upward in Prescription
Drug Abuse
Ten Year Trend Analysis of Drug of Abuse
40.00%
35.00%
% of Total Admissions
30.00%
Alcohol
25.00%
Marijuana
Crack/Cocaine
20.00%
Heroin
Other Opiates
15.00%
Methamphetamine
Prescription
Other Drugs
10.00%
5.00%
0.00%
FY 01-02
FY 02-03
FY 03-04
FY 04-05
FY 05-06 FY 06-07
Fiscal Year
FY 07-08
FY 08-09
FY 09-10
FY 10-11
State Data
Overdoses – Opiates and Benzo’s
Florida
counties with
high rates of
opiate
overdoses
Florida
counties with
high rates of
benzodiazepine
overdoses
State Data
Hospitalizations and Emergency Department Visits for
Unintentional Rx Drug Poisonings
Rate per 100,000 population
30
23.8
23.8
20
15.2
12.3
10
0
2006
2007
Opiate Poisoning
2008
2009
2010
Tranquilizer Poisoning
Source: Agency for Health Care Administration Emergency Department and Inpatient Hospital Datasets
Oxycodone Suspected Suicides
800
700
668
600
583
Number
500
430
400
326%
Increase
368
305
302
300
294
260
227
200
205
100
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year
January 20, 2011
Florida Poison Information Center Tampa
264%
Increase
Oxycodone Cases
1800
1600
1590
1523
1525
1432
1400
1284
1200
Number
1054
1000
919
809
800
600
761
602
400
200
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year
January 20, 2011
Florida Poison Information Center Tampa
State Data
Drug Overdose Deaths 2003 - 2009
Death rates for all substances increased with the exception
of heroin and cocaine.
Heroin decreased 62.2%
Cocaine decreased 10.8%
Death rates for prescription drugs increased 84.2%.
7.3 to 13.4 per 100,000
Substance specific death rates.
Oxycodone rose
Alprazolam rose
Methadone rose
Ethanol rose
264.6%
233.8%
79.2%
81.4%
Source : MMWR July 8, 2011/60 (26);869-872
Prescription Drug Monitoring Program
(PDMP)
 Florida lacked a system for monitoring drug prescriptions
until Governor Scott signed a bill into law on June 3, 2011;
 The law strengthens reporting requirements to a prescription
drug database, increases penalties for overprescribing,
tracks wholesale distribution of specific controlled
substances, bans most doctors who prescribe narcotics from
dispensing them and provides funding to support law
enforcement and state prosecutor efforts;
 Attorney General Pam Bondi has made prescription drug
abuse her top priority;
 98 of the top 100 doctors dispensing Oxycodone nationally
are in Florida – concentrated in the Miami, Tampa and
Orlando regions.
Prescription Drug Monitoring Program
(PDMP)
The state of Florida has established a program that
will improve patient quality of care and reduce
controlled prescription drug abuse and diversion.
The PDMP will reduce the chances for patients to
repeatedly and illegally divert prescription drugs.
Overall the program will dramatically reduce doctor
and pharmacy shopping.
Local Data - Pasco County
Prescription Drug Abuse Becomes Priority
 Parents began calling local substance abuse coalition (ASAP) to get
involved;
 Legislators asking for community members to get involved;
 Law enforcement was highlighting the prescription drug related
crimes: (impaired driving, stolen property, drug trafficking, pill mills,
etc.);
 Detoxification unit seeing unprecedented number of admissions for
prescription drug dependency (specifically females aged 18 to 40);
 FYSAS indicated increase in
prescription drug use by students;
 Pill mills and drug trafficking arrests
increased significantly in Pasco County;
 Pain Management practitioner reached
out to local provider and coalition
to become part of the solution.
Local Data - Pasco County
Lethal Level of Drug Present at Death
According to the Medical Examiner, there were 103 deaths from Oxycodone alone in 2010. District 6, which
consists of both Pasco and Pinellas Counties identified higher amounts of prescription drugs tracked by the
Medical Examiner at the time of death then any other district in the State of Florida. Primary drug of choice is
Oxycontin (30 mg), followed by Xanax.
Pasco County is higher than Pinellas County in per capita drug-related deaths.
Primary route of delivery; crushing and inhaling, followed by an equal amount of oral and injection.
Approximately 80% obtain from “friends” who sell off the streets and approximately 20% steal from a parent or
family member who is prescribed.
Local Data
Pasco County
Trends in Newborn Withdrawal diagnoses, 2005 - 2010
Pasco (+2,840%)
160
2000
Pinellas (+595%)
1800
Florida (+433%)
1600
1400
120
1200
1000
80
800
600
40
400
200
0
0
2005
2006
2007
2008
2009
2010
Pasco County has the Highest Rates of Diagnoses of Newborn withdrawal per 1000 live births in the State of
Florida. Source: DCF
Pinellas and Pasco Counties ranked 1 and 2 respectively in the state of Florida for the number of substance
exposed newborns. Pasco saw a 2,840% increase from 5 in 2005 to 147 in 2010 and nearly doubled the from
2009 to 2010 (75 to 147 respectively). Data obtained from the Florida Agency for Health Care Administration
(AHCA)
Florida
Counties
200
Local Data - Pasco County
63.2% of the 399 women ages 18 - 40 (child bearing age) that entered
treatment, reported a prescription drug as their primary drug of choice in
Pasco County (BayCare Behavioral Health 2009 - 2010).
4.1% of Pasco County high school students report past 30-day use of
prescription pain relievers (2010, Florida Youth Substance Abuse Survey).
In 2008 in Pasco County, there were 159 ER visits for an Opioid related
incident. There were 86 overdoses of Benzodiazepine and 20 overdoses
involving other tranquilizers (2008 Agency for Healthcare Administration).
The number of female inmates in Pasco Sheriff’s County jails that are
pregnant and have substance abuse problems with prescription drugs is
increasing.
59% of Pasco residents feel that there is not enough enforcement of
prescription drugs (2010 Pasco Alcohol Policy and Prescription Drug Use
Survey).
Supporting Your Local Community:
What Can I Do As a Provider?
 Gather data to prioritize the public health problem related to
prescription drugs;
 Start a local Initiative with rapid action planning;
 Join learning collaboratives and list serves;
 Leverage grants and other funding initiatives;
 Educate policy makers, funders, providers, individuals,
families and communities about the public health issue and
advocate for policies to reduce morbidity and mortality rates;
 Explore with local community the recovery supports for
supportive housing, activities of daily living, phone outreach,
peer mentors, recovery coaches wellness centers, etc.;
 Focus on what happens BEFORE and AFTER primary
treatment with greater emphasis on the physical, social and
cultural environment in which recovery succeeds or fails;
Supporting Your Local Community:
What We Did as a Provider
 Leverage collaborative initiatives to combat epidemic
(coalition’s, stakeholders, specialty clinics, legislators, law
enforcement, etc.).
 Frame your system of care with a focus on integrated care
partnerships (FQHC, health clinics, primary care, specialty
care clinics, hospitals, emergency departments, etc.);
Collaborative Initiatives
1. In 2010 we created a Prescription Drug Initiative to address the growing number of
individuals seeking treatment for prescription drug use, increased deaths related to
prescription drug use, increased substance exposed newborns and the increased
number of unauthorized pain management clinics in Pasco County.
2. Focus was to review, research and make recommendations on how to address the
increasing prescription drug problems within our community.
3. Committee was composed of law enforcement, treatment providers, parents,
judiciary, pain clinics and community partners.
4. One of the recommendations from that effort was the development of a proposed
innovative project to assist Pasco County in the epidemic fight against prescription
drug use.
5. The proposed project would harness six environmental strategies that would bring
about community change that was adopted as a useful framework by the
Community Anti-Drug Coalitions of America (CADCA).
Provide Information - Enhance Skills - Provide Support - Change Consequences
Change Physical Design - Enhance Access
Collaborative Initiatives
Enhance
Skills
Provide
Information
Provide
Support
Eliminating
Prescription
Drug Abuse in
Communities
Change
Consequences
Change
Physical
Design
Enhance
Access
Collaborative Initiatives
Sample Description of Activities
Provide Information
 Community Forums, Marchman Act training, prescription drug tool kits and
social norms marketing campaign, etc.
Enhance Skills
 Prescriber training, parent and youth summit, student and faculty training,
motivational interview training, screening and intervention training, community
education, etc.
Provide Support
 Prescription drug information line, medication disposal pill drop boxes, Rx drug
safes, etc.
Change Consequences
 Pain clinic best practices, pain clinic compliance, pain clinic drug screenings,
enhance drug court Ambassador Program, etc.
Change Physical Design
 Intelligence Led Policing enforcement activities, Take Back events, etc.
Enhance Access
 Outreach, care management, community education, substance abuse screening
tools, expanded treatment capacity, etc.
Integrated Care Partnerships
“Integrated care is a service that combines
medical and behavioral health services to more
fully address the spectrum of problems that
patients bring to their medical care providers.”
“It allows patients to feel that, for almost any
problem, they have come to the right place.”
Alexander Blount, Ed.D.
Why do Integrated Care?
 To strengthen collaboration between behavioral health and
health care;
 To reduce cost and utilization factors;
 To improve outcomes, access to care and engagement;
 To integrate population based care into system redesign;
 To prepare for payment reform and overall system redesign;
 Because with reform primary care and behavioral health
services must be available in all clinical settings;
 Because behavioral health settings must have streamlined
access to medical services;
 Because all healthcare settings must have care coordination
capability in the continuum based on case mix and severity;
 Because it is the right thing to do.
How do I get started?
Building an Integrated Model
 Establish administrative and clinical leadership “buy-in”;
 Create a sense of urgency;
 Establish an Integrated Care Initiative;
 Complete an environmental scan - readiness assessment;
 Benchmark the perception of healthcare professionals
regarding integration;
 Design and deploy strategically (PCP, FQHC, Hospitals, ED,
Pain Clinics, etc.);
 Identify and address funding/financial barriers;
 Develop and revise business modeling/practices;
 Seek partners who bring needed expertise or consultation;
 Commit on transformation from volume to value.
Qualities of an Integrated Model
1)
2)
3)
4)
5)
Culturally competent
Stepped care approach
Shortened sessions
Condensed treatment pathways
Multiple delivery formats
Benefits of an Integrated Model









More likely to keep appointments
Treat person where they feel
comfortable
Focus on preventative care
Offset medical cost
On site behavioral services available
Better communication
Better outcomes
Mind/body connection
Whole person approach
Measure, Measure, Measure
Develop metrics (satisfaction, efficacy,
productivity, cost, access, utilization,
capacity, health indicators, etc.)
Key Findings and Challenges of
Integrated Care
 Not one size fits all (cultural tailoring, developing common language, variance in
population based needs, training, etc.);
 Quality outcomes and measurement are vital (future pay structure, integrated
record, reliable data, etc.);
 Care management/coordination imperative (break down silos, use skills with care
management, cross train, home based practice, patient education coaching, focus
on raising health of population, etc.);
 Payment alignment and reimbursement is challenging (transforming from fee for
service model to delivering model of brief care, internal and external barriers,
minimal current state flexibility, minimal consultation reimbursement/care
management/ telephone contact, pursuit of cost offset not immediate, etc.);
 Access and the ability to ramp immediately based on the unmet demand by
primary care is urgent (physician demands, access to care, multiple primary sites,
psychiatric evaluation requests, etc.);
 Changing the system of care is essential (finding the right staff, brief stepped care
approach, pathway driven model, limited short sessions with focus on triage, group
preventive care with focus on at risk patient, linkage to specialty care clinics for
diversion of high risk patients, emphasis on early identification, etc.);
Key Findings and Challenges of
Integrated Care
 Cultural competencies are critical (recognizing differences,
assessments/screenings/interventions are appropriate, linkage to
community support services, etc.);
 Sustainability is crucial.
 Data and Outcomes (integrated electronic health record, measurement
moving from encounters to overall health outcomes, increased
productivity for physicians, patient/family satisfaction will be driver of
long term market differentiation, change in care being based on
managing health of population. physician satisfaction, quality of life
increased, identifying and documenting added values, payment for
those of us that deliver, etc.).
Four Level
Integration Model
Staff Model
Integration
Level 4
Deep Integration
Co-Located
Level 3
Basic Integration
Co-Located
Level 2
Basic Collaboration
At-a-Distance
Level 1
ACCESS
Single Site
One Reception
One Visit for All Needs
Specialty Care Referrals
Single Site
Same Reception
Warm Handoff Referral
Specialty Care Referrals
Single Site
Separate Reception
On Site Paper Referral
Separate Sites
2 Front Doors
Referral to BH Clinic
SERVICES
1 Prescriber
1 Treatment Plan Fully Integrated
Licensed Clinician in Staff Model
1 Treatment Team
Patient Prevention - Wellness Groups
Integrated Care Manager On Site
In Home Clinical Services Available
Integrated Appointment with PC
2 Prescribers with On Site Psych. Consult
2 Treatment Plans with Integrated Goals
Licensed Clinician On Site
Multi Disciplinary Treatment Team Staffing
Patient Prevention Groups
Same Day Appt. as Primary Appointment
Referrals Made to Case Management
2 Prescribers with Psych. Phone Consult
2 Treatment Plans with Information Sharing
Licensed Clinician On Site
Informal On Site Staffing
Patient Prevention Materials Distributed
Scheduled Appointments for BH On Site
2 Prescribers
2 Separate Treatment Plans
Licensed Clinician At A Distance
Phone Consultation for Staffing
VALUE ADDED
PRACTICES
Integrated Clinical/Critical Pathways
Brief Therapy Model and SBIRT Model
Motivational Interviewing
Care Management Model
Care Manager Conducts Screenings
Team Monitoring Health Conditions
Psychiatric Training
Patient Centered Medical Home
Manage Multiple Chronic Conditions
Integrated Clinical Pathways
Brief Therapy and SBIRT Model (4-8 sessions)
Motivational Interviewing
On Site Clinician Conducts Screenings
Joint Monitoring Health Conditions
Psychiatric Training
Specialized Clinical Pathways
Brief Therapy Model (15 - 30 minute sessions)
Motivational Interviewing
Screening Tools On Site (e.g. PHQ9, CAGE)
Traditional Clinical Pathways
Traditional Therapy Models
Motivational Interviewing
Try to avoid this……
What’s Next?
QUESTIONS
Contact Information
Doug Leonardo, LCSW
Tracey Kaly, LMHC
BayCare Behavioral Health
8132 King Helie Blvd.
New Port Richey, Florida 34653
[email protected]
[email protected]