Linking Healthcare and Substance Use Disorders Services: Implications for the Addiction Treatment Field 6 th Annual COSIG Grantee Meeting Bethesda, MD June 28, 2010 H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services
4 444 Past Month Alcohol Use - 2008 Any Use: 52%(129 million) Binge Use:23%(58 million) Heavy Use: 7%(17 million) Source: NSDUH 2008 (Current, Binge, and Heavy Use estimates are similar to those in 2007)
5 Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2008 Source: NSDUH, 2008
6 20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use Felt They Needed Treatment and Did Make an Effort Did Not Feel They Needed Treatment Felt They Needed Treatment and Did Not Make an Effort 1.1% 95.2% Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2008 (766,000) (233,000) (19.8 Million) Source: NSDUH 2008
7 Substance Dependence or Abuse among Adults Aged 18 or Older, by Serious Mental Illness in the Past Year: 2008 Source: SAMHSA NSDUH 2008 2.5 Million Adults have Co-Occurring SMI and Substance Use Disorder
8 Treatment Admissions: Psychiatric & Substance Abuse Problems Admissions to treatment reporting psychiatric problems in addition to substance abuse problems more than doubled between 1992 and 2007. Source: SAMHSA Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to 2007
9 Treatment for Substance use Problems Only Mental Health Care Only Both Mental Health Care & Treatment for Substance Use Problems 45.2% Past Year Mental Health Care and Treatment for Substance Use Problems among Adults (18+) with Both Serious Mental Illness and a Substance Use Disorder: 2008 Note: The percentages add to less than 100% due to rounding. Source: NSDUH 2008 39.5% 11.4% 3.7% No Treatment Despite the rise in treatment admissions for co-occurring disorders, the percentage of those seeking treatment for both mental health and substance use disorders is still small.
10 Treatment Challenges for Co-occurring Disorders Mental health services tend not to be well prepared to deal with patients having both mental health and substance abuse problems. Often only one of the two problems is identified. If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them. Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders. Source: National Alliance on Mental Illness, retrieved 06/21/10 from http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23 049
11 Outpatient Mental Health Services - 2008 Source: 2008 NSDUH 4.2 million seen by Primary Care 17 Million adults (18+ years) seen for outpatient MH treatment/ counseling:
12 Substance Abuse Treatment in 2008 Source: 2008 NSDUH 1.7 million seen by Primary Care 7.5 Million adults (12+ years) seen for substance abuse treatment:
13 Community Health Centers Health Resources and Services Administration (HRSA) supported Health Centers provide comprehensive, primary health care services to underserved communities & vulnerable populations. In 2007, 1080 Community Health Centers (CHC) reported seeing 17 million patients. Mental health services were provided to 677,213, and substance abuse services to 92,406 – approximately 4% of total patients receiving services. Source: HRSA National Total Summary Data, Retrieved 6/24/2010 from http://hrsa.gov/data-statistics/health-center- data/NationalData
14 Community Health Centers (contd) 2.8% of CHC staff are mental health personnel; 0.7% are substance abuse treatment professionals. CHCs reported an average of 4.5 encounters for patients with alchol related disorders, 6.8 encounters for those with other substance related disorders, 3 encounters for those with depression and other mood disorders 2.3 encounters for anxiety disorders, including PTSD 3.1 encounters for ADD Behavior Disorders, and 3 encounters for other mental disorders (including mental retardation Were patients linked to other services/organizations? Source: HRSA National Total Summary Data, Retrieved 6/24/2010 from http://hrsa.gov/data-statistics/health-center- data/NationalData
15 What Should the Role of CHCs Be In Integrated Care? What should the role of CHCs be, given staffing levels? Are COSIGS linking with CHCs? COSIG GranteeCHCs in StateCOSIG GranteeCHCs in State Alaska160Arizona119 Arkansas68New Mexico106 Hawaii71Oklahoma54 Louisiana79Virginia132 Missouri145Connecticut179 Pennsylvania223District of Col.33 Texas305Maine114 Vermont43Minnesota49 South Carolina127Delaware10 South Dakota34
16 Benefits of Linking Primary and Behavioral Health Care Improved cross-disciplinary knowledge/understanding Shared priorities/initiatives Better integrated management (less siloing) Braided/blended funding streams Integrated/linked health information technology (HIT) Integrated, co-located service delivery Consolidated reporting of client outcomes
17 Integrated Health Care Integrated health care: Creates a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for achieving optimal health throughout the life span. Shifts the focus of the health care system toward efficient, evidence-based practice, prevention, wellness, and patient-centered care, creating a more personalized, predictive, and participatory health care experience. Source: Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit (2009) Institute of Medicine (IOM), Retrieved from http://www.iom.edu/Reports/2009/Integrative-Medicine-Health-Public.aspx
18 The Cost Benefit of Integrated Care Individuals with co-occurring substance abuse/medical problems randomized to integrated care had significantly lower total medical costs than those in independent care. Following SA treatment, inpatient and emergency room costs decline by approximately 35% and 39% respectively.¹ Total medical costs per patient per month decline from $431 to $200.² One state study found that treatment lead to a decrease in Medicaid costs of about 5% over a 5-year period.³ Treatment for Medicaid patients in a comprehensive HMO reduced medical costs by 30% per treatment member. 4 ¹ Parthasarathy, S. et al. (2001) J Stud Alcohol. 62(1): 89-97 ² Parthasarathy, S. et al. (2003) Med Care. 41(3): 357-367 ³ Luchasnky, B. et al. (1997) Cost Savings in Medicaid Medical Expenses [Briefing Paper] Olympia, WA: Research & Data Analysis, Dept. of Social & Health Svcs. 4 Walter, L.J. et al. (2005) J Behav Health Serv Res. July-Sep. 32(3): 253-263
19 Barriers to Integrated Care Delivery System Design Physical separation of services, fragmented communication, language differences between systems Financing Siloed payment & reporting systems, competition for scarce resources Legal/Regulatory HIPAA and confidentiality rules, conflicting mandates at federal, state & local levels, categorical program requirements Source: Report of the California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (2009, October 22) [PowerPoint Slides] Retrieved from http://www.ibhp.org/index.php?section=news&subsection=show_news_details&news_id=80
20 Barriers to Integrated Care (contd.) Workforce Feared loss of identity and priority Lack of cross-training Shortage of providers, need for cultural competence/linguistic capacity Health Information Technology Lack of common IT systems, electronic health records (EHRs) often unable to support multi- system information Source: Report of the California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (2009, October 22) [PowerPoint Slides] Retrieved from http://www.ibhp.org/index.php?section=news&subsection=show_news_details&news_id=80
21 Steps to Improve Primary and Behavioral Health Care Linkage Recognize benefits and inevitability of improved linkage. Improve collaboration and cross-training, especially primary care identification of patients with and at risk for substance use disorders. Focus on holistic health, including prevention and recovery. Better integrate funding, including federal grants. Co-locate service delivery where possible. Enhance referral relationships.
22 Reduced Criminal Involvement Stability in Housing Cost Effectiveness Perception Of Care Retention Abstinence Employment/ Education Evidence-Based Practice Social ConnectednessAccess/Capacity Ongoing Systems Improvement Recovery Health Wellness Outcomes Mental Health Primary Care Child Welfare Housing Human Services Educational Criminal Justice Employment Private Health Care Systems of Care Organized Recovery Community DoD & Veterans Affairs Indian Health Service Addictions Tribes/Tribal Organizations Bureau of Indian Affairs Child Care Housing/ Transportation Financial Legal Case Mgt Peer Support Health Care Mental Health Alcohol/Drug Vocational Education Spiritual Civic Organizations Mutual Aid Services & Supports Community Individual Family Recovery-oriented Systems of Care (ROSC) Approach Community Coalitions Business Community
Federal Efforts to Integrate Primary and Behavioral Health Care 15
24 Affordable Care Act Interagency Collaborative Efforts Collaboration Medicaid State Plan Amendment for Health HomesCMS, SAMHSA Grants to behavioral health programs for co-occurring primary care conditions SAMHSA, HRSA National Public-Private Outreach and Education Campaign regarding prevention benefits CDC, SAMHSA, HRSA Primary Care Extension Education Program Regarding Chronic Conditions AHRQ with SAMHSA and others Behavioral Health Professional Ed/Training GrantsHRSA, SAMHSA Paraprofessional Child/Adolescent Behavioral Health Worker Training HRSA, SAMHSA Definition of Essential Benefits under health reformAll Agencies
25 Other Affordable Care Act BH/PC Integration Efforts ProgramIntegration Aspect Centers of Excellence for Depression Comprehensive basic, clinical services in interdisciplinary research and practice Medicaid outreach to vulnerable and underserved groups Includes individuals with mental health or substance-related disorders Medicaid Emergency Psychiatric Demonstration Pay IMDs for stabilization services and provides waiver authority for others (report and recommendation) Amended Medicaid rehabilitation option prevention services Must include SBIRT alcohol, depression screening with no co-pays
26 Other Affordable Care Act BH/PC Integration Efforts (contd.) ProgramIntegration Aspect Medicare State/tribal community interdisciplinary health teams to assist primary care providers Must include behavioral and mental health providers (including substance use disorder prevention and treatment providers.) Maternal, infant & early childhood home visiting program States must assess capacity for substance abuse treatment and target families with SA history. School-based health centers Should provide MH/SA assessment, counseling, treatment, referral
27 Other Affordable Care Act BH/PC Integration Efforts (contd.) ProgramIntegration Aspect National Prevention & Health Promotion Strat. Priorities must address MH, SA disorders Study on community- based prevention/ wellness programs Must include mental health Surgeon Generals public health sciences track 100 of 850 annual slots reserved for behavioral health Prevention Trust FundIncludes SAMHSA funding
28 HHS Behavioral Health Integration HHS Interdepartmental Behavioral Health Committee SAMHSA/HRSA Collaboration, e.g., National Health Service Corps and MAT Health Reform regulations/CMS Expanding and integrating SBIRT services Medical residency curriculum development (SBIRT) Health information technology development/ONC
30 SAMHSAs Strategic Initiatives SAMHSAs strategic initiatives focus on behavioral health and crosscut the Centers. The goal is to improve lives and capitalize on emerging opportunities, align resources, and create a consistent message. They are works in progress that will continue to benefit from public input and reflect the concepts of open government.
31 SAMHSAs Strategic Initiatives Prevention of Substance Abuse & Mental Illness Trauma and Justice Military Families – Active, Guard, Reserve, and Veteran Health Insurance Reform Implementation Housing and Homelessness Jobs and the Economy Health Information Technology for Behavioral Health Providers Behavioral Health Workforce – In Primary and Specialty Care Settings Data Quality and Outcomes – Demonstrating Results Public Awareness and Support
32 Enhanced Collaboration within SAMHSA Close integration of work as part of SAMHSA-wide behavioral health approach Cross-unit collaboration on 10 Strategic Initiatives More jointly funded grant programs (braided funding) Better integration of substance abuse and mental health within other efforts (Recovery Month, TIPS, data systems, etc.)
33 SAMHSA Braided Funding Resources from two or more programs used to support single program effort (RFA) 2010 example: mental health placed based Community Resilience and Recovery (CRRI) grants combined with SA treatment drug court funds Funds must maintain separate identities Co-project officers from contributing sources Emphasis on comprehensive behavioral health will require increased collaboration at local level.
34 Jointly-Funded/Managed Programs 2010 Community Resilience and Recovery Initiative, $4.2M (CMHS and CSAT) Training/TA Center for Primary and Behavioral Health Integration, $2M (SAMHSA and HRSA) Adult Drug Courts, $10M (SAMHSA and DOJ) 2011 Substance Abuse and Mental Health SBIRT, $15M (CMHS and CSAT) Integration of behavioral health into FQHCs, $25M (HRSA, VA, SAMHSA) Others expected for 2011
35 Summary This is a critical time for the future of all federal health programs, including behavioral health. Health care reform and other initiatives will inevitably result in primary and behavioral health integration. It is essential to begin now to foster enhanced linkages. Emphasis will continue to be on improved system efficiency and performance within a patient/client centered, holistic approach.