1. The Integration of Behavioral Health and Primary Care George Rust, MD, MPH, FAAFP, FACPM Father of Dan & Christina, Husband of Cindy, Professor of Family Medicine and Director, National Center for Primary Care National Center for Primary Care Morehouse School of Medicine

2. National Center for Primary Care at Morehouse School of Medicine Promoting Excellence in Community-Oriented Primary Health Care and Optimal Health Outcomes for all Americans

3. What Is Primary Care? C First Contact Care C Comprehensive C Continuous C Coordinated C Context of Family & Community

4. What Is Primary Care? Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Institute of Medicine, 1996

5. Primary Care is Relational Care Personalismo y Confianza Trump Evidence-Based Medical Advice

6. Behavioral Health  Physical Health “Baseball is 90% mental -- the other half is physical." -- Yogi Berra

7. Partnerships on Behavioral Health in Primary Care Rollins School of Public Health Southeast Regional Clinicians’ Network Satcher Health Leadership Institute National Center for Primary Care Carter Center Federal Partners Senior Workgroup

8. Burden of Disease in Industrialized Nations Percent of Total All cardiovascular conditions 18.6 All mental illness including suicide15.4 All malignant disease (cancer)15.0 All respiratory conditions4.8 All alcohol use4.7 All infectious and parasitic disease2.8 All drug use1.5 WHO Global Burden of Disease Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: World Health Organization and the World Bank, Harvard University Press, 1996. www.who.int/msa/mnh/ems/dalys/intro.htm www.who.int/msa/mnh/ems/dalys/intro.htm All Behavioral Health -- Mental Illness, Suicide, Alcohol, & Drug Use = 21.6%

9. Depression in Primary Care Survey of 1898 patients in 88 primary care practices Patients meeting DSM criteria for depression w/in past 30 days 21.7% of women 12.7% of men Rowe MG. Correlates of Depression in Primary Care. Journal of Family Practice, 1995.

10. 18% Prevalence of Alcohol Abuse or Dependence in Primary Care Why Primary Care? McQuade et al; Detecting symptoms of alcohol abuse in primary care. Archives of Family Medicine, 2000.

11. Screening vs. Readiness to Change 7 VA Clinics -- 36% screened positive for alcohol misuse Readiness to Change in Primary Care Patients Who Screened Positive for Alcohol Misuse Williams et al. Ann Fam Med 2006;4:213-220.

12. “ About 70 percent of the population sees one of the 255,173 primary care physicians at least once every two years.” BUT: “94 percent of primary care physicians failed to include substance abuse among the five diagnoses they offered when presented with early symptoms of alcohol abuse in an adult patient.” “Most patients (53.7 percent) said their primary care physician did nothing about their substance abuse: –43 percent said their physician never diagnosed it –10.7 percent believe their physician knew about their addiction and did nothing about it.” Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. CASA- National Center on Addiction & Substance Abuse at Columbia University, April 2000. Is Primary Care Failing?

13. Usual Care = Sub-Optimal Care Fail to screen / detect Fail to diagnose Fail to treat Fail to treat adequately Fail to treat to remission

14. “Typical” Primary Care Patient A. A1C (Diabetes) B. BP (Hypertension) C. Cholesterol /LDL D. Depression Plus – Osteoarthritis / Pain Mgt (Self-medicating with sister’s Vicodin) Plus – Social Complexities Husband unemployed, now drinking heavily; teens caught up in juvenile justice system.

15. Co-morbidities Abound! InpatientOutptPhysicianOtherRx DrugsTotal $218,460$7,435$28,984$12,923$13,444$281,246 He’s just one patient, how bad could it be??? Diabetes Arthritis COPD CHF Stroke Pneumonia Cancer Depression Alcohol / substance abuse * 21 ER Visits * 139 hospital bed-days

16. Mental Health Co-Morbidities in the Disabled Medicaid Population

17. Complex Co-Morbidities Among disabled Medicaid patients with HTN: –60% have at least 3 other serious physical conditions (on a billed claim within the past year) –26.7% have a mental health diagnosis –17.6 % have a substance use disorder diagnosis –36.5% have either a mental health or substance use disorder diagnosis –9.8% have both a mental health and a substance use disorder diagnosis Medical Chronic Dz Mental Health Dx Substance Use Disorder

18. Prescription Drug Abuse 15.1 million Americans admit abusing prescription drugs The number of people who admit abusing controlled prescription drugs increased from 7.8 million in 1992 to 15.1 million in 2003. In 2003, 2.3 million teens between the ages of 12 and 17 (9.3 percent) admitted abusing a prescription drug in the past year; 83 percent of them admitted abusing opioids. In 2002, controlled prescription drugs accounted for 23 percent of all drug-related emergency department mentions in the U.S -- Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. (July 2005); CASA – The National Center on Addiction and Substance Abuse at Columbia University

19. Pain Management vs Opioid Addiction Achieve Adequate Pain Control Prevent Prescription Drug Addiction You are now entering...... the No-Win Zone!

20. Screening Brief Intervention Motivational Interviewing Referral Care Management Medication-Assisted Recovery Recovery-Oriented Systems of Care Strategies to Address At-Risk Substance Use and SUDs in Primary Care Setting

21. Primary Care without A Team Approach Preventive Services = 7.4 hrs / day Chronic Dz (well-controlled panel) = 3.5 hrs/day Chronic Dz (poorly- controlled panel) = 10.6 hrs/day Preventive Services = 7.4 hrs / day Chronic Dz (well-controlled panel) = 3.5 hrs/day Chronic Dz (poorly- controlled panel) = 10.6 hrs/day Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005 May-Jun;3(3):209-14.

22. Screening in Primary Care CAGE CAGE-AID AUDIT-C ASSIST DAST CRAFFT PHQ-9 Hamilton-D GAD-7 Beck Anxiety Inventory HITS (domestic violence) Epworth Sleepiness Scale

23. Screening & Brief Intervention in Primary Care AHRQ Evidence Review does recommend alcohol screening & brief intervention After primary care brief, multi-contact interventions, patients reduced average drinks per week by 13%–34% and increased the proportion drinking at moderate or safe levels by 10%–19% compared with controls. Whitlock EP, Green CA, Polen MR, Berg A, Klein J, Siu A, Orleans CT. Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 Mar. BUT,... the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.

24. Brief Intervention -- FRAMES Feedback –“I am specifically concerned about your substance use because…” Responsibility –“What you do with your substance use is up to you.” Advice –“In my medical opinion, you can best minimize your health risks by…” Menu –“What do you think would work for you if you decided to make a change?” Empathy –“It is not easy to change.” Self-Efficacy –“I can see that you are a strong person.”

25. Primary Care Needs the Partnership with Behavioral Health !!!

26. “ Seven Characteristics of the Patient-Centered Medical Home” Personal Relationship with Physician Team Approach Comprehensive Whole Person Approach Coordination and Integration of Care Quality and Safety as Hallmarks Expanded Access to Care Added Value Recognized http://pcpcc.net/files/pcmhpurchasersummary.pdf

27. Does the Mental Health Sector Need More Primary Care? S Brown. Excess mortality of schizophrenia. A meta-analysis The British Journal of Psychiatry 171: 502-508 (1997) 25-year survival deficit -- Schizophrenia Excess Mortality 28% due to  suicide 12% due to  accidents 60% due to  everything else

28. Uncoordinated Care – When We Just Don’t Talk Jane Doe -- 37 y/o F w/ Bipolar Disorder –Lithium (Lithobid ®) –Aripiprazole (Abilify ® ) –Divalproex Sodium (Depakote ® ) Jane Doe – 37 y/o fertile female smoker with HTN & two-weeks of productive cough –Azithromycin (Zithromax Z-Pack ® ) –ACE + HCTZ (Vaseretic ® ) –OCP’s (Yaz ® ) –Bupropion (Zyban ® or Wellbutrin ® )

29. Three-Way Integration – Mental Health, Substance Abuse, & Primary Care 40 percent of those with an alcohol use disorder also had an independent mood disorder and 60 percent of those with a drug use disorder had an independent mood disorder (Grant, Stinson, Dawson, Chou, Dufour, Compton, et al., 2004). Integrated treatment for both problems is the standard of care for clients with substance abuse and depressive symptoms or any co-occurring mental disorder. –TIP 48:Managing Depressive Symptoms in Substance Abuse Clients during Early Recovery. SAMHSA/CSAT Treatment Improvement Protocol Series; 2008.

30. Clinical Scenarios MENTAL HEALTH Schizophrenia patient gains 100 lbs and develops diabetes Bipolar patient on lithium has hypothyroidism and high blood pressure PRIMARY CARE Diabetic patient with depression Insomnia patient using increasing doses of Xanax ® CHF patient who self-treats PTSD with alcohol Chronic back pain patient develops opioid addiction SUBSTANCE ABUSE TREATMENT Alcohol patient in detox with HTN and chest pain Sickle cell patient with heroin addiction has painful crisis Obese, smoking diabetic worried that he is addicted to the Darvocet ® he takes for neuropathic pain.

31. Status Quo = Fragmentation Silos: –Public health –Medical care –Behavioral Health –Mental health –Substance Abuse –Faith Communities –Employers –Legislators policymakers –Payors / Funders

32. How’s that workin’ for ya???

33. Choices Real People Make 54 yr old Depressed, Alcoholic, Diabetic Man Agree to Accept Referral and then Don’t Go Accept Referral to Behavioral Practice Deal with Alcohol & Mental Health Problems in Primary Care Setting Only Get Help X  Avoid Stigma  X  Get Optimal Treatment X  X Coordinate Medical & Behavioral Rx X ? 

34. Screening for Medical Co-Morbidities Treatment of Co-Morbid Medical Conditions –Asthma/COPD, Blood Pressure, Diabetes, etc. Coordination / Care Management with Medical Specialty Providers –Infectious Disease (HIV-AIDS, Hepatitis C, Tuberculosis) –Gastroenterology / Hepatology (Liver Failure, Cirrhosis, Hepatitis) Coordination / Care Management with Mental Health Specialty Providers Roles for Primary Care in Specialty Substance Abuse Treatment Setting

35. Survey of 2878 patients in 52 treatment programs –At 12-month follow-up, patients who attended programs with on-site primary medical care (compared with patients who attended programs with no primary medical care) experienced : Significantly less addiction severity No significant difference in medical severity. Referral to off-site primary care exerted no detectable effects on either addiction severity or medical severity. Can Primary Care Improve SA Treatment Effectiveness? Friedmann PD, Zhang Z, Hendrickson J, Stein MD, Gerstein DR. Effect of primary medical care on addiction and medical severity in substance abuse treatment programs. J Gen Intern Med. 2003 Jan;18(1):1-8.

36. DESIGN: Randomized controlled trial conducted between April 1997 and December 1998. SETTING AND PATIENTS: Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif. INTERVENTIONS: Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. Primary Care Impact on SA Treatment Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA. 2001 Oct 10;286(14):1715-23.

37. RESULTS: –Both groups showed improvement on all drug and alcohol measures. –Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18). –Patients with SA-related medical conditions (SAMCs) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P =.006; odds ratio [OR], 1.90) –This was true for both those with medical (OR, 3.38) and psychiatric (OR, 2.10) SAMCs. Impact on Outcomes

38. Four- Quadrant Model (~2004)

39. Four- Quadrant Clinical Integration Model (~2010) --National Council, B. Mauer

40. Continuum of Integration SeparateReferralCoordinatedCollaborativeIntegrated SeparateCo-LocatedCommon

41. INTEGRATING APPROPRIATE SERVICES FOR SUBSTANCE USE CONDITIONS IN HEALTH CARE SETTINGS An Issue Brief on Lessons Learned and Challenges Ahead 2010 http://www.niatx.net/pdf /ARC/Integrating_A ppropriate- Services_TRI.pdf

42. Coordinated Care Tracking & Confirmation of Referrals & Follow-up Sharing of Medical Records Sharing of Prescribing Changes & Medication Lists Inter-Operable Electronic Health Records Mutual Participation in Effective Health Information Exchange

43. Collaborative Care All of the Above plus... Team-Based Case Conferences Frequent Interaction on Therapeutic Strategy Patient-Centered, Shared Decision-Making Shared Care Management Joint Decision-Making on Medication Changes Frequent, secure communication by phone, e-mail, & videoconferencing

44. Continuum of Integration SeparateReferralCoordinatedCollaborativeIntegrated SeparateCo-LocatedCommon

45. National Collaborations http://www.niatx.net/Content/ContentPage.aspx?PNID=4&NID=245

46. Baby Steps NIATx / NACHC Collaborative

47. NIATx Resource Links http://www.niatx.net/Content/ContentPage.aspx?NID=24 9#skip3

48. Resources

49. Review of Evidence (& Best-Practices)

50. “Best-Practices” Integrating Behavioral Health & Primary Care Cherokee Health System

51. Cherokee Health Systems “CHS follows a generalist approach even for behavioral health issues. The PCP has to deal with everyone that walks in the door, and the BHC should be able to as well.” Integration of Mental Health, Substance Abuse, & Primary Care; AHRQ, 2008. http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf

52. Haight Ashbury Integrated Care “Haight Ashbury’s vision of integrated care follows an “any door is the right door” philosophy. The integrated care clinic on Mission Street provides primary care, substance abuse treatment services, mental health services, and intensive case management (which can include referrals to other organizations for assistance with housing, food, clothing, and employment) within a unified team service delivery model.” -- AHRQ Evidence Report Over 200 paid staff and 500 volunteers provide services at over 15 facilities to over 19,000 clients, with the vast majority served by the substance abuse programs.

53. Haight Ashbury Lessons Learned: –Patients are socially and clinically complex – HIV, homelessness, and addiction commonly co-occur. A team approach is essential. –Weekly team meetings include front desk staff since they are the first point of contact and thereby necessarily involved in the triage process. –Clients meet initially with a case manager and “are literally walked from office to office” by the case manager as they move through the system. –Warm hand-offs have been instrumental in patient adherence with treatment plans. Obstacles to Overcome: –Each of the three services, primary care, mental health, and substance abuse treatment, have their own traditional charting cultures and legal requirements. Combining the three into one comprehensive charting system has involved legal counsel along with cultural and process considerations of the three services.

54. Behavioral Expert Working in Primary Care

55. Personal Perspectives (cont.)

56. Integration Allows us to Triangulate Interventions Patient Systems Change Primary Care Team Family & Community Psychologists & Behavioral Health

57. The Power of Integration What would happen if all the health professionals came together and created a therapeutic community of healers for whole people? Faith Communities Mental Health Substance Abuse Treatment Primary Care

58. Community-Level Teamwork – A Real System of Care Inpatient Programs Primary Care Mental Health Substance Abuse Treatment Behavioral Health Community-Level Teamwork – A Therapeutic Community Faith Communities Family

59. Recovery-Oriented Systems of Care No one can whistle a symphony. It takes a whole orchestra to play it. -- H.E. Luccock

60. Embracing One Another, Soaring Together “We are all as angels, with only one wing; We can only fly when we embrace each other. -- Luciano de Crescenzo