1. Thomas E. Freese, PhD Sherry Larkins, PhD UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center 1

2. The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration:  The LACDMH/DHS Collaboration Program  Healthy Way L.A. Community Partners  Project 50  MHSA Innovation Programs  Center for Community Health of Downtown Los Angeles  LACDMH & HealthCare Partners Collaborative Care Program

3.  The LACDMH/DHS Collaboration Program DMH has co-located small teams comprised of social workers, marriage and family counselors, and medical case workers, in DHS Comprehensive Health Centers (CHC) and Multiservice Ambulatory Care Clinics (MACC) on a full-time basis. The DMH teams deliver short- term, early intervention, evidenced-based, specialty mental health services using the Mental Health Integration Program (MHIP) model to treat persons with mild to moderate mental health symptoms. MHIP is a stepped collaborative care model shown effective in treating persons with depression and anxiety seen in primary care settings. Clinical consultation with a psychiatrist is available to both the treatment teams and to the primary care providers. 3

4.  Healthy Way L.A. Community Partners DMH has partnered with numerous health care agencies under contract with the DHS, known as Community Partners (CP), to provide short-term, early intervention, evidence-based, specialty mental health services on-site at the CP agencies. CPs, many of which are also Federally Qualified Health Centers (FQHC), are providing services using the MHIP model. DMH has and continues to provide training on the MHIP model to clinical staff employed by the CPs who are providing services to individuals with mild to moderate mental health symptoms. Furthermore, partnerships have been established between the CPs and existing DMH directly-operated and contracted specialty mental health clinics to provide a well-coordinated referral process between health and mental health when a consumer requires a level of care beyond a short-term early intervention. 4

5.  Project 50 Project 50 is a demonstration program to identify, engage, house and provide integrated supportive services to the 50 most vulnerable, long-term chronically homeless adults living on the streets of Skid Row. The Los Angeles County Board of Supervisors passed the motion to implement Project 50 in November 2007. Project 50 involves three phases: 1.Registry Creation 2.Outreach Team 3.Integrated Supportive Services Team. Currently, Project 50 is operating in the third phase. Four Project 50 Replication sites have been developed in Santa Monica, Van Nuys, Venice and Hollywood. They are at various stages of implementation. 5

6.  MHSA Innovation Programs DMH community stakeholders have identified four (4) models of care that integrate mental health, physical health and substance abuse services. MHSA Innovation (INN) model programs seek to learn which practices increase quality of services, improve consumer outcomes, promote community collaboration and the most cost effective in order to meet the spectrum of needs of individuals who are uninsured/ economically disadvantaged, homeless and members of underrepresented ethnic populations. By implementation and evaluation of new and innovative approaches, the time-limited MHSA INN model programs will contribute to learning and inform future practice. The four Innovation Models include: ◦ Integrated Clinic Model (ICM) ◦ Integrated Mobile Health Team Model (IMHT) ◦ Community-Designed Integrated Service Management Model (ISM) ◦ Integrated Peer Run Models-Peer Run Integrated Service Management (PRISM) & Peer Run Respite Care Homes (PRRCH) 6

7.  Center for Community Health of Downtown Los Angeles Led by the Los Angeles County Chief Executive Office (CEO), the Center for Community Health of Downtown Los Angeles (CCHDLA) is a private/public partnership that employs a one-stop shop of resources approach for homeless and low-income people in the Skid Row area of downtown Los Angeles. Opened in 2009, it has increased access to all health-related services, including primary health care, specialty care, mental health, substance abuse, optometry, dentistry, medication, x- rays, HIV education and prevention, and STD and TB clinics. Known as an “Integrated Care for the Homeless Model,” CCHDLA employs an Integrated Services Team approach in which all partner agencies involved in the consumer’s care confer and develop a comprehensive, integrated treatment plan and service delivery. 7

8.  LACDMH & HealthCare Partners Collaborative Care Program DMH has developed an integrated pilot program with HealthCare Partners (HCP) and LA Care Health Plan to treat chronically and persistently mentally ill (CPMI) patients through collaborative care. Dually-eligible (Medicare/Medi-Cal) individuals who enroll in an LA Care Medicare Advantage program will be primarily treated in HCP's Collaborative Care Centers, though they could also receive their care at home, in long-term care facilities and elsewhere depending on the individual needs of the patient. The patient's treatment plan is co- managed by a medical doctor and a psychiatrist along with a team of nurse practitioners, care managers, social workers, and psychologists. The patient’s medical care is fully integrated with behavioral health interventions that include pharmacologic and behavioral/social skills. It is anticipated that diagnoses included in this treatment model will predominately include: schizophrenia, bi-polar and obsessive- compulsive disorders, severe major depression with and without psychotic features, severe chemical dependency and dementia. 8

9.  These projects represent a dramatic shift toward a whole health orientation. This means that we all need to think about the work that we do as part of a wholistic system, rather than a separate entity.  This new orientation leads to the need for mental health staff to fulfill new roles in all DMH settings that ensure that services are provide in an integrated way. This will: ◦ Increase treatment efficacy ◦ Improve client outcomes ◦ Increase staff satisfaction and decrease burnout See Handout for a full description of each project

10.  Primary care culture and effective communication  Role definitions for Mental Health staff in primary care settings  Medical issues that commonly co-occur with mental health and substance use  Barriers to service access  A case example. 10

11. Average spending on health per capita ($US PPP) Total health expenditures as percent of GDP Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012. 11

12. Health Care Costs Concentrated in Sick Few— Sickest 10 Percent Account for 65 Percent of Expenses Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey. Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 1% 5% 10% 50% 65% 22% 50% 97% $90,061 $40,682 $26,767 $7,978 Annual mean expenditure

13.  In the USA and Canada, mental health disorders account for 25% of all years of life lost to disability and premature mortality 1  One in four American adults experience a mental health disorder in a given year, and 1 in 17 have a seriously debilitating mental illness 2  Among those who die by suicide, more than 90%  have a diagnosable disorder 4.  In 2008, suicide was the tenth leading cause of death in the USA 6. 13 1. World Health Organization. (2004). The world health report 2004: changing history. Annex Table 3. A126-A127. Geneva: WHO. 2. Kessler RC, et al. (2005). Archives of General Psychiatry, 62: 617-627. 3. US Department of Health and Human Services. (1999). Mental health: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, 1999. 4. Minino AM, et al. (2011). Final Data for 2008. National Vital Statistics Reports 2011; 59(10): 01-127. Available: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf.

14.  Mental health and substance use services are integral to health care services. The goals of DMH initiatives are: ◦ Ensure positive experiences of care ◦ Enhance customer services  Ensure care is effective ◦ Develop bi-directional care/behavioral health homes ◦ Implement data outcomes system to enable monitoring of client progress  Control/reduce costs ◦ Develop strategies to extend care ◦ Develop strategies to reduce readmission and preventable hospitalizations 14

15. Primary Care  The aims of primary care are to provide broad spectrum of care ◦ both preventive and curative; ◦ over a period of time; and ◦ to coordinate all of the care the patient receives.  All family physicians and most pediatricians and internists are in primary care. ◦ www.medicinenet.com 15

16. Primary Care  Practitioner must possess a wide breadth of knowledge in many areas.  Patients consult the same primary care doctor for routine check-ups, and initial consultation about a new complaint.  Common chronic illnesses, often treated in primary care, include: ◦ Hypertension-- Diabetes ◦ Asthma and COPD-- Depression and anxiety ◦ Arthritis and other pain 16

17. 1. The person receiving services is called… 2. The building(s)/place(s) where the person receives services is called… 3. The room where the person receives services is called… 4. The person who has the ultimate responsibility for the care of the person is called… 5. The person who is responsible for care coordination is called… 17

18. 18

19.  It is important to understand the system with which you are working 19

20.  It is important to understand the system with which you are working  Learn about the medical conditions that bring people to primary care 20

21.  It is important to understand the system with which you are working  Learn about the medical conditions that bring people to primary care  Expand your vocabulary to facilitate communication 21

22.  It is important to understand the system with which you are working  Learn about the medical conditions that bring people to primary care  Expand your vocabulary to facilitate communication  Stay within your scope of practice in your interactions 22

23.  It is important to understand the system with which you are working  Learn about the medical conditions that bring people to primary care  Expand your vocabulary to facilitate communication  Stay within your scope of practice in your interactions  Make yourself visible and useful 23

24.  It is important to understand the system with which you are working  Learn about the medical conditions that bring people to primary care  Expand your vocabulary to facilitate communication  Stay within your scope of practice in your interactions  Make yourself visible and useful  Be accessible and available

25. Who does what in an integrated care system? 25

26. In an integrated care system, what is the best role of each of the following disciplines. What should they take lead on? How should they be involved in collaboration?  Medical Provider  Mental Health Provider  Substance Use Disorder Provider  Behavioral Health Specialist  Peer Specialist  Family 26

27.  Differing practice styles  Differing practice cultures and language  Difficulty in matching provider skills with patient needs  Heavy reliance on physician services  Tension between direct patient care services (reimbursable) and integrative (non- reimbursable) services 27

28.  Lack of recognition of provider limitations  Lack of MH knowledge in PC providers and lack of health knowledge in BH providers  Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context  Differing confidentiality and information sharing procedures  Differing coding and billing systems  Provider resistance 28

29. From Co-Location to Fully Integrated Care Bill Rosenfeld 29

30.  Behavioral Health Consultant (BHC) placed in medical clinic  Considered a member of the primary care team  Provides consultation (not therapy)  Goal of immediate access, minimal barriers  Emphasizes psychoeducation, population mgmt  Focus on improving QOL, quality of health care 30

31.  Part-time IBH coverage  Allowing the BHC “Office Hermit” to go on too long  Clinician’s housed outside of medical providers service delivery area.  Approaching commercial insurance for reimbursement…boomerang effect  Implementing a co-location model 31

32. HTNRelaxation skills training, breathing, problem solving DiabetesPromote goal identification and attainment, enhance mood stability, identify and restructure alarmist thinking, stress reduction Chronic Pain (multiple presentations), including fibromyalgia syndrome Promote the use of attention diversion techniques, relaxation skills, stages of pain, values clarification ObesityPromote goal identification and attainment, behavioral modification, support healthy lifestyle attainment, motivational change, diet/exercise, motivation for change Medical DiagnosisBehavioral Health Intervention

33.  Better blood sugar control  Diminished Missed School Days  Diminished rate of patients asked to leave practice  Patient confidence in self-care enhanced  Ratio of SM goals set and education attended enhanced These goals are important to the patient event if they do not have a primary care provider 33

34.  All PCPs reported:  Satisfaction with the BHC service  Access to BHC as “immediate” and “very helpful”  Better able to address behavioral problems  Recommend the service for other medical providers  A majority (> 80%) said because of BHC:  Have greater confidence in how BH issues are treated within the collaborative framework  Able to see more patients in 20 minutes  Better recognize patient behavioral issues 34

35.  90% said visit length “Very Good”, or “Excellent”  88% rated quality of BHC care as “Very Good” or “Excellent”  94% would recommend BHC to family or friends  89% said it was helpful to meet w/ BHC  82% felt BHC involvement resulted in improved health status 35

36.  MPHC dismisses 75% fewer patients from our practice since socially embedding a BHC in Internal Medicine  Positive impact on recruitment of medical providers  Broad range of staff training possibilities 36

37. Thanks for Bill Rosenfeld for providing this information www.mountainparkhealth.org/ 37

38. 38

39. 39

40.  Type 1 diabetes is usually diagnosed in children and young adults. The the body does not produce insulin. Only 5% of people with diabetes have this form of the disease.  Type 2 diabetes, the most common form of diabetes, either the body does not produce enough insulin or the cells ignore the insulin. Insulin takes the sugar from the blood into the cells. If insulin is not working, glucose builds up in the blood instead of going into cells, it can lead to diabetes complications. Type 2 diabetes is more common in African Americans, Latinos, Native Americans, Asian Americans, Native Hawaiians and other Pacific Islanders, as well as the aged population. 40

41. Basic Overview: ◦ Metabolic disease. ◦ Hyperglycemia (too much sugar) due to insulin resistance and defects in insulin secretion. ◦ Diabetes can lead to:  blindness  heart & blood vessel disease  stroke  kidney failure  amputations  nerve damage. http://safediabetes.blogspot.com/2010/1 2/how-to-reduce-impact-type-2- diabete.html 41

42.  Often no symptoms at all.  Most common symptoms include: ◦ Blurred vision ◦ Erectile dysfunction ◦ Fatigue ◦ Frequent or slow-healing infections ◦ Increased appetite ◦ Increased thirst ◦ Increased urination http://www.thetype2diabetesdiet.com/wp- content/uploads/2009/03/symptoms-for- type-2-diabetes.gif 42

43. Gender*Age*Ethnicity** *American Diabetes Association, 2011. **US DHHS Office of Minority Health, 2010 43

44.  The hemoglobin A1c test is used to determine how diabetes is being controlled.  HbA1c provides an average of your blood sugar control over a six to 12 week period.  When blood sugar is too high, sugar builds up in your blood and combines with your hemoglobin, becoming "glycated."  For people without diabetes, the normal range for the HbA1c test is 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than 7%.  Retest should occur every three months to determine level of control. 44

45.  The Medical Provider  The Substance Use Disorders Provider  The Mental Health Provider  Peers and Family 45

46. Relationship with SUD ◦ Heavy alcohol consumption can increase risk factors including: body-mass index, low HDL (“good”) cholesterol and cigarette smoking (Tsumura, 1999). ◦ A history of substance use is associated with earlier age of onset of diabetes (Johnson, 2001). ◦ SUD is associated with increased mortality in diabetics (Jackson, 2007). Significance of Behavioral Health ◦ Diabetes patients also have increased depression. Both diet control and depression respond to behavioral activation strategies ◦ In 2006, it was the seventh leading cause of death, and cost the US $174 billion in medical costs, loss of productivity, disability costs 46

47.  Medical services available on-site better link clients in SUD treatment to medical services compared to those with outside referrals (Friedmann, 1999).  Social support for abstinence can increase linkage to medical services. (Saitz, 2004).  Encourage activities that improve diabetes: ◦ Better diet. ◦ Reduce simple carbohydrate intake (i.e. potatoes, white bread, corn, soda, candy, sweets). ◦ More exercise. ◦ Maintain regular appointments with doctor overseeing diabetes treatment. 47

48. Common Medical Issues Associated with Mental Health and Substance Use Disorders 48

49. Gender*Ethnicity* *Centers for Disease Control and Prevention, 2012. Age* 49

50.  Blood pressure (BP) is the force against the walls of one’s arteries while blood is pumping.  Hypertension is when BP is too high.  Example BP: 120/80 mmHg (“120 over 80”) ◦ Systolic (top number): pressure while heart contracts.  Normal is 180. ◦ Diastolic (bottom number) pressure while heart relaxes & enlarges.  Normal is 80. 50

51.  Increased risk of: ◦ Stroke ◦ Blood vessel damage (arteriosclerosis) ◦ Heart attack ◦ Tearing of heart’s inner wall (aortic dissection) ◦ Vision loss ◦ Brian damage (NIH, 2010) 51

52.  Three or more drinks per day increases BP & risk of hypertension in both women and men (Sesso, 2008).  Decreasing alcohol consumption associated with dose-dependent reduction in BP (Xin, 2001).  Stimulants like cocaine or amphetamines can cause HTN and other acute and chronic cardiovascular diseases. (McMahon, 2010).  HTN risk associated with quantity of cigarettes smoked daily and the duration of smoking (Orth, 2004). ◦ Former smokers have higher rates of hypertension than those who never smoked (Orth, 2004). 52

53.  HTN can be well controlled in primary care for most patients (Williams 2004). ◦ Some many need help finding transportation. ◦ Some may need help finding free or low-cost clinics.  Ask about alcohol consumption. Encourage limiting to 2 or less drinks per day.  If client smokes, give advice and support to quit smoking (NICE, 2006).  Encourage weight loss and salt reduction. ◦ Losing 10kg (22 lbs) can reduce systolic BP by 10 points (Cappuccio, 2007). 53

54. Common Medical Issues Associated with Mental Health and Substance Use Disorders 54

55.  In 2011, at least 100 million adult Americans have common chronic pain conditions (excl. acute pain and children)*.  Pain costs society at least $560-$635 billion annually (an amount equal to about $2,000 for everyone living in the U.S.)*.  Women are more likely to experience pain (in the form of migraines, neck pain, lower back pain, or face or jaw pain) than men**.  Adults age 45-64 years were most likely to report pain lasting more than 24 hrs. (30%), followed by young adults age 20-44 (25%0, and adults age 65 and over (21%)***. *IOM, 2011; CDC, 2009; NCHS, 2006. 55

56. http://www.rxreform.org/wp-content/uploads/2011/06/Toblin-2011-Kansas-Pain-corrected-proof.pdf ConditionNumber of SufferersSource Chronic Pain100 million AmericansInstitute of Medicine of The National Academies Diabetes25.8 million Americans (diagnosed and estimated undiagnosed) American Diabetes Association Coronary Heart Disease (heart attack and chest pain) Stroke 16.3 million Americans 7.0 million Americans American Heart Association Cancer11.9 million AmericansAmerican Cancer Society 56

57. Prescription Drug Misuse  Any prescription drug can be “misused”  Misuse = “non-medical use” = Any use that is outside of medically prescribed regimen: ◦ Non-compliance ◦ Taking different dose ◦ Sharing ◦ Obtaining from non-medical source ◦ Taking for psychoactive effects ◦ Taking for effects not indicated ◦ Use with alcohol or other substances 57

58. Relieves pain Relieves suffering Relieves misery Makes you feel better Makes you feel good Makes you “ high ” 58

59.  Broad availability of prescription drugs ◦ e.g., via the medicine cabinet, family, friends, Internet, and physicians  Misperceptions about their safety  Focus on a pill for every ill (cultural trend, media)  High rates of other substance use including abuse cigarettes, drugs and alcohol  Childhood history of abuse, trauma and neglect  High rates of depression and anxiety 59

60.  Pain: An unpleasant sensory and emotional experience arising from the actual or potential tissue damage or described in terms of such damage  It is always subjective. Each individual learns the application of the word through experiences related to injury in early life (International Association for the Study Pain [IASP]) Early life – historical Experience—learned Subjective—private Individual--unique 60

61. 65% of patients with depression experience pain 5% to 85% of patients with pain have depression 75% of primary care patients with depression present only with physical complaints and do not attribute their pain to depression  0 or 1 physical symptom - 2% were found to have depression  ≥ 9 physical symptoms – 60% were depressed  Increasing pain severity, frequent pain episodes, diffuse pain, and treatment resistant pain are associated with more severe depression  In patients with pain, depression is associated with more pain complaints, greater intensity, longer duration of and greater likelihood of nonrecovery Bair MJ et al, ARCH INTERN MED, 2003 61

62. Trends in opioid prescribing (2000 and 2005) with and without MH and SUDs Insured  34.9% with an MH or SUD  27.8% without MH and SUD Arkansas Medicaid  55.4% with an MH or SUD  39.8% without an MH or SUD InsuredAR Medicaid 62

63.  Chronic use of prescription opioids for NCPC is much higher and growing faster in patients with MH and SUDs than in those without these diagnoses  Clinicians should monitor the use of prescription opioids in these vulnerable groups to determine whether opioids are substituting for or interfering with appropriate MH and substance abuse treatment Edlund, Mark et al, Clinical Journal of Pain 2010 63

64.  Kowalski & Bondmass (2008) study of pain and grief correlation in widows  Self-reported physical symptoms included: ◦ Pain ◦ Gastro-intestinal problems ◦ Medical/surgical conditions ◦ Sleep disturbances ◦ Neurological/circulatory issues  Psychological symptoms: ◦ Depression ◦ Anxiety ◦ Loneliness  Of the 173 women in the sample, about two-thirds the sample reported at least one physical complaint following spousal loss Kowalski & Bondmass, 2008 64

65. The Dilemma Need to accurately diagnose disease and provide effective analgesia Some illnesses have no diagnostic test, but are frequently cited as reasons for pain syndromes needing medication treatment(s) Headache Low back pain Pelvic pain Arthritis Fibromyalgia Chronic Fatigue Syndrome Has contributed to misuse of pain pills and addiction 65

66.  Predictive factors; as non-pain patients ◦ Personal or family history of drug abuse ◦ Current addiction to alcohol or cigarettes ◦ History of problems with prescriptions ◦ Co-morbid psychiatric disorders 66

67.  No validated diagnostic criteria for addiction in pain patients; only “at risk” behaviors: ◦ Control ◦ Compulsive use ◦ Continue use despite harm ◦ Craving  Identifying “at risk” patients: ◦ History ◦ Screening instruments ◦ Behavioral checklists ◦ Therapeutic maneuver 67

68. Mark each box that applies: Female Male 1.Family history of substance abuse Alcohol1 3 Illegal drugs2 3 Prescription drugs4 4 2.Personal history of substance abuse Alcohol3 3 Illegal drugs4 4 Prescription drugs5 5 3.Age (mark box if between 16-45 years)1 1 4.History of preadolescent sexual abuse3 0 5.Psychological disease ADO, OCD, bipolar, schizophrenia2 2 Depression1 1 Scoring totals: Scoring 0-3: low risk (6%) 4-7: moderate risk (28%) > 8: high risk (> 90%) Administration On initial visit Prior to opioid therapy Webster, et al. Pain Med. 2005;6:432. 68

69. Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose ⇧s Recurrent prescription losses Passik and Portenoy, 1998 69

70. Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose ⇧s Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher dose Med hoarding when symptoms are reduced Requesting specific meds Acquisition of similar meds from other medical sources 1-2 unsanctioned dose ⇧ Unapproved use of the med for another symptom Reporting psychic effects not intended by the clinician Passik and Portenoy, 1998 70

71. 71 “Luz” A client from EXODUS ICM

72.  Cl is a 55year old Hispanic (Puerto Rican) female, divorced, mother of 5 adult children, 4 sons and a daughter who passed away 6 yrs ago. Currently estranged from all family members except for one son. Currently renting a bedroom in a home. Cl receives recently was awarded SSI and Medi-Cal benefits. Enrolled in the ICM program September 2012. 72

73.  Presenting problems  Initially presented to clinic with sx of depression, anxiety, crying spells, labile moods, angry outbursts, hopelessness and restless sleep.  Reports she has been depressed most of her life but depression exacerbated 6 yrs ago after the death of her daughter in an MVA. She has extensive drug abuse hx. Drugs of choice are crack and ETOH. Client recently graduated from a residential treatment program and has been sober for 3 yrs.  In January 2013, client exhibited hypomania and delusions that she is pregnant. Presented with elevated mood, decreased need for sleep, racing thoughts, increase in goal directed bx, auditory and visual hallucinations, heavy make- up and poor hygiene. Her diagnosis was noted as Bipolar D/O. 73

74.  History  Client born in Puerto Rico. She has a 3 rd grade education but is illiterate. Speaks Spanish and English. Reports hx of severe physical and sexual abuse at the hands of her father beginning at age 8. Children have been removed form her custody due to drugs and domestic violence with her boyfriend. Family hx of addictions and depression.  Client has no work history other than “selling drugs” and “prostitution”.  Psychiatric history  Client was referred by her rehab program to Exodus Urgent Care Center and then to Exodus ICM. She has previously received brief crisis based services. 74

75.  Medical history:  Client has Type 2 Diabetes, hypertension, COPD, and obesity. At intake, her BP was 139/82, BMI 44.79, Hemoglobin A1C 8.2, smoking 1 pack of cigarettes a day.  Most recent values are as follows: BP 112/75, BMI 41.56, Hemoglobin A1C 5.8, smoking 3-4 cigarettes a day.  Laboratory Normal Values:  BP: ◦ Normal systolic is 180. ◦ Normal diastolic is 80.  HbA1c: ◦ Normal 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than 7%.  BMI: ◦ Underweight = <18.5 ◦ Normal weight = 18.5–24.9 ◦ Overweight = 25–29.9 ◦ Obesity = BMI of 30 or greater 75

76.  Diagnosis  Axis I 296.44 Bipolar D/O, Manic w/ Psychotic features. 304.80 Polysubstance Dependence in full sustained remission. Axis II No Diagnosis Axis III Type 2 Diabetes, hypertension, hyperlipidemia, COPD, and obesity Axis IV Problems with primary support group, social environment, educational, occupational, economic, access to health care, legal, other Axis V GAF 55  Medications  Lithium 600mg QHS (mood stablizer) Celexa 20mg QAM (depression) Abilify 2mg QAM (adjunctive tx for for bipolar disorder) 76

77. Stages of Change: Primary Tasks in Linking MH and SU 1. Precontemplation Definition: Not yet considering change or is unwilling or unable to change. Primary Task: Raising Awareness—Connect SU and MH Sxs 2. Contemplation Definition: Sees the possibility of change but is ambivalent and uncertain. Primary Task: Resolving ambivalence/ Helping to choose change 3. Determination Definition: Committed to changing. Still considering what to do. Primary Task: Help identify appropriate strategies to improve MH/ reduce SU 4. Action Definition: Taking steps toward change but hasn’t stabilized in the process. Primary Task: Help implement change strategies to decrease MH Sxs and SU 5. Maintenance Definition: Has achieved the goals and is working to maintain change. Primary Task: Develop new skills to maintain improvements in MH and SU 6. Recurrence Definition: Experienced a recurrence of the symptoms. Primary Task: Cope with consequences, relate to MH functioning as precursor and outcome

78. Stages of Change: Intervention Matching Guide to Link MH and SU Offer factual information about MH-SU connection Explore the events that brought them to treatment—Impact of SU/MH Explore results of previous efforts to improve MH. What was the role of SU? Explore pros and cons of improving MH and decreasing SU Explore the person’s sense of self- efficacy to reduce MH symptoms Explore expectations about change— What is the role of SU on MH Sxs? Summarize self-motivational statements for change in MH and SU Continue exploration of pros and cons of improving MH and decreasing SU Offer menu of options for addressing MH Sxs and SU Help identify pros and cons of various change options Identify and lower barriers to change Help enlist social/peer support Encourage person to publicly announce plans to change Support a realistic view of change through small steps Identify high-risk situations for SU and impact of use on MH functioning Develop coping strategies Assist in finding new reinforcers of positive change including feeling better Help access family/social/peer support Help identify and try supportive behaviors and drug-free activities to maintain goals. Maintain supportive contact and highlight progress in maintaining improved functioning--What was the role of SU? Set new short and long term goals for MH and SU Frame recurrence as a learning opportunity—What was the impact on MH? Explore possible psychological, behavioral and social antecedents Help to develop alternative coping strategies for strong emotions Encourage person to stay in the process and maintain support 1. Pre- contemplation 2. Contemplation 3. Determination 4. Action 5. Maintenance 6. Recurrence

79.  Substance use ◦ Maintenance of abstinence ◦ Supportive behaviors and drug-free activities ◦ Maintain supportive contact ◦ Set new short and long term goals for MH and SU  Diabetes ◦ Blood sugar monitoring and control ◦ Identify and support dietary changes. ◦ Promote self mgt. ◦ Enhance mood stability ◦ Stress Reduction

80.  Obesity ◦ Monitoring food/diet ◦ Goal identification and attainment ◦ Exercise goal identification and tracking  COPD ◦ Identifying Triggers ◦ Smoking cessation (medical and behavioral) ◦ Medication compliance ◦ Daily Monitoring, Action Planning  Social support ◦ Identify drug free activities including 12-step, church, and recreation

81.  Cl was initially identified primarily as depressed and aggressive with people. Client only sought treatment at the request of her rehab program. When she graduated from rehab program, she became homeless. Program assisted her with renting a room.  Client was encouraged to participate in Lunch & Learn, Diabetes Support, Self Help and Seeking Safety groups.  She began making better food choices, reduced her smoking and began walking daily. She lost 17 lbs and has been abstinent from drugs for over 3 yrs.  Cl generally complies with meds and all medical and mental health appointments. She engages in groups 3-4 days/wk, goes to 12 step meetings, and participates in community activities offered by the program. She arrives at the clinic early, is good at seeking support, resources and referrals, and always follows through. 81

82. The Warm Hand-Off 82

83. Approximately 5% of patients screened will require referral to substance use evaluation and treatment. A patient may be appropriate for referral when: Assessment of the patient’s responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use. These high risk patients will receive a brief intervention followed by referral. 83

84. Describe treatment options to patients based on available services Develop relationships between health centers, who do screening, and local treatment centers Facilitate hand-off by: Calling to make appointment for patient/student Providing directions and clinic hours to patient/student Coordinating transportation when needed 84

85. Thomas E. Freese, PhD tfreese@mednet.ucla.edu Sherry Larkins, PhD larkins@ucla.edu Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs www.psattc.org www.uclaisap.org 85