1. Promoting Health through Interdisciplinary Substance Use Consultation in Primary Care Chantelle Thomas, PhD, Behavioral Health Consultant Elizabeth Zeidler-Schreiter, PsyD, Behavioral Health Consultant Meghan Fondow, PhD, Behavioral Health Consultant Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session # E3A October 17, 2014

2. Faculty Disclosure We currently have the following relevant financial relationships (in any amount) during the past 12 months: – Dr. Zeidler-Schreiter is a consultant for primarycareshrink.com.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Describe the evolution and implementation of the Health Promotions Clinic including clinic pathways informing patient care flow and provider feedback Define the role of the behavioral health team as it relates to referral and day to day operations of the health promotions clinic Identify clinic, provider, and patient characteristics best served by this model Discuss optimization of technology with patient engagement, treatment, and enhancing awareness of clinically relevant information

4. Bibliography / Reference 1.Substance Abuse and Mental Health Services Administration (2014) “Co-Occurring Disorders.” Online. Available: http://media.samhsa.gov/co-occurring/ http://media.samhsa.gov/co-occurring/ National Alliance on Mental Illness (2014) “Dual Diagnosis: Substance Abuse and Mental Illness.” Online. Available: http://www.nami.org/Template.cfm?Section=By_Illness&Template=/ TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=2304 9ion=By_Illness&Template=/ TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=2304 9 Cacciola, Alterman, DePhilippis, Drapkin, Valadez, Fala, Oslin, & McKay (2012) Philadelphia Veterans’ Administration Medical Center. Brief Addiction Monitor Scale.Cacciola, Alterman, DePhilippis, Dra The Implementer’s Guide To Primary Care Behavioral Health. Serrano, Neftali. (2014)

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Access Community Health Centers Certified Federally Qualified Health Centers Three clinic sites including University of Wisconsin Family Medicine Training Clinic 26,000 patients served in 2013 Approximately 6,000 BHC visits in 2013 50% white, 26% Latino/Hispanic, 21% African American 56% Medicaid, 21% Uninsured, 17% Commercial, 5% Medicare

7. Fully Integrated PCBH Model Three scheduled BHC visits per clinic (6 total per day) 60-70% of patient visits are warm handoffs Approximately 1 to 3 BHC clinicians per clinic Number of visits per day range from 8 to 15 Clinic is set up to promote interdisciplinary contact with medical providers, medical assistants, dietitians, and triage nursing staff

8. Access Hallways

9. Provider, BHC, & Triage

10. Transparency

11. Behavioral Health Consultation

12. Determining Need According to Substance Abuse and Mental Health Services Administration (2014): 8.9 million adults have co-occurring disorders Only 7.4 percent of individuals receive treatment for both conditions with 55.8 percent receiving no treatment at all Certain people with mental illness (males, low SES, increased medical illness) are at increased risk of abusing drugs and alcohol One-third of people with all mental illnesses and approximately one half of people with severe mental illnesses experience substance abuse

13. Impact of Lacking Treatment There are many consequences of undiagnosed, untreated or under treated co-occurring disorders including higher likelihood of experiencing (SAMHSA, 2014): homelessness incarceration mental illness suicide early mortality

14. National Alliance of Mental Illness (2014) People who are actively using with dual diagnosis are: less likely to follow through with the treatment plans less likely to adhere to their medication regimens more likely to miss appointments which leads to more psychiatric hospitalizations and other adverse outcomes increased risk of impulsive and potentially violent acts more likely to both attempt suicide and to die from their suicide attempts

15. Complications of dual diagnosis How do we treat patients who are still using? How do we treat those who are “not ready” for residential or outpatient treatment? Many of these patients are limited by: insurance practical/financial/psychosocial barriers Severity of mental health sx prevents follow through Previous treatment history has limited available options

16. Better Patient Care & Management Meet patients where they are! Eliminate barriers to follow through Provide options to reduce risk/harm Stabilize mental health symptoms Enhance motivation Facilitate treatment readiness Maintain the relationship

17. Health Promotions Clinic Developed in 2012 Staffed by Randy Brown, MD, PhD Takes place in clinic on Tuesday morning Over the last 6 month period 159 face to face encounters with MD (8 per clinic) No show rate of 28% 116 face to face encounters with BHC (6 per clinic) Addiction Medicine Fellow started this year

18. Clinic Statistics Current 52 active patients 80% actively involved with BHC Written vs Verbal consults Ongoing vs One time consults Number of referrals in 2012: 38 referred, 27 seen Number of referrals in 2013: 34 referred, 29 seen Number of referrals in 2014: 19 referred, 12 seen

19. Health Promotions Patient Makeup 80% Caucasian, 20% African American 51% female, 49% male 87% dual-diagnosis, 70% two or more mental health dxs 61% deemed medically complex 50% managed on Suboxone 42% Polysubstance Use Disorder 8% transgender patients

20. Health Promotions in morning huddle

21. Health Promotions-Clinic Flow Patients seen first by BHC team to evaluate level of appropriateness for referral Patient chart is copied to the health promotions behavioral health coordinator Further reviewed and forwarded to MD to determine appropriateness for scheduling Forwarded to triage to contact patient for scheduling Documentation in chart of status of referral

22. Information Obtained Severity of Use Current Insurance Previous treatment history Motivational assessment Assessment of additional barriers to treatment Assessment of risk - IV drug using, Hep C, HIV, pregnant, single parenting of small children

23. Informed Consent Wingra Family Medicine Clinic is part of Access Community Health Centers and the treatment providers at Wingra will be sharing information with your primary care provider in order to provide you with the best possible care. During your time at Wingra you will meet with the Behavioral Health Team and with Dr. Randy Brown, a physician who specializes in strategies for harm reduction and substance use issues. Your visits with the Primary Care Health Promotions Team will become part of your medical record and this information can be viewed by individuals involved in your care. If you are accepted and seen by this clinic, your primary care doctor will remain your primary care doctor. For all other general medical needs, you will continue to seek medical care with your regular doctor at your regular clinic as you did previously. About your work with the Primary Care Health Promotions Team. 1. We work as a group so you will likely see multiple members of the team. 2. We communicate very well with each other so you should not need to repeat yourself at each visit. 3. We are strategic in our visits, usually spending about 15-30 minutes with you to troubleshoot what is most important to you. 4. We communicate with your provider (primary care provider) regularly using our notes in the medical record and verbally.

24. Who is appropriate? Difficult question to summarize No hard and fast rules Good candidates for pharmacotherapy Limited community treatment options High risk folks not ready for more intensive tx Patients with co-morbid pain where there is concern of addiction

25. SEVA ~ selfless caring Smart phone application developed by University of Wisconsin, School of Engineering, Center for Health Enhancement Studies Utilizes innovative technology to assist substance abusing patients across three federally qualified health care centers (Montana, Wisconsin, & New York) Smart phone application previously used for patients following residential treatment now being implemented across the country Provides psycho-education skills development pertaining to relapse prevention, cognitive behavioral therapy, & harm reduction – (TES) Creates a virtual online recovery community for patients

26. Therapeutic Education System - TES Self-directed, web-based behavioral intervention for substance use disorders (licensed by HealthSim, LLC) Built into the SEVA application (skills training) Addresses broad array of skills and behavior designed to help substance abusing individuals stop their substance use, gain life skills, and establish new, healthy, and adaptive behaviors

27. SEVA - Patient Screen

28. Clinician Dashboard

29. Current Recruitment Goal is to ultimately recruit 100 patients, (50+ currently) Recruiting patients with varied ranges of substance use disorders, mental health sx, & psychosocial instability System includes patients that are & are not abstinent Patients are referred by behavioral health team & medical providers Efforts to engage hard to reach patients are paired with existing medical provider visits

30. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!