1. 1 Access to Best Practices for Co-Occurring Disorders: Research and Practice Partnerships Constance Weisner, DrPH, MSW Stacy Sterling, MSW, MPH Sujaya Parthasarathy, PhD Jennifer Mertens, MA Charlie Moore, MD, MBA University of California at San Francisco and Division of Research, Northern California Kaiser Permanente University of California at San Francisco and Division of Research, Northern California Kaiser Permanente Conference on “Complexities of Co-Occurring Conditions: Harnessing Services Research to Improve Care for Mental Health, Substance Use, and Medical/Physical Disorders,” June 24, 2004, Washington, DC From studies funded by the National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, Center for Substance Abuse Treatment, and Robert Wood Johnson Foundation

2. 2 Broadening the research focus in improving access and utilization of best practices ► Asking new research questions ► develop questions in collaboration with clinicians ► Studying the implementation process ► the variety of stakeholders that influence adoption of, and access to, best practices

3. 3 Sources of Research Questions Research literature Policy issues Clinical concerns Program change implemented  Health Plan  Clinicians  Program (CD & MH)  Primary Care  Consumers  Purchasers/employers  Accreditation bodies  Health policy Generates research intervention study Intervention evaluated Stakeholder concerns shape implementation Sterling & Weisner, (2002) “Closing the Loop: A Model to Address the Transfer of Research to Practice”

4. 4 OVERVIEW ► Importance of access Screening, assessment, and integrated services ► Conceptual model and application

5. 5 Research Supporting Integrated Services ► Assessment: Many individuals entering CD and MH treatment have co-occurring problems. (Rounds-Bryant et al., Grella et al. 2001; Rao, 2000; Greenbaum et al., 1996) ► Screening: These co-occurring problems could be identified earlier before they are severe. (Samet et al., 2001) ► Integrating services: Providing services that address those problems is related to outcomes. (McLellan et al., 1998, 1993; Willenbring & Olson, 1999)

6. 6 Oakland Sacramento Setting ► Non-profit, group practice prepaid HMO ► 3.2 million members (35% of commercially insured population) ► “Carved-in” psychiatry and chemical dependency services Vallejo Vacaville Kaiser Permanente Medical Care Program of Northern California

7. 7 Adolescent Chemical Dependency Treatment Sample ► 419 adolescents (143 girls, 276 boys) and parents ► 4 facilities ► Age ranged from 13 to 18 years ► Ethnicity: 9% Native American/Asian 16% African-American 20% Hispanic 49% White ► Treatment intake, 6-month, and 1-, 3-, & 5 years ► Response rate: 6-month 91.4%; 1-year 92.1%

8. 8 Psychiatric Conditions of Adolescents Entering CD Treatment (in %) Intakes (419) Matched Controls (2007)p-value Depression24.00.3<.0001 Conduct Disorder with ODD 17.00.2 <.0001 Conduct Disorder11.00.2<.0001 ADHD10.00.7<.0001 Anxiety6.40.3<.0001 Eating Disorders1.20.1<.01 1+ Psychiatric Conditions 37.02.0<.0001

9. 9 ARE PSYCHIATRIC SERVICES RELATED TO OUTCOME?

10. 10 Receiving mental health services while in chemical dependency services was related to better alcohol and drug outcomes at 6 months. Role of Dual Treatment: Logistic Regression Predicting Abstinence at 6 Months

11. 11 An Adult Example: 5-Year Abstinence when Psychiatric Services Provided For those who still had psychiatric problems at 12 month follow-up: 2 or more hours/year over the 5 years O.R. = 5.5* *P<.05 Controlling for age, gender, type of dependence, abstinence goal, readmission, # of 12- step meetings, recovery-oriented social support, treatment intensity

12. 12 Are Medical Services Related to Outcome?

13. 13 An Adult Example: CD Patients and Matched Health Plan Members: Medical Conditions* CD Patients (N=747) Matched Members (N=3,690) Injury and Overdoses25.6%12.1% Lower Back Pain11.2%5.8% Headache9.2%3.8% Hypertension7.2%3.4% Asthma6.8%2.6% Acid-related Disorders5.5%2.1% Arthritis3.9%1.3% *all p<.001 Mertens, Lu, Parthasarathy, Moore, Weisner. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: Comparison to matched controls. Archives of Internal Medicine.

14. 14 Randomized Adult SAMC Group: Logistic Regression Predicting Abstinence at 6 Months: Independent VariableO.R.95% C.I. Integrated Care (vs. Usual Care) 1.90(1.22, 2.96) Controlling for baseline alcohol and drug severity Weisner C, Mertens J, Parthsarathy S, Moore C, Lu Y. (2001). Integrating primary medical care with addiction treatment: A randomized controlled trial. JAMA 286(14):1715-1723.

15. 15 Medical Costs 12 Months after Treatment for Randomized CD Patients with Psychiatric & Medical Conditions *p<.05; **p<.01 Parthasarathy S, Mertens J, Moore C, Weisner C. (2003). The utilization and cost impact of integrating substance abuse treatment and primary care. Medical Care.

16. 16 Sources of Research Questions Research literature Policy issues Clinical concerns Program change implemented  Health Plan  Clinicians  Program (CD & MH)  Primary Care  Consumers  Purchasers/employers  Accreditation bodies  Health policy Generates research intervention study Intervention evaluated Stakeholder concerns shape implementation Sterling & Weisner, (2002)“Closing the Loop: A Model to Address the Transfer of Research to Practice”

17. 17 Research Practice Model CD & MH Directors’/Chiefs’ Groups: ► Business case: outcomes & cost ► Parity legislation ► Identifying next generation of research questions ► Survey of pediatricians Clinicians ► Development of assessment for MH and CD clinics ► PC & ER physicians ► Results to their professional organizations ► Identifying next generation of research questions ► Assessment in MH and CD clinics ► Readiness to change AOD use in MH clinics Dual Diagnosis Best Practice Committee ► Concept & development of liaison model ► Core competencies, care guidelines ► Training ► Identifying next generation of research questions ► Dual diagnosis continuity of care, utilization & cost

18. 18 Conclusions ► A wide variety of stakeholders influence access ► Demonstrating both outcome and cost is important in improving access ► Integrating research and practice can lead to better understanding how to study and address access

19. 19 COLLABORATORS  Felicia Chi, MPH  Steve Allen, PhD  David Pating, MD  Bill Brostoff, MD  Christine Waters, MD  Agatha Hinman, BA  Georgina Berrios, BA  Tom Ray, M.A.  Wendy Lu, MPH  Cynthia Campbell, PhD  Derek Satre, PhD  Carolynn Kohn, PhD  Melanie Jackson, BA  Cynthia Perry-Baker, BA  Lynda Tish, BA  Barbara Picchoto, BA Kaiser Permanente Clinics Oakland Sacramento San Francisco Stockton Vacaville Vallejo