Post on 26-Mar-2015
Presented by:H. Westley Clark, M.D.
COD Initiatives at SAMHSA
Linking Healthcare and Substance Use Disorders Services: Implications for
the Addiction Treatment Field
6th 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 TreatmentSubstance Abuse Mental Health Services Administration
U.S. Department of Health & Human Services
4444
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)
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Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2008
8.0%8.3%8.1%7.9%8.2%8.3%8.0%
5.8%6.0%6.0%6.1%6.2%6.2%6.1%
2.8%2.9%2.7%2.5%2.7%2.7%2.5%
0.8%1.0%1.0%0.8%1.0%0.9% 0.7%0.4%0.4%0.4%0.4%0.4%0.5% 0.4%0%
1%2%3%4%5%6%7%8%9%
2002 2003 2004 2005 2006 2007 2008
Perc
ent U
sing i
n Pa
st M
onth
Illicit Drugs Marijuana Psychotherapeutics Cocaine Hallucinogens
Source: NSDUH, 2008
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20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use
3.7%
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
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Substance Dependence or Abuse among Adults Aged 18 or Older, by Serious Mental Illness in the Past Year: 2008
25.2%
8.3%
11.9%
2.2%
19.4%
7.1%
0%
5%
10%
15%
20%
25%
30%
% D
epen
dent
on
or A
busi
ng S
ubst
ance
Drug or AlcoholDependence or Abuse
Drug Dependence orAbuse
Alcohol Dependence orAbuse
Had SMI in the Past Year Did Not Have SMI in the Past Year
Source: SAMHSA NSDUH 2008
2.5 Million Adults have Co-Occurring SMI and Substance Use Disorder
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Treatment Admissions: Psychiatric & Substance Abuse Problems
27.2%
11%
0
5
10
15
20
25
30
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Perc
ent
of A
dmis
sion
s
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
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Treatment for Substance use Problems Only
Mental Health Care Only
Both Mental Health Care & Treatment for Substance
Use Problems45.2%
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.
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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=23049
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Outpatient Mental Health Services - 2008
Source: 2008 NSDUH
3,352
8,744
234
98
248
2,992
1,345
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Outpatient MH Clinic/Center
Office of Private Therapist, Psychologist, Psychiatrist,Social Worker or Counselor - Not part of clinic
Partial Day Hospital/Day Treatment Program
School or University Clinic/Center
Some other Place
Doctor's Office - not clinic
Outpatient Medical Clinic
Numbers in Thousands
4.2 million seen by Primary Care
17 Million adults (18+ years) seen for outpatient MH treatment/ counseling:
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Substance Abuse Treatment in 2008
Source: 2008 NSDUH
675
672
374
743
1,455
1,054
2,187
343
0 500 1000 1500 2000 2500
Hospital-Inpatient
Private Doctor's Office
Emergency Room
Rehab Facility - Inpatient
Rehab Facility-outpatient
MH Center - outpatient
Self-Help Group
Prison/Jail
Numbers in Thousands
1.7 million seen by Primary Care
7.5 Million adults (12+ years) seen for substance abuse treatment:
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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
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Community Health Centers (cont’d)
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
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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 Grantee CHCs in State COSIG Grantee CHCs in State
Alaska 160 Arizona 119
Arkansas 68 New Mexico 106
Hawaii 71 Oklahoma 54
Louisiana 79 Virginia 132
Missouri 145 Connecticut 179
Pennsylvania 223 District of Col. 33
Texas 305 Maine 114
Vermont 43 Minnesota 49
South Carolina 127 Delaware 10
South Dakota 34
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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
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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
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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 HMOreduced 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
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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
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Barriers to Integrated Care (cont’d.)
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
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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.
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ReducedCriminalInvolvement
Stability inHousing
Cost Effectiveness
PerceptionOf 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 HealthCare
Systems of Care
Organized RecoveryCommunity
DoD &Veterans Affairs
Indian Health Service
Addictions
Tribes/Tribal Organizations
Bureau of Indian Affairs
Child Care
Housing/Transportation
Financial
LegalCase Mgt
Peer Support
Health Care
Mental Health
Alcohol/Drug
VocationalEducation
SpiritualCivic 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
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24
Affordable Care ActInteragency Collaborative Efforts
Collaboration
Medicaid State Plan Amendment for Health Homes CMS, 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 Grants HRSA, SAMHSA
Paraprofessional Child/Adolescent Behavioral Health Worker Training
HRSA, SAMHSA
Definition of “Essential Benefits” under health reform All Agencies
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Other Affordable Care Act BH/PC Integration Efforts
Program Integration AspectCenters 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
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Other Affordable Care Act BH/PC Integration Efforts (cont’d.)
Program Integration AspectMedicare 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
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Other Affordable Care Act BH/PC Integration Efforts (cont’d.)
Program Integration Aspect
National Prevention & Health Promotion Strat.
Priorities must address MH, SA disorders
Study on community-based prevention/ wellness programs
Must include mental health
Surgeon General’s public health sciences track
100 of 850 annual slots reserved for behavioral health
Prevention Trust Fund Includes SAMHSA funding
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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
Collaboration/Integration within SAMHSA
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30
SAMHSA’s Strategic Initiatives
SAMHSA’s 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.
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SAMHSA’s 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
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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.)
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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.
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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
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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.
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Thank you.Thank you.