Promoting Health through Interdisciplinary Substance Use
Consultation in Primary Care
Chantelle Thomas, PhD, Behavioral Health ConsultantElizabeth Zeidler-Schreiter, PsyD, Behavioral Health Consultant
Meghan Fondow, PhD, Behavioral Health Consultant
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session # E3AOctober 17, 2014
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.
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
Bibliography / Reference
1.Substance Abuse and Mental Health Services Administration (2014) “Co-Occurring Disorders.” Online. Available: 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=23049•Cacciola, Alterman, DePhilippis, Drapkin, Valadez, Fala, Oslin, & McKay (2012) Philadelphia Veterans’ Administration Medical Center. Brief Addiction Monitor Scale. •The Implementer’s Guide To Primary Care Behavioral Health. Serrano, Neftali. (2014)
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
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
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
Access Hallways
Provider, BHC, & Triage
Transparency
Behavioral Health Consultation
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
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
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
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
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
Health Promotions ClinicDeveloped 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
Clinic StatisticsCurrent 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
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
Health Promotions in morning huddle
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
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
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.
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
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
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
SEVA - Patient Screen
Clinician Dashboard
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
Session Evaluation
• Please complete and return theevaluation form to the classroom monitor before leaving this session.
• Thank you!
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