Transcript Southeast Regional Clinicians’ Network

National Center for Primary Care
Morehouse School of Medicine
The Integration of
Behavioral Health
and Primary Care
George Rust, MD, MPH, FAAFP, FACPM
Father of Dan & Christina, Husband of Cindy,
Professor of Family Medicine and
Director, National Center for Primary Care
National Center for Primary Care
at Morehouse School of Medicine
Promoting Excellence in Community-Oriented Primary Health Care
and Optimal Health Outcomes for all Americans
What Is Primary Care?
•C
•C
•C
•C
•C
First Contact Care
Comprehensive
Continuous
Coordinated
Context of Family
& Community
What Is Primary Care?
• Primary care is the provision of
integrated, accessible health care
services by clinicians who are
accountable for addressing a large
majority of personal health care needs,
developing a sustained partnership
with patients, and practicing in the
context of family and community.
Institute of Medicine, 1996
Primary Care is
Relational Care
Personalismo y Confianza
Trump Evidence-Based
Medical Advice
Behavioral Health Physical Health
• “Baseball is 90%
mental -- the other
half is physical."
-- Yogi Berra
Partnerships on Behavioral Health
in Primary Care
Federal Partners
Senior Workgroup
Satcher
Health
Leadership
Institute
Carter
Center
National Center
for Primary Care
Rollins
School of
Public Health
Southeast Regional
Clinicians’ Network
WHO Global Burden of Disease
Burden of Disease in
Industrialized Nations
Percent
of Total
All Behavioral Health -- Mental Illness, Suicide, Alcohol, & Drug Use = 21.6%
All cardiovascular conditions
All mental illness including suicide
18.6
All malignant disease (cancer)
15.0
All respiratory conditions
4.8
All alcohol use
4.7
All infectious and parasitic disease
2.8
All drug use
1.5
15.4
Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive
assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to
2020. Cambridge, MA: World Health Organization and the World Bank, Harvard University Press, 1996.
www.who.int/msa/mnh/ems/dalys/intro.htm
Depression in Primary Care
• Survey of 1898 patients in 88
primary care practices
• Patients meeting DSM criteria
for depression w/in past 30 days
•21.7% of women
•12.7% of men
Rowe MG. Correlates of Depression in Primary Care.
Journal of Family Practice, 1995.
Why
Primary Care?
18%
Prevalence of
Alcohol
Abuse or
Dependence
in Primary
Care
McQuade et al; Detecting
symptoms of alcohol abuse
in primary care. Archives of
Family Medicine, 2000.
Screening vs. Readiness to Change
• 7 VA
Clinics -36%
screened
positive for
alcohol
misuse
Readiness to Change in Primary Care Patients
Who Screened Positive for Alcohol Misuse
Williams et al. Ann Fam Med 2006;4:213-220.
Is Primary Care Failing?
• “About 70 percent of the population
sees one of the 255,173 primary care physicians
at least once every two years.”
BUT:
• “94 percent of primary care physicians failed to include
substance abuse among the five diagnoses they offered when
presented with early symptoms of alcohol abuse in an adult
patient.”
• “Most patients (53.7 percent) said their primary care physician
did nothing about their substance abuse:
– 43 percent said their physician never diagnosed it
– 10.7 percent believe their physician knew about their addiction
and did nothing about it.”
Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse.
CASA- National Center on Addiction & Substance Abuse at Columbia University, April 2000.
Usual Care = Sub-Optimal Care
• Fail to screen / detect
• Fail to diagnose
• Fail to treat
• Fail to treat adequately
• Fail to treat to remission
“Typical” Primary Care Patient
A.
B.
C.
D.
A1C (Diabetes)
BP (Hypertension)
Cholesterol /LDL
Depression
Plus – Osteoarthritis / Pain Mgt
(Self-medicating with sister’s Vicodin)
Plus – Social Complexities
Husband unemployed, now drinking heavily;
teens caught up in juvenile justice system.
Co-morbidities Abound!
He’s just one patient,
how bad could it be???
• Diabetes
• Arthritis
• COPD
• CHF
• Stroke
• Pneumonia
• Cancer
• Depression
• Alcohol / substance abuse
* 21 ER Visits
Inpatient
$218,460
Outpt
$7,435
* 139 hospital bed-days
Physician
$28,984
Other
$12,923
Rx Drugs
$13,444
Total
$281,246
Mental Health Co-Morbidities in the
Disabled Medicaid Population
D iseas es Assoc iated w ith H ig h C o -M orb id ity R ates (> 50% w ith > 3 com orbid ities)
D ise a se
Dia g n o sis
(D x )
n
Pre va le nce o f
th is
D ia g n o sis
in a d ult,
nonp re g na n t
A BD
Po p u la tio n
% am o n g Po p w ith
th is D x w h o
a lso ha ve a t
lea st 3 O th e r
C o -M o rbid
D ise a se s
% am o n g Po p
w ith th is D x
w h o a lso
h a ve a ny
M e n ta l
H e alth D x *
% am o n g Po p
w ith th is D x
w h o a lso
h a ve a ny
S u b sta n ce
Ab u se
% am o n g Po p w th th is
D x w h o also ha ve
e ith er M e n ta l
H e alth o r
S u b sta n ce Ab u se
(o r b o th )
10,545
30.0%
60.2%
26.7%
17.6%
36.5%
M u sc ulo ske le ta l
8,683
24.7%
54.6%
33.1%
19.8%
42.4%
L ip id / M e ta b o lic
7,613
21.6%
63.2%
29.7%
17.8%
39.4%
D ia be te s
5,187
14.8%
67.1%
25.0%
14.2%
32.9%
S u b sta n ce Ab u se
3,735
10.6%
72.7%
48.5%
100.0%
100.0%
C O PD
2,944
8.4%
75.4%
35.7%
38.2%
56.1%
H e art (n o t C H F /C AD )
2,530
7.2%
78.4%
24.9%
28.4%
41.9%
V a sc u la r
2,365
6.7%
81.6%
27.5%
28.5%
44.1%
C o ro n a ry D z (C AD )
2,130
6.1%
87.3%
25.1%
30.7%
44.0%
Blo o d (n o t h e m o p h ilia )
2,099
6.0%
77.6%
30.7%
29.2%
47.1%
C a n ce r
1,998
5.7%
61.0%
25.6%
22.5%
38.5%
As th m a
1,798
5.1%
52.5%
35.7%
28.0%
49.0%
H y p erte n sio n
Complex Co-Morbidities
• Among disabled Medicaid patients with HTN:
– 60% have at least 3 other serious physical conditions
(on a billed claim within the past year)
– 26.7% have a mental health diagnosis
– 17.6 % have a substance use disorder diagnosis
– 36.5% have either a mental health or substance use
disorder diagnosis
Medical
– 9.8% have both a mental health and
Chronic Dz
a substance use disorder diagnosis
Substance
Use
Disorder
Mental
Health Dx
Prescription Drug Abuse
• 15.1 million Americans admit
abusing prescription drugs
• The number of people who admit
abusing controlled prescription
drugs increased from 7.8 million
in 1992 to 15.1 million in 2003.
• In 2003, 2.3 million teens
between the ages of 12 and 17
(9.3 percent) admitted abusing a
prescription drug in the past year;
83 percent of them admitted
abusing opioids.
• In 2002, controlled prescription drugs accounted for 23 percent of
all drug-related emergency department mentions in the U.S
-- Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. (July 2005);
CASA – The National Center on Addiction and Substance Abuse at Columbia University
Pain Management vs Opioid Addiction
You are now
entering . . .
. . . the
No-Win Zone!
Strategies to Address At-Risk Substance
Use and SUDs in Primary Care Setting
• Screening
• Brief Intervention
• Motivational Interviewing
• Referral
• Care Management
• Medication-Assisted Recovery
• Recovery-Oriented Systems of Care
Primary Care without
A Team Approach
Preventive
Services =
7.4 hrs / day
Chronic Dz
(well-controlled
panel) = 3.5
hrs/day
Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is
there time for management of patients with chronic diseases in primary care?
Ann Fam Med. 2005 May-Jun;3(3):209-14.
Chronic Dz
(poorlycontrolled
panel) = 10.6
hrs/day
Screening in Primary Care
CAGE
CAGE-AID
AUDIT-C
ASSIST
DAST
CRAFFT
PHQ-9
Hamilton-D
GAD-7
Beck Anxiety
Inventory
HITS (domestic
violence)
Epworth
Sleepiness Scale
Screening & Brief Intervention
in Primary Care
• AHRQ Evidence Review does recommend
alcohol screening & brief intervention
• After primary care brief, multi-contact interventions, patients reduced
average drinks per week by 13%–34% and increased the proportion
drinking at moderate or safe levels by 10%–19% compared with controls.
BUT, . . . the USPSTF concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening adolescents, adults, and
pregnant women for illicit drug use.
Whitlock EP, Green CA, Polen MR, Berg A, Klein J, Siu A, Orleans CT. Behavioral
Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use.
Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 Mar.
Brief Intervention -- FRAMES
• Feedback
– “I am specifically concerned about your substance use because…”
• Responsibility
– “What you do with your substance use is up to you.”
• Advice
– “In my medical opinion, you can best minimize your health risks by…”
• Menu
– “What do you think would work for you
if you decided to make a change?”
• Empathy
– “It is not easy to change.”
• Self-Efficacy
– “I can see that you are a strong person.”
Primary Care Needs the Partnership
with Behavioral Health !!!
“ Seven Characteristics of the
Patient-Centered Medical Home”
• Personal Relationship with Physician
• Team Approach
• Comprehensive Whole Person Approach
• Coordination and Integration of Care
• Quality and Safety as Hallmarks
• Expanded Access to Care
• Added Value Recognized
http://pcpcc.net/files/pcmhpurchasersummary.pdf
Does the Mental Health Sector
Need More Primary Care?
• 25-year survival deficit -Schizophrenia Excess Mortality
• 28% due to  suicide
• 12% due to  accidents
• 60% due to  everything else
• S Brown. Excess mortality of schizophrenia. A meta-analysis The
British Journal of Psychiatry 171: 502-508 (1997)
Uncoordinated Care –
When We Just Don’t Talk
• Jane Doe -- 37 y/o F w/ Bipolar Disorder
– Lithium (Lithobid®)
– Aripiprazole (Abilify®)
– Divalproex Sodium (Depakote®)
• Jane Doe – 37 y/o fertile female smoker with
HTN & two-weeks of productive cough
–
–
–
–
Azithromycin (Zithromax Z-Pack®)
ACE + HCTZ (Vaseretic®)
OCP’s (Yaz®)
Bupropion (Zyban® or Wellbutrin®)
Three-Way Integration – Mental Health,
Substance Abuse, & Primary Care
• 40 percent of those with an alcohol use disorder
also had an independent mood disorder and 60
percent of those with a drug use disorder had an
independent mood disorder (Grant, Stinson,
Dawson, Chou, Dufour, Compton, et al., 2004).
• Integrated treatment for both problems is the
standard of care for clients with substance abuse
and depressive symptoms or any co-occurring
mental disorder.
– TIP 48:Managing Depressive Symptoms in Substance Abuse Clients during Early
Recovery. SAMHSA/CSAT Treatment Improvement Protocol Series; 2008.
Clinical Scenarios
PRIMARY CARE
• Diabetic patient
with depression
• Insomnia patient
using increasing
doses of Xanax®
• CHF patient who
self-treats PTSD
with alcohol
• Chronic back pain
patient develops
opioid addiction
SUBSTANCE ABUSE
TREATMENT
• Alcohol patient in
detox with HTN
and chest pain
• Sickle cell patient
MENTAL HEALTH
with heroin
• Schizophrenia patient
addiction has
gains 100 lbs and
painful crisis
develops diabetes
• Obese, smoking
• Bipolar patient on
diabetic worried
lithium has
that he is addicted
hypothyroidism and
to the Darvocet®
high blood pressure
he takes for
neuropathic pain.
Status Quo = Fragmentation
• Silos:
–
–
–
–
–
–
–
–
Public health
Medical care
Behavioral Health
Mental health
Substance Abuse
Faith Communities
Employers
Legislators
policymakers
– Payors / Funders
How’s that
workin’
for ya???
Choices Real People Make
Accept
Referral to
Behavioral
Practice
Deal with
Alcohol &
Mental Health
Problems in
Primary Care
Setting Only
X



X

Get Optimal
Treatment
X

X
Coordinate
Medical &
Behavioral Rx
X
?

Agree to
54 yr old
Accept
Depressed,
Referral
Alcoholic,
and then
Diabetic
Don’t Go
Man
Get Help
Avoid Stigma
Roles for Primary Care in Specialty
Substance Abuse Treatment Setting
• Screening for Medical Co-Morbidities
• Treatment of Co-Morbid Medical Conditions
– Asthma/COPD, Blood Pressure, Diabetes, etc.
• Coordination / Care Management
with Medical Specialty Providers
– Infectious Disease
(HIV-AIDS, Hepatitis C, Tuberculosis)
– Gastroenterology / Hepatology
(Liver Failure, Cirrhosis, Hepatitis)
• Coordination / Care Management
with Mental Health Specialty Providers
Can Primary Care Improve SA
Treatment Effectiveness?
• Survey of 2878 patients in 52 treatment programs
– At 12-month follow-up, patients who attended programs with on-site
primary medical care (compared with patients who attended
programs with no primary medical care) experienced :
• Significantly less addiction severity
• No significant difference in medical severity .
• Referral to off-site primary care exerted no
detectable effects on either addiction severity or
medical severity.
Friedmann PD, Zhang Z, Hendrickson J, Stein MD, Gerstein DR. Effect of primary
medical care on addiction and medical severity in substance abuse treatment
programs. J Gen Intern Med. 2003 Jan;18(1):1-8.
Primary Care Impact on SA Treatment
• DESIGN: Randomized controlled trial conducted between April
1997 and December 1998.
• SETTING AND PATIENTS: Adult men and women (n = 592)
who were admitted to a large health maintenance organization
chemical dependency program in Sacramento, Calif.
• INTERVENTIONS: Patients were randomly assigned to receive
treatment through an integrated model, in which primary health
care was included within the addiction treatment program (n =
285), or an independent treatment-as-usual model, in which
primary care and substance abuse treatment were provided
separately (n = 307). Both programs were group based and
lasted 8 weeks, with 10 months of aftercare available.
Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care
with addiction treatment: a randomized controlled trial. JAMA. 2001 Oct
10;286(14):1715-23.
Impact on Outcomes
• RESULTS:
– Both groups showed improvement on all drug
and alcohol measures.
– Overall, there were no differences in total abstinence
rates between the integrated care and independent care
groups (68% vs 63%, P =.18).
– Patients with SA-related medical conditions
(SAMCs) were more likely to be abstinent in the
integrated care group than the independent care
group (69% vs 55%, P =.006; odds ratio [OR], 1.90)
– This was true for both those with medical (OR, 3.38)
and psychiatric (OR, 2.10) SAMCs.
FourQuadrant
Model
(~2004)
FourQuadrant
Clinical
Integration
Model
(~2010)
--National Council,
B. Mauer
Continuum of Integration
Separate
Referral
Separate
Coordinated
Co-Located
Collaborative
Integrated
Common
INTEGRATING
APPROPRIATE
SERVICES FOR
SUBSTANCE USE
CONDITIONS IN
HEALTH CARE
SETTINGS
An Issue Brief on
Lessons Learned
and Challenges
Ahead
2010
http://www.niatx.net/pdf
/ARC/Integrating_A
ppropriateServices_TRI.pdf
Coordinated Care
• Tracking & Confirmation
of Referrals & Follow-up
• Sharing of Medical Records
• Sharing of Prescribing
Changes & Medication Lists
• Inter-Operable
Electronic Health Records
• Mutual Participation in Effective
Health Information Exchange
Collaborative Care
•
•
•
•
•
•
All of the Above plus . . .
Team-Based Case Conferences
Frequent Interaction on Therapeutic Strategy
Patient-Centered, Shared Decision-Making
Shared Care Management
Joint Decision-Making on
Medication Changes
• Frequent, secure communication by
phone, e-mail, & videoconferencing
Continuum of Integration
Separate
Referral
Separate
Coordinated
Co-Located
Collaborative
Integrated
Common
National Collaborations
•
http://www.niatx.net/Content/ContentPage.aspx?PNID=4&NID=245
Baby Steps
• NIATx /
NACHC
Collaborative
NIATx Resource Links
http://www.niatx.net/Content/ContentPage.aspx?NID=24
Resources
Review of Evidence (& Best-Practices)
“Best-Practices” Integrating
Behavioral Health & Primary Care
• Cherokee Health System
Cherokee Health Systems
• “CHS follows a generalist
approach even for behavioral
health issues. The PCP has to deal
with everyone that walks in the
door, and the BHC should be able
to as well.”
Integration of Mental Health, Substance Abuse, & Primary Care; AHRQ, 2008.
http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf
Haight Ashbury Integrated Care
Over 200 paid staff and 500 volunteers provide services at over 15 facilities to over
19,000 clients, with the vast majority served by the substance abuse programs.
“Haight Ashbury’s vision of integrated care follows an “any door is the right door” philosophy.
The integrated care clinic on Mission Street provides primary care, substance abuse
treatment services, mental health services, and intensive case management (which can
include referrals to other organizations for assistance with housing, food, clothing, and
employment) within a unified team service delivery model.”
-- AHRQ Evidence Report
Haight Ashbury
• Lessons Learned:
– Patients are socially and clinically complex – HIV, homelessness, and
addiction commonly co-occur. A team approach is essential.
– Weekly team meetings include front desk staff since they are the first
point of contact and thereby necessarily involved in the triage process.
– Clients meet initially with a case manager and “are literally walked from
office to office” by the case manager as they move through the system.
– Warm hand-offs have been instrumental in patient adherence with
treatment plans.
• Obstacles to Overcome:
– Each of the three services, primary care, mental health, and substance
abuse treatment, have their own traditional charting cultures and legal
requirements. Combining the three into one comprehensive charting
system has involved legal counsel along with cultural and process
considerations of the three services.
Behavioral Expert Working in Primary Care
Personal Perspectives (cont.)
Integration Allows us to
Triangulate Interventions
Family &
Community
Patient
Systems
Change
Primary
Care
Team
Psychologists &
Behavioral Health
The Power of Integration
Faith
Communities
Mental
Health
Substance
Abuse
Treatment
Primary
Care
What would
happen if all
the health
professionals
came
together and
created a
therapeutic
community of
healers for
whole
people?
Community-Level
Community-LevelTeamwork
Teamwork– –
A
A Therapeutic
Real SystemCommunity
of Care
Faith
Communities
Mental Health
Substance Abuse
Treatment
Behavioral Health
Family
Inpatient
Programs
Primary Care
Recovery-Oriented Systems of Care
• No one can
whistle a
symphony.
It takes a
whole
orchestra to
play it.
-- H.E. Luccock
Embracing One Another,
Soaring Together
“We are all as angels,
with only one wing;
We can only fly
when we embrace each other.
-- Luciano de Crescenzo