Transcript 02 Mon 900 AM COD Initiatives at SAMHSA, Clark

COD Initiatives at SAMHSA
Presented by:
H. Westley Clark, M.D.
Linking Healthcare and Substance Use
Disorders Services: Implications for
the Addiction Treatment Field
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse Mental Health Services Administration
U.S. Department of Health & Human Services
6th Annual COSIG Grantee Meeting
Bethesda, MD  June 28, 2010
Past Month Alcohol Use - 2008
Any Use:
52% (129 million)
Binge Use:
23% (58 million)
Heavy Use:
7%
(17 million)
(Current, Binge, and Heavy Use estimates are similar to
those in 2007)
Source: NSDUH 2008
4
4
Past Month Use of Selected Illicit Drugs among
Persons Aged 12 or Older: 2002-2008
Percent Using in Past Month
Illicit Drugs
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Marijuana
8.3%
8.2%
6.2%
6.2%
2.7%
2.7%
0.9%
0.5%
2002
Source: NSDUH, 2008
1.0%
0.4%
2003
Psychotherapeutics
Cocaine
Hallucinogens
7.9%
8.1%
8.3%
8.0%
6.1%
6.0%
6.0%
5.8%
2.5%
2.7%
2.9%
2.8%
0.8%
1.0%
0.4%
2004
8.0%
6.1%
2.5%
0.4%
2005
1.0%
0.4%
2006
0.8%
0.4%
2007
0.7%
0.4%
2008
5
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
Did Not Feel
They Needed
Treatment
(19.8 Million)
95.2%
Felt They Needed
Treatment and Did Not
Make an Effort
(766,000)
3.7%
1.1%
Felt They Needed
Treatment and Did
Make an Effort
(233,000)
20.8 Million Needing But Not Receiving
Treatment for Illicit Drug or Alcohol Use
Source: NSDUH 2008
6
Substance Dependence or Abuse among Adults Aged 18 or
Older, by Serious Mental Illness in the Past Year: 2008
2.5 Million Adults have Co-Occurring SMI and Substance Use Disorder
% Dependent on or Abusing Substance
Had SMI in the Past Year
Did Not Have SMI in the Past Year
30%
25.2%
25%
19.4%
20%
11.9%
15%
8.3%
10%
7.1%
2.2%
5%
0%
Drug or Alcohol
Dependence or Abuse
Source: SAMHSA NSDUH 2008
Drug Dependence or
Abuse
Alcohol Dependence or
Abuse
7
Treatment Admissions: Psychiatric & Substance
Abuse Problems
Admissions to treatment reporting psychiatric problems in
addition to substance abuse problems more than doubled
between 1992 and 2007.
30
Percent of Admissions
25
27.2%
20
15
10
11%
5
0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: SAMHSA Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to 2007
8
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
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.
Mental Health
Care Only
45.2%
11.4%
Both Mental Health Care &
Treatment for Substance
Use Problems
3.7%
No Treatment
39.5%
Note: The percentages add to less than 100% due to rounding.
Source: NSDUH 2008
Treatment for Substance
use Problems Only
9
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=23
049
10
Outpatient Mental Health Services - 2008
17 Million adults (18+ years) seen for outpatient MH treatment/
counseling:
1,345
Outpatient Medical Clinic
2,992
Doctor's Office - not clinic
4.2 million seen by
Primary Care
248
Some other Place
98
School or University Clinic/Center
234
Partial Day Hospital/Day Treatment Program
Office of Private Therapist, Psychologist, Psychiatrist,
Social Worker or Counselor - Not part of clinic
8,744
3,352
Outpatient MH Clinic/Center
0
Source: 2008 NSDUH
1000 2000 3000 4000 5000 6000 7000 8000 9000 1000
0
Numbers in Thousands
11
Substance Abuse Treatment in 2008
7.5 Million adults (12+ years) seen for substance abuse treatment:
Prison/Jail
343
Self-Help Group
2,187
MH Center - outpatient
1,054
Rehab Facility-outpatient
1,455
Rehab Facility - Inpatient
743
Emergency Room
374
Private Doctor's Office
672
Hospital-Inpatient
675
0
Source: 2008 NSDUH
1.7 million seen by
Primary Care
500
1000
1500
Numbers in Thousands
2000
2500
12
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-centerdata/NationalData
13
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-centerdata/NationalData
14
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
15
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
16
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
17
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 HMO
reduced 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
18
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
19
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 multisystem 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
20
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.
21
Recovery-oriented
Systems of Care
(ROSC) Approach
Outcomes
Evidence-Based
Practice
Employment/
Education
Systems of Care
Business Community
Addictions
Cost
Effectiveness
Child Welfare
Tribes/Tribal
Organizations
Services &
Peer Support
Supports
Mental Health
Alcohol/Drug
Housing/
Transportation
Reduced
Criminal
Involvement
Mental Health
Primary Care
Child Care
Housing
Wellness
Financial
Educational
Perception
Of Care
Education
Community
Individual
Family
Recovery
Mutual Aid
Vocational
Community
Coalitions
DoD &
Veterans Affairs
Spiritual
Civic Organizations
Legal
Employment
Indian Health
Service
Stability in
Housing
Case Mgt
Criminal Justice
Retention
Health Care
Private Health
Care
Bureau of Indian Affairs
Human Services
Abstinence
Organized Recovery
Community
Access/Capacity
Social Connectedness
Health
Ongoing Systems Improvement
22
Federal Efforts to Integrate Primary and
Behavioral Health Care
15
Affordable Care Act
Interagency 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
24
Other Affordable Care Act BH/PC Integration Efforts
Program
Integration Aspect
Centers of Excellence for
Depression
Medicaid outreach to
vulnerable and
underserved groups
Medicaid Emergency
Psychiatric
Demonstration
Amended Medicaid
rehabilitation option
prevention services
Comprehensive basic, clinical services in
interdisciplinary research and practice
Includes “individuals with mental health
or substance-related disorders”
Pay IMDs for stabilization services and
provides waiver authority for others
(report and recommendation)
Must include SBIRT alcohol, depression
screening with no co-pays
25
Other Affordable Care Act BH/PC Integration Efforts
(cont’d.)
Program
Medicare State/tribal
community
interdisciplinary health
teams to assist primary
care providers
Maternal, infant & early
childhood home visiting
program
School-based health
centers
Integration Aspect
Must include “behavioral and mental
health providers (including substance use
disorder prevention and treatment
providers.)”
States must assess capacity for substance
abuse treatment and target families with
SA history.
Should provide MH/SA assessment,
counseling, treatment, referral
26
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 communitybased prevention/
wellness programs
Surgeon General’s public
health sciences track
Prevention Trust Fund
Must include mental health
100 of 850 annual slots reserved for
behavioral health
Includes SAMHSA funding
27
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
28
Collaboration/Integration
within SAMHSA
21
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.
30
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

31
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.)
32
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.
33
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
34
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.
35
Thank you.
36