Working in the Health Care System The Culture of Integrated Services

1. Working in the Health Care SystemThe Culture of Integrated Services Thomas E. Freese, PhD tfreese@mednet.ucla.edu UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center

2. What Will We Cover? • Primary care culture and effective communication • Role definitions for Mental Health staff in primary care settings • Medical issues that commonly co-occur with mental health and substance use • Barriers to service access • A case example.

3. International Comparison of Spending on Health, 1980–2010 Average spending on healthper capita ($US PPP) Total health expenditures aspercent of GDP Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012.

4. Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 65 Percent of Expenses 1% 5% 22% $90,061 10% 50% $40,682 65% 50% $26,767 97% $7,978 Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 Annual mean expenditure Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

5. Consequences of MH Disorders • In the USA and Canada, mental health disorders account for 25% of all years of life lost to disability and premature mortality1 • One in four American adults experience a mental health disorder in a given year, and 1 in 17 have a seriously debilitating mental illness2 • Among those who die by suicide, more than 90% • have a diagnosable disorder4. • In 2008, suicide was the tenth leading cause of death in the USA6. World Health Organization. (2004). The world health report 2004: changing history. Annex Table 3. A126-A127. Geneva: WHO. Kessler RC, et al. (2005). Archives of General Psychiatry, 62: 617-627. US Department of Health and Human Services. (1999). Mental health: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, 1999. Minino AM, et al. (2011). Final Data for 2008. National Vital Statistics Reports 2011; 59(10): 01-127. Available: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf.

6. Shifting to a Whole Health Perspective • Mental health and substance use services are integral to health care services. The goals of DMH initiatives are: • Ensure positive experiences of care • Enhance customer services • Ensure care is effective • Develop bi-directional care/behavioral health homes • Implement data outcomes system to enable monitoring of client progress • Control/reduce costs • Develop strategies to extend care • Develop strategies to reduce readmission and preventable hospitalizations

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9. What is “Primary Care Integration”? • Primary care integration is the collaboration between SUD service providers and primary care providers (e.g., FQHC’s, CHC’s) • Collaboration can take many forms along a continuum* MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt Coordinated Co-located Integrated *Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.

10. Minimal Coordination The Primary Care System SUD Care System MH Care System • BH and PC providers • work in separate facilities, • have separate systems, and • communicate sporadically.

11. Basic AT A DISTANCE The Primary Care System SUD Care System • BH And PC providers • Engage in regular communication about shared patients leading to improved coordination MH Care System

12. Basic On Site (co-location of services) The Primary Care System Referral SUD Care System • BHand PC providers • Still have separate systems • Some services are co-located (e.g., screening, groups, etc). SBI Counseling Counseling Referral MH Care System MH Services

13. Basic On Site (reverse co-location) The Primary Care System Referral SUD Care System • BH and PC providers • Still have separate systems • Primary care services are integrated into BH Settings Medical Services Medical Services Referral MH Care System

14. Integrated Integrated Care System The Primary Care System SUD Care System • PC providers • Develop and provide their won services MAT MH Care System

15. Integrated Integrated Care System The Primary Care System SUD Care System • BH and PC providers • share the same facility • have systems in common (e.g., financing, documentation • regular face-to-face communication MH Care System

16. Is Integration Inevitable? We did some research …

17. Many California Counties Are Involved in Integration Initiatives n=44 counties Percent of Counties Involved in Integration Initiatives

18. Counties are at all Stages of Integration

19. Counties are Involved in a Variety of Integration Models • Coordinated – Increased referrals to and coordination with primary care • Reverse Co-Located/Partially Integrated– Primary care in SUD setting • Co-Located/Partially Integrated – SUD specialist is placed in primary care setting or hospital • Integrated SBIRT – Medical professional conducts SBIRT or MAT in primary care setting

20. The Medical System • Managed Care • Any system that manages healthcare delivery with the aim of controlling costs. • Typically a primary care physician acts as gatekeeper for other health services such as specialty medical care, surgery, or physical therapy. • www.medicinenet.com

21. Managed and Fee-for-Service Care http://extension.missouri.edu/hes/infosheets/

22. The Medical System Primary Care • The aims of primary care are to provide broad spectrum of care • both preventive and curative; • over a period of time; and • to coordinate all of the care the patient receives. • All family physicians and most pediatricians and internists are in primary care. • www.medicinenet.com

23. The Medical System Primary Care • Practitioner must possess a wide breadth of knowledge in many areas. • Patients consult the same primary care doctor for routine check-ups, and initial consultation about a new complaint. • Common chronic illnesses, often treated in primary care, include: • Hypertension -- Diabetes • Asthma and COPD -- Depression and anxiety • Arthritis and other pain

24. Strategies for successful communication • It is important to understand the system with which you are working • Learn about the medical conditions that bring people to primary care • Expand your vocabulary to facilitate communication • Stay within your scope of practice in your interactions • Make yourself visible and useful zzzz

25. The Medical System Primary Care • The aims of primary care are to provide broad spectrum of care • both preventive and curative; • over a period of time; and • to coordinate all of the care the patient receives. • All family physicians and most pediatricians and internists are in primary care. • www.medicinenet.com

26. The Medical System Primary Care • Practitioner must possess a wide breadth of knowledge in many areas. • Patients consult the same primary care doctor for routine check-ups, and initial consultation about a new complaint. • Common chronic illnesses, often treated in primary care, include: • Hypertension -- Diabetes • Asthma and COPD -- Depression and anxiety • Arthritis and other pain

27. Service Definitions • The person receiving services is called… • The building(s)/place(s) where the person receives services is called… • The room where the person receives services is called… • The person who has the ultimate responsibility for the care of the person is called… • The person who is responsible for care coordination is called…

28. Role Delineation Who does what in an integrated care system?

29. Discussion—Roles In an integrated care system, what is the best role of each of the following disciplines. What should they take lead on? How should they be involved in collaboration? • Medical Provider • Mental Health Provider • Substance Use Disorder Provider • Behavioral Health Specialist • Peer Specialist • Family

30. Provider/practice barriers • Differing practice styles • Differing practice cultures and language • Difficulty in matching provider skills with patient needs • Heavy reliance on physician services • Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services 30

31. Provider/practice barriers • Lack of recognition of provider limitations • Lack of MH knowledge in PC providers and lack of health knowledge in BH providers • Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context • Differing confidentiality and information sharing procedures • Differing coding and billing systems • Provider resistance

32. Medical issues that commonly co-occur with mental health and substance use

33. Diabetes

34. Type 1 and Type 2 Diabetes • Type 1 diabetes is usually diagnosed in children and young adults. The the body does not produce insulin. Only 5% of people with diabetes have this form of the disease. • Type 2 diabetes, the most common form of diabetes, either the body does not produce enough insulin or the cells ignore the insulin. Insulin takes the sugar from the blood into the cells. If insulin is not working, glucose builds up in the blood instead of going into cells, it can lead to diabetes complications. Type 2 diabetes is more common in African Americans, Latinos, Native Americans, Asian Americans, Native Hawaiians and other Pacific Islanders, as well as the aged population.

35. Type 2 Diabetes Overview Basic Overview: • Metabolic disease. • Hyperglycemia (too much sugar) due to insulin resistance and defects in insulin secretion. • Diabetes can lead to: • blindness • heart & blood vessel disease • stroke • kidney failure • amputations • nerve damage. http://safediabetes.blogspot.com/2010/12/how-to-reduce-impact-type-2-diabete.html

36. Sign & Symptoms • Often no symptoms at all. • Most common symptoms include: • Blurred vision • Erectile dysfunction • Fatigue • Frequent or slow-healing infections • Increased appetite • Increased thirst • Increased urination http://www.thetype2diabetesdiet.com/wp-content/uploads/2009/03/symptoms-for-type-2-diabetes.gif

37. Percent of Individuals with Diabetes Gender* Age* Ethnicity** *American Diabetes Association, 2011. **US DHHS Office of Minority Health, 2010

38. Importance of Hemoglobin A1c Test (HbA1c) • The hemoglobin A1c test is used to determine how diabetes is being controlled. • HbA1c provides an average of your blood sugar control over a six to 12 week period. • When blood sugar is too high, sugar builds up in your blood and combines with your hemoglobin, becoming "glycated." • For people without diabetes, the normal range for the HbA1c test is 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than 7%. • Retest should occur every three months to determine level of control.

39. Why is it important to know the Hemoglobin A1c for: • The Medical Provider • The Substance Use Disorders Provider • The Mental Health Provider • Peers and Family

40. Type 2 Diabetes Relationship with SUD • Heavy alcohol consumption can increase risk factors including: body-mass index, low HDL (“good”) cholesterol and cigarette smoking (Tsumura, 1999). • A history of substance use is associated with earlier age of onset of diabetes (Johnson, 2001). • SUD is associated with increased mortality in diabetics (Jackson, 2007). Significance of Behavioral Health • Diabetes patients also have increased depression. Both diet control and depression respond to behavioral activation strategies • In 2006, it was the seventh leading cause of death, and cost the US $174 billion in medical costs, loss of productivity, disability costs

41. Type 2 Diabetes & Your Clients • Medical services available on-site better link clients in SUD treatment to medical services compared to those with outside referrals (Friedmann, 1999). • Social support for abstinence can increase linkage to medical services. (Saitz, 2004). • Encourage activities that improve diabetes: • Betterdiet. • Reduce simple carbohydrate intake (i.e. potatoes, white bread, corn, soda, candy, sweets). • More exercise. • Maintainregular appointments with doctor overseeing diabetes treatment.

42. Hypertension Common Medical Issues Associated with Mental Health and Substance Use Disorders

43. Percent of Individuals with Hypertension (Age 20+) Gender* Age* Ethnicity* *Centers for Disease Control and Prevention, 2012.

44. Hypertension: Clinical Description • Blood pressure (BP) is the force against the walls of one’s arteries while blood is pumping. • Hypertension is when BP is too high. • Example BP: 120/80 mmHg (“120 over 80”) • Systolic (top number): pressure while heart contracts. • Normal is <120. High is >180. • Diastolic (bottom number) pressure while heart relaxes & enlarges. • Normal is <80. High is >80.

45. Consequences of Hypertension (HTN) • Increased risk of: • Stroke • Blood vessel damage (arteriosclerosis) • Heart attack • Tearing of heart’s inner wall (aortic dissection) • Vision loss • Brian damage • (NIH, 2010)

46. Blood Pressure Link to SUD • Three or more drinks per day increases BP & risk of hypertension in both women and men (Sesso, 2008). • Decreasing alcohol consumption associated with dose-dependent reduction in BP (Xin, 2001). • Stimulants like cocaine or amphetamines can cause HTN and other acute and chronic cardiovascular diseases. (McMahon, 2010). • HTN risk associated with quantity of cigarettes smoked daily and the duration of smoking (Orth, 2004). • Former smokers have higher rates of hypertension than those who never smoked (Orth, 2004).

47. Hypertension & Your Clients • HTNcan be well controlled in primary care for most patients (Williams 2004). • Some many need help finding transportation. • Some may need help finding free or low-cost clinics. • Askabout alcohol consumption. Encourage limiting to 2 or less drinks per day. • If client smokes, give advice and support toquitsmoking(NICE, 2006). • Encourageweightlossand salt reduction. • Losing 10kg (22 lbs) can reduce systolic BP by 10 points (Cappuccio, 2007).

48. Pain Common Medical Issues Associated with Mental Health and Substance Use Disorders

49. Pain • In 2011, at least 100 million adult Americans have common chronic pain conditions (excl. acute pain and children)*. • Pain costs society at least$560-$635 billion annually (an amount equal to about $2,000 for everyone living in the U.S.)*. • Women are more likely to experience pain (in the form of migraines, neck pain, lower back pain, or face or jaw pain) than men**. • Adults age45-64 years were most likely to report pain lasting more than 24 hrs. (30%), followed by young adults age 20-44 (25%0, and adults age 65 and over (21%)***. *IOM, 2011; CDC, 2009; NCHS, 2006.

50. Incidence of Pain, as compared to other Chronic Conditions http://www.rxreform.org/wp-content/uploads/2011/06/Toblin-2011-Kansas-Pain-corrected-proof.pdf