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Access to Best Practices for Co-Occurring Disorders: Research and

Practice Partnerships

Constance Weisner, DrPH, MSWStacy Sterling, MSW, MPHSujaya Parthasarathy, PhD

Jennifer Mertens, MACharlie Moore, MD, MBA

University of California at San Francisco and University of California at San Francisco and

Division of Research, Northern California Kaiser Division of Research, Northern California Kaiser PermanentePermanente

Conference on “Complexities of Co-Occurring Conditions: Harnessing Services Research to Improve Care for Mental Health, Substance Use, and

Medical/Physical Disorders,” June 24, 2004, Washington, DC

From studies funded by the National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, Center for Substance Abuse Treatment, and Robert Wood Johnson Foundation

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Broadening the research focus in improving access and utilization of

best practices

► Asking new research questions► develop questions in collaboration with

clinicians

► Studying the implementation process► the variety of stakeholders that influence

adoption of, and access to, best practices

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Sources of Research Questions

Research literaturePolicy issuesClinical concerns

Program change implemented

Health Plan CliniciansProgram (CD & MH)Primary CareConsumersPurchasers/employersAccreditation bodiesHealth policy

Generates research intervention study

Intervention evaluated

Stakeholder concerns shape implementation

Sterling & Weisner, (2002) “Closing the Loop: A Model to Address the Transfer of Research to Practice”

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OVERVIEW

► Importance of access

Screening, assessment, and integrated services

► Conceptual model and application

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Research Supporting Integrated Services

► Assessment: Many individuals entering CD and MH treatment have co-occurring problems. (Rounds-Bryant et al., Grella et al. 2001; Rao, 2000; Greenbaum et al., 1996)

► Screening: These co-occurring problems could be identified earlier before they are severe. (Samet et al., 2001)

► Integrating services: Providing services that address those problems is related to outcomes. (McLellan et al., 1998, 1993; Willenbring & Olson, 1999)

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• Oakland

• Sacramento

Setting

► Non-profit, group practice prepaid HMO

► 3.2 million members (35% of commercially insured population)

► “Carved-in” psychiatry and chemical dependency services

• Vallejo•Vacaville

Kaiser Permanente Medical Care Program

of Northern California

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Adolescent Chemical Dependency Treatment Sample

► 419 adolescents (143 girls, 276 boys) and parents

► 4 facilities

► Age ranged from 13 to 18 years

► Ethnicity: 9% Native American/Asian

16% African-American

20% Hispanic

49% White

► Treatment intake, 6-month, and 1-, 3-, & 5 years

► Response rate: 6-month 91.4%; 1-year 92.1%

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Psychiatric Conditions of Adolescents

Entering CD Treatment (in %)

Intakes

(419)

MatchedControls(2007) p-value

Depression 24.0 0.3 <.0001

Conduct Disorder with ODD

17.0 0.2 <.0001

Conduct Disorder 11.0 0.2 <.0001

ADHD 10.0 0.7 <.0001

Anxiety 6.4 0.3 <.0001

Eating Disorders 1.2 0.1 <.01

1+ Psychiatric Conditions

37.0 2.0 <.0001

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ARE PSYCHIATRIC SERVICES

RELATED TO OUTCOME?

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Receiving mental health services while in chemical dependency services was related to better alcohol and drug outcomes at 6 months.

Role of Dual Treatment: Logistic Regression

Predicting Abstinence at 6 Months

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An Adult Example: 5-Year Abstinence when Psychiatric Services Provided

For those who still had psychiatric problems at 12 month follow-up:

2 or more hours/year over the 5 years

O.R. = 5.5*

*P<.05

Controlling for age, gender, type of dependence, abstinence goal, readmission, # of 12-step meetings, recovery-oriented social support, treatment intensity

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Are Medical Services Related to Outcome?

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An Adult Example: CD Patients and Matched Health Plan Members:

Medical Conditions*

CD Patients (N=747)

Matched Members(N=3,690)

Injury and Overdoses 25.6% 12.1%Lower Back Pain 11.2% 5.8%

Headache 9.2% 3.8%

Hypertension 7.2% 3.4%

Asthma 6.8% 2.6%

Acid-related Disorders 5.5% 2.1%

Arthritis 3.9% 1.3%*all p<.001

Mertens, Lu, Parthasarathy, Moore, Weisner. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: Comparison to matched controls. Archives of Internal Medicine.

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Randomized Adult SAMC Group: Logistic Regression Predicting

Abstinence at 6 Months:

Independent Variable O.R. 95% C.I.

Integrated Care(vs. Usual Care)

1.90 (1.22, 2.96)

Controlling for baseline alcohol and drug severity

Weisner C, Mertens J, Parthsarathy S, Moore C, Lu Y. (2001). Integrating primary medical care with addiction treatment: A randomized controlled trial. JAMA 286(14):1715-1723.

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Medical Costs 12 Months after Treatment for Randomized CD

Patients with Psychiatric & Medical Conditions

$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

Med SAMC Subgrp Psych SAMC Subgrp

Integrated Care

Independent Care

*p<.05; **p<.01

Parthasarathy S, Mertens J, Moore C, Weisner C. (2003). The utilization and cost impact of integrating substance abuse treatment and primary care. Medical Care.

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Sources of Research Questions

Research literaturePolicy issuesClinical concerns

Program change implemented

Health Plan CliniciansProgram (CD & MH)Primary CareConsumersPurchasers/employersAccreditation bodiesHealth policy

Generates research intervention study

Intervention evaluated

Stakeholder concerns shape implementation

Sterling & Weisner, (2002)“Closing the Loop: A Model to Address the Transfer of Research to Practice”

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Research Practice Model

CD & MH Directors’/Chiefs’ Groups:

► Business case: outcomes & cost► Parity legislation► Identifying next generation of research questions

► Survey of pediatricians

Clinicians► Development of assessment for MH and CD clinics► PC & ER physicians► Results to their professional organizations► Identifying next generation of research questions

► Assessment in MH and CD clinics► Readiness to change AOD use in MH clinics

Dual Diagnosis Best Practice Committee► Concept & development of liaison model► Core competencies, care guidelines► Training► Identifying next generation of research questions

► Dual diagnosis continuity of care, utilization & cost

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Conclusions

► A wide variety of stakeholders influence access

► Demonstrating both outcome and cost is important in improving access

► Integrating research and practice can lead to better understanding how to study and address access

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COLLABORATORS

Felicia Chi, MPH Steve Allen, PhD David Pating, MD Bill Brostoff, MD Christine Waters, MD Agatha Hinman, BA Georgina Berrios, BA Tom Ray, M.A. Wendy Lu, MPH Cynthia Campbell, PhD Derek Satre, PhD Carolynn Kohn, PhD Melanie Jackson, BA Cynthia Perry-Baker, BA Lynda Tish, BA Barbara Picchoto, BA

Kaiser Permanente Clinics

OaklandSacramento

San FranciscoStockton Vacaville Vallejo