major system change forces that are reshaping substance use disorder services in california richard...
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Major System Change Forces that Major System Change Forces that are Reshaping Substance Use are Reshaping Substance Use Disorder Services in CaliforniaDisorder Services in California
Richard A. Rawson, PhDRichard A. Rawson, PhD
UCLA Integrated Substance Abuse UCLA Integrated Substance Abuse ProgramsPrograms
I was seldom able to see an I was seldom able to see an opportunity until it had ceased opportunity until it had ceased
to be one.to be one.
Mark Twain Mark Twain
Major System Change Forces in Major System Change Forces in CaliforniaCalifornia
Affordable Care ActAffordable Care Act Mental Health Parity and Addiction Equity ActMental Health Parity and Addiction Equity Act California’s Bridge to Reform1115 WaiverCalifornia’s Bridge to Reform1115 Waiver Mental Health Services Act: Prop 63.Mental Health Services Act: Prop 63. AB 109: Criminal Justice RealignmentAB 109: Criminal Justice Realignment Elimination of California’s Department of Elimination of California’s Department of
Alcohol and Drug Programs (July 1, 2013)Alcohol and Drug Programs (July 1, 2013)
Affordable Care ActAffordable Care Act
The Patient Protection and Affordable Care The Patient Protection and Affordable Care Act (PPACA) Act (PPACA)
andand
The Health Care and Education The Health Care and Education Reconciliation Act of 2010Reconciliation Act of 2010
ACA 2014 ChangesACA 2014 Changes
New insurance for about 32 million more New insurance for about 32 million more adults.adults.
Medicaid (2014): To 133 % of poverty.Medicaid (2014): To 133 % of poverty. State Health Insurance Exchanges State Health Insurance Exchanges
(2014): Individual and Small Group Plans.(2014): Individual and Small Group Plans. In California, it is estimated that 1.4 million In California, it is estimated that 1.4 million
people will be newly eligible for Medi-Cal people will be newly eligible for Medi-Cal coverage. coverage.
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Wellstone-Domenici Mental Health Parity Wellstone-Domenici Mental Health Parity and Addiction Equity Act of and Addiction Equity Act of
2008(MHPAEA) and the Interim Final 2008(MHPAEA) and the Interim Final Rule (IFR)Rule (IFR)
Mental Health Parity and Addiction Equity: Mental Health Parity and Addiction Equity: Overview of the LawOverview of the Law
Effective January 1, 2010Effective January 1, 2010 Expected to affect more than 150 million people Expected to affect more than 150 million people Adds SUD to MHPAdds SUD to MHP Impacts retirement care (ERISA) plans for the first Impacts retirement care (ERISA) plans for the first
timetime Impacts Medicaid Managed Care Plans Impacts Medicaid Managed Care Plans Stronger State Laws ProtectedStronger State Laws Protected
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Overview of the Parity LawOverview of the Parity Law
Mental health and addiction treatment benefits Mental health and addiction treatment benefits must have the same financial terms, conditions, must have the same financial terms, conditions, requirements, and treatment limitations as they do requirements, and treatment limitations as they do for medical and surgical conditions for medical and surgical conditions
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Wellstone-Domenici Parity Act Wellstone-Domenici Parity Act of 2008of 2008
Does Address:Does Address: MH and SUD TxMH and SUD Tx Private health plans Private health plans
that cover 50 or more that cover 50 or more personspersons
Day and visit limits Day and visit limits care management care management factorsfactors
MBHCOs combine MBHCOs combine data with MCOs for data with MCOs for single deductible. single deductible.
Does Not Address:Does Not Address: Small group (<50) or Small group (<50) or
individual plansindividual plans MedicareMedicare The uninsured The uninsured A common definition of A common definition of
medical necessitymedical necessity Scope of servicesScope of services Quality or outcome.Quality or outcome.
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How will Health Care Reform How will Health Care Reform and Parity effect the treatment and Parity effect the treatment of substance use disorders?of substance use disorders?
Substance Use Substance Use Disorders (SUD)Disorders (SUD)
The language we use mattersThe language we use matters
Addiction
Abuse
Addict
Substance Misuse
Chemical DependenceDependence
Abuser
Drug Addict Alcoholic
What happens when benefits What happens when benefits for SUD are expanded? Hints for SUD are expanded? Hints
from…from…
Massachusetts Vermont Maine
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Background
2006-2008 - 39 States enacted laws to expand access to health insurance
Maine, Massachusetts and Vermont – the states that sought to achieve universal health coverage
Need empirical studies of HCR effects on access to, as well as quality and outcomes of, substance abuse treatment (SAT) services
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1515
Under State Health Care ReformUnder State Health Care Reform
Maine, Massachusetts and Vermont:Maine, Massachusetts and Vermont: Saw the percent of uninsured dropSaw the percent of uninsured drop
• ME - 13% in 2002 to 10.3% in 2007 ME - 13% in 2002 to 10.3% in 2007
• MA - 11.7% in 2004 to 2.6% in 2009 MA - 11.7% in 2004 to 2.6% in 2009
• VT - 9.8% in 2006 to 7.6% in 2009VT - 9.8% in 2006 to 7.6% in 2009 SUD admissions rose between 50% (Maine and SUD admissions rose between 50% (Maine and
Massachusetts) to 100% (Vermont).Massachusetts) to 100% (Vermont). Uninsured rate dropped, admissions rose, but many Uninsured rate dropped, admissions rose, but many
individuals with SUD clients still without health insuranceindividuals with SUD clients still without health insurance
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Integration of SUD/MH Services Integration of SUD/MH Services into Primary Careinto Primary Care
What is “Primary Care Integration”?What is “Primary Care Integration”? Primary care integration is the Primary care integration is the
collaboration between SUD service collaboration between SUD service providers and primary care providers providers and primary care providers (e.g., (e.g., FQHC’s, CHC’s)FQHC’s, CHC’s)
Collaboration can take many forms along Collaboration can take many forms along a continuuma continuum
MINIMAL BASIC
At a Distance
BASIC
On-Site
CLOSE
Partly Integrated
CLOSE
Fully Integrated
Coordinated Co-located Integrated
What SUD/MH/PC Integration Does What SUD/MH/PC Integration Does (Hopefully)(Hopefully)
Strengthens organizational linkages between medical Strengthens organizational linkages between medical and behavioral health careand behavioral health care
Improves access by expanding availability of services Improves access by expanding availability of services and removing barriers (administrative, transportation)and removing barriers (administrative, transportation)
Improves coordination of servicesImproves coordination of services Identifies service needs and links clients to appropriate Identifies service needs and links clients to appropriate
treatmenttreatment Blends interventions to treat whole person rather than Blends interventions to treat whole person rather than
isolated problems or disorders.isolated problems or disorders. Reduces overall healthcare costs by addressing MH and Reduces overall healthcare costs by addressing MH and
SUD problems which can cause/exacerbate costly SUD problems which can cause/exacerbate costly medical conditions. (See Weisner and others)medical conditions. (See Weisner and others)
Healthcare Settings for locating Healthcare Settings for locating individuals with SUD individuals with SUD
Primary care settings Primary care settings Emergency rooms/Emergency rooms/
Trauma centersTrauma centersPrenatal clinics/OB/Gyn officesPrenatal clinics/OB/Gyn officesMedical specialty settings for Medical specialty settings for
diabetes, liver and kidney disease, diabetes, liver and kidney disease, transplant programstransplant programs
Pediatrician officesPediatrician officesCollege health centersCollege health centersMental health settingsMental health settings
FQHCs in CaliforniaFQHCs in California
• 113 clinic corporations with 1,049 sites113 clinic corporations with 1,049 sites• 3.7 million patients served3.7 million patients served• 53% of state’s population below 100% of Federal 53% of state’s population below 100% of Federal
Poverty Level (FPL) and 26% below 200%Poverty Level (FPL) and 26% below 200%• 15% of state’s uninsured residents served15% of state’s uninsured residents served• 46% of total revenues from Medi-Cal46% of total revenues from Medi-Cal
SUD Integration in FQHCs (SIF)SUD Integration in FQHCs (SIF)
Study on SUD/PC integration in a sample of Study on SUD/PC integration in a sample of California FQHCs (survey data, administrative California FQHCs (survey data, administrative data, qualitative interviews and focus groups).data, qualitative interviews and focus groups).
18 FQHCs in 5 counties invited to complete a 18 FQHCs in 5 counties invited to complete a web based survey, 14 (78%) have completed web based survey, 14 (78%) have completed survey. survey.
Interviews and focus groups are also currently Interviews and focus groups are also currently being scheduled with these FQHCsbeing scheduled with these FQHCs
SIF ResultsSIF Results
57% reported screening all patients for SUD, 57% reported screening all patients for SUD, 21% reported screening a targeted group of 21% reported screening a targeted group of patients, and 21% did not screen for SUD. patients, and 21% did not screen for SUD.
43% of organizations do not yet have an 43% of organizations do not yet have an electronic medical record system that integrates electronic medical record system that integrates physical health and mental health and SUD.physical health and mental health and SUD.
79% reported having individual SUD counseling 79% reported having individual SUD counseling available onsite, and 29% reported having group available onsite, and 29% reported having group counseling onsite.counseling onsite.
SIF SurveySIF Survey
The most common behavioral practices include The most common behavioral practices include motivational interviewing, cognitive behavioral motivational interviewing, cognitive behavioral therapy, and social skills building (all 50%). therapy, and social skills building (all 50%).
Only 21% reported prescribing Buprenorphine Only 21% reported prescribing Buprenorphine (Subutex, Suboxone) “sometimes”, and none do (Subutex, Suboxone) “sometimes”, and none do it routinely. Lower percentages were reported it routinely. Lower percentages were reported for extended release naltrexone (Vivitrol).for extended release naltrexone (Vivitrol).
78% agreed that additional SUD-related training 78% agreed that additional SUD-related training would be helpful for their clinic’s staff.would be helpful for their clinic’s staff.
SIF SurveySIF Survey
(57%) included SUD services in their FQHC (57%) included SUD services in their FQHC prospective payment system rate, however 21% prospective payment system rate, however 21% provide SUD services without any provide SUD services without any reimbursement 36% bill to other county sources, reimbursement 36% bill to other county sources, including grants (36%).including grants (36%).
No organizations reported providing SUD No organizations reported providing SUD services on the same day as a primary care services on the same day as a primary care referral. 29% said it happened within seven referral. 29% said it happened within seven days. The other 71% reported more than seven days. The other 71% reported more than seven daysdays
SIF RecommendationsSIF Recommendations
There were three recommendations that There were three recommendations that were brought up by multiple FQHCs:were brought up by multiple FQHCs:
Expand the billable workforceExpand the billable workforce Allow same day billing of two servicesAllow same day billing of two services Stabilize fundingStabilize funding
County Medical Services County Medical Services Program Behavioral Health Pilot Program Behavioral Health Pilot
ProgramProgram
County Medical Services Program County Medical Services Program Behavioral Health Pilot ProgramBehavioral Health Pilot Program
The County Medical Services Program (CMSP) provides The County Medical Services Program (CMSP) provides health coverage for low-income, indigent adults in thirty-health coverage for low-income, indigent adults in thirty-five, primarily rural California counties.five, primarily rural California counties.
The CMSP Governing Board initiated the Behaviroal The CMSP Governing Board initiated the Behaviroal Health Pilot Program (BHPP) to test the effectiveness of Health Pilot Program (BHPP) to test the effectiveness of providing short-term mental health and SUD services providing short-term mental health and SUD services integrated with primary care in improving health, integrated with primary care in improving health, utilization, and cost outcomes.utilization, and cost outcomes.
Conducted at 14 sites over 3 years (March 2008 to Conducted at 14 sites over 3 years (March 2008 to February 2011). February 2011).
Pilot included 15 of 34 CMSP counties.Pilot included 15 of 34 CMSP counties.
CMSP Behavioral Health Pilot ProgramCMSP Behavioral Health Pilot Program
Primary care providers referred patients to a Primary care providers referred patients to a licensed behavioral health provider for an licensed behavioral health provider for an assessment when appropriateassessment when appropriate
The pilot allowed reimbursement on the same The pilot allowed reimbursement on the same day as a primary care visit to encourage day as a primary care visit to encourage continuity of care and coordination.continuity of care and coordination.
Utilization and cost-effectiveness were evaluated Utilization and cost-effectiveness were evaluated by comparing CMSP claims data for a sample of by comparing CMSP claims data for a sample of 1,649 pilot participants with an equivalent 1,649 pilot participants with an equivalent number of matched control group membersnumber of matched control group members
CMSP Behavioral Health Pilot CMSP Behavioral Health Pilot ProjectProject
Services offered per calendar year Services offered per calendar year included:included:
• Mental health: 1 behavioral assessment Mental health: 1 behavioral assessment and 10 counseling sessions (individual or and 10 counseling sessions (individual or group)group)
• SUD: 1 alcohol and drug assessment, 2 SUD: 1 alcohol and drug assessment, 2 individual counseling sessions, and 20 individual counseling sessions, and 20 SUD group counseling sessions (no SUD group counseling sessions (no medications)medications)
CMSP Behavioral Health Pilot Program CMSP Behavioral Health Pilot Program ResultsResults
The most commonly diagnosed conditions were: The most commonly diagnosed conditions were: Depression (40%) Depression (40%) Anxiety (38%)Anxiety (38%) SUD (23%)SUD (23%)
Far more pilot participants received MH counseling Far more pilot participants received MH counseling (79.6%) than SUD counseling (5.8%) (79.6%) than SUD counseling (5.8%)
Few participants received both MH and SUD counseling Few participants received both MH and SUD counseling (1.5%) (1.5%)
More participants who received SUD treatment were in More participants who received SUD treatment were in groups (5.3%) rather than individual counseling (2.5%)groups (5.3%) rather than individual counseling (2.5%)
Cost-Effectiveness and Utilization Cost-Effectiveness and Utilization FindingsFindings
The pilot resulted in a massive redistribution of The pilot resulted in a massive redistribution of total costs. total costs. PMPM costs for study participants increased by PMPM costs for study participants increased by
20.3% (from $453.29 to $545.51) 20.3% (from $453.29 to $545.51) PMPM costs increased by 17.5% for the control group PMPM costs increased by 17.5% for the control group
($523.01 to $614.47).($523.01 to $614.47). Utilization shifted from inpatient hospitalization Utilization shifted from inpatient hospitalization
towards primary care and outpatient behavioral towards primary care and outpatient behavioral health services (e.g., clinic, outpatient, and health services (e.g., clinic, outpatient, and pharmacy), as summarized below for selected pharmacy), as summarized below for selected measuresmeasures
Cost-Effectiveness and Utilization Cost-Effectiveness and Utilization FindingsFindings
Pilot Group Control Group
Outpatient Clinic Costs +57.6% +8.9%
Physician Costs +40.7% +22.3%
Number of Psychiatric Prescriptions
+69.0% +36.6%
ER Utilization -12.3% -7.8%
Psychiatric Hospitalizations
-57.9% -22.4%
CALIFORNIA BRIDGE TO CALIFORNIA BRIDGE TO REFORMREFORM
A SECTION 1115 WAIVERA SECTION 1115 WAIVER
California’s Bridge to ReformCalifornia’s Bridge to Reform1115 Waiver1115 Waiver
Federal government approved a section 1115 Federal government approved a section 1115 Medicaid Demonstration Waiver entitled Medicaid Demonstration Waiver entitled “California’s Bridge to Reform” “California’s Bridge to Reform”
Approved for the five-year period ending Approved for the five-year period ending October 31, 2015October 31, 2015
Roughly $10 billion in federal Medicaid matching Roughly $10 billion in federal Medicaid matching funds available for expanding coverage to low-funds available for expanding coverage to low-income uninsured adults income uninsured adults
California’s Bridge to ReformCalifornia’s Bridge to Reform
Allows the state to test models of integrated care Allows the state to test models of integrated care ahead of the nationwide expansion required by ahead of the nationwide expansion required by 20142014
The state will extend coverage to 500,000 low-The state will extend coverage to 500,000 low-income adults through a Low Income Health income adults through a Low Income Health Program (LIHP) Program (LIHP)
The 1115 Waiver did not require an SUD benefit The 1115 Waiver did not require an SUD benefit but it allowed it as an option (mental health but it allowed it as an option (mental health services were included as a required benefit). services were included as a required benefit).
LIHP CountiesLIHP Counties
Eight counties explicitly proposed add-on SUD Eight counties explicitly proposed add-on SUD services in their Low Income Health Program services in their Low Income Health Program (LIHP) applications to the California Department (LIHP) applications to the California Department of Healthcare Services of Healthcare Services
Counties include: Kern, Orange, Riverside, San Counties include: Kern, Orange, Riverside, San Francisco, San Mateo, Santa Clara, Santa Cruz, Francisco, San Mateo, Santa Clara, Santa Cruz, and Tulareand Tulare
San Francisco LIHP ProgramSan Francisco LIHP Program
Setting/Population: All SUD clients eligible for LIHP Setting/Population: All SUD clients eligible for LIHP (including PC patients)(including PC patients)
Screening: Conducted by PC provider using CAGE if Screening: Conducted by PC provider using CAGE if provider suspects SUDprovider suspects SUD
Brief Intervention: Conducted by Behaviorist at same Brief Intervention: Conducted by Behaviorist at same clinic visit (if available)clinic visit (if available)
Referral: Behaviorist provides up to 6 individual sessions Referral: Behaviorist provides up to 6 individual sessions and refers offsite for higher levels of careand refers offsite for higher levels of care
Santa Cruz: LIHP ProgramSanta Cruz: LIHP Program
Setting/Population: PC patients in two county-operated Setting/Population: PC patients in two county-operated clinicsclinics
Screening: Conducted by medical assistant and PC Screening: Conducted by medical assistant and PC provider using AUDIT and DASTprovider using AUDIT and DAST
Brief Intervention: Conducted by SUD counselor and PC Brief Intervention: Conducted by SUD counselor and PC provider (if SUD counselor not available)provider (if SUD counselor not available)
AOD Counselor can provide up to 12 on-site group and 2 AOD Counselor can provide up to 12 on-site group and 2 individual counseling visits, refer to off-site treatment for individual counseling visits, refer to off-site treatment for more intensive caremore intensive care
San Mateo CountySan Mateo County
Population/Setting: All primary care patients in 2 Population/Setting: All primary care patients in 2 county operated clinicscounty operated clinics
Model: SBIRT with LIHP patientsModel: SBIRT with LIHP patients Screening: Medical assistant using DAST and Screening: Medical assistant using DAST and
AuditAudit Brief intervention by SUD counselorBrief intervention by SUD counselor SUD counselor may deliver up to 10 treatment SUD counselor may deliver up to 10 treatment
sessions on site and for more serious cases, sessions on site and for more serious cases, referral to specialty care.referral to specialty care.
All data entered into EHRAll data entered into EHR
Orange County Orange County
Population/Setting: Frequent emergency Population/Setting: Frequent emergency department usersdepartment users
Model: SBIRT with high cost populationsModel: SBIRT with high cost populations Brief interventions done by behavioral Brief interventions done by behavioral
health personnelhealth personnel All treatment for SUD referred to specialty All treatment for SUD referred to specialty
carecare
Kern CountyKern County
Population/Setting: All medical inpatients Population/Setting: All medical inpatients and all emergency room patients.and all emergency room patients.
Model: SBIRT with high cost populationsModel: SBIRT with high cost populations 2 item screener implemented by nurse2 item screener implemented by nurse Brief intervention done by SUD counselorBrief intervention done by SUD counselor Referral to SUD treatment off site.Referral to SUD treatment off site. All data captured in patient EHRAll data captured in patient EHR
Riverside CountyRiverside County
Population/Setting: SBIRT with psychiatric Population/Setting: SBIRT with psychiatric hospital patientshospital patients
Model: SBIRT with high cost populationsModel: SBIRT with high cost populations Screening using a clinical interview by MH Screening using a clinical interview by MH
staff.staff. Brief intervention done by SUD counselorBrief intervention done by SUD counselor Referral for co-occurring disorder Referral for co-occurring disorder
treatment off site.treatment off site.
Santa Clara CountySanta Clara County
Population/Setting: All SUD patients in Population/Setting: All SUD patients in SUD treatment specialty care.SUD treatment specialty care.
Model: Enroll all eligible SUD patients in Model: Enroll all eligible SUD patients in LIHP and increase access to medical care.LIHP and increase access to medical care.
Plan is to analyze data on changes in Plan is to analyze data on changes in hospital and ER costs for SUD patients hospital and ER costs for SUD patients before and after enrollment in LIHPbefore and after enrollment in LIHP
Mental Health Services Act Mental Health Services Act (MHSA) Projects(MHSA) Projects
Mental Health Services Act Mental Health Services Act (MHSA)(MHSA)
MHSA imposes a 1% income tax on personal MHSA imposes a 1% income tax on personal income in excess of $1 million. Statewide, the income in excess of $1 million. Statewide, the Act was projected to generate approximately Act was projected to generate approximately $254 million in fiscal year 2004-05, $683 million $254 million in fiscal year 2004-05, $683 million in 2005-06 and increasing amounts thereafter. in 2005-06 and increasing amounts thereafter.
In a number of counties, MHSA funding has In a number of counties, MHSA funding has been used for pilots of SUD/MH/PC Integration.been used for pilots of SUD/MH/PC Integration.
Kern County SUD/MH/PC PilotKern County SUD/MH/PC Pilot
Integrating Mental Health & Substance Use Integrating Mental Health & Substance Use Disorder Services into Primary Care: Disorder Services into Primary Care:
Kern CountyKern County
Kern County Mental Health (KCMH) is working Kern County Mental Health (KCMH) is working with FQHC partners to implement an SBIRT with FQHC partners to implement an SBIRT model within 6 FQHCs (Project Care). model within 6 FQHCs (Project Care).
Using MHSA funds Project Care provides select Using MHSA funds Project Care provides select MH and SUD screening and brief intervention MH and SUD screening and brief intervention and brief treatment services within the FQHCs. and brief treatment services within the FQHCs.
Referrals to specialty care are made when Referrals to specialty care are made when appropriate. appropriate.
Kern County Integration Kern County Integration ModelModel
Universal screeningUniversal screening Brief consultation in the exam roomBrief consultation in the exam room Brief interventionsBrief interventions Brief treatmentBrief treatment Integrated case conferencingIntegrated case conferencing Using data to monitor progressUsing data to monitor progress
Kern County: Project Care Kern County: Project Care
The goals of Project Care are to provide universal The goals of Project Care are to provide universal screening of all adult patients in 6 FQHCs. screening of all adult patients in 6 FQHCs.
Three screening instruments are used (PHQ9, GAD7, and Audit-Three screening instruments are used (PHQ9, GAD7, and Audit-C+). C+).
Brief interventions are delivered onsite and include SUD Brief interventions are delivered onsite and include SUD assessment and MH solution centered treatment (using assessment and MH solution centered treatment (using the Assist Model and Motivational Interviewing the Assist Model and Motivational Interviewing techniques) that take place over 6-10 visits. techniques) that take place over 6-10 visits.
Integrated case conferencing with the physician, Integrated case conferencing with the physician, psychiatrist, and behavioral health staff are mandatory psychiatrist, and behavioral health staff are mandatory
Provider trainings have included Confidentiality/Ethics, Provider trainings have included Confidentiality/Ethics, SBIRT and MI, Pain Management, and key principles of SBIRT and MI, Pain Management, and key principles of behavioral care within a primary healthcare setting.behavioral care within a primary healthcare setting.
Project Care Program EvaluationProject Care Program Evaluation
Kern County has contracted with UCLA to provide Kern County has contracted with UCLA to provide program evaluation services of Project Care. program evaluation services of Project Care.
The evaluation component consists of: The evaluation component consists of: Administrative data analysisAdministrative data analysis Measures of the level of integration at each clinic Measures of the level of integration at each clinic
using the Dual Diagnosis Capability in Health Care using the Dual Diagnosis Capability in Health Care Settings (DDCHCS) toolSettings (DDCHCS) tool
Qualitative interviewsQualitative interviews Staff satisfaction surveysStaff satisfaction surveys
DDCHCS as an Evaluation MetricDDCHCS as an Evaluation Metric The Dual Diagnosis Capability in Healthcare Settings The Dual Diagnosis Capability in Healthcare Settings
(DDCHCS) designed to measure the degree of (DDCHCS) designed to measure the degree of PC/MH/SUD integration within health care settings is PC/MH/SUD integration within health care settings is used as an integration measure. (McGovern and others)used as an integration measure. (McGovern and others)
DDCHCS requires an in-person site visit, inspection of DDCHCS requires an in-person site visit, inspection of the site and records, and interviews with staff. UCLA the site and records, and interviews with staff. UCLA conducted DDCHCS with all sites in 2011. conducted DDCHCS with all sites in 2011.
All organizations had scores between 3.0 and 3.8 on the All organizations had scores between 3.0 and 3.8 on the five point scale, indicating moderate levels of integration. five point scale, indicating moderate levels of integration.
UCLA is currently in the process of conducting a second UCLA is currently in the process of conducting a second round of DDCHCS visits. The follow-up data being round of DDCHCS visits. The follow-up data being collected will be compared to the 2011 data to determine collected will be compared to the 2011 data to determine what changes have occurred. what changes have occurred.
Administrative Data/Staff PerceptionsAdministrative Data/Staff Perceptions
UCLA has been working with FQHCs to obtain UCLA has been working with FQHCs to obtain administrative data on the number of people screened, administrative data on the number of people screened, their scores, the number assessed, treated, and referred. their scores, the number assessed, treated, and referred. When fully implemented, this data will be generated by When fully implemented, this data will be generated by each organization using i2i registry software. each organization using i2i registry software.
Surveys adapted from the Integrated Behavioral Health Surveys adapted from the Integrated Behavioral Health ProjectProject
Behavioral Healthcare Provider Satisfaction SurveyBehavioral Healthcare Provider Satisfaction Survey Physician and Nurse Provider Satisfaction SurveyPhysician and Nurse Provider Satisfaction Survey Other Staff Satisfaction Survey Other Staff Satisfaction Survey
Los Angeles County Los Angeles County SUD/MH/PC PilotSUD/MH/PC Pilot
LA County Department of Mental LA County Department of Mental Health PilotsHealth Pilots
LA County DMH is piloting 4 different models of LA County DMH is piloting 4 different models of Integration through Mental Health Services Act Integration through Mental Health Services Act funds under their "Innovations" (INN) projects. funds under their "Innovations" (INN) projects.
Orange County and several other counties are Orange County and several other counties are piloting integration projectspiloting integration projectsunder the same funding mechanism.under the same funding mechanism.
Integration Models: Integrated Clinical Integration Models: Integrated Clinical Model (ICM) Model (ICM)
ICM - this is the most conventional of the INN projects. There ICM - this is the most conventional of the INN projects. There are 5 clinical sites (3 FQHC and 2 MH) that are integrating are 5 clinical sites (3 FQHC and 2 MH) that are integrating MH and SUD services through subcontracted collaborations MH and SUD services through subcontracted collaborations and partnerships. and partnerships.
Example: The Saban Clinic (an FQHC, formerly LA Free Example: The Saban Clinic (an FQHC, formerly LA Free Clinic), has partnered with Jewish Family Services to provide Clinic), has partnered with Jewish Family Services to provide behavioral health services.behavioral health services. JFS employees are now integrated in with the other JFS employees are now integrated in with the other
primary care and BH staff dedicated to the clinical project. primary care and BH staff dedicated to the clinical project.
Every collaboration has a PC, MH and SUD partner except in Every collaboration has a PC, MH and SUD partner except in a few cases where the MH agency already had SUD capacity.a few cases where the MH agency already had SUD capacity.
Integration Models: Integrated Mobile Integration Models: Integrated Mobile Health Team (IMHT) Health Team (IMHT)
IMHT - this is 100% field-based services. IMHT - this is 100% field-based services. The integrated health team consists of a PC( physician or The integrated health team consists of a PC( physician or
PA/NP), medical coordinators, psychiatrist, social workers, PA/NP), medical coordinators, psychiatrist, social workers, addiction counselors, peers, housing coordinators, addiction counselors, peers, housing coordinators, wellness coaches, etc - and they function in a team in the wellness coaches, etc - and they function in a team in the community - via vans, cars, etc. community - via vans, cars, etc.
The street-based team screens/assesses and treat as The street-based team screens/assesses and treat as indicated.indicated.
There are 7 of these teams across the county. They all There are 7 of these teams across the county. They all consist of a lead agency (3 leads are MH and 4 are consist of a lead agency (3 leads are MH and 4 are FQHCs), and 1-2 subcontracted partners to provide the FQHCs), and 1-2 subcontracted partners to provide the staff to treat the other services.staff to treat the other services.
Integration Models: Integrated Services Integration Models: Integrated Services Model (ISM)Model (ISM)
ISM - This model is a combination of field (on the street, ISM - This model is a combination of field (on the street, in homes, etc) and clinic based services. in homes, etc) and clinic based services.
There is a lead agency (either an FQHC or MH agency) There is a lead agency (either an FQHC or MH agency) who oversees the entire integrated clinical team.who oversees the entire integrated clinical team.
This is more of a casework model - moving the client This is more of a casework model - moving the client where they need to go to get their needs met, rather than where they need to go to get their needs met, rather than providing the services all in one location.providing the services all in one location.
Ethnic group-focused. There are 14 different ISMs, and Ethnic group-focused. There are 14 different ISMs, and they target different high-need high risk pops - American they target different high-need high risk pops - American Indian/NA; African American; Latino; Armenian, Asian Indian/NA; African American; Latino; Armenian, Asian Pacific Islander; Gay/Lesbian populations. Pacific Islander; Gay/Lesbian populations.
Integration Model: Peer-Led Model Integration Model: Peer-Led Model
Peer-Led Model - This one has not rolled-out Peer-Led Model - This one has not rolled-out yet. yet.
It is a peer-based model using health navigators It is a peer-based model using health navigators and others peers to help integrate service needs and others peers to help integrate service needs for the clients.for the clients.
Other California PC/SUD/MH Other California PC/SUD/MH Integration ProjectsIntegration Projects
California Institute of Mental Health California Institute of Mental Health (CIMH) Care Integration Collaborative(CIMH) Care Integration Collaborative
CIMH Care Integration Collaborative CIMH Care Integration Collaborative Pilot ProgramPilot Program
Consists of five teams of county partners from the local Consists of five teams of county partners from the local Medi-Cal health plan and PC/MH/SUD agencies. Medi-Cal health plan and PC/MH/SUD agencies.
Counties include Los Angeles, Napa, Nevada, Orange, Counties include Los Angeles, Napa, Nevada, Orange, and Riverside. and Riverside.
Goal of the collaborative is to test a number of Goal of the collaborative is to test a number of integration models for their usefulness to improve health integration models for their usefulness to improve health outcomes of individuals living with serious mental illness outcomes of individuals living with serious mental illness and/or substance use disorders as well as and/or substance use disorders as well as cardiovascular disease, diabetes and/or metabolic cardiovascular disease, diabetes and/or metabolic syndrome.syndrome.
CIMH Care Integration Collaborative CIMH Care Integration Collaborative Pilot Program Pilot Program
A key part of this effort is the use of Plan-Do-Study-Act A key part of this effort is the use of Plan-Do-Study-Act (PDSA) cycles, which illustrates a convergence of (PDSA) cycles, which illustrates a convergence of methods with past SUD quality improvement pilots by methods with past SUD quality improvement pilots by organizations including NIATx and UCLA .organizations including NIATx and UCLA .
Participation involves a kickoff and pre-work period, and Participation involves a kickoff and pre-work period, and then four learning sessions. then four learning sessions.
In early 2013, participating organizations will share what In early 2013, participating organizations will share what worked/and what changes were not as effective. worked/and what changes were not as effective.
CiMH CIC Pilot ModelCiMH CIC Pilot Model
California Integration Learning California Integration Learning CollaborativeCollaborative
California Integration Learning California Integration Learning CollaborativeCollaborative
The California ILC is a multi-county information sharing collaborative The California ILC is a multi-county information sharing collaborative for county leaders to learn from each others’ experiences when for county leaders to learn from each others’ experiences when conducting SUD integration activities. conducting SUD integration activities.
Among the topics addressed in the ILC are: Among the topics addressed in the ILC are: how to develop partnerships with primary care providers; how to develop partnerships with primary care providers; which integration model works best in which settings; which integration model works best in which settings; how to fund integration pilots; how to fund integration pilots; how to document SUD services in non-SUD settings, how to document SUD services in non-SUD settings, how implications from 42 CFR and HIPAA regulations affect how implications from 42 CFR and HIPAA regulations affect
implementation,implementation, how to adapt SUD services to fit health care settings. how to adapt SUD services to fit health care settings.
The ILC provides an interactive forum where integration stakeholders The ILC provides an interactive forum where integration stakeholders collaborate on finding and developing sustainable approaches for the collaborate on finding and developing sustainable approaches for the integration of SUD services within the broader healthcare setting. integration of SUD services within the broader healthcare setting.
ILC TopicsILC Topics
County Presentations: San Diego, Riverside, County Presentations: San Diego, Riverside, San Bernardino, Santa Clara, Butte, Merced, San Bernardino, Santa Clara, Butte, Merced, Orange, Los Angeles, and KernOrange, Los Angeles, and Kern
Other Topics: Data Privacy, Health Homes, Other Topics: Data Privacy, Health Homes, Billing/Funding, Workforce Considerations, Billing/Funding, Workforce Considerations, HCR in other Large States, Brief Treatment, HCR in other Large States, Brief Treatment, Medication Assisted Treatment (MAT), and Medication Assisted Treatment (MAT), and the Prescription Drug Abuse Problem the Prescription Drug Abuse Problem (epidemiological update)(epidemiological update)
Integration Learning CollaborativeIntegration Learning Collaborative
The ILC meetings are held on a monthly basis, The ILC meetings are held on a monthly basis, via webinar with topics determined via webinar with topics determined collaboratively by UCLA, and the participating collaboratively by UCLA, and the participating members. members.
Meetings commenced in April 2011 and are Meetings commenced in April 2011 and are ongoing. ongoing.
All meeting materials and summaries are posted All meeting materials and summaries are posted on the Integration Learning Collaborative on the Integration Learning Collaborative Website: Website: http://www.uclaisap.org/Affordable-Care-Act/html/learning-collaborative/index.html. .
Center for Integrated Solutions Health Center for Integrated Solutions Health Networks Collaborative: Expanding the Networks Collaborative: Expanding the
Use of Medications in Treating Use of Medications in Treating Individuals with SUD in Safety Net Individuals with SUD in Safety Net
SettingsSettings
CIHS Network CollaborativeCIHS Network Collaborative
California is one of 3 states to participate in this Center California is one of 3 states to participate in this Center for Integrated Health Services network collaborative.for Integrated Health Services network collaborative.
2 California Counties (Yolo and Alameda) together with 2 California Counties (Yolo and Alameda) together with representatives of State ADP, will develop networks representatives of State ADP, will develop networks including SUD providers and PC providers to promote including SUD providers and PC providers to promote the use of medication assisted treatment (MAT).the use of medication assisted treatment (MAT).
Goal of the project is to determine key steps needed to Goal of the project is to determine key steps needed to build networks across organizations that will promote build networks across organizations that will promote effective use of MAT.effective use of MAT.
UCLA-LA County Telepsychiatry UCLA-LA County Telepsychiatry ProjectProject
UCLA psychiatrist prescribes and manages psychiatric UCLA psychiatrist prescribes and manages psychiatric medications via telemedicine for individuals with co-medications via telemedicine for individuals with co-occurring MH/SUD disorders in large rural residential occurring MH/SUD disorders in large rural residential SUD treatment program.SUD treatment program.
Telepsychiatry services provides excellent psychiatric Telepsychiatry services provides excellent psychiatric care at a lower cost than for in-person care and care at a lower cost than for in-person care and satisfaction is rated highly by staff and patients.satisfaction is rated highly by staff and patients.
Planning underway to expand service to other SUD and Planning underway to expand service to other SUD and PC service delivery sites.PC service delivery sites.
AB 109: Criminal Justice AB 109: Criminal Justice RealignmentRealignment
AB 109 allows non-violent, non-serious, and non sex AB 109 allows non-violent, non-serious, and non sex offenders to serve their sentence in county jails instead offenders to serve their sentence in county jails instead of state prisons.of state prisons.
Will result in a reduction in the state prison population of Will result in a reduction in the state prison population of 30,000 individuals.30,000 individuals.
Counties will now be responsible for managing the Counties will now be responsible for managing the sentences of these individuals and will receive additional sentences of these individuals and will receive additional funds.funds.
May be opportunities to see increased use of treatments May be opportunities to see increased use of treatments for individuals with SUD, including MAT, as a way of for individuals with SUD, including MAT, as a way of reducing county jail populations. reducing county jail populations.
Elimination of California’s Department of Elimination of California’s Department of Alcohol and Drug Programs (July 1, 2013)Alcohol and Drug Programs (July 1, 2013)
Since 1979, the California Department of Alcohol and Since 1979, the California Department of Alcohol and Drug Programs has served as the Single State Agency Drug Programs has served as the Single State Agency overseeing alcohol and drug treatment in California. The overseeing alcohol and drug treatment in California. The director for ADP is appointed by the governor.director for ADP is appointed by the governor.
As of July 1, 2013, the agency will be merged with the As of July 1, 2013, the agency will be merged with the Department of Mental Health and together, will become Department of Mental Health and together, will become the Division of Mental Health and Substance Use the Division of Mental Health and Substance Use Disorders in the Department of Health Care Services. Disorders in the Department of Health Care Services. The division will be lead by a deputy director in DHCS. The division will be lead by a deputy director in DHCS.
Impact: More integration with other health care Impact: More integration with other health care services? Less visibility for drug and alcohol issues services? Less visibility for drug and alcohol issues within the California government?within the California government?
