Promoting Health through Interdisciplinary Substance Use

Consultation in Primary Care

Chantelle Thomas, PhD, Behavioral Health ConsultantElizabeth Zeidler-Schreiter, PsyD, Behavioral Health Consultant

Meghan Fondow, PhD, Behavioral Health Consultant

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # E3AOctober 17, 2014

Faculty Disclosure

•We currently have the following relevant financial relationships (in any amount) during the past 12 months:–Dr. Zeidler-Schreiter is a

consultant for primarycareshrink.com.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe the evolution and implementation of the Health Promotions Clinic including clinic pathways informing patient care flow and provider feedback

• Define the role of the behavioral health team as it relates to referral and day to day operations of the health promotions clinic

• Identify clinic, provider, and patient characteristics best served by this model

• Discuss optimization of technology with patient engagement, treatment, and enhancing awareness of clinically relevant information

Bibliography / Reference

1.Substance Abuse and Mental Health Services Administration (2014) “Co-Occurring Disorders.” Online. Available: http://media.samhsa.gov/co-occurring/•National Alliance on Mental Illness (2014) “Dual Diagnosis: Substance Abuse and Mental Illness.” Online. Available: http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049•Cacciola, Alterman, DePhilippis, Drapkin, Valadez, Fala, Oslin, & McKay (2012) Philadelphia Veterans’ Administration Medical Center. Brief Addiction Monitor Scale. •The Implementer’s Guide To Primary Care Behavioral Health. Serrano, Neftali. (2014)

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Access Community Health Centers

Certified Federally Qualified Health Centers

Three clinic sites including University of Wisconsin Family Medicine Training Clinic

26,000 patients served in 2013

Approximately 6,000 BHC visits in 2013

50% white, 26% Latino/Hispanic, 21% African American

56% Medicaid, 21% Uninsured, 17% Commercial, 5% Medicare

Fully Integrated PCBH Model

Three scheduled BHC visits per clinic (6 total per day)

60-70% of patient visits are warm handoffs

Approximately 1 to 3 BHC clinicians per clinic

Number of visits per day range from 8 to 15

Clinic is set up to promote interdisciplinary contact with medical providers, medical assistants, dietitians, and triage nursing staff

Access Hallways

Provider, BHC, & Triage

Transparency

Behavioral Health Consultation

Determining Need According to Substance Abuse and Mental Health Services Administration (2014):

8.9 million adults have co-occurring disorders

Only 7.4 percent of individuals receive treatment for both conditions with 55.8 percent receiving no treatment at all

Certain people with mental illness (males, low SES, increased medical illness) are at increased risk of abusing drugs and alcohol

One-third of people with all mental illnesses and approximately one half of people with severe mental illnesses experience substance abuse

Impact of Lacking Treatment

There are many consequences of undiagnosed, untreated or under treated co-occurring disorders including higher likelihood of experiencing (SAMHSA, 2014):

homelessness

incarceration

mental illness

suicide

early mortality

National Alliance of Mental Illness (2014)

People who are actively using with dual diagnosis are:

less likely to follow through with the treatment plans

less likely to adhere to their medication regimens

more likely to miss appointments which leads to more psychiatric hospitalizations and other adverse outcomes

increased risk of impulsive and potentially violent acts

more likely to both attempt suicide and to die from their suicide attempts

Complications of dual diagnosis

How do we treat patients who are still using?

How do we treat those who are “not ready” for residential or outpatient treatment?

Many of these patients are limited by:

insurance

practical/financial/psychosocial barriers

Severity of mental health sx prevents follow through

Previous treatment history has limited available options

Better Patient Care & Management

Meet patients where they are!

Eliminate barriers to follow through

Provide options to reduce risk/harm

Stabilize mental health symptoms

Enhance motivation

Facilitate treatment readiness

Maintain the relationship

Health Promotions ClinicDeveloped in 2012

Staffed by Randy Brown, MD, PhD

Takes place in clinic on Tuesday morning

Over the last 6 month period

159 face to face encounters with MD (8 per clinic)

No show rate of 28%

116 face to face encounters with BHC (6 per clinic)

Addiction Medicine Fellow started this year

Clinic StatisticsCurrent 52 active patients

80% actively involved with BHC

Written vs Verbal consults

Ongoing vs One time consults

Number of referrals in 2012: 38 referred, 27 seen

Number of referrals in 2013: 34 referred, 29 seen

Number of referrals in 2014: 19 referred, 12 seen

Health Promotions Patient Makeup

80% Caucasian, 20% African American

51% female, 49% male

87% dual-diagnosis, 70% two or more mental health dxs

61% deemed medically complex

50% managed on Suboxone

42% Polysubstance Use Disorder

8% transgender patients

Health Promotions in morning huddle

Health Promotions-Clinic Flow

Patients seen first by BHC team to evaluate level of appropriateness for referral

Patient chart is copied to the health promotions behavioral health coordinator

Further reviewed and forwarded to MD to determine appropriateness for scheduling

Forwarded to triage to contact patient for scheduling

Documentation in chart of status of referral

Information Obtained Severity of Use

Current Insurance

Previous treatment history

Motivational assessment

Assessment of additional barriers to treatment

Assessment of risk - IV drug using, Hep C, HIV, pregnant, single parenting of small children

Informed Consent • Wingra Family Medicine Clinic is part of Access Community Health Centers and the

treatment providers at Wingra will be sharing information with your primary care provider in order to provide you with the best possible care. During your time at Wingra you will meet with the Behavioral Health Team and with Dr. Randy Brown, a physician who specializes in strategies for harm reduction and substance use issues. Your visits with the Primary Care Health Promotions Team will become part of your medical record and this information can be viewed by individuals involved in your care.

• If you are accepted and seen by this clinic, your primary care doctor will remain your primary care doctor. For all other general medical needs, you will continue to seek medical care with your regular doctor at your regular clinic as you did previously.

• About your work with the Primary Care Health Promotions Team.

• 1. We work as a group so you will likely see multiple members of the team.

• 2. We communicate very well with each other so you should not need to repeat yourself at each visit.

• 3. We are strategic in our visits, usually spending about 15-30 minutes with you to troubleshoot what is most important to you.

• 4. We communicate with your provider (primary care provider) regularly using our notes in the medical record and verbally.

Who is appropriate?

Difficult question to summarize

No hard and fast rules

Good candidates for pharmacotherapy

Limited community treatment options

High risk folks not ready for more intensive tx

Patients with co-morbid pain where there is concern of addiction

SEVA ~ selfless caring• Smart phone application developed by University of

Wisconsin, School of Engineering, Center for Health Enhancement Studies

• Utilizes innovative technology to assist substance abusing patients across three federally qualified health care centers (Montana, Wisconsin, & New York)

• Smart phone application previously used for patients following residential treatment now being implemented across the country

• Provides psycho-education skills development pertaining to relapse prevention, cognitive behavioral therapy, & harm reduction – (TES)

• Creates a virtual online recovery community for patients

Therapeutic Education System - TES

• Self-directed, web-based behavioral intervention for substance use disorders (licensed by HealthSim, LLC)

• Built into the SEVA application (skills training)

• Addresses broad array of skills and behavior designed to help substance abusing individuals stop their substance use, gain life skills, and establish new, healthy, and adaptive behaviors

SEVA - Patient Screen

Clinician Dashboard

Current Recruitment• Goal is to ultimately recruit 100 patients,

(50+ currently)

• Recruiting patients with varied ranges of substance use disorders, mental health sx, & psychosocial instability

• System includes patients that are & are not abstinent

• Patients are referred by behavioral health team & medical providers

• Efforts to engage hard to reach patients are paired with existing medical provider visits

Session Evaluation

• Please complete and return theevaluation form to the classroom monitor before leaving this session.

• Thank you!