1 ADVANCING THE BEHAVIORAL HEALTH OF THE NATION TOGETHER Pamela S. - - PowerPoint PPT Presentation

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ADVANCING THE BEHAVIORAL HEALTH OF THE NATION – TOGETHER

Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Services Administration

North Carolina’s Evidence Based Practices Center 10th Anniversary Celebration Raleigh, NC • September 18, 2014

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TODAY’S DISCUSSION

NATIONAL BH AND NC BH BAROMETER ACA CHANGING THE BH LANDSCAPE WORKFORCE – ACA IMPACT, CULTURAL COMPETENCY, EBPs SAMHSA’s ROLE IN LEADING CHANGE

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BEHAVIORAL HEALTH: THE NATIONAL PICTURE

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2013 NSDUH: SUBSTANCE DEPENDENCE OR ABUSE, PAST YEAR, 12 AND ↑

SA/Dependence – 21.6 M (8.2 percent)

• Same as 29 M (9.3 percent) with diabetes

Non-medical use of pain relievers  from 2.1 percent in 2009 to 1.7 percent in 2013 Heroin comparable to 2012 rates, But…

• # of past year users almost doubled 2007 – 2013 (373K to 681K)
• Past month heroin use has risen as well but at a lower rate –

from a low of 119,000 in 2003 to 289,000 in 2013 Cocaine/Methamphetamine ↓

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2013: MARIJUANA AND ALCOHOL USE

Alcohol – most commonly used substance

• 136.9 M (52.2 percent) reported past month use
• 60.1 M (22.9 percent) reported binge drinking
• 16.5 M (6.3 percent) reported heavy use

Marijuana – most commonly used “illicit” drug

• 19.8 M (7.5 percent) past month users,  from 5.8 percent

in 2007

• Daily use ↑ from low of 3.1 percent to 5.7 percent in 2013
• 2002 – 2013, use 20+ days per month ↑ from 4.8 percent to

8.1 percent

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2013: FIRST SPECIFIC DRUG ASSOCIATED W/INITIATION OF ILLICIT DRUG USE, PAST YEAR, 12 AND 

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BY AGE . . . YOUTH

Youth aged 12 to 17:

• Illicit drug use continues to fall from 2009 (10.1

percent) to 2013 (8.8 percent)

• Marijuana, psychotherapeutics, inhalant, and

hallucinogen use down over last several years.

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BY AGE . . . YOUNG ADULTS

Aged 18 to 25, the news is not so good:

• Illicit drug use overall, no change from 2009 (21.4

percent to 21.6 percent)

• Marijuana use ↑ from 2008; flat since 2010
• Therapeutic and cocaine use ↓
• Hallucinogen use – fairly stable since 2002
• Heavy and binge drinking high or increasing

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BY AGE . . . BABY BOOMERS

Aged 50-64 – Past month use of any illicit drug has continued to trend upward over last 10 years

• 50 – 54: 3.4 percent in 2002 to 7.9 percent in 2013
• 55 – 59: 1.9 percent in 2002 to 5.7 percent in 2013
• 60 – 64: 1.1 percent in 2003 to 3.9 percent in 2013

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95.5%

2.9% 1.6%

Didn't feel they needed Tx Felt they needed Tx but made no effort Felt they needed Tx and made effort

> 20.2 MILLION AMERICANS W/ SUDs

UNTREATED IN 2013 – ABOUT 90 PERCENT

Individuals >12 years old

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2013 NSDUH: MENTAL HEALTH PAST YEAR & RECEIVED TREATMENT

CAVEAT – Non-institutional, civilian populations

• Not jails, prisons or juvenile justice detention centers
• Not active military

Any Mental Illness: ~ 43.8 M (18.5 percent)

• Represents 1 in 5 adults, as compared to 11.3 percent of adults

(26.6 million) diagnosed w/heart disease

• Only 44.7 percent received treatment in specialty care

facility/program

Serious Mental Illness: ~10 M (4.2 percent)

• Only 68.5 percent received MH services in specialty care

facility/program

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MH PAST YEAR AND RECEIVED TREATMENT (Cont’d)

 Major Depressive Episode (Adolescents 12-17): ~ 2.6 M (10.7 percent)

• Represents 1 in 10 adolescents
• 38.1 percent received treatment
• 45 percent with severe impairment received treatment
• Months or years after first symptoms (compared to days or weeks after

first symptoms of physical health conditions)  Suicide: 39,500 deaths in 2011; more than homicides, traffic accidents, HIV/AIDS.

• Almost 1/3 have BAC level above legal limit; growing understanding of

connection to other drugs

• 9.3 M (3.9 percent) adults had serious thoughts; over 2.5 M young people

in grades 9 – 12 (high school age) have serious thoughts

• 2.7 M adults (1.1 percent) made a plan
• 1.3 M adults (0.6 percent) attempted

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BH BAROMETER – SA NORTH CAROLINA, 12 AND : 2008-2012

Alcohol Dependence/Abuse: Rate was lower than national rate; ~ 398,000 (5.1%) Tx for Alcohol Dependence/Abuse: Rate was similar to national rate; ~ 35,000 (8.7%) Illicit Drug Dependence/Abuse: Rate was similar to national rate; ~ 220,000 (2.8%) Tx for Illicit Drug Dependence/Abuse: Rate was similar to national rate; ~24,000 (11.0%)

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BH BAROMETER – MH NORTH CAROLINA, 2008-2012

Adults w/suicidal thoughts: Percentage was similar to national percentage; ~ 237,000 adults (3.4%) SMI among adults: Rate was similar to national rate; ~ 222,000 adults (3.2%) MH treatment among adults w/AMI: Rate was similar to national rate; 532,000 adults w/AMI (45.8%) MDE among youths: Rate was similar to national rate; ~ 55,000 youths (7.7%) Treatment for depression among youths w/MDE: Rate was similar to national rate; ~ 20,000 youths (36.0%)

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HEALTH REFORM: A CHANGING HEALTH CARE ENVIRONMENT

Prevention and wellness rather than illness – a public health approach

• National Prevention Strategy (5 of 7 strategies are about BH)

Recovery rather than chronicity or disability Integration rather than silo’d care; changes where and who provides treatment

• Workforce issue – not just BH and not just primary care

Access to coverage and care rather than significant parts

• f America uninsured – (Parity issue)

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CHANGING ENVIRONENT (Cont’d)

Quality rather than quantity; cost control through better care rather than more care (EBPs that produce results)

• National Quality Strategy (AHRQ)
• National Behavioral Health Quality Framework (SAMHSA)

Role of states increasing; state choices impacting care and outcomes

• Participation in duals demos, Medicaid expansion, Medicaid

state plan coverage

• Exchanges, EHB benchmark plans for parity, MHPAEA

enforcement

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ACA ACCOMPLISHMENTS SO FAR www.HHS.gov/HealthCare

> 8 M Americans selected plans in state/federal Marketplaces; 7.3 M paid premiums (357,584 in NC; > 90 percent eligible for subsidies) 7.2 M enrolled in Medicaid or Children’s Health Insurance Program (65,833 in NC; 377,000 IF NC EXPANDED MEDICAID) 7.8 M young adults (to age 26) able to stay on a parent’s health plan (3 M since ACA; 95,000 young adults in NC) 62.5 M eligible for increased or first time BH coverage (1.9 M in NC) 8.2 M Medicare beneficiaries rec’d > $11.5 B drug rebates & discounts ($359,091,609 for NC; in 2013, 148,288 NC saved $896 per person; in 2014, 53 percent discount on covered brand name and 28 percent on generic drugs)

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ACA ACCOMPLISHMENTS (CONT’D)

76 M privately insured gained improved preventive services coverage (2,266,000 in NC; 917,000 women)

• Includes screening for depression, behavioral disorders among youth

105 M Americans had lifetime limits removed from insurance (3,091,000 in NC) All enroll without consideration of pre-existing conditions (4,099,922 non-elderly NC w/ pre-existing conditions; 539,092 children) Lowest rate ↑s in health/insurance cost in decades (e.g., 80/20 rule alone – 182,517 in NC rec’d $8,488,477 in refunds, averaging $77/family) Lowest rate of uninsured – 11.5 percent nationally Number of available plans significantly increased

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NEXT OPEN ENROLLMENT: KEY DATES FOR THE HEALTH INSURANCE MARKETPLACE

November 15, 2014: Open Enrollment begins – apply for, keep, or change coverage December 15, 2014: Enroll by the 15 for new coverage that begins

• n January 1, 2015

December 31, 2014: Coverage ends for 2014 plans; coverage for 2015 plans can start as soon as January 1 February 15, 2015: This is the last day to apply for 2015 coverage before the end of Open Enrollment

www.healthcare.gov and www.cuidadodesalud.gov

Coverage to Care Initiative Spring to Fall 2014

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PREVALENCE OF BH CONDITIONS AMONG UNINSURED ADULTS AGES 18-34 WITH INCOMES <400% FPL

Source: National and State Estimates of the Prevalence of Behavioral Health Conditions Among the Uninsured, 2013, http://store.samhsa.gov/product/National-and-State-Estimates-of-the-Prevalence-of-Behavioral-Health-Conditions-Among- the-Uninsured/PEP13-BHPREV-ACA

44.0% SMI/ SPD/ SUD 56.0%

“Behavioral Health Conditions” includes serious mental illness (SMI), serious psychological distress (SPD) and substance abuse disorders (SUD)

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PREVALENCE OF BH CONDITIONS AMONG UNINSURED ADULTS AGES 35 AND OVER WITH INCOMES <400% FPL

Source: National and State Estimates of the Prevalence of Behavioral Health Conditions Among the Uninsured, 2013, http://store.samhsa.gov/product/National-and-State-Estimates-of-the-Prevalence-of-Behavioral-Health-Conditions-Among- the-Uninsured/PEP13-BHPREV-ACA

23.8%SMI/ SPD/ SUD

76.2%

“Behavioral Health Conditions” includes serious mental illness (SMI), serious psychological distress (SPD) and substance abuse disorders (SUD)

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NC: PREVALENCE OF BH CONDITIONS AMONG Marketplace POPULATION

CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey Source: National and State Estimates of the Prevalence of Behavioral Health Conditions Among the Uninsured, 2013, North Carolina Profile, http://store.samhsa.gov/product/National-and-State-Estimates-of-the-Prevalence-of-Behavioral-Health-C onditions-Among-the-Uninsured/PEP13- BHPREV-ACA

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NC: PREVALENCE OF BH CONDITIONS AMONG Medicaid Expansion POPULATION

CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey Source: National and State Estimates of the Prevalence of Behavioral Health Conditions Among the Uninsured, 2013, North Carolina Profile, http://store.samhsa.gov/product/National-and-State-Estimates-of-the-Prevalence-of-Behavioral-Health-C onditions-Among-the-Uninsured/PEP13- BHPREV-ACA

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MORE COVERAGE & ACCESS = MORE & DIFFERENT WORKERS

Bi-directional integration with primary, specialty, emergency and rehabilitative care with increasing emphasis on screening/early intervention Different financial models driving different team-based models Skills re HIT/EHRs for billing, changing practice models, and quality/outcomes Recovery-oriented systems/principles: individual responsibility, shared decision-making, self-directed care, patient-oriented delivery systems, wellness care not just sick care Value of prevention and preventionists Increased value & use of peers & paraprofessional practitioners Different credentialing/licensure/competencies

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SAMHSA BH WORKFORCE REPORT TO CONGRESS MARCH 2013: ISSUES

• 1. Capacity
• Numbers, aging, credentialing, pay, minorities
• 2. Data and Collection Processes
• Minimum Data Set Project w/ HRSA
• 3. Training and Education
• Evidence-Based Practices & thinking
• Technology in training and practice
• Readiness of safety-net providers for managed care & newer

payment structures – BH is now a cost center!

• Readiness for integrated care (w/health and w/in BH)
• 4. Non-Traditional Workforce
• Peers and paraprofessionals

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BH WORKFORCE SHORTAGES (HRSA 2012)

55 percent of US counties (all rural) do not have any practicing BH workers (MH or SA) 77 percent had a severe shortage of MH workers 96 percent reported unmet need for MH prescribers 3,699 MH professionals in Health Professional Shortage Areas (HPSAs) covering 91 M people –

• nly 1 psychiatrist for every 30,000 residents
• 1,846 psychiatrists and 5,931 other practitioners needed

to reduce or eliminate HPSAs

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MINORITY BEHAVIORAL HEALTH PRACTITIONERS

Although minorities make up ~ 30 percent of the U.S. population, they account for only:

• 19.2 percent of psychiatrists
• 5.1 percent of psychologists
• 17.5 percent of social workers
• 10.3 percent of counselors
• 7.8 percent of marriage & family therapists
• 30 percent of addiction counselors**

Mental Health, United States, SAMHSA 2012 **Ryan, et al 2012-ATTC Vital Signs

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SAMHSA’S WORKFORCE FRAMEWORK AND ACTIVITIES TO DATE

Action plans, reports, discussions, data – to shed light Technology transfer/TA/training on EBPs & practice issues Creating/assessing evidence for BH services (e.g., peers, IOP, residential treatment, etc.) Creating and evaluating new practices (e.g., trauma-informed care; adult trauma; supported employment; SBIRT; PBHCI; crisis systems; etc.) Manuals, publications, apps, data, articles, web & social media resources Knowledge transfer (BHbusiness, TA Centers) Recruiting/training a diverse workforce (e.g., MFP, NNED)

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National Network to Eliminate Disparities in Behavioral Health (NNED)

FY 2008 through FY 2014 National Partners: 727 Additional Partner Staff: 617 Affiliates: 886 Total: 2,230

www.nned.net

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NREPP, KAP and KITS

http://store.samhsa.gov

 NREPP – Prevention/Treatment of M/SUDs

• Voluntary rating and classification system
• Defines EBPs
• Descriptions and quantitative ratings
• Transparent reviews
• Describes intervention implementation
• Provides information on fidelity measurement
• At least 20 of 339 programs in NC

 KAP – Expanding SU Treatment Capacity

• Knowledge Adoption
• Treatment Improvement Protocols (TIPs)
• Technical Assistance Publications (TAPs)
• Multi-Language Initiative (MLI)
• Workforce Development tools

 KIT – Moving Effective BH Practices into Community-Based Service Settings

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GUIDE TO EBPs ON THE WEB

Provides simple, direct connections to 35 web sites containing information about interventions to prevent and/or treat mental and substance use disorders

• Specific EBPs
• Comprehensive reviews of research findings

Website referenced in SAMHSA discretionary grant RFAs

www.samhsa.gov/ebpwebguide

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RECOVERY TO PRACTICE INITIATIVE – WITH PRACTITIONER GUILDS

 Incorporates recovery into everyday practices of MH professionals in all disciplines  National Steering Committee advises on most effective practices in promoting/sustaining recovery  Supports SAMHSA’s commitment to promoting MH recovery through the priority area of workforce development and by developing and disseminating training strategies based on the 10 key recovery concepts RTP initiative centers on 2 components:

• 1. Creating RTP resources for MH professionals

complete with Web-based and print materials, training, and TA for professionals engaged in transformation process

• 2. Creating/disseminating recovery-oriented

training materials for each of the major MH professions

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PRESIDENT’S PLAN – MENTAL HEALTH AS A PUBLIC HEALTH ISSUE 23 Executive Actions to reduce access to guns and increase MH services FY 2014 Budget MH Proposals –

• SAMHSA – $115M of $130M requested, of

which $40 M workforce; $11 M more for FY15

• CDC, DOJ, ED also received funding

National Dialogue on Mental Health – www.mentalhealth.gov

• Twitter
• Facebook
• Community Conversations

LESS THAN HALF OF PEOPLE W/ BH CONDITIONS RECEIVE CARE

“We are going to need to work on making access to mental health care as easy as access to a gun.” – President Obama

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WORKFORCE STRATEGIC INITIATIVE FY 2015 – FY 2018

1.Competencies – Develop/disseminate workforce training, education tools and core competencies

• Primary care, specialty, emergency and rehabilitative healthcare

workers have to be trained in BH as we train more BH specialists

2.Peer Practitioners – Develop/support deployment of peer practitioners in all public health and health care delivery settings 3.Data – Help increase #s of practitioners to address capacity issues in prevention, treatment, & recovery support settings 4.Funding – Influence and support fair/adequate funding and payment for BH providers and practitioners

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SAMHSA’S THEORY OF CHANGE

A Framework for Developing and Disseminating EBPs and Promising Practices to Advance the BH of the Nation

INNOVATION Proof of concept Services Research Practice-based Evidence TRANSLATION Implementation Science Demonstration Programs Curriculum Development Policy Development Financing Models and Strategies DISSEMINATION Technical Assistance Policy Academies Practice Registries Social Media Publications Graduate Education IMPLEMENTATION Capacity Building Infrastructure Development Policy Change Workforce Development Systems Improvement WIDESCALE ADOPTION Medicaid SAMHSA Block Grants Medicare Private Insurance DOD/VA/DOL/DOJ/ED ACF/CDC/HRSA/IHS

SURVEILLANCE

EVALUATION

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Leadership & Voice – Influencing Public Policy Data & Surveillance Practice Improvement Strategic Grant-Making Regulation/Guidelines Public Awareness/Education

SAMHSA’S HERE TO HELP . . .

www.samhsa.gov