COURAGE TO CHANGE VITKA EISEN, MSW, EDD 1 OVERVIEW Intro - - PowerPoint PPT Presentation
COURAGE TO CHANGE VITKA EISEN, MSW, EDD 1 OVERVIEW Intro Evolution of SUD treatment Current definitions and interventions Review of chronic disease management at it applies to SUD Review collaborative care model for SUD Changing operating
VITKA EISEN, MSW, EDD
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Intro Evolution of SUD treatment Current definitions and interventions Review of chronic disease management at it applies to SUD Review collaborative care model for SUD Changing operating environment in California Challenges and opportunities
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Whole person care for low-income adults, youth, and families
health:
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Haight Ashbury Free Clinics Walden House
HealthRIGHT 360
Lyon Martin Health Services Tenderloin Health Services Women’s Recovery Association Asian America Recovery Services North County Serenity House Prototypes
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Mission: Build health, give hope, and change lives for people in need. View overall health improvement as our primary purpose—no matter which point of entry.
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Client
SUD Tx MH Tx Medical Social Svces
CORE TREATMENT PRINCIPLES
Compassionate, non-judgmental, and welcoming services for high need, complex, low-income clients Evidenced-based interventions Medication Assisted Treatment where indicated Trauma informed services Assessment-driven individualized care Full integration of substance use, mental health, and primary medical care Gender responsive services Culturally and linguistically appropriate care for diverse clients Clients never fail treatment; treatment fails clients
Operates in 10 counties in California, from Solano to San Diego Provides treatment in 4 state prisons and 2 county jails 38,000 clients treated last fiscal year Annual revenue of $110M 1,100 employees House 1,238 people in California every night, either in treatment bed, interim or permanent housing
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Moral failing Adaptive coping mechanism Chronic brain condition
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CHANGING DEFINITION OF SUD
National Institute of Drug Abuse: Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works. These brain changes can be long lasting and can lead to many harmful, often self-destructive, behaviors. ASAM: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Unbroken Brain (Szalavitz): Addiction is a developmental learning disorder
22.7 million individuals in the US with a SUD 2.5 million received treatment Of the 20.2 million people that did not receive treatment, 19 million did not think they needed it. Total social cost of alcohol and drug misuse is $700 billion annually
EVIDENCED-BASED PSYCHOSOCIAL INTERVENTIONS
Motivational interviewing Contingency management Cognitive behavioral therapy Community reinforcement approach plus vouchers Trauma informed treatment Facilitated 12-step
EVIDENCED BASED PHARMACOLOGIC INTERVENTIONS
Medication assisted treatment
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NOT EFFECTIVE OR LACKING IN EVIDENCE
Acupuncture as sole intervention Relaxation therapy as standalone Individual psychotherapy as sole intervention Unstructured group psychotherapy Confrontational therapy Discharging patients for return to drug use
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CHANGING TREATMENT FRAMEWORKS
Acute/long- term care Acute/episodic brief care Chronic care/ongoing support
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WHAT IS CHRONIC DISEASE MANAGEMENT
An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve quality of life while reducing health care costs by preventing or minimizing the effects of a disease. Elements*:
resources
solving and peer support
resources
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McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, McNeely J. Can substance use disorders be managed using the Chronic Care Model? Review and recommendations from a NIDA consensus group. Public Health Reviews. 2014; 35(2):2107–6952.
Framework for SUD treatment includes services along a continuum, matched to patient need, integrated with primary care
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Team based care Services embrace evidence- based guidelines Person centered Info sharing Self- management and recovery support Link to community resources
Referral
facilities
key element
Co-located
proximity
specific cases
Collaborative
transformation
care with shared information
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COLLABORATIVE CARE MODEL FOR SUD
Team driven: Multidisciplinary team includes PCP, SUD care coordinator, mental health, social worker, nurse, etc. as indicated Population focused: Team responsible for the provision of care and health outcomes of defined population Measurement guided: Team uses disease-specific as well as patient reported outcome measures to drive clinical decision making Evidenced-based: Team employs scientifically proven interventions to achieve improved health outcomes
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Dissemination of Integrated Care within Adult Primary Care Setting: Collaborative Care Model (2016) American Psychiatric Association Academy of Psychosomatic Medicine.
populations that share multiple clinical and social attributes
cultural, economic and environmental factors that impact well- being
integrated systems that deliver the Quadruple Aim:
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Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV.
Better health Improved patient experience Improved care team experience Reduced cost Healthcare
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A systematic effort to improve health outcomes in sub- populations that share multiple clinical and social attributes
under 25, patients w/history of incarceration, Pacific Islander patients, etc.)
population
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Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV.
Reflects the interdependence of biology, behaviors, social, cultural, economic and environmental factors that impact well-being
determinants of health
conditions that may impede health improvement
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Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV.
Patient outcome measures: Must be collected frequently to accurately assess recent clinical picture Must be reliable and sensitive to change Must be relatively simple and low cost to implement Must include patient-reported (not just clinician reported) data Should be tightly correlated to diagnosis
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Screening
Assessment
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Unlike primary care, SUD has no nationally agreed upon measures
ADAI Library: Substance Use Screening & Assessment Instruments Database. http://lib.adai.uw.edu/instruments/
Access Patient engagement Patient experience Medication adherence Transitions in care Readmission/time to readmission Quality of Life measures (WHOQOL-BREF) Other health measures (HEDIS) Productivity Utilization
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Team based care
professional, client
Quality improvement strategy
for rapid cycle improvement
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Weekly Integrated Care Team Meeting
worker, AOD counselor
SBIRT in clinic with referrals for specialty care where indicated Medical team will participate in residential tx to assess for withdrawal mgmt and MAT where indicated Chronic pain pt registry Soon to develop high-user care team
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CHALLENGES TO OUR COLLABORATIVE CARE GOAL
FFS payment structure Technology—separate EHRs Lack of easy access to data from other points of care—ED,
Workforce and training
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CHALLENGES
No national set of outcome measures for SUD Insurance/payment systems for SUD treatment do not necessarily follow patient needs Payment models do not follow collaborative care model No financial incentives to cover the cost of population health mgmt Workforce
OPPORTUNITIES
Opioid use epidemic has become a bipartisan national issue and a part of the national conversation Improved MediCal benefit for treating SUD
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OPPORTUNITIES
System redesign to allow for continuum
Funding less county/local tax contingent Telemedicine Medical-incident to More mobility
CHALLENGES
Shorter LoS Strict definition of episode Will rates cover increased cost? 32
Technologies Medications Cognitively impaired clients (TBI, Dementia, FASD)
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Technology delivered CBT Smart-phone based video counseling and recovery supports Avatar-facilitated motivational interventions Stress reduction and mindfulness-based apps GPS/geolocation interventions Brain-training software designed to remediate executive function impairment associated with SUD
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No FDA-approved pharmacological interventions for stimulant use disorder. Several under investigation
Haglund, M., Ling, W., Mooney, L. (2014). Treating methamphetamine abuse disorder: Experience from research and practice. Current Psychiatry ; 13(9):36-42, 44
DMC-ODS waiver requires system of care to treat ASAM Level 3.3: patients with cognitive impairment Include brief neurocognitive assessment as part of intake process Modify treatment accordingly*:
training
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Grossman, D., & Onken, L. (2003). Developing Behavioral Treatments for Drug Abusers with Cognitive
FASD is an umbrella term describing the range of effects that can
Effects may include
Effects are a result of damage to the developing fetus and they are permanent.
For a developing fetus:
amount of exposure for a developing fetus.
age (i.e., aged 18–44 years) drink alcohol, and 18% of women who drink alcohol in this age group binge drink.
33 reported binge drinking in the past 30 days
Tan, C. H., Denny, C. H., Cheal, N. E., Sniezek, J. E., & Kanny, D. (2015). Alcohol use and binge drinking among women of childbearing age — United States, 2011–2013. MMWR. Morbidity and Mortality Weekly Report MMWR
PRIMARY CHALLENGES FROM FASD
SECONDARY CHALLENGES FROM FASD
AND
mental health issues problems in daily living (hygiene, health and diet) disrupted school experience trouble with the law interpersonal relationship challenges increased likelihood for
joint issues, ear infections) unplanned pregnancies/parenting challenges maintaining housing, employment
FASD prevalence in US estimated between 2%-5% (CDC, 2014). This number may be low because:
pregnancy, + neurodevelopmental and/or intellectual deficits OR
deficits
(CONTINUED)
Only 17% of individuals with FASD have facial dysmorphology and maternal confirmation may be impossible to obtain. And, it can be very difficult to get confirmation of PAE, particularly for adults So, if no facial dysmorphology and no maternal confirmation
SUD PREVALENCE AMONG PATIENTS WITH FASD
Of the individuals with a FASD age 12 and over, the prevalence of alcohol or drug problems was 35%. Of the adults with PAE, 53% of males and 70% of females experienced substance use problems. This is more than 5 times that of the general population.
Streissguth, A.P., Barr, H.M., Kogan, J. & Bookstein, F. L. (1996). Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (PAE). Final Report to the Centers for Disease Control and Prevention (CDC). Seattle: University of Washington, Fetal Alcohol & Drug Unit, Tech. Rep. No. 96- 06
Most FASD is undiagnosed… and individuals with FASD are at increased risk of substance use disorders… and treatment programs do not routinely screen for FASD, or modify treatment programming…
IT IS LIKELY THAT AT: a) a) FASD MAY BE FOUND AT AT A HIGHER RAT ATE AMONG OUR CLIENTS THAN THE GENERAL POPULATION. b) b) WE ARE FAILING TO IDENTIFY CLIENTS WITH FASD OR OTHER BRAIN INJURIES WITHIN OUR TREAT ATMENT PROGRAMS. c) c) WE ARE FAILING TO PROVIDE ADEQUAT ATE SUPPORT FOR OUR CLIENTS WHO MAY HAVE A FASD.
Research needed to better screen Develop and test interventions
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veisen@healthright360.org
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ADAI Library: Substance Use Screening & Assessment Instruments Database. http://lib.adai.uw.edu/instruments/ Dissemination of Integrated Care within Adult Primary Care Setting: Collaborative Care Model (2016) American Psychiatric Association Academy of Psychosomatic Medicine. Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV. Grossman, D., & Onken, L. (2003). Developing Behavioral Treatments for Drug Abusers with Cognitive
Haglund, M., Ling, W., Mooney, L. (2014). Treating methamphetamine abuse disorder: Experience from research and practice. Current Psychiatry ; 13(9):36-42, 44 Kiluck, B.D., & Carroll, K.M. (2013). New Developments in Behavioral Treatments for Substance Use
McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, McNeely J. Can substance use disorders be managed using the Chronic Care Model? Review and recommendations from a NIDA consensus group. Public Health Reviews. 2014; 35(2):2107–6952. Streissguth, A.P., Barr, H.M., Kogan, J. & Bookstein, F. L. (1996). Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (PAE). Final Report to the Centers for Disease Control and Prevention (CDC). Seattle: University of Washington, Fetal Alcohol & Drug Unit, Tech. Rep. No. 96-06 Tan, C. H., Denny, C. H., Cheal, N. E., Sniezek, J. E., & Kanny, D. (2015). Alcohol use and binge drinking among women of childbearing age — United States, 2011–2013. MMWR. Morbidity and Mortality Weekly Report MMWR Morb. Mortal. Wkly. Rep., 64(37), 1042-1046. doi:10.15585/mmwr.mm6437a3 Volkow, N.D., Koob, G.F., McLellan, T. (2016) Neurobiologic Advances from the disease model of addiction. New JAMA,374;4
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