1 paul mclaughlin, m.a. hartford dispensary nida steering committee presentation: bethesda, maryland...
TRANSCRIPT
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Paul McLaughlin, M.A.Hartford Dispensary
NIDA Steering Committee Presentation: Bethesda, Maryland
September, 2010
Integrating Medical & Dental Services into an Addiction Treatment Setting
Hartford Dispensary
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Hartford Dispensary is a private not-for-profit organization establish in 1871 as an out-patient medical and dental clinic.
In the 1960’s, the agency Board of Directors redesigned its health care services in response to the heroin epidemic in the Hartford area.
The agency presently operates nine (9) fully licensed and accredited clinics in Connecticut that currently serves over 3,800 MMTP patients on a daily basis. In 2009, 5,735 unduplicated patients were served
Hartford Dispensary Background and Overview
Integrating Behavioral Health & Primary Care Services
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Improve the patients’ quality of life and productivity.
Reduce untimely deaths associated with narcotic use.
Reduce the risk of the transmission and spread of infectious diseases.
Reduce crime associated with narcotic addiction.
Integrating Behavioral Health & Primary Care Services
Mission & Recovery Philosophy
Mission Statement:
“Personal Health; Public Health; Public Safety “
Hartford Dispensary’s recovery philosophy is based on the fundamental goals of medication assisted treatment:
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Year Established Patient Census 8/2010
1971 Hartford - Doctors Clinic 669
1971 Hartford - Henderson-Johnson 736
1980 Norwich Clinic 390
1992 New London Clinic 362
1994 New Britain Clinic 408
1989 Willimantic Clinic 381
2003 Bristol Clinic 444
2008 Manchester Clinic 465
Clinic Development and Census Expansion
Integrating Behavioral Health & Primary Care Services
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Since the mid 1980s, the agency had developed a comprehensive Infectious Disease Program. This increased our interest in addressing the unmet infectious disease related medical issues presented by patients.
Patient surveys consistently indicated high interest in both on-site medical and dental services. A number of patients explained they did not have access to primary care or dental services in the community.
By 2000, the agency began to experience budget surpluses which the Board of Directors wanted to use to address unmet patient needs. Surpluses could be returned to the state
In 2004, the agency had medical staffing in our two Hartford area clinics, sufficient to serve over 2,400 patients.
The agency had over 5,000 sq feet of excess, unused space at the Henderson-Johnson Clinic in Hartford, and,
In 2005, at the time the agency was reviewing its strategic plan, the Commissioner of DMHAS expressed support to our Board for development of on-site, community based primary care & dental services.
Presentation SummaryIntegrating Behavioral Health & Primary Care Services
Hartford Dispensary developed and implemented a Primary Care & Dental Services program in a Hartford based clinic in 2006 as a result of a convergence of several factors:
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Medication assisted treatment with physician and nursing services – physicals, lab follow-ups, medication management.
Substance abuse counseling and referral services,
Mental health & psychiatric services, to include a Co-occurring Disorder program,
Comprehensive infectious disease services, with hepatitis C screening, assessment and on-site treatment & hepatitis A & B vaccinations.
Women’s Services; and Acupuncture
Developing a Continuum of Behavioral Healthcare Services
Integrating Behavioral Health & Primary Care Services
Since 1971, in addition to opening six (6) new clinics, the agency has developed a comprehensive behavioral health care program that includes:
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The aging population increases the probability of more patients with chronic disease management needs.
Aging Population & Chronic Disease Management
Integrating Behavioral Health & Primary Care Services
Consistent with national population trends, the population served is aging. Since 1997, the percentage of agency patients aged 51 and over increased from 5.7 % to 21.7 %. Hartford Dispensary
2010 Performance Improvement Report
5.7 6.37.5
10 10.612.3 13.2 14.2
15.9 16.919
21.4 21.7
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
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10
15
20
25
30
35
40
Percentage 5.7 6.3 7.5 10 10.6 12.3 13.2 14.2 15.9 16.9 19 21.4 21.7
Percentage (%) of Patients by Age: 51 and Older
Percentage (%) of Population 51 or Older
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From the mid -1980s the agency infectious disease focus was on Hepatitis B, TB, & STDs.
During the 1980’s, the agency established and continually enhanced a comprehensive HIV/AIDS services program, following the review of the outcomes of an agency-wide HIV/AIDS prevalence study.
During the 1990’s, Hepatitis C was identified as a growing problem for intravenous drug users. In 2000, the agency conducted a Hepatitis C prevalence study of 1,000 patients. The study revealed that 50 -72% of patients had the Hepatitis C antibody.
Data from the study was shared with state agencies, who encouraged us to provide Hepatitis C training to staff and a patient education program was established.
Integrating Behavioral Health & Primary Care Services
Evolution of the HD Infectious Disease Component
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In 2001, in order to guide the development of hepatitis C screening, evaluation, and treatment services, the agency hired a Gastroenterologist and an addictions psychiatrist. On-site hepatitis C treatment for patients began December 2001.
In 2002, in collaboration with CT DPH, the agency established a hepatitis A & B vaccination program in our two (2) Hartford-area facilities using the Twinrix vaccine provided by CT DPH.
In 2003, the vaccination services were implemented at the agency's Willimantic Clinic. In 2006, vaccination services were established in agency clinics in New London, Norwich, New Britain and Bristol. And in 2008, vaccination services began in the new Manchester Clinic.
As of April 2010, some 5,000 patients had began the Twinrix A & B vaccination protocol. From 2002-2005 the completion rte was over 70%.
Addition of Hepatitis A & B Vaccination Program
Integrating Behavioral Health & Primary Care Services
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Development of Primary Care & Dental Services
Integrating Behavioral Health & Primary Care Services
In 2002, the agency Board of Directors inquired as to the availability of dental and medical services to patients and authorized the Executive Director to explore dental options.
In 2003, the agency conducted a patient survey to determine patient interest in both medical and dental services. A majority of patients indicated they would be interested in on-site services
The dean of the University of Connecticut Dental School was contacted and showed a high interest in our under-served population. The dean recommended we establish a relationship with a FQHC as a referral services provider.
The agency formed a collaborative agreement for dental services with Community Health Services – a local FQHC. The relationship worked well for over a year. Due to transportation reliability issues; the placement of our patients “last in line”; and budget reductions, the agency considered an alternative model.
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Development of Primary Care & Dental Services
Integrating Behavioral Health & Primary Care Services
The dean of the University of Connecticut Dental School was again contacted and proposed a contract for dental services between the agency and the Dental School. The Dental School would provide a dentist and dental students.
In March 2005, the Commissioner of the CT Department of Mental Health and Addiction Services spoke to the agency Board of Directors and acknowledged his support for integrating primary care serves and dental with behavioral health care
The Executive Director and various agency staff then toured the central medical unit at the APT foundation in New Haven, CT. to study their 12 year old primary care program model and their implementation process.
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In July 2005, the agency prepared a “Primary Care & Dental Services Business Plan” which was approved by the agency Board of Directors.
Our approach to developing the unit was to consolidate and centralize medical resources to a renovated unit in one Hartford clinic. This was completed by the summer of 2006.
The initial project objectives included:
Provision high quality, relevant primary care and dental services to an underserved population 8 am to 3:30 pm, five days a week
Enhancement of our Recovery Model of Care by improving patient access to primary care & dental services.
Establishment of a national model for the process of introducing Primary Care Services - to include dental services - into community based medication assisted treatment programs.
Development of Primary Care & Dental Services
Integrating Behavioral Health & Primary Care Services
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Hartford is ranked as one of the poorest communities in the country and is designated as a medically underserved city.
The agency’s two Hartford area - Henderson-Johnson Clinic (H-J) and Doctors Clinic- had a combined patient population of over 2,400 patients in 2005, with medical staff e.g. physicians, nurses, and support staff assigned to each unit.
The H-J Clinic, the agency’s largest clinic, served as the
central intake unit for the two clinics.
As a result, the H-J Clinic was chosen as the location for the new unit. The campus had two building. The second floor of one was under-utilized and renovated to serve as the Primary Care & Dental Unit.
Primary Care & Dental Program: Office Development
Integrating Behavioral Health & Primary Care Services
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On 1/17/07 the unit received an Outpatient Clinic, Primary Care Services license from the CT Department of Public Health (DPH).
On 6/20/07 DPH revised the license to reflect the addition of Dental Service, effective 6/7/07.
On 2/29/09 the Primary Care Unit was accredited under newly developed CARF Integrated Behavioral Health Primary Care standards
Primary Care & Dental Program Licensure & Accreditation
Integrating Behavioral Health & Primary Care Services
In preparing for licensure and accreditation, the agency initially developed Primary Care Unit policies and procedures based on the APT foundation model and The Joint Commission, Ambulatory Care accreditation standards.
The Primary Care & Dental Unit opened May 2006, initially providing intake and annual physicals to the medication assisted treatment patient populations of Henderson-Johnson & Doctors clinics.
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Primary Care & Dental Program Offices
Integrating Behavioral Health & Primary Care Services
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The agency initially provided physicians for the Primary Care Unit by moving physician hours from the two Hartford medication assisted treatment program to the new unit.
In addition to new primary care services, the medical staff continued to provide initial and annual medical evaluations, testing, and medication monitoring, for the medication assisted treatment patients served by the two Hartford clinics.
A receptionist, and two (2) medical assistants were transferred to the program and a Primary Care Coordinator was hired
Dental services for patients were provided through a contract with the University of Connecticut, Dental School. A dentist plus dental students provide patient services. The agency hired and funded two (2) part-time dental assistants.
Primary Care & Dental Program Staffing
Integrating Behavioral Health & Primary Care Services
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Methadone Maintenance Services: Admission and annual physicals; lab follow-ups; Hepatitis A& B vaccinations; infectious disease testing
Primary Care Medical Services:
Comprehensive History and Physical exams. Disease management: diagnosis and management of major/minor
illnesses. Prevention services: nutrition and weight management & smoking
cessation. Infectious disease services to include on-site Hepatitis C treatment.
(Seven current patients July 2010) Laboratory services. Pregnancy testing and referral. Medical referrals for specialty services
Primary Care Medical Services
Integrating Behavioral Health & Primary Care Services
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2009 Primary Care Program VolumeIntegrating Behavioral Health & Primary Care Services
2009: PCUPT Volume
Total # of Patient Visits
MMTPAdmissionPhysicals
MMTPAnnualPhysicals
New PCPatients
Total PC Patient visitsper month
Patent Lab Follow-ups
January 223 52 53 7 62 52
February 294 47 89 16 76 75
March 371 50 150 15 59 104
April 443 45 175 8 65 148
May 270 38 101 8 47 79
June 335 37 97 14 92 104
July 251 36 76 14 60 65
August 246 33 69 13 71 70
September 281 40 120 1 40 70
October 290 47 86 6 49 96
November 256 35 85 6 60 51
December 219 44 52 8 68 45
Total 3177 504 1084 116 749 959Average Per
Month 265 42 90 8.8 62.4 80
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2009 Dental Program Services: June 2010Integrating Behavioral Health & Primary Care Services
170 patient visits were scheduled. 136 visits took place. 80 individual patients received services. This was an average of 1.7 visits per patient served. Hartford Dispensary
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17
13
11
10
7
5
3
16
33
Fillings
Emergency Extraction
Extraction
Full Mouth X-Ray
Scaling and Root Planing
Full Exam
Limited Emergency Evaluation
Cleaning
Other
Continuing Care
0 10 20 30 40 50
Number
Primary Care Dental Program
Services Provided June 2010
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The primary care unit changed from a “walk-in-clinic” to a “continuous practice model” in 2007. New physicians with this focus were hired
A nutritionist was hired in 2007. (However the position was defunded by the state in 2009).
During 2009, based on a reduced patient census, the staffing model was modified from two (2) full time primary care physicians to two (2) part-time physician and one (1) full time Physician’s Assistant.
Primary Care & Dental Program Modifications
Integrating Behavioral Health & Primary Care Services
Since 2006, primary care & dental program modifications have occurred based on patient volume, changes in resources, and program outcomes
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In 2009, the agency's Chief of Medical Staff, an addictions psychiatrist, was relocated to the Primary Care & Dental Unit to further develop the “one-stop-shopping” model.
In 2010, the Dental Services Unit was expanded under a new contract with UCONN from two (2) days per week, to three (3) days per week due to increasing demand for dental services.
35% of the agency population served are female. As 55% of primary care patients are women, a part-time APRN is being recruited to focus on expanding women's medical services.
Primary Care & Dental Program Modifications
Integrating Behavioral Health & Primary Care Services
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“Build-it-and-they-will-come”. Over 1,400 individual patients from two (2) agency clinics were seen at least once during 2009.
A 2010 survey of 2,288 patients in the agency’s other six clinics revealed 1850, or 81% of patients would use dental services if provided on site while 1,807 or 70% of the population stated they would use medical services if provided on site.
The medication assisted treatment program requirement for intake and annual physicals provides an opportunity to market primary care and dental services.
Lessons Learned in Integrating BH & Primary Care Services
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Re-aligning current medical and support staff, and co-locating then in a single location can be an efficient and cost effective method to develop and staff a primary care unit.
Models need to be flexible enough to change based on patient volume, changes in resources, changes in patient demographics, etc.
For example, the age of persons served is increasing, thus more chronic disease management medical resources will be required.
Lessons Learned in Integrating BH & Primary Care Services
Integrating Behavioral Health & Primary Care Services
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Lessons Learned in Integrating BH & Primary Care Services
Integrating Behavioral Health & Primary Care Services
Consolidating multiple services and co-location in a central location creates synergy and can improve patient access to all services.
Monitoring data on clinician productivity, billing and claims is essential for use in managing and modifying services to properly meet customer needs in a cost effective manner.
Relationships with medical specialty referrals sources must be developed to address complex patient medical needs.
Partnering with medical & dental schools in collaborative relationships can create benefits for all parties.
For example, nearly 25% of all 3rd year UCONN dental students now rotate through the agency dental clinic, gaining exposure to community based treatment and the needs of underserved populations