Developing a Bidirectional Integrated Care System to

Treat Dual Diagnosis

Center of Excellence for Integrated CareCathy M. Hudgins, Ph.D., LPC, LMFT

“Do I contradict myself. Very well, I contradict myself. (I am large. I contain multitudes).”

Walt Whitman, 1855

What common issues are related to your clients’ MH/SA?

What factors impede adherence and recovery? What parts of your client’s whole-person health

are outside of your scope of practice? What do you want and need to know about the

other parts of your client’s whole-person health to fully address the whole person in front of you?

How you can help other providers understand the whole-person needs of your client?

The Mind/Behavioral Body Connection

Assumes that health is a shared community responsibility and can be achieved through the dissolution of barriers that result in silo-style service provision (Mauer & Jarvis, 2010).

Mental health and medical care providers work together to coordinate the detection, treatment, and follow-up of both the physical and mental health needs of their patients.

Strategic framework stressing team-based care that supports individuals in their whole-person health needs and goals.

Meets the Triple Aim.

What is Integrated Care?

The majority of people have comorbid mental health and medical problems but do not receive care consistent with established practice guidelines (Institute of Medicine, 2006).

Developing an interdisciplinary cadre of health care providers that work with patients and their loved ones can ensure that whole-person, evidence-based care is the standard of care (Kaslow et al., 2007).

Whole-Person Care

Physical Health

Emotional/Behavioral Health

Oral Health

Spiritual

Social/Community

Others?

Treating the Whole Person

The Whole-Person Community Context

Policy/ Law/Statutes

Patient/ Family

Practice

Social Services

Behavioral health issues affect quality of life

◦ SMI population die at younger ages(25 years less than average life expectancy) than people with non-major mental illness diagnoses (Lutterman et al., 2003).

◦ SMI population less likely to be linked to a primary care home (Collins et al., 2010).

Why Integrate?

Why Integrated Care? ANNUAL MEDICAL COSTS FOR ADULTS

Without MH With MH• All adults $1,913 $3,545• Heart Condition $4,697 $6919• High BP $3,481 $5492• Asthma $2,908 $4,028• Diabetes $4,172 $5559

Robert Graham Center for Policy Studies in Family Medicine and Primary Care, March, 2008. Information from US DHHS 2002 and 2003 MEPS AHRQ

Bidirectional Integrated Care

Bidirectional Integrated Care involves placing primary health care providers into specialty mental health settings.

Levels of bidirectional integration are also on a continuum.

Primary Care services do not replace the need for more intensive, specialty care. The focus is on targeted medical issues for the population in the setting (Mauer & Jarvis, 2010).

Benefits of Bidirectional Integration

Research shows benefits ranging from: Lowered long-term healthcare costs; Decreased outpatient costs; Dramatic reductions in Emergency Department visits; Reduced costs to treat high-cost, high-risk patients; Reduction in inpatient cost, reduction in ER cost, and

reduction in total medical cost for substance abuse patients; Significantly higher abstinence rates for substance abuse

patients; Significantly increased rates and number of visits to medical

providers and reduced likelihood of ER use; Significantly improved quality of most routine preventive

services; Increased receipt of recommended preventive services, and Increased patient work productivity and reduction in work

absenteeism. (Collins et al., 2010; Mauer & Jarvis, 2010)

Additional Rationales for Bidirectional Integration

Completes the continuum of care. Focuses on lifting the barriers to gaining access or

receiving primary care services, including the impediments related to negotiating complex health systems.

Bridges the division between physical and mental health, patient-centered care, which calls for “meeting people where they are.”

Traditional primary care settings may not be perceived as a welcoming place to those with mental and behavioral health diagnosis, resulting in poor access and poor health outcomes.

Addresses ineffective referral methods that do not work and that easily disrupt care.(Collins et al., 2010; Mauer & Jarvis,

2010)

Common Goals for Bidirectional Integrated Care

Recognition and treatment of medical disorders that exacerbate/interact with psychosocial problems;

Early detection of “at risk” clients, with the aim of preventing further physical deterioration;

Prevention of relapse or morbidity in conditions that tend to recur over time;

Prevention and management of addiction to pain medicine or other medications prescribed to address physical symptoms;

Prevention and management of work and/or functional disability related to whole-health problems;

Efficient and effective treatment and management of clients with chronic health problems;

Efficiently moving clients into appropriate medical or mental health specialty care when indicated.

(Open Door, 2005)

Common Goals, cont’d

Gastrointestinal Disorders Cardiovascular Disorders Hematologic Disorders Pulmonary Disorders (Other Than Infectious) Neurologic System Infectious Diseases Other Conditions

(SAHMSA, 2006)

Co-occurring Medical and MH/SA Disorders

Disease Model of Addiction The disease model reflects the progression of

the disorder.◦ At a certain point, the addict loses control over the

use (compulsion)◦ Not a moral choice/not a character flaw (Moral

model)◦ The idea that one may never use again on any level

(relapse)◦ Could be used as an excuse (one of the criticisms)◦ Relevance of this model

Helps the treatment provider determine the severity and intervention

Helps the addict’s family, friends, coworkers, etc. better understand the progressive nature of the disease and reduces blame and hurt

DSM 5 Diagnosis

DSM 5 diagnosis criteria reflects a progression of use.

Usefulness ChallengesFlexibility

◦ DSM 5 no longer identifies abuse and dependence as distinct disorders – they are identified on a continuum.

• Contemporary medical diagnosis criterion is unilateral and should be combined with other factors, such as those included in the DSM to determine the nature of the use and the type of treatment required (Borges, et al., 2010).

Individualized Assessment Criteria

The criteria for substance abuse and dependence diagnosis should be individualized

ToleranceWithdrawalSocial/interpersonal consequencesCulture, age, gender, and other contextual factors

Identification requires a more comprehensive, whole-person view (biopsychosocial model of assessment).

BiologicalPsychologicalCognitiveSocial InterpersonalDevelopmental

Unified whole-person care definition and vision Policy change on all system levels Need for cross-training and technical support Collaborative data collection and analysis to

support change Development of community collaboration and

partnerships to address issues outside of the Integrated Care scope of practice

TEAMWORK!!!! Think outside of your silo – reject the status quo!

Making this Work

Teamwork is KeyTwo Teams (may include some or many of the same members*): Program

Implementation Team Clinical Team

Possible Members*: PCPs BHPs Practice Manager Nursing Staff Care

Manager/coordinator Receptionist/support

staff Medical records staff Risk Management

Officer Others?

North Carolina’s health system is built to meet the needs of the high moderate to severe needs population. Result: Gap in care for those with emerging or

moderate to mild healthcare needs. Result: Patients with moderate to mild issues divert

needed resources away those with the high-moderate to severe issues.

Many MH/SA have difficulty navigating and feeling welcome in traditional healthcare settings. One solution: Integrated Care provides continuity of

care in a stigma-free environment for those who need brief, focused treatment for mild to moderate healthcare needs.

Needs for Integrated Care in NC

Concerns and Issues Related to Integrating

Finding referrals for SMI/Chronic SA Populations for more intensive healthcare

Ethical Issues Scope of the healthcare services Paradigm Shift Culture Shift Others?

North Carolina Foundation for Advanced Programs ◦ http://www.ncfahp.org/

Center of Excellence for Integrated Care◦ (ICARE) http://www.ncfahp.org/nc-center-of-

excellence.aspx

Staff:Cathy M. Hudgins, Ph.D., LMFT, LPC -- DirectorChristine Borst, Ph.D., LMFT -- Clinical CoordinatorMaria Dover, M.S., LMFT -- Pediatric Program ManagerPeter Rives, M.S. -- ConsultantEric Christian, M.S., LPC -- Consultant

Who We Are

Who we are:

The Center is a multidisciplinary group of experts assembled to promote, support, develop, sustain, and improve local, regional and statewide Integrated Care (IC) efforts.

Center of Excellence for Integrated Care (ICARE)

What we do:◦ Consult and provide technical assistance

services to support and advance IC services in all types of healthcare and mental health settings.

◦ Present IC information related to best practices to local, state, national stakeholders.

◦ Research and develop resources to facilitate efficient and sustainable whole-person, IC systems.

◦ Maintain an up-to-date clearinghouse of the IC existing and evolving resources, literature and research to support evolving systems.

Center of Excellence for Integrated Care (ICARE)

Questions?

References Borges, G., Ye, Y., Bond, J., Cherpitel, C., Cremonte, M., Moskalewicz, J., Swiatkiewicz,

G., & Rubio-Stipec, M. (2010). The dimensionality of alcohol use disorders and alcohol consumption from a cross-national perspective. Addiction, 105, 240-254.

Collins, C., Hewson, D., Munger, R., & Wade, T. (2010). Evolving models of behavioral health integration in primary care. Retrieved from http://www.integratedprimarycare.com/Milbank%20Integrated%20Care%20Report.pdf

Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions. Washington, DC: National Academies Press.

Kaslow, N. J., Bollini, A. M., Druss, B., Glueckauf, R. L., Goldfrank, L. R., Kelleher, K. J., ... & Zeltzer, L. (2007). Health care for the whole person: Research update. Professional Psychology: Research and Practice, 38, 278.

Lutterman, T., Ganju, V., Schacht, L., Monihan, K., & Huddle, M. (2003). Sixteen state study on mental health performance measures Rockville: Center for Mental Health Services. Substance Abuse and Mental Health Services Administration.

Mauer, B., & Jarvis, D. (2010). The business case for bidirectional integrated care. Retrieved from http://www.thenationalcouncil.org/galleries/policy-file/CiMH%20Business%20Case%20for%20Integration%206-30-2010%20Final.pdf

Open Door Community Health Center (2005). Open door community health center’s behavioral health program. Retrieved on March 10, 2010 from http://www.opendoorhealth.com/resourceguide.php.

Substance Abuse and Mental Health Services Administration (US). (2006). SAHMSA Treatment Improvement Protocol (TIP) Series, No. 45. Rockville, MD: Center for Substance Abuse Treatment.

Whitman, W. (1860). Leaves of grass. Boston, MA: George C. Rand & Avery.