Presented by:H. Westley Clark, M.D.

COD Initiatives at SAMHSA

Linking Healthcare and Substance Use Disorders Services: Implications for

the Addiction Treatment Field

6th Annual COSIG Grantee Meeting

Bethesda, MD June 28, 2010

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director

Center for Substance Abuse TreatmentSubstance Abuse Mental Health Services Administration

U.S. Department of Health & Human Services

4444

Past Month Alcohol Use - 2008

Any Use: 52% (129 million)

Binge Use: 23% (58 million)

Heavy Use: 7% (17 million)

Source: NSDUH 2008

(Current, Binge, and Heavy Use estimates are similar to those in 2007)

5

Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2008

8.0%8.3%8.1%7.9%8.2%8.3%8.0%

5.8%6.0%6.0%6.1%6.2%6.2%6.1%

2.8%2.9%2.7%2.5%2.7%2.7%2.5%

0.8%1.0%1.0%0.8%1.0%0.9% 0.7%0.4%0.4%0.4%0.4%0.4%0.5% 0.4%0%

1%2%3%4%5%6%7%8%9%

2002 2003 2004 2005 2006 2007 2008

Perc

ent U

sing i

n Pa

st M

onth

Illicit Drugs Marijuana Psychotherapeutics Cocaine Hallucinogens

Source: NSDUH, 2008

6

20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use

3.7%

Felt They Needed Treatment and Did

Make an Effort

Did Not Feel They Needed

Treatment

Felt They Needed Treatment and Did Not

Make an Effort

1.1%95.2%

Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not

Receiving Treatment for Illicit Drug or Alcohol Use: 2008

(766,000)

(233,000)

(19.8 Million)

Source: NSDUH 2008

7

Substance Dependence or Abuse among Adults Aged 18 or Older, by Serious Mental Illness in the Past Year: 2008

25.2%

8.3%

11.9%

2.2%

19.4%

7.1%

0%

5%

10%

15%

20%

25%

30%

% D

epen

dent

on

or A

busi

ng S

ubst

ance

Drug or AlcoholDependence or Abuse

Drug Dependence orAbuse

Alcohol Dependence orAbuse

Had SMI in the Past Year Did Not Have SMI in the Past Year

Source: SAMHSA NSDUH 2008

2.5 Million Adults have Co-Occurring SMI and Substance Use Disorder

8

Treatment Admissions: Psychiatric & Substance Abuse Problems

27.2%

11%

0

5

10

15

20

25

30

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Perc

ent

of A

dmis

sion

s

Admissions to treatment reporting psychiatric problems in addition to substance abuse problems more than doubled between 1992 and 2007.

Source: SAMHSA Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to 2007

9

Treatment for Substance use Problems Only

Mental Health Care Only

Both Mental Health Care & Treatment for Substance

Use Problems45.2%

Past Year Mental Health Care and Treatment for Substance Use Problems among Adults (18+) with Both Serious Mental Illness and a

Substance Use Disorder: 2008

Note: The percentages add to less than 100% due to rounding. Source: NSDUH 2008

39.5%

11.4%

3.7%

No Treatment

Despite the rise in treatment admissions for co-occurring disorders, the percentage of those seeking treatment for both mental health and substance use disorders is still small.

10

Treatment Challenges for Co-occurring Disorders

Mental health services tend not to be well prepared to deal with patients having both mental health and substance abuse problems.

Often only one of the two problems is identified. If both are recognized, the individual may bounce

back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them.

Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders.

Source: National Alliance on Mental Illness, retrieved 06/21/10 from http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049

11

Outpatient Mental Health Services - 2008

Source: 2008 NSDUH

3,352

8,744

234

98

248

2,992

1,345

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Outpatient MH Clinic/Center

Office of Private Therapist, Psychologist, Psychiatrist,Social Worker or Counselor - Not part of clinic

Partial Day Hospital/Day Treatment Program

School or University Clinic/Center

Some other Place

Doctor's Office - not clinic

Outpatient Medical Clinic

Numbers in Thousands

4.2 million seen by Primary Care

17 Million adults (18+ years) seen for outpatient MH treatment/ counseling:

12

Substance Abuse Treatment in 2008

Source: 2008 NSDUH

675

672

374

743

1,455

1,054

2,187

343

0 500 1000 1500 2000 2500

Hospital-Inpatient

Private Doctor's Office

Emergency Room

Rehab Facility - Inpatient

Rehab Facility-outpatient

MH Center - outpatient

Self-Help Group

Prison/Jail

Numbers in Thousands

1.7 million seen by Primary Care

7.5 Million adults (12+ years) seen for substance abuse treatment:

13

Community Health Centers

Health Resources and Services Administration (HRSA) supported Health Centers provide comprehensive, primary health care services to underserved communities & vulnerable populations.

In 2007, 1080 Community Health Centers (CHC) reported seeing 17 million patients.

Mental health services were provided to 677,213, and substance abuse services to 92,406 – approximately 4% of total patients receiving services.

Source: HRSA National Total Summary Data, Retrieved 6/24/2010 from http://hrsa.gov/data-statistics/health-center-data/NationalData

14

Community Health Centers (cont’d)

2.8% of CHC staff are mental health personnel; 0.7% are substance abuse treatment professionals.

CHCs reported an average of 4.5 encounters for patients with alchol related disorders,• 6.8 encounters for those with other substance related

disorders,• 3 encounters for those with depression and other mood

disorders• 2.3 encounters for anxiety disorders, including PTSD• 3.1 encounters for ADD Behavior Disorders, and• 3 encounters for other mental disorders (including mental

retardation Were patients linked to other services/organizations?

Source: HRSA National Total Summary Data, Retrieved 6/24/2010 from http://hrsa.gov/data-statistics/health-center-data/NationalData

15

What Should the Role of CHCs Be In Integrated Care?

What should the role of CHCs be, given staffing levels? Are COSIGS linking with CHCs?

COSIG Grantee CHCs in State COSIG Grantee CHCs in State

Alaska 160 Arizona 119

Arkansas 68 New Mexico 106

Hawaii 71 Oklahoma 54

Louisiana 79 Virginia 132

Missouri 145 Connecticut 179

Pennsylvania 223 District of Col. 33

Texas 305 Maine 114

Vermont 43 Minnesota 49

South Carolina 127 Delaware 10

South Dakota 34

16

Benefits of “Linking” Primary and Behavioral Health Care

Improved cross-disciplinary knowledge/understanding Shared priorities/initiatives Better integrated management (less siloing) Braided/blended funding streams Integrated/linked health information technology (HIT) Integrated, co-located service delivery Consolidated reporting of client outcomes

17

Integrated Health Care

Integrated health care: Creates a seamless engagement by patients and

caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for achieving optimal health throughout the life span.

Shifts the focus of the health care system toward efficient, evidence-based practice, prevention, wellness, and patient-centered care, creating a more personalized, predictive, and participatory health care experience.

Source: Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit (2009) Institute of Medicine (IOM), Retrieved from http://www.iom.edu/Reports/2009/Integrative-Medicine-Health-Public.aspx

18

The Cost Benefit of Integrated Care

Individuals with co-occurring substance abuse/medical problems randomized to integrated care had significantly lower total medical costs than those in independent care.

Following SA treatment, inpatient and emergency room costs decline by approximately 35% and 39% respectively.¹

Total medical costs per patient per month decline from $431 to $200.²

One state study found that treatment lead to a decrease in Medicaid costs of about 5% over a 5-year period.³

Treatment for Medicaid patients in a comprehensive HMOreduced medical costs by 30% per treatment member.4

¹ Parthasarathy, S. et al. (2001) J Stud Alcohol. 62(1): 89-97 ² Parthasarathy, S. et al. (2003) Med Care. 41(3): 357-367 ³ Luchasnky, B. et al. (1997) Cost Savings in Medicaid Medical Expenses [Briefing Paper] Olympia, WA: Research & Data Analysis, Dept. of Social & Health Svcs.4 Walter, L.J. et al. (2005) J Behav Health Serv Res. July-Sep. 32(3): 253-263

19

Barriers to Integrated Care

Delivery System Design • Physical separation of services, fragmented

communication, language differences between systems

Financing • Siloed payment & reporting systems, competition

for scarce resources Legal/Regulatory

• HIPAA and confidentiality rules, conflicting mandates at federal, state & local levels, categorical program requirements

Source: Report of the California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (2009, October 22) [PowerPoint Slides] Retrieved from http://www.ibhp.org/index.php?section=news&subsection=show_news_details&news_id=80

20

Barriers to Integrated Care (cont’d.)

Workforce • Feared loss of identity and priority• Lack of cross-training• Shortage of providers, need for cultural

competence/linguistic capacity Health Information Technology

• Lack of common IT systems, electronic health records (EHRs) often unable to support multi-system information

Source: Report of the California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (2009, October 22) [PowerPoint Slides] Retrieved from http://www.ibhp.org/index.php?section=news&subsection=show_news_details&news_id=80

21

Steps to Improve Primary and Behavioral Health Care Linkage

Recognize benefits and inevitability of improved linkage.

Improve collaboration and cross-training, especially primary care identification of patients with and at risk for substance use disorders.

Focus on holistic health, including prevention and recovery.

Better integrate funding, including federal grants. Co-locate service delivery where possible. Enhance referral relationships.

22

ReducedCriminalInvolvement

Stability inHousing

Cost Effectiveness

PerceptionOf Care

Retention Abstinence

Employment/Education

Evidence-Based Practice

Social ConnectednessAccess/Capacity

Ongoing Systems Improvement

Recovery

Health

Wellness

Outcomes

Mental Health

Primary Care

Child Welfare

Housing

Human Services

Educational

Criminal Justice

Employment

Private HealthCare

Systems of Care

Organized RecoveryCommunity

DoD &Veterans Affairs

Indian Health Service

Addictions

Tribes/Tribal Organizations

Bureau of Indian Affairs

Child Care

Housing/Transportation

Financial

LegalCase Mgt

Peer Support

Health Care

Mental Health

Alcohol/Drug

VocationalEducation

SpiritualCivic Organizations

Mutual Aid

Services & Supports

Community Individual Family

Recovery-oriented Systems of Care (ROSC) Approach

Community Coalitions

Business Community

Federal Efforts to Integrate Primary and Behavioral Health Care

15

24

Affordable Care ActInteragency Collaborative Efforts

Collaboration

Medicaid State Plan Amendment for Health Homes CMS, SAMHSA

Grants to behavioral health programs for co-occurring primary care conditions

SAMHSA, HRSA

National Public-Private Outreach and Education Campaign regarding prevention benefits

CDC, SAMHSA, HRSA

Primary Care Extension Education Program Regarding Chronic Conditions

AHRQ with SAMHSA and others

Behavioral Health Professional Ed/Training Grants HRSA, SAMHSA

Paraprofessional Child/Adolescent Behavioral Health Worker Training

HRSA, SAMHSA

Definition of “Essential Benefits” under health reform All Agencies

25

Other Affordable Care Act BH/PC Integration Efforts

Program Integration AspectCenters of Excellence for Depression

Comprehensive basic, clinical services in interdisciplinary research and practice

Medicaid outreach to vulnerable and underserved groups

Includes “individuals with mental health or substance-related disorders”

Medicaid Emergency Psychiatric Demonstration

Pay IMDs for stabilization services and provides waiver authority for others (report and recommendation)

Amended Medicaid rehabilitation option prevention services

Must include SBIRT alcohol, depression screening with no co-pays

26

Other Affordable Care Act BH/PC Integration Efforts (cont’d.)

Program Integration AspectMedicare State/tribal community interdisciplinary health teams to assist primary care providers

Must include “behavioral and mental health providers (including substance use disorder prevention and treatment providers.)”

Maternal, infant & early childhood home visiting program

States must assess capacity for substance abuse treatment and target families with SA history.

School-based health centers

Should provide MH/SA assessment, counseling, treatment, referral

27

Other Affordable Care Act BH/PC Integration Efforts (cont’d.)

Program Integration Aspect

National Prevention & Health Promotion Strat.

Priorities must address MH, SA disorders

Study on community-based prevention/ wellness programs

Must include mental health

Surgeon General’s public health sciences track

100 of 850 annual slots reserved for behavioral health

Prevention Trust Fund Includes SAMHSA funding

28

HHS Behavioral Health Integration

HHS Interdepartmental Behavioral Health Committee SAMHSA/HRSA Collaboration, e.g., National Health

Service Corps and MAT Health Reform regulations/CMS Expanding and integrating SBIRT services Medical residency curriculum development (SBIRT) Health information technology development/ONC

Collaboration/Integration within SAMHSA

21

30

SAMHSA’s Strategic Initiatives

SAMHSA’s strategic initiatives focus on behavioral health and crosscut the Centers.

The goal is to improve lives and capitalize on emerging opportunities, align resources, and create a consistent message.

They are works in progress that will continue to benefit from public input and reflect the concepts of open government.

31

SAMHSA’s Strategic Initiatives

Prevention of Substance Abuse & Mental Illness Trauma and Justice Military Families – Active, Guard, Reserve, and Veteran Health Insurance Reform Implementation Housing and Homelessness Jobs and the Economy Health Information Technology for Behavioral Health

Providers Behavioral Health Workforce – In Primary and Specialty Care

Settings Data Quality and Outcomes – Demonstrating Results Public Awareness and Support

32

Enhanced Collaboration within SAMHSA

Close integration of work as part of SAMHSA-wide behavioral health approach

Cross-unit collaboration on 10 Strategic Initiatives More jointly funded grant programs (braided

funding) Better integration of substance abuse and mental

health within other efforts (Recovery Month, TIPS, data systems, etc.)

33

SAMHSA Braided Funding

Resources from two or more programs used to support single program effort (RFA)

2010 example: mental health “placed based” Community Resilience and Recovery (CRRI) grants combined with SA treatment drug court funds

Funds must maintain separate identities Co-project officers from contributing sources Emphasis on comprehensive behavioral health will

require increased collaboration at local level.

34

Jointly-Funded/Managed Programs

2010 Community Resilience and Recovery Initiative, $4.2M (CMHS

and CSAT) Training/TA Center for Primary and Behavioral Health

Integration, $2M (SAMHSA and HRSA) Adult Drug Courts, $10M (SAMHSA and DOJ)2011 Substance Abuse and Mental Health SBIRT, $15M (CMHS and

CSAT) Integration of behavioral health into FQHCs, $25M (HRSA, VA,

SAMHSA) Others expected for 2011

35

Summary

This is a critical time for the future of all federal health programs, including behavioral health.

Health care reform and other initiatives will inevitably result in primary and behavioral health integration.

It is essential to begin now to foster enhanced linkages.

Emphasis will continue to be on improved system efficiency and performance within a patient/client centered, holistic approach.

36

Thank you.Thank you.