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 environment in California Challenges and opportunities 2
HEALTHRIGHT 360 Whole person care for low-income adults, youth, and families • Substance use disorder (SUD) treatment • Residential • Outpatient • Medication Assisted Treatment • Mental health services • Primary medical care (FQHC) • Support services that address the social determinants of health: • Education, • Employment prep, • Housing case management and transitional housing 3
HEALTHRIGHT 360 Lyon Martin Health Services Haight Tenderloin Health Services Ashbury Women’s Recovery Association Free Asian America Recovery Clinics Services North County Serenity House Prototypes HealthRIGHT 360 Walden House 4
OUR MISSION AND MODEL 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. MH Tx Medical Social SUD Tx Svces Client 5
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
HEALTHRIGHT 360 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 7
A long strange trip… 8
VIEWS OF ADDICTION Chronic brain condition Adaptive coping mechanism Moral failing 9
SPECIALTY CARE FOR SUD • Aversion therapies • Institutionalization/incarceration • Detoxification • NTPs • Minnesota Model • Therapeutic Communities
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
SUD PREVALENCE AND COST 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 • Managing withdrawal and preventing cravings • Methadone • Buprenorphine • Nicotine replacement • Therapies to manage cravings and/or block euphoric effects • Naltrexone (oral and injectable) • Acamprosate • Disulfiram • Zyban • Chantix 14
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 15
CHANGING TREATMENT FRAMEWORKS Chronic care/ongoing support Acute/episodic brief care Acute/long- term care 16
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*: • Healthcare delivery system redesign towards preventative care • Healthcare organizational support/organizational leadership and resources • Expert informed decision support • Improve information systems to track and coordinate care • Fostering patient self-management through coaching, problem solving and peer support • Linking patients to community by enhancing access to community resources McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, McNeely J. Can substance use 17 disorders be managed using the Chronic Care Model? Review and recommendations from a NIDA consensus group. Public Health Reviews . 2014; 35(2):2107 – 6952.
CHRONIC CARE MODEL Framework for SUD treatment includes services along a continuum, matched to patient need, integrated with primary care Services Self- embrace Link to Team based Person management evidence- Info sharing community care centered and recovery based resources support guidelines 18
INTEGRATED CARE FOR SUD Referral Co-located Collaborative • Separate • Practice • Physical facilities transformation proximity • Communication • Team-based • Meet to discuss key element care with specific cases shared information 19
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 Dissemination of Integrated Care within Adult Primary Care Setting: 20 Collaborative Care Model (2016) American Psychiatric Association Academy of Psychosomatic Medicine.
POPULATION HEALTH • A systematic effort to improve health outcomes in sub- populations that share multiple clinical and social attributes • Reflects the interdependence of biology, behaviors, social, cultural, economic and environmental factors that impact well- being • Compels providers to envision and develop organized and integrated systems that deliver the Quadruple Aim: 21 Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV.
QUADRUPLE AIM Improved patient Better health experience Healthcare Improved care Reduced cost team experience 22
POPULATION HEALTH A systematic effort to improve health outcomes in sub- populations that share multiple clinical and social attributes • Patient registries • Reviewing data in the aggregate (e.g. patients over 50 or under 25, patients w/history of incarceration, Pacific Islander patients, etc.) • Reviewing health outcomes and distributions within a population • Reviewing patterns of determinants of the outcomes 23 Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV.
POPULATION HEALTH Reflects the interdependence of biology, behaviors, social, cultural, economic and environmental factors that impact well-being • Efforts to improve population health must address the social determinants of health • Such efforts should be focused on both improving the health of individual patients as well as changing/improving the social conditions that may impede health improvement 24 Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV.
MEASURE 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 25
BEHAVIORAL HEALTH MEASURES Screening Assessment • CAGE-AID • ASI • DAST • GAIN • AUDIT • PCL • PHQ-9 • ACE-R • BSI • BDI ADAI Library: Substance Use Screening & Assessment Instruments Database. http://lib.adai.uw.edu/instruments/ Unlike primary care, SUD has no nationally agreed upon measures 26
AND MEASURE 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 27
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