Behavioral Health Integration Panel

2

Behavioral Health Integration Panel▪ Goal: Learn about the integration of mental health and substance use services in the primary care setting. Topics include co-location workflows, OASAS offsite services, motivational interviewing and buprenorphine waivers for PCPs.

▪ Moderator: Jessica Steinhart, MPH, PCMH CCE, Director of Ambulatory Care Initiatives

▪ Panelists:

▪Rosemarie Santoro, Victory Internal Medicine and Steven Rudolf, LCSW, Mental Health Service Corps

▪Nadeen Makhlouf, PharmD, MPH, Staten Island Partnership for Community Wellness

▪Anthony Perrone, LMHC, Silver Lake Behavioral Health and Diana Ciavarella, CMHC, Silver Lake Behavioral Health

▪Marianne Howard-Siewers, MS, RN, Staten Island PPS

Rosemarie Santoro, Manager, Practice Transformation and QI, Victory Internal MedicineSteven Rudolf, LCSW, Supervising Social Worker, Mental Health Service Corps

Work flows & Warm Handoffs1. PHQ-2 screening at every office visit.2. Positive screenings are reviewed by Physician.3. Physician will the bring Karina in the room to initiate the warm

handoff.4. Follow up appointment with Karina is scheduled at check out.

Timeframe Working days Total patients seen

AveragePatients seen Per day

Variance

10/2/2017 –10/31/2017

14 47 3 N/A

11/3/2017 –11/21/2017

11 66 6

Patients seen by LMSW

Cancellations have dropped from 42 in October, to only 29 cancellations in November.

89% cancellation rate in October43% cancellation rate in November

✓ Decreased PHQ – 9 scores✓ Decreased GAD scores✓ Decreased symptoms in a number of clients

• LCSW Supervisor: Supervise clinical work via weekly supervision and ongoing contact.

• Consulting Psychiatrist: Review caseload with LMSW and provide consultation to PCPs as needed.

• Site Coordinator: Assist with non-clinical workflow.

Medication Assisted Treatment with Buprenorphine for Opioid Use

Disorder in Primary Care

Nadeen Makhlouf, Pharm D., MPHSenior Clinical Education & Outreach Coordinator

Staten Island Partnership for Community Wellness

AgendaO Overview Opioid Use Disorder

O Burden of overdose deaths on Staten Island

O Medication Assisted Treatment (MAT)

O How to identify in clinical practice

O Buprenorphine in office based setting

O Benefits/Advantages

O Concerns, barriers, and resources

O How to become waivered

O Myths and Misconceptions about MAT

Opioid Use DisorderOpioid use disorder is a chronic, relapsing disease, with significant economic, personal, and public health consequences. (ASAM)

Defined as; “a primary, chronic disease of brain reward, motivation, memory, and related circuitry” (ASAM)

ASAM practice guidelines https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-

docs/asam-national-practice-guideline-supplement.pdf

Staten Island 2016 overdose deaths

Medication-assisted treatment (MAT)

Opioid agonist treatment

• Methadone

• Buprenorphine

Opioid antagonist treatment

• Long-acting naltrexone (Vivitrol injection)

Methadone Vs. Buprenorphine

Methadone Buprenorphine

Full opioid agonist Partial opioid agonist

Available in opioid treatment

programs (OTPs)

Ceiling to side effects, including

respiratory depression

Highly regulated As effective as methadone

Patients supervised Available in primary care, not

only drug treatment programs

Prescribers need certification

(waiver)

OUD treated like any other

chronic disease

Universal Screening

▪ DAST-10

▪ The Drug Abuse Screening Test (DAST-10) is a 10-item brief

screening tool that can be administered by a clinician or self-

administered. Each question requires a yes or no response, and

the tool can be completed in less than 8 minutes.

▪ https://www.drugabuse.gov/sites/default/files/dast-10.pdf

Buprenorphine Benefits/Advantages

O Buprenorphine treatment is the gold standard for treatment of opioid use disorder

O Can be prescribed and managed in primary care

O Risk of misuse is lower with buprenorphine than with full opioid agonists (e.g Methadone)

O Long acting and ceiling effect limits euphoria

O Counseling, though not a requirement, can happen in primary care settings or referred to outpatient programs

O When taken as prescribed Buprenorphine is safe and appropriate for short- & long-term use

https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine

Buprenorphine

Subutex

O Formulation: Sublingual Tablet

O Dosage: single daily dose

Suboxone: Contains naloxone

O Formulation: Sublingual Film, Sublingual Tablet

O Dosage: single daily dose

https://www.naabt.org/faq_answers.cfm?ID=2

Clinical/Treatment ConcernsTreatment Concern American Society of Addiction

Medicine (ASAM) Guidelines

Patient is positive/using

marijuana, stimulants, etc.

Should not be a reason to

suspend tx. (suspend if benzos &

other sedative hypnotics)

Induction time @ office Home BUPE induction may be

considered

Counseling/Psychosocial

treatment

OASAS offsite services

Fear of Diversion

Frequent office visits(weekly in

early treatment), urine testing for

BUPE

Concerns with having to

discontinue BUPE

There is no recommended time

limit for treatment

Barriers & Resources

Perceived Barriers Resources & Solutions

Waiver Training Offered by NYCDOHMH for FREE

“Not my patient population” Universal Screening

Lack of time to perform universal

screening

DAST can be self administered by

the patient

Lack of expertise/training using

BUPE

NYC DOHMH Mentorship

Waiver Drug Addiction Treatment Act 2000 (DATA 2000)

o Qualified physicians may apply for waivers to treat opioid dependency with approved buprenorphine products in any settings in which they are qualified to practice, including an office, community hospital, health department, or correctional facility.

Comprehensive Addiction and Recovery Act (CARA ACT)

o On July 22, 2016 president Obama signed the CARA ACT

o Extends Buprenorphine prescribing privileges to NPs and PAs

Waiver Process O MD/DO: 8 hour training (4 live, 4 online)

O NP/PA: 24 hour training O May take the same 8 hour training as physicians, the remaining

16 hours are available online for free by SAMHSA through https://pcssmat.org/education-training/mat-waiver-training/

O All: Post training, complete a NOI (notification of intent) online (SAMHSA), the application is forwarded to the DEA which then assigns a special ID number.

O DEA regulations require this number to be included on all buprenorphine prescriptions for opioid dependency treatment

O SAMHSA reviews applications within 45 days and notifies of approval via Email

Waiver Limits Physicians (MD/DO)

O First year: 30 patients

O Second year: 100 patients

O May apply to increase to a maximum of 275 (must wait 1 year between each limit increase is granted)

O NP/PA: at the moment are only granted a maximum of 30 patients

O Online request for patient limit increase can be found at http://buprenorphine.samhsa.gov/forms/select-practitioner-type.php

Myths and misconceptions about MAT

O Someone taking MAT is not really in recovery

O People who take MAT have less willpower than

people who do not

O MAT is substituting one drug for another

O The lowest dose is preferable

O Shortest length of treatment is preferable

O You need to detox before starting buprenorphine

YOU CAN HELP TO CHANGE THESE MYTHS

Summary-Benefits of Buprenorphine inprimary care

O Life saving!

O Office based

O Makes treatment available to those who need it

O Reduces stigmatization that may deter people from seeking

care

Thank You Contact Information

Nadeen Makhlouf Pharm D., MPHStaten Island Partnership for Community Wellness

Telephone: 718-215-8303

Email: Nadeen@sipcw.org

In Community Services

Anthony Perrone, LMHC

Clinical Director

Diana Ciavarella, CMHC

Intake Coordinator

Our focus is on total wellness

– the health of mind, body and

spirit

– a holistic approach to

recovery.

Who We Serve

Our patients come from all walks of life; addiction

and mental illness do not discriminate by age,

gender, income or family background. Our mission is

to stabilize, enrich and enhance the lives of every

patient, so they can successfully rejoin society and

their own communities.

What We Do

Silver Lake Behavioral Health offers quality,

comprehensive treatment for substance abuse and mental health in a warm,

community-based outpatient setting.

Offer initial assessment appointments usually within

24 hours

Offer Urgent Access hours

Treatment at Silver Lake may require a recovery plan

that is specific to your chosen goals in every area

of your life.

Everything you need for recovery in one place

Treatment Services

Individual Counseling

Medication Supported Recovery

Psychiatric Services

In-Community Services

Family Services Group CounselingIntegrated

Treatment For Dually-Diagnosed

Support Services

Trauma-Informed Care/ EMDR

Community Education

DWI/DUI Incident Prevention and

Treatment Program

In Community Services

At Silver Lake Behavioral Health, all services that we offer onsite in our

treatment facility, are also offered offsite in the community

In community services can take place in:

The patient’s home

A Primary Care Physician’s Office

A Nursing or Residential Facility

A public place (with consideration to confidentiality)

Virtually anywhere!

Why We Offer In Community Services

To fill the gap in care

To reduce stigma by meeting the patient where the individual feels most comfortable

To re-engage patients who may be having difficulty making it to their scheduled appointments due to:

Relapse

Mental health issues

Child care issues

Crises

To offer assessments and treatment information to individuals in the community, who may not be ready to come to the treatment center

To offer our services in locations the individual is already affiliated with, or is most comfortable, such as doctor’s offices, or various other referral agency locations

To meet the patient where they’re at, literally

To facilitate the process of a hot handoff

Recovery Happens Here

201 Forest Avenue

Staten Island, NY 10301

Ph.(718) 815-3155 Fax. (718) 815-3151

www.s i l ve r l akebehav io ra lhea l th .com

Motivational Interviewing: Engagement Practice

MARIANNE HOWARD-SIEWERS, MS, RN

CLINICAL CONSULTANT

37

Collaborative Care is…

Patient-Centered

• Effective team-based care and holistic, wrap-around services

• Collaboration and communication between PCPs and Behavioral Health Providers

Population-Based Care

• Patients tracked and monitored in registry so no one “falls through the cracks”

• Patients who are not improving receive psychiatric consultation/change in treatment

Measurement-Based Treatment to Target

• Measurable treatment goals and outcomes defined and tracked for each patients

• Treatments actively adjusted until clinical goals are achieved

Evidence-Based Care

• Treatments used are ‘evidence-based’: Motivational Interviewing, Behavioral Activation, Problem-Solving Treatment

37

38

Why are we providing Collaborative Care? Unmet behavioral health needs

▪Mental health conditions are the leading cause of disability worldwide

▪In the US, more than 25% of the population is affected by one or more mental health condition at any one time

▪30-50% of referrals to behavioral health from primary care don’t make first appt

▪Among patients with easy access to primary care who are accurately diagnosed with depression, fewer than 15% receive adequate treatment

▪Two-thirds of PCPs report not being able to access outpatient BH for their patients. ▪ Shortages of mental health providers, health plan barriers, and lack or coverage/inadequate

coverage are all cited by PCPs as critical barriers to behavioral healthcare access

1. The global burden of disease: 2004 update. World health Organization; Geneva: 2008

2. Kessler RC, Wang PS. The descriptive epidemiology of commonly occurring mental disorders in the United States. Annu Rev Public Health. 2008;29:115–29

3. Fisher & Ransom, Arch Intern Med. 1997;6:324-333.

39

Why does Collaborative Care work?

▪Primary care teams have an established, trusting relationship with the patient

▪Primary care teams are accustomed to coordinating complex care plans

▪Referral success rate rises from 15-20% to 40-60%

▪Opportunities for informal consultation with behavioral health

401 NHDS,NAMCS,NHAMCS,MayoClin.Proc73:3292 J.Katon W. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues in Clinical Neuroscience. 2011;13(1):7-23.3. Tsai AC, Weiser SD, Petersen ML, Ragland K, Kushel MB, Bangsberg DR. A Marginal Structural Model to Estimate the Causal Effect of Antidepressant Medication Treatment on Viral Suppression AmongHomeless and Marginally Housed Persons With HIV. Arch Gen Psychiatry. 2010;67(12):1282-1290. doi:10.1001/archgenpsychiatry.2010.160

Chronic medical illness is consistently associated with an increased risk of depression

41

Why use Collaborative Care in Primary Care?

▪Access

▪ Serve patients where they are

▪Patient-centered

▪ Treat the whole patient

▪Effectiveness

▪ Better clinical outcomes

42

Tackling the obstacles to improving client participation in health care▪Engagement

▪Meet the client where they are at

▪Utilize current evidence-based models of interviewing and communication

43

Engagement▪Differentiate between empathy and sympathy

▪All individuals have obstacles in their lives

▪We aren’t as different as we think - compassion drives us

▪Provide opportunity for client to have control over what is happening- foster respect

▪Providers align with client vs. “expert”= Partnering

▪Honor the others’ perspective of what is happening

▪Be familiar with Prochaska’s Stages of Change when creating a plan with the client

44

Stages of Change▪Pre-contemplation “ what problem?”

▪Contemplation “Maybe I have a problem.”

▪Preparation “ I have a problem.”

▪Action “I’m ready to do something about the problem.”

▪Maintenance “I’ve made the changes I want. How can I keep it going?”

▪Relapse “ What have I learned from this setback? How can I get back on track?”

45

Motivational Interviewing▪Motivational Interviewing is an evidence-based approach to engaging clients in caring for themselves.

▪It is goal oriented and promotes self- efficacy.

▪It respects that the client makes autonomous decisions as to their well being.

▪The tools of MI help the provider elicit intrinsic motivation for change rather than influencing client behavior with extrinsic or “expert” instruction.

- Research has shown that motivation-enhancing approaches are associated with greater participation in treatment and positive treatment outcomes. (Landry, 1996) (Miller et al. 1999)

46

Motivational Interviewing▪Is focused on competency and strength-

It affirms the client, emphasizes free choice, supports self- efficacy and encouragesoptimism that changes can be made.

▪Is individualized and client centered-

Using brief action planning the client creates a SMART goal and a few realistic interventions for themselves vs. the clinician “prescribing” the care the client “should” “must” adopt

▪Threats of negative outcomes do not motivate clients to change. Only increases resistance.

47

Motivational Interviewing▪Does not label-

It avoids using labels, especially with clients who may not agree with a diagnosis or who do not believe that a specific behavior is problematic.

▪It creates therapeutic partnerships-

Motivational Interviewing creates an active partnership where the client and the clinician work together to establish agreed upon treatment goals and interventions.

48

The Spirit of Motivational Interviewing▪Partnership= collaboration

▪Acceptance*

*Acceptance in the context of MI does not mean you are agreeing with the client but rather you are accepting what they are saying or their opinion at the time without challenging them or becoming the authority.

▪Compassion- a commitment to pursue the welfare and best interest of the other

▪Evocation- people already have within them much of what is needed to change, clinicians approach their clients from a strength based perspective and are charged with helping the client identify their strengths and call them forward when working on a plan for their health.

49

MI Core Skills▪“OARS”

▪O- open ended questions

▪A -affirmations

▪R -reflections

▪S- summarize

50

Elicit Change Talk with Open Ended Questions

Ask about disadvantages of status quo-What worries you about not making this change?-How has [behavior] stopped you from doing things that are important to you?

Ask about advantages of change-If you were to make a change in this area, how would you feel after doing so?

-Why would the people in your life you love want you to make this change?

-If you could make this change by magic, how might things be better for you?

Ask about optimism and confidence-When else in your life have you been successful in making a change?

-Who might you be able to get support from if you decide make this change?

-What is a small first step you could take today toward making this change?

-On a scale of 1-10, how confident are you that you could make this change?

51

Brief Action Planning: Step 1

51

Decrease Activities

that maintain

depressive symptoms

1 2 3

Is there anything you want to do for your health OR to improve your mood in the next week or 2?

Have an idea?

“That’s fine. If it’s ok

with you, Ill check with

you next time.”

[Schedule next

session]

1) Ask permission to share ideas

2) Share 2-3 ideas

3) Ask: Do you think any of these

ideas might work or do you have

another idea?

Not at this time

Not Sure?

Behavioral

Health Menu

Proceed to step 2: Smart Behavioral Plan

52

Brief Action Planning: Step 252

Decrease Activities

that maintain

depressive symptoms

1 2 3

SMART BEHAVIORAL PLAN

Elicit Commitment Statement

How confident do you feel about carrying out your plan (on

a scale of 1-10)

Confidence < 7 “A __ is higher than a 0. That’s good. We

know that people are more likely to complete a plan if it’s

higher than a 7”

Problem Solving: “Any ideas about what might raise your

confidence?”

YES NO

Behavioral Health Menu

Assure improved

confidence

Confidence > 7

“That’s great!”

Restate plan. Would it be helpful to set up a time

to check on how things are going with your plan?

How?

When?

With Permission

1) What

2) Where

3) When

4) How often/ long/much?

5) Start date

53

Checking on Brief Action Plan

53

“How did it go with your plan”

“What would you like to do next?”

Did not carry out plan

Reassure that this

is a common

occurrence

1 2 3

Completion Partial Completion

Recognize

SuccessRecognize Partial

Completion

54

Summary▪Tackling the obstacles to improving client participation in health care▪ Engagement

▪ Motivational Interviewing

▪ Meet the client where they are at

▪ Stages of Change

▪ Utilize current evidence-based models of interviewing and communication

▪ Brief Action Planning

55

Behavioral Health Integration Panel

Thank you!

www.statenislandpps.org