How Behavioral Health Organizations Can Positively Impact Communities Effected by Prescription...
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How Behavioral Health Organizations Can Positively Impact Communities Effected by Prescription Drug Abuse
Doug Leonardo, LCSWExecutive Director
Tracey Kaly, LMHCClinical Services Manager
Learning Objectives
1) Learn about state/local prescription drug abuse data related to mortality rates, neonatal abstinence syndrome and pain clinic monitoring.
2) Learn a minimum of 3 ways a behavioral health center can support their local community.
3) Learn some of the steps needed to develop an integrated care model to provide behavioral health services onsite in specialty care sites (e.g.; pain management clinics, health clinics, primary care offices and hospitals).
Agenda
1) Who We Are
2) State and Local Data Trends
3) Supporting Your Local Community
4) Building an Integrated Care Model
Who We Are
• BayCare - large community-based non profit health care system in Florida
• Located in Tampa Bay Region• Network of hospitals and outpatient facilities • 22,000 team members• We are the behavioral health service provider for the
BayCare Health System• Full continuum of adult and children's behavioral
health services• Services provided in 5 counties in Tampa Bay area
Addiction
…a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing the development and manifestations. It is characterized by behaviors that include one or more of the following:– Impaired control over drug use– Compulsive use– Continued use despite harm– Craving
(American Society of Addiction Medicine, 2001)
State Data 10 Year Trend Upward in Prescription Drug Abuse
FY 01-02 FY 02-03 FY 03-04 FY 04-05 FY 05-06 FY 06-07 FY 07-08 FY 08-09 FY 09-10 FY 10-110.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Ten Year Trend Analysis of Drug of Abuse
AlcoholMarijuanaCrack/CocaineHeroinOther OpiatesMethamphetaminePrescription Other Drugs
Fiscal Year
% o
f Tot
al A
dmis
sion
s
Florida counties with high rates of opiate overdoses
Florida counties with high rates of benzodiazepine overdoses
State Data Overdoses – Opiates and Benzo’s
State Data Hospitalizations and Emergency Department Visits for Unintentional Rx Drug Poisonings
12.3
23.8
15.2
23.8
0
10
20
30
2006 2007 2008 2009 2010
Rate
per
100
,000
pop
ulati
on
Opiate Poisoning Tranquilizer Poisoning
Source: Agency for Health Care Administration Emergency Department and Inpatient Hospital Datasets
Florida Poison Information Center Tampa
Oxycodone Suspected Suicides
205
260
302
227
305 294
368
430
583
668
0
100
200
300
400
500
600
700
800
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber
Year
326%Increase
January 20, 2011
Florida Poison Information Center Tampa
602
761809
919
1523 1525
1284
1054
1432
1590
0
200
400
600
800
1000
1200
1400
1600
1800
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Num
ber
Oxycodone Cases 264% Increase
January 20, 2011
State Data Drug Overdose Deaths 2003 - 2009
Death rates for all substances increased with the exceptionof heroin and cocaine. Heroin decreased 62.2% Cocaine decreased 10.8%
Death rates for prescription drugs increased 84.2%. 7.3 to 13.4 per 100,000
Substance specific death rates. Oxycodone rose 264.6% Alprazolam rose 233.8% Methadone rose 79.2% Ethanol rose 81.4%
Source : MMWR July 8, 2011/60 (26);869-872
Prescription Drug Monitoring Program (PDMP)
Florida lacked a system for monitoring drug prescriptions until Governor Scott signed a bill into law on June 3, 2011;
The law strengthens reporting requirements to a prescription drug database, increases penalties for overprescribing, tracks wholesale distribution of specific controlled substances, bans most doctors who prescribe narcotics from dispensing them and provides funding to support law enforcement and state prosecutor efforts;
Attorney General Pam Bondi has made prescription drug abuse her top priority;
98 of the top 100 doctors dispensing Oxycodone nationally are in Florida – concentrated in the Miami, Tampa and Orlando regions.
Prescription Drug Monitoring Program (PDMP)
The state of Florida has established a program that will improve patient quality of care and reduce controlled prescription drug abuse and diversion.
The PDMP will reduce the chances for patients to repeatedly and illegally divert prescription drugs.
Overall the program will dramatically reduce doctor and pharmacy shopping.
Local Data - Pasco County Prescription Drug Abuse Becomes Priority
Parents began calling local substance abuse coalition (ASAP) to get involved;
Legislators asking for community members to get involved; Law enforcement was highlighting the prescription drug related
crimes: (impaired driving, stolen property, drug trafficking, pill mills, etc.);
Detoxification unit seeing unprecedented number of admissions for prescription drug dependency (specifically females aged 18 to 40);
FYSAS indicated increase in prescription drug use by students;
Pill mills and drug trafficking arrests increased significantly in Pasco County;
Pain Management practitioner reached out to local provider and coalition to become part of the solution.
Local Data - Pasco County Lethal Level of Drug Present at Death
According to the Medical Examiner, there were 103 deaths from Oxycodone alone in 2010. District 6, which consists of both Pasco and Pinellas Counties identified higher amounts of prescription drugs tracked by the Medical Examiner at the time of death then any other district in the State of Florida. Primary drug of choice is Oxycontin (30 mg), followed by Xanax.
Pasco County is higher than Pinellas County in per capita drug-related deaths.
Primary route of delivery; crushing and inhaling, followed by an equal amount of oral and injection.
Approximately 80% obtain from “friends” who sell off the streets and approximately 20% steal from a parent or family member who is prescribed.
Local Data Pasco County
0
200
400
600
800
1000
1200
1400
1600
1800
2000
0
40
80
120
160
200
2005 2006 2007 2008 2009 2010
FloridaCoun
ties
Trends in Newborn Withdrawal diagnoses, 2005 - 2010
Pasco (+2,840%)
Pinellas (+595%)
Florida (+433%)
Pasco County has the Highest Rates of Diagnoses of Newborn withdrawal per 1000 live births in the State of Florida. Source: DCFPinellas and Pasco Counties ranked 1 and 2 respectively in the state of Florida for the number of substance exposed newborns. Pasco saw a 2,840% increase from 5 in 2005 to 147 in 2010 and nearly doubled the from 2009 to 2010 (75 to 147 respectively). Data obtained from the Florida Agency for Health Care Administration (AHCA)
Local Data - Pasco County
63.2% of the 399 women ages 18 - 40 (child bearing age) that entered treatment, reported a prescription drug as their primary drug of choice in Pasco County (BayCare Behavioral Health 2009 - 2010).
4.1% of Pasco County high school students report past 30-day use of prescription pain relievers (2010, Florida Youth Substance Abuse Survey).
In 2008 in Pasco County, there were 159 ER visits for an Opioid related incident. There were 86 overdoses of Benzodiazepine and 20 overdoses involving other tranquilizers (2008 Agency for Healthcare Administration).
The number of female inmates in Pasco Sheriff’s County jails that are pregnant and have substance abuse problems with prescription drugs is increasing.
59% of Pasco residents feel that there is not enough enforcement of prescription drugs (2010 Pasco Alcohol Policy and Prescription Drug Use Survey).
Supporting Your Local Community:What Can I Do As a Provider?
Gather data to prioritize the public health problem related to prescription drugs;
Start a local Initiative with rapid action planning; Join learning collaboratives and list serves; Leverage grants and other funding initiatives; Educate policy makers, funders, providers,
individuals, families and communities about the public health issue and advocate for policies to reduce morbidity and mortality rates;
Explore with local community the recovery supports for supportive housing, activities of daily living, phone outreach, peer mentors, recovery coaches wellness centers, etc.;
Focus on what happens BEFORE and AFTER primary treatment with greater emphasis on the physical, social and cultural environment in which recovery succeeds or fails;
Supporting Your Local Community:What We Did as a Provider
Leverage collaborative initiatives to combat epidemic (coalition’s, stakeholders, specialty clinics, legislators, law enforcement, etc.).
Frame your system of care with a focus on integrated care partnerships (FQHC, health clinics, primary care, specialty care clinics, hospitals, emergency departments, etc.);
Collaborative Initiatives
1. In 2010 we created a Prescription Drug Initiative to address the growing number of individuals seeking treatment for prescription drug use, increased deaths related to prescription drug use, increased substance exposed newborns and the increased number of unauthorized pain management clinics in Pasco County.
2. Focus was to review, research and make recommendations on how to address the increasing prescription drug problems within our community.
3. Committee was composed of law enforcement, treatment providers, parents, judiciary, pain clinics and community partners.
4. One of the recommendations from that effort was the development of a proposed innovative project to assist Pasco County in the epidemic fight against prescription drug use.
5. The proposed project would harness six environmental strategies that would bring about community change that was adopted as a useful framework by the Community Anti-Drug Coalitions of America (CADCA).
Provide Information - Enhance Skills - Provide Support - Change ConsequencesChange Physical Design - Enhance Access
Collaborative Initiatives
Provide Information
Change Physical Design
Enhance Access
Change Consequences
Provide Support
Enhance Skills
Eliminating Prescription
Drug Abuse in Communities
Collaborative Initiatives
Sample Description of ActivitiesProvide Information Community Forums, Marchman Act training, prescription drug tool kits and social
norms marketing campaign, etc.Enhance Skills Prescriber training, parent and youth summit, student and faculty training,
motivational interview training, screening and intervention training, community education, etc.
Provide Support Prescription drug information line, medication disposal pill drop boxes, Rx drug
safes, etc. Change Consequences Pain clinic best practices, pain clinic compliance, pain clinic drug screenings,
enhance drug court Ambassador Program, etc.Change Physical Design Intelligence Led Policing enforcement activities, Take Back events, etc.Enhance Access Outreach, care management, community education, substance abuse screening
tools, expanded treatment capacity, etc.
Integrated Care Partnerships
“Integrated care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their medical care providers.”
“It allows patients to feel that, for almost any problem, they have come to the right place.”
Alexander Blount, Ed.D.
Why do Integrated Care?
To strengthen collaboration between behavioral health and health care; To reduce cost and utilization factors; To improve outcomes, access to care and engagement; To integrate population based care into system redesign; To prepare for payment reform and overall system redesign; Because with reform primary care and behavioral health services must be available in all clinical settings; Because behavioral health settings must have streamlined access to medical services; Because all healthcare settings must have care coordination capability in the continuum based on case mix and severity; Because it is the right thing to do.
How do I get started?Building an Integrated Model Establish administrative and clinical leadership “buy-in”; Create a sense of urgency; Establish an Integrated Care Initiative; Complete an environmental scan - readiness assessment; Benchmark the perception of healthcare professionals
regarding integration; Design and deploy strategically (PCP, FQHC, Hospitals, ED,
Pain Clinics, etc.); Identify and address funding/financial barriers; Develop and revise business modeling/practices; Seek partners who bring needed expertise or consultation; Commit on transformation from volume to value.
Qualities of an Integrated Model
1) Culturally competent2) Stepped care approach 3) Shortened sessions4) Condensed treatment pathways5) Multiple delivery formats
Benefits of an Integrated Model
More likely to keep appointments Treat person where they feel
comfortable Focus on preventative care Offset medical cost On site behavioral services available Better communication Better outcomes Mind/body connection Whole person approach
Measure, Measure, Measure
Develop metrics (satisfaction, efficacy, productivity, cost, access, utilization,
capacity, health indicators, etc.)
Key Findings and Challenges ofIntegrated Care
Not one size fits all (cultural tailoring, developing common language, variance in population based needs, training, etc.);
Quality outcomes and measurement are vital (future pay structure, integrated record, reliable data, etc.);
Care management/coordination imperative (break down silos, use skills with care management, cross train, home based practice, patient education coaching, focus on raising health of population, etc.);
Payment alignment and reimbursement is challenging (transforming from fee for service model to delivering model of brief care, internal and external barriers, minimal current state flexibility, minimal consultation reimbursement/care management/ telephone contact, pursuit of cost offset not immediate, etc.);
Access and the ability to ramp immediately based on the unmet demand by primary care is urgent (physician demands, access to care, multiple primary sites, psychiatric evaluation requests, etc.);
Changing the system of care is essential (finding the right staff, brief stepped care approach, pathway driven model, limited short sessions with focus on triage, group preventive care with focus on at risk patient, linkage to specialty care clinics for diversion of high risk patients, emphasis on early identification, etc.);
Key Findings and Challenges of Integrated Care
Cultural competencies are critical (recognizing differences, assessments/screenings/interventions are appropriate, linkage to community support services, etc.);
Sustainability is crucial. Data and Outcomes (integrated electronic health record, measurement
moving from encounters to overall health outcomes, increased productivity for physicians, patient/family satisfaction will be driver of long term market differentiation, change in care being based on managing health of population. physician satisfaction, quality of life increased, identifying and documenting added values, payment for those of us that deliver, etc.).
Staff Model Integration
Level 4
Deep IntegrationCo-Located
Level 3
Basic IntegrationCo-Located
Level 2
Basic CollaborationAt-a-Distance
Level 1
Four Level Integration Model
Separate Sites2 Front DoorsReferral to BH Clinic
Staff Model
Integration
Deep Integration
Co-Located
Basic Integration
Co-Located
Basic Collaboration
At-a-Distance
ACCESS
Single SiteSeparate ReceptionOn Site Paper Referral
Single SiteSame ReceptionWarm Handoff ReferralSpecialty Care Referrals
Single SiteOne ReceptionOne Visit for All NeedsSpecialty Care Referrals
2 Prescribers2 Separate Treatment PlansLicensed Clinician At A DistancePhone Consultation for Staffing
Staff Model
Integration
Deep Integration
Co-Located
Basic Integration
Co-Located
Basic Collaboration
At-a-Distance
SERVICES
2 Prescribers with Psych. Phone Consult2 Treatment Plans with Information Sharing Licensed Clinician On SiteInformal On Site StaffingPatient Prevention Materials DistributedScheduled Appointments for BH On Site
2 Prescribers with On Site Psych. Consult2 Treatment Plans with Integrated GoalsLicensed Clinician On SiteMulti Disciplinary Treatment Team StaffingPatient Prevention Groups Same Day Appt. as Primary AppointmentReferrals Made to Case Management
1 Prescriber 1 Treatment Plan Fully IntegratedLicensed Clinician in Staff Model1 Treatment TeamPatient Prevention - Wellness GroupsIntegrated Care Manager On SiteIn Home Clinical Services AvailableIntegrated Appointment with PC
Traditional Clinical PathwaysTraditional Therapy ModelsMotivational Interviewing
Staff Model
Integration
Deep Integration
Co-Located
Basic Integration
Co-Located
Basic Collaboration
At-a-Distance
VALUE ADDED PRACTICES
Specialized Clinical PathwaysBrief Therapy Model (15 - 30 minute sessions)Motivational InterviewingScreening Tools On Site (e.g. PHQ9, CAGE)
Integrated Clinical PathwaysBrief Therapy and SBIRT Model (4-8 sessions)Motivational InterviewingOn Site Clinician Conducts ScreeningsJoint Monitoring Health ConditionsPsychiatric Training
Integrated Clinical/Critical PathwaysBrief Therapy Model and SBIRT ModelMotivational InterviewingCare Management ModelCare Manager Conducts ScreeningsTeam Monitoring Health Conditions Psychiatric TrainingPatient Centered Medical HomeManage Multiple Chronic Conditions
Try to avoid this……
What’s Next?
QUESTIONS
Contact Information
Doug Leonardo, LCSWTracey Kaly, LMHC
BayCare Behavioral Health8132 King Helie Blvd.New Port Richey, Florida 34653
[email protected]@baycare.org