Thomas E. Freese, PhD [email protected] UCLA Integrated Substance Abuse Programs Pacific...

Working in the Health Care System

The Culture of Integrated Services

Thomas E. Freese, [email protected]

UCLA Integrated Substance Abuse ProgramsPacific Southwest Addiction Technology Transfer Center

1

Primary care culture and effective communication

Role definitions for Mental Health staff in primary care settings

Medical issues that commonly co-occur with mental health and substance use

Barriers to service access A case example.

What Will We Cover?

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International Comparison of Spending on Health, 1980–2010

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US

SWIZ

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Average spending on healthper capita ($US PPP)

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USNETHFRGERCANSWIZUKJPNAUS

Total health expenditures aspercent of GDP

Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.

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Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 65 Percent of

Expenses

U.S. population Health expenditures

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009

1%5%

10%

50%

65%

22%

50%

97%

$90,061

$40,682

$26,767

$7,978

Annual mean expenditure

In the USA and Canada, mental health disorders account for 25% of all years of life lost to disability and premature mortality1

One in four American adults experience a mental health disorder in a given year, and 1 in 17 have a seriously debilitating mental illness2

Among those who die by suicide, more than 90% have a diagnosable disorder4. In 2008, suicide was the tenth leading cause of

death in the USA6.

Consequences of MH Disorders

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1. World Health Organization. (2004). The world health report 2004: changing history. Annex Table 3. A126-A127. Geneva: WHO.

2. Kessler RC, et al. (2005). Archives of General Psychiatry, 62: 617-627.

3. US Department of Health and Human Services. (1999). Mental health: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, 1999.

4. Minino AM, et al. (2011). Final Data for 2008. National Vital Statistics Reports 2011; 59(10): 01-127. Available: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf.

Mental health and substance use services are integral to health care services. The goals of DMH initiatives are:◦ Ensure positive experiences of care ◦ Enhance customer services

Ensure care is effective◦ Develop bi-directional care/behavioral health homes◦ Implement data outcomes system to enable

monitoring of client progress Control/reduce costs

◦ Develop strategies to extend care◦ Develop strategies to reduce readmission and

preventable hospitalizations

Shifting to a Whole Health Perspective

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We’re planning on filling in the details later

What is “Primary Care Integration”?

Primary care integration is the collaboration between SUD service providers and primary care providers (e.g., FQHC’s, CHC’s)

Collaboration can take many forms along a continuum*

*Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.

MINIMAL BASIC

At a Distance

BASIC

On-Site

CLOSE

Partly Integrt

CLOSE

Fully Integrt

Coordinated Co-located Integrated

The Primary Care System

SUD Care Syste

m

Minimal Coordination

• BH and PC providers – work in separate facilities, – have separate systems, and – communicate sporadically.

MH Care Syste

m


BH And PC providers ◦ Engage in regular

communication about shared patients leading to improved coordination

Basic AT A DISTANCE

SUD Care Syste

m

MH Care Syste

m


BHand PC providers ◦ Still have separate systems ◦ Some services are co-

located (e.g., screening, groups, etc).

Basic On Site (co-location of services)

Referral

Referral

SBI

Counseling

SUD Care Syste

m

MH Services

Counseling

MH Care Syste

m

BH and PC providers ◦ Still have separate systems ◦ Primary care services are

integrated into BH Settings

Basic On Site (reverse co-location)

SUD Care Syste

mMedical

Services


Referral

MH Care Syste

m

Medical

Services

Referral

PC providers ◦ Develop and provide their won

services

Integrated Care System

Integrated


SUD Care Syste

m

MH Care Syste

m

MAT

BH and PC providers ◦ share the same facility ◦ have systems in common (e.g.,

financing, documentation◦ regular face-to-face

communication

Integrated Care System

Integrated


SUD Care Syste

m

MH Care Syste

m

Is Integration Inevitable?We did some research …

Many California Counties Are Involved in Integration Initiatives

57%

41%

2%

Chart Title

Involved in IntegrationNot Involved in In-tegration Don't Know

Percent of Counties Involved in Integration Initiatives

n=44 counties

Counties are at all Stages of Integration

Learning Partnering Planning Integrating0

1

2

3

4

5

6

7

8

9

Stage of Integration

Number of Counties

Counties are Involved in a Variety of Integration Models

• Coordinated – Increased referrals to and coordination with primary care

• Reverse Co-Located/Partially Integrated – Primary care in SUD setting

• Co-Located/Partially Integrated – SUD specialist is placed in primary care setting or hospital

• Integrated SBIRT – Medical professional conducts SBIRT or MAT in primary care setting

The Medical System Managed Care

◦ Any system that manages healthcare delivery with the aim of controlling costs.

◦ Typically a primary care physician acts as gatekeeper for other health services such as specialty medical care, surgery, or physical therapy.

◦ www.medicinenet.com

Managed Care Traditional Insurance

Choosing a physician Selected from plan list Any

Specialty care Primary care referral Any

Quality of Care

Insurer determines prior to enrolling the provider

Patient responsible for determining

Payment for Services Capitation Individual pays fee for service.

Gets (partial) reimbursement

Advantages Overall cost savings Maximum flexibility

Disadvantages

Too few services provided High cost

Managed and Fee-for-Service Care

http://extension.missouri.edu/hes/infosheets/

The Medical System

Primary Care The aims of primary care are to provide

broad spectrum of care◦ both preventive and curative;◦ over a period of time; and ◦ to coordinate all of the care the patient receives.

All family physicians and most pediatricians and internists are in primary care.


The Medical SystemPrimary Care Practitioner must possess a wide breadth of

knowledge in many areas. Patients consult the same primary care

doctor for routine check-ups, and initial consultation about a new complaint.

Common chronic illnesses, often treated in primary care, include:◦ Hypertension -- Diabetes◦ Asthma and COPD -- Depression and

anxiety◦ Arthritis and other pain

Strategies for successful communication

zzzz It is important to understand the system with which you are working

Learn about the medical conditions that bring people to primary care

Expand your vocabulary to facilitate communication

Stay within your scope of practice in your interactions

Make yourself visible and useful

Primary Care The aims of primary care are to provide

broad spectrum of care◦ both preventive and curative;◦ over a period of time; and ◦ to coordinate all of the care the patient receives.

All family physicians and most pediatricians and internists are in primary care.


The Medical System

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Primary Care Practitioner must possess a wide breadth of

knowledge in many areas. Patients consult the same primary care doctor

for routine check-ups, and initial consultation about a new complaint.

Common chronic illnesses, often treated in primary care, include:◦ Hypertension -- Diabetes◦ Asthma and COPD -- Depression and anxiety◦ Arthritis and other pain

The Medical System

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1. The person receiving services is called…2. The building(s)/place(s) where the person

receives services is called…3. The room where the person receives

services is called…4. The person who has the ultimate

responsibility for the care of the person is called…

5. The person who is responsible for care coordination is called…

Service Definitions

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Role DelineationWho does what in an

integrated care system?

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In an integrated care system, what is the best role of each of the following disciplines. What should they take lead on? How should they be involved in collaboration? Medical Provider Mental Health Provider Substance Use Disorder Provider Behavioral Health Specialist Peer Specialist Family

Discussion—Roles

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Differing practice styles

Differing practice cultures and language

Difficulty in matching provider skills with patient needs

Heavy reliance on physician services

Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services

Provider/practice barriers

30 30

Lack of recognition of provider limitations Lack of MH knowledge in PC providers and lack

of health knowledge in BH providers Lack of clinical competence in integrated service

models (MH/SU and BH/PC) and selection of proper integration model based on practice context

Differing confidentiality and information sharing procedures

Differing coding and billing systems Provider resistance

Provider/practice barriers

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Medical issues that commonly co-occur with mental health

and substance use

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Diabetes

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Type 1 diabetes is usually diagnosed in children and young adults. The the body does not produce insulin. Only 5% of people with diabetes have this form of the disease.

Type 2 diabetes, the most common form of diabetes, either the body does not produce enough insulin or the cells ignore the insulin. Insulin takes the sugar from the blood into the cells. If insulin is not working, glucose builds up in the blood instead of going into cells, it can lead to diabetes complications. Type 2 diabetes is more common in African Americans, Latinos, Native Americans, Asian Americans, Native Hawaiians and other Pacific Islanders, as well as the aged population.

Type 1 and Type 2 Diabetes

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Basic Overview:◦Metabolic disease.◦Hyperglycemia (too much

sugar) due to insulin resistance and defects in insulin secretion.

◦Diabetes can lead to: blindness heart & blood vessel

disease stroke kidney failure amputations nerve damage.

Type 2 Diabetes Overview

http://safediabetes.blogspot.com/2010/12/how-to-reduce-impact-type-2-diabete.html

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Often no symptoms at all. Most common symptoms

include:◦ Blurred vision◦ Erectile dysfunction◦ Fatigue◦ Frequent or slow-healing

infections◦ Increased appetite◦ Increased thirst◦ Increased urination

Sign & Symptoms

http://www.thetype2diabetesdiet.com/wp-content/uploads/2009/03/symptoms-for-type-2-diabetes.gif

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Percent of Individuals with Diabetes

Mal

e

Fem

ale

<20

20-6

465

+

NH Whi

tes

NH Bla

ckHis

p AI PI0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

12%11%

0.3%

11%

27%

8%

13% 13%

16%

24%

Gender* Age* Ethnicity**

*American Diabetes Association, 2011. **US DHHS Office of Minority Health, 2010

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The hemoglobin A1c test is used to determine how diabetes is being controlled.

HbA1c provides an average of your blood sugar control over a six to 12 week period.

When blood sugar is too high, sugar builds up in your blood and combines with your hemoglobin, becoming "glycated."

For people without diabetes, the normal range for the HbA1c test is 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than 7%.

Retest should occur every three months to determine level of control.

Importance of Hemoglobin A1c Test (HbA1c)

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The Medical Provider The Substance Use Disorders Provider The Mental Health Provider Peers and Family

Why is it important to know the Hemoglobin A1c for:

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Relationship with SUD◦Heavy alcohol consumption can increase risk

factors including: body-mass index, low HDL (“good”) cholesterol and cigarette smoking (Tsumura, 1999).

◦ A history of substance use is associated with earlier age of onset of diabetes (Johnson, 2001).

◦ SUD is associated with increased mortality in diabetics (Jackson, 2007).

Significance of Behavioral Health ◦ Diabetes patients also have increased

depression. Both diet control and depression respond to behavioral activation strategies

◦ In 2006, it was the seventh leading cause of death, and cost the US $174 billion in medical costs, loss of productivity, disability costs

Type 2 Diabetes

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Medical services available on-site better link clients in SUD treatment to medical services compared to those with outside referrals (Friedmann, 1999).

Social support for abstinence can increase linkage to medical services. (Saitz, 2004).

Encourage activities that improve diabetes:◦ Better diet.◦Reduce simple carbohydrate intake (i.e.

potatoes, white bread, corn, soda, candy, sweets).

◦ More exercise.◦ Maintain regular appointments with doctor

overseeing diabetes treatment.

Type 2 Diabetes & Your Clients

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Hypertension

Common Medical Issues Associated with Mental Health and Substance Use Disorders

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Percent of Individuals with Hypertension (Age 20+)

Male

Fem

ale

20-4

4

45-6

4

65-7

4

75+

NH

Whit

e

NH

Bla

ck

Mexic

an

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

31% 30%

41%

67%

30%

42%

10%

28%

77%

Gender* Ethnicity*

*Centers for Disease Control and Prevention, 2012.

Age*52

Blood pressure (BP) is the force against the walls of one’s arteries while blood is pumping.

Hypertension is when BP is too high.

Example BP: 120/80 mmHg (“120 over 80”)◦ Systolic (top number):

pressure while heart contracts. Normal is <120. High is >180.

◦ Diastolic (bottom number) pressure while heart relaxes & enlarges. Normal is <80. High is >80.

Hypertension: Clinical Description

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Increased risk of:◦Stroke◦Blood vessel damage (arteriosclerosis)

◦Heart attack◦Tearing of heart’s inner wall (aortic dissection)

◦Vision loss◦Brian damage

Consequences of Hypertension (HTN)

(NIH, 2010)54

Three or more drinks per day increases BP & risk of hypertension in both women and men (Sesso, 2008).

Decreasing alcohol consumption associated with dose-dependent reduction in BP (Xin, 2001).

Stimulants like cocaine or amphetamines can cause HTN and other acute and chronic cardiovascular diseases. (McMahon, 2010).

HTN risk associated with quantity of cigarettes smoked daily and the duration of smoking (Orth, 2004).◦ Former smokers have higher rates of hypertension

than those who never smoked (Orth, 2004).

Blood Pressure Link to SUD

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HTN can be well controlled in primary care for most patients (Williams 2004).◦ Some many need help finding transportation. ◦ Some may need help finding free or low-cost

clinics. Ask about alcohol consumption.

Encourage limiting to 2 or less drinks per day.

If client smokes, give advice and support to quit smoking (NICE, 2006).

Encourage weight loss and salt reduction.◦ Losing 10kg (22 lbs) can reduce systolic BP by

10 points (Cappuccio, 2007).

Hypertension & Your Clients

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Pain

Common Medical Issues Associated with Mental Health and

Substance Use Disorders

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In 2011, at least 100 million adult Americans have common chronic pain conditions (excl. acute pain and children)*.

Pain costs society at least $560-$635 billion annually (an amount equal to about $2,000 for everyone living in the U.S.)*.

Women are more likely to experience pain (in the form of migraines, neck pain, lower back pain, or face or jaw pain) than men**.

Adults age 45-64 years were most likely to report pain lasting more than 24 hrs. (30%), followed by young adults age 20-44 (25%0, and adults age 65 and over (21%)***.

Pain

*IOM, 2011; CDC, 2009; NCHS, 2006. 58

Incidence of Pain, as compared to other Chronic Conditions

http://www.rxreform.org/wp-content/uploads/2011/06/Toblin-2011-Kansas-Pain-corrected-proof.pdf

Chronic Pain

Diabetes Heart Disease

Stroke Cancer0

20

40

60

80

100

120

100

25.816.3

7 11.9

Incidence in MillionsCondition Number of Sufferers Source

Chronic Pain 100 million Americans Institute of Medicine of The National Academies

Diabetes 25.8 million Americans(diagnosed and estimated undiagnosed)

American Diabetes Association

Coronary Heart Disease(heart attack and chest pain)

Stroke

16.3 million Americans

7.0 million Americans

American Heart Association

Cancer 11.9 million Americans American Cancer Society

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Prescription Drug Misuse

Any prescription drug can be “misused” Misuse = “non-medical use” = Any use that is

outside of medically prescribed regimen:◦ Non-compliance ◦ Taking different dose◦ Sharing◦ Obtaining from non-medical source◦ Taking for psychoactive effects◦ Taking for effects not indicated ◦ Use with alcohol or other substances

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Opioids for Chronic Pain

• Relieves pain• Relieves suffering• Relieves misery

• Makes you feel better • Makes you feel good• Makes you “high”

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Broad availability of prescription drugs ◦e.g., via the medicine cabinet, family,

friends, Internet, and physicians Misperceptions about their safety Focus on a pill for every ill (cultural trend,

media) High rates of other substance use

including abuse cigarettes, drugs and alcohol

Childhood history of abuse, trauma and neglect

High rates of depression and anxiety

Risks of Becoming Addicted

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Pain: An unpleasant sensory and emotional experience arising from the actual or potential tissue damage or described in terms of such damage

It is always subjective. Each individual learns the application of the word through experiences related to injury in early life (International Association for the Study Pain [IASP])

Early life – historicalExperience—learnedSubjective—privateIndividual--unique

Pain: “Define yourself, then we shall converse”--Voltaire

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Reciprocal Nature: Depression-Pain Relationship

65% of patients with depression experience pain

5% to 85% of patients with pain have depression

75% of primary care patients with depression present only with physical complaints and do not attribute their pain to depression

0 or 1 physical symptom - 2% were found to have depression

≥ 9 physical symptoms – 60% were depressed

Increasing pain severity, frequent pain episodes, diffuse pain, and treatment resistant pain are associated with more severe depression

In patients with pain, depression is associated with more pain complaints, greater intensity, longer duration of and greater likelihood of nonrecovery

Bair MJ et al, ARCH INTERN MED, 2003 64

Trends in opioid prescribing (2000 and 2005) with and without MH and SUDs

Insured 34.9% with an MH or SUD 27.8% without MH and SUD

Arkansas Medicaid 55.4% with an MH or SUD 39.8% without an MH or SUD

Nature of the Link Between Increasing Opioid Prescribing for Noncancer Pain

and Abuse

2000 2005 2000 20050

5

10

15

20

25

30

35No MH/SUDAny MH/SUD

Insured AR Medicaid65

Chronic use of prescription opioids for NCPC is much higher and growing faster in patients with MH and SUDs than in those without these diagnoses

Clinicians should monitor the use of prescription opioids in these vulnerable groups to determine whether opioids are substituting for or interfering with appropriate MH and substance abuse treatment

Edlund, Mark et al, Clinical Journal of Pain 2010

Nature of the Link Between Increasing Opioid Prescribing for Noncancer Pain

and Abuse

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Kowalski & Bondmass (2008) study of pain and grief correlation in widows

Self-reported physical symptoms included:◦ Pain◦ Gastro-intestinal

problems◦ Medical/surgical

conditions◦ Sleep disturbances◦ Neurological/circulatory

issues Psychological

symptoms:◦ Depression◦ Anxiety◦ Loneliness

Of the 173 women in the sample, about two-thirds the sample reported at least one physical complaint following spousal loss

Grief and Pain

Kowalski & Bondmass, 2008

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The Dilemma Need to accurately diagnose disease and

provide effective analgesia Some illnesses have no diagnostic test, but

are frequently cited as reasons for pain syndromes needing medication treatment(s) Headache Low back pain Pelvic pain Arthritis Fibromyalgia Chronic Fatigue Syndrome

Has contributed to misuse of pain pills and addiction

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Predictive factors; as non-pain patients◦Personal or family history of drug abuse

◦Current addiction to alcohol or cigarettes

◦History of problems with prescriptions

◦Co-morbid psychiatric disorders

History and Screening

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No validated diagnostic criteria for addiction in pain patients; only “at risk” behaviors: ◦Control◦Compulsive use◦Continue use despite harm◦Craving

Identifying “at risk” patients:◦ History◦ Screening instruments ◦ Behavioral checklists◦ Therapeutic maneuver

Diagnosing Addiction Opioid-maintained Pain Patients

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Opioid Risk Tool (ORT)

Mark each box that applies: Female Male

1. Family history of substance abuse

Alcohol 1 3

Illegal drugs 2 3

Prescription drugs 4 4

2. Personal history of substance abuse

Alcohol 3 3

Illegal drugs 4 4

Prescription drugs 5 5

3. Age (mark box if between 16-45 years) 1 1

4. History of preadolescent sexual abuse 3 0

5. Psychological disease

ADO, OCD, bipolar, schizophrenia 2 2

Depression 1 1

Scoring totals:

Scoring

• 0-3: low risk (6%)

• 4-7: moderate risk (28%)

• > 8: high risk (> 90%)

Administration

• On initial visit

• Prior to opioid therapy

Webster, et al. Pain Med. 2005;6:432. 71

Probably more predictive• Selling prescription drugs• Prescription forgery• Stealing or borrowing

another patient’s drugs• Injecting oral formulation• Obtaining prescription

drugs from non-medical sources

• Concurrent abuse of related illicit drugs

• Multiple unsanctioned dose ⇧s

• Recurrent prescription losses

Aberrant Drug-Taking Behaviors

Passik and Portenoy, 1998 72

Probably more predictive• Selling prescription drugs• Prescription forgery• Stealing or borrowing

another patient’s drugs• Injecting oral formulation• Obtaining prescription

drugs from non-medical sources

• Concurrent abuse of related illicit drugs

• Multiple unsanctioned dose ⇧s

• Recurrent prescription losses

Probably less predictive• Aggressive complaining

about need for higher dose

• Med hoarding when symptoms are reduced

• Requesting specific meds• Acquisition of similar

meds from other medical sources

• 1-2 unsanctioned dose ⇧• Unapproved use of the

med for another symptom• Reporting psychic effects

not intended by the clinician

Aberrant Drug-Taking Behaviors

Passik and Portenoy, 1998 73

Endocarditis

Common Medical Issues Associated with Mental Health and Substance Use Disorders

Endocarditis: Basic Description

Endocarditis is inflammation of the inside lining of the heart chambers and heart valves (endocardium)

Usually caused by bacterial infection but can also be fungal.

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/18142.jpg



Risk factorsInjection drug use increase risk: Particulate matter in injected drugs Poor injection hygiene (e.g., not cleaning

skin before injecting) Using unsterile equipment. Contaminated drug solutions. Physiological responses to certain drugs.

E.g., cocaine causes blood vessels to constrict (vasospasm) and damages cardiac tissue.

Many studies shows speedball (heroin and cocaine together) injection is a significant risk factor of bacterial infections (Phillips, 2010).

Signs & Symptoms Symptoms can develop slowly

(subacute) or suddenly (acute).◦ Common

Chills Excessive sweating Fever

◦ Abnormal urine color (bloody or dark)

◦ Fatigue/weakness◦ Red, painless skin spots on the palms and soles

(Janeway lesions)◦ Red, painful nodes in the pads of the fingers and

toes (Osler's nodes)◦ Joint pain, muscle aches and pains◦ Nail abnormalities (splinter hemorrhages under the

nails)◦ Swelling of feet, legs, abdomen

Endocarditis & Your Clients Clinical manifestations in injection drug

users:◦2/3 of patients do not display evidence of

underlying heart disease. ◦ Only 35% of IDUs demonstrate heart murmurs on

admission (Baddour, 2005). Treatment is intensive but largely

successful. ◦ Most patients need to be hospitalized.◦ Cure rates are high (85%) for right-sided

endocarditis.◦ Treatment cures infection relatively quickly (about

4 weeks). Severe cases exhibiting heart valve

damage, stroke, or heart failure may require valve replacement (NIH, 2010)

Chronic Obstructive Pulminary Disease (COPD)

Common Medical Issues Associated with Substance Use Disorders

COPD Overview(Chronic Obstructive Pulmonary Disease)

Progressive disease that makesit hard to breathe

Cigarette smoking is the leading cause of COPDCOPD includes 2 main conditions:

Emphysema: walls between air sacs are damaged decreasing the amount of gas in the lungs

Chronic Bronchitis: lining of the airways is constantly irritated and inflamed causing the lining to thicken. Thick mucus forms in the airways, making it hard to breathe

Signs & SymptomsSigns of Emphysema Shortness of breath, especially during physical

activities Wheezing Chest tightness

Signs of chronic bronchitis include Having to clear your throat first thing in the

morning, especially if you smoke A chronic cough that produces yellowish sputum Shortness of breath in the later stages Frequent respiratory infections

• Build-up of fluid in the lungs (acute pulmonary edema) has been reported due to use of inhaled crack cocaine and methamphetamines (Wesselius, 1997).

• Emphysema has been shown to develop secondary to IV drug use (Wesselius, 1997).

• Individuals are 3 times more likely to develop COPD when tobacco is used in conjunction with marijuana but studies are limited and evidence is inconclusive (ScienceDaily, 2009).

COPD Link to SUD

• Treatment depends on severity and general medical condition. It is usually managed in a primary care setting.

• Encourage your clients to stop smoking and using drugs. Provide them with smoking cessation and drug counseling options.

• Encourage compliance with medications , home oxygen therapy, and pulmonary rehabilitation (MayoClinic, 2010).

COPD & Your Clients

Let’s talk about a case…

89

“Luz” A client from and Integrated Clinic

Cl is a 55year old Hispanic (Puerto Rican) female, divorced, mother of 5 adult children, 4 sons and a daughter who passed away 6 yrs ago. Currently estranged from all family members except for one son. Currently renting a bedroom in a home. Cl receives recently was awarded SSI and Medi-Cal benefits. Enrolled in the ICM program September 2012.

Case Presentation – “Luz”

90

Presenting problems Initially presented to clinic with sx of depression, anxiety,

crying spells, labile moods, angry outbursts, hopelessness and restless sleep.

Reports she has been depressed most of her life but depression exacerbated 6 yrs ago after the death of her daughter in an MVA. She has extensive drug abuse hx. Drugs of choice are crack and ETOH. Client recently graduated from a residential treatment program and has been sober for 3 yrs.

In January 2013, client exhibited hypomania and delusions that she is pregnant. Presented with elevated mood, decreased need for sleep, racing thoughts, increase in goal directed bx, auditory and visual hallucinations, heavy make-up and poor hygiene. Her diagnosis was noted as Bipolar D/O.


91

History Client born in Puerto Rico. She has a 3rd grade education

but is illiterate. Speaks Spanish and English. Reports hx of severe physical and sexual abuse at the hands of her father beginning at age 8. Children have been removed form her custody due to drugs and domestic violence with her boyfriend. Family hx of addictions and depression.

Client has no work history other than “selling drugs” and “prostitution”.

Psychiatric history Client was referred by her rehab program to Exodus Urgent

Care Center and then to Exodus ICM . She has previously received brief crisis based services.


92

Medical history: Client has Type 2 Diabetes, hypertension, COPD, and

obesity. At intake, her BP was 139/82, BMI 44.79, Hemoglobin A1C 8.2, smoking 1 pack of cigarettes a day.

Laboratory Normal Values: BP:

◦ Normal systolic is <120. High is >180.◦ Normal diastolic is <80. High is >80.

HbA1c:◦ Normal 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than

7%.

BMI: ◦ Underweight = <18.5◦ Normal weight = 18.5–24.9◦ Overweight = 25–29.9◦ Obesity = BMI of 30 or greater


93

Medical history: Client has Type 2 Diabetes, hypertension, COPD, and

obesity. At intake, her BP was 139/82, BMI 44.79, Hemoglobin A1C 8.2, smoking 1 pack of cigarettes a day.

Most recent values are as follows: BP 112/75, BMI 41.56, Hemoglobin A1C 5.8, smoking 3-4 cigarettes a day.

Laboratory Normal Values: BP:

◦ Normal systolic is <120. High is >180.◦ Normal diastolic is <80. High is >80.

HbA1c:◦ Normal 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than

7%.

BMI: ◦ Underweight = <18.5◦ Normal weight = 18.5–24.9◦ Overweight = 25–29.9◦ Obesity = BMI of 30 or greater


94

Diagnosis Axis I 296.44 Bipolar D/O, Manic w/ Psychotic features.

304.80 Polysubstance Dependence in full sustained remission. Axis II No Diagnosis Axis III Type 2 Diabetes, hypertension, hyperlipidemia, COPD, and obesityAxis IV Problems with primary support group, social environment, educational, occupational, economic, access to health care, legal, otherAxis V GAF 55

Medications Lithium 600mg QHS (mood stablizer)

Celexa 20mg QAM (depression)Abilify 2mg QAM (adjunctive tx for for bipolar disorder)


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Stages of Change:

Primary Tasks in Linking MH and SU

1. PrecontemplationDefinition:

Not yet considering change or is unwilling or unable to change.

Primary Task:Raising Awareness—Connect

SU and MH Sxs2. Contemplation

Definition: Sees the possibility of change but

is ambivalent and uncertain.

Primary Task:Resolving ambivalence/

Helping to choose change

3. DeterminationDefinition:

Committed to changing.Still considering what to do.

Primary Task:Help identify appropriate strategies to improve MH/

reduce SU4. ActionDefinition:

Taking steps toward change but hasn’t stabilized in the process.

Primary Task:Help implement change strategies

to decrease MH Sxs and SU

5. MaintenanceDefinition:

Has achieved the goals and is working to maintain change.

Primary Task:Develop new skills to maintain

improvements in MH and SU

6. RecurrenceDefinition:

Experienced a recurrence of the symptoms.

Primary Task:Cope with consequences , relate to

MH functioning as precursorand outcome

Stages of Change: Intervention Matching Guide to Link MH and SU

• Offer factual information about MH-SU connection

• Explore the events that brought them to treatment—Impact of SU/MH

• Explore results of previous efforts to improve MH. What was the role of SU?

• Explore pros and cons of improving MH and decreasing SU

• Explore the person’s sense of self-efficacy to reduce MH symptoms

• Explore expectations about change—What is the role of SU on MH Sxs?

• Summarize self-motivational statements for change in MH and SU

• Continue exploration of pros and cons of improving MH and decreasing SU

• Offer menu of options for addressing MH Sxs and SU

• Help identify pros and cons of various change options

• Identify and lower barriers to change• Help enlist social/peer support • Encourage person to publicly

announce plans to change

• Support a realistic view of change through small steps

• Identify high-risk situations for SU and impact of use on MH functioning

• Develop coping strategies• Assist in finding new reinforcers of

positive change including feeling better• Help access family/social/peer support

• Help identify and try supportive behaviors and drug-free activities to maintain goals.

• Maintain supportive contact and highlight progress in maintaining improved functioning--What was the role of SU?

• Set new short and long term goals for MH and SU

• Frame recurrence as a learning opportunity—What was the impact on MH?

• Explore possible psychological, behavioral and social antecedents

• Help to develop alternative coping strategies for strong emotions

• Encourage person to stay in the process and maintain support

1. Pre-contemplation

2.Contemplation

3.Determination

4.Action

5.Maintenance

6.Recurrence

Areas for behavioral interventions

Substance use◦ Maintenance of abstinence◦ Supportive behaviors and drug-free activities◦ Maintain supportive contact◦ Set new short and long term goals for MH and SU

Diabetes◦ Blood sugar monitoring and control◦ Identify and support dietary changes.◦ Promote self mgt. ◦ Enhance mood stability◦ Stress Reduction

Areas for behavioral interventions

Obesity◦ Monitoring food/diet◦ Goal identification and attainment◦ Exercise goal identification and tracking

COPD◦ Identifying Triggers◦ Smoking cessation (medical and behavioral)◦ Medication compliance ◦ Daily Monitoring, Action Planning

Social support◦ Identify drug free activities including 12-step,

church, and recreation

Cl was initially identified primarily as depressed and aggressive with people. Client only sought treatment at the request of her rehab program. When she graduated from rehab program, she became homeless. Program assisted her with renting a room.

Client was encouraged to participate in Lunch & Learn, Diabetes Support, Self Help and Seeking Safety groups.

She began making better food choices, reduced her smoking and began walking daily. She lost 17 lbs and has been abstinent from drugs for over 3 yrs.

Cl generally complies with meds and all medical and mental health appointments. She engages in groups 3-4 days/wk, goes to 12 step meetings, and participates in community activities offered by the program. She arrives at the clinic early, is good at seeking support, resources and referrals, and always follows through.


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Making Effective Referrals for Care

The Warm Hand-Off

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Referral to Treatment• Approximately 5% of patients

screened will require referral to substance use evaluation and treatment.

• A patient may be appropriate for referral when:• Assessment of the patient’s responses to the

screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use.

These high risk patients will receive a brief intervention followed by referral.

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“Warm hand-off” Approach to Referrals

• Describe treatment options to patients based on available services

• Develop relationships between health centers, who do screening, and local treatment centers

• Facilitate hand-off by:

• Calling to make appointment for patient/student

• Providing directions and clinic hours to patient/student

• Coordinating transportation when needed

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Thomas E. Freese, [email protected]

Pacific Southwest Addiction Technology Transfer CenterUCLA Integrated Substance Abuse Programs

www.psattc.org www.uclaisap.org

Contact information

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Thomas E. Freese, PhD [email protected] UCLA Integrated Substance Abuse Programs Pacific...

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