Together at Last: Addiction Medicine and the Behaviorally Enhanced Healthcare Home

• Mark McGrail, MD, Director of Addiction Medicine

• Suzanne Bailey, PsyD, Director of Integrative Care

• Brittany Tenbarge, PhD, Behavioral Health Consultant

Session #I5

CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas

Faculty DisclosureThe presenters of this session have NOT had any relevant

financial relationships during the past 12 months.

Conference Resources

Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017

Slides and handouts are also available on the mobile app.

Learning Objectives

At the conclusion of this session, the participant will be able to:

•Describe the epidemiology of substance use disorders and co-morbid psychiatric and medical illnesses that supports the integration of addiction medicine with behavioral health and primary care.

•Identify the main components of the Cherokee Program with regard to addiction medicine levels of care, staff, and implementation.

•Discuss the importance and utility of community partnerships for the execution of a successful integrated addiction medicine program.

•Describes measures of effectiveness and performance metrics necessary to develop, maintain, and grow a successful integrated addiction medicine program.

1. James, L., & O’Donohue, W. (2009). The Primary Care Toolkit: Practical Resources for the Behavioral Health Provider. Springer, New York.

2. O’Donohue, W.T., Byrd, M.R., Cummings, N.A., & Henderson, D.A. (2005). Behavioral integrative care: Treatments that work in the primary care setting. Brunner-Routledge: New York.

3. Watkins, K.E., Paddock, S. M., Hudson, T. J., Ounpraseuth, S., Schrader, A. M., Hepner, K. A., & Stein, B. D. (2017). Association between process measures and mortality in individuals with opioid use disorders. Drug and Alcohol Dependence, 177, 307-314.

4. Thomas, C. P., Fullerton, C. A., Kim, M., Lyman, D. R., Doughterty, R. H., Daniels, A. S.,…Delphin-Rittman, M. E. (2014). Medication-assisted treatment with buprenorphine: Assessing the evidence. Psychiatric Services, (65)2, 158-170.

5. Jones, H.E., Heil, S. H., Tuten, M., Chisolm, M. S., Foster, J. M., Grady, K. E. O., & Kaltenbach, K. (2013). Drug Alcohol Dependence,131(3), 271-277.

Bibliography / Reference

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted

at the end of this presentation.

Our Mission…To improve the quality of life

for our patients through the blending of primary care and behavioral health.

Together…Enhancing Life

Cherokee Health Systems:Merging the Missions of

CMHCs and FQHCs

Primary Service Area

HAMBLEN

GRAINGER

CLAIBORNE

HAMILTON

MCMINNMONROE

LOUDONBLOUNT

SEVIER

KNOX

COCKE

JEFFERSON

UNION

CAMPBELL

ANDERSON

Te n n e s s e e

K e n t u c k y

N o r t hC a r o l i n a

V i r g i n i a

G e o r g i a

A r k a n s a s

M i s s i s s i p p i A l a b a m a

M i s s o u r i

Cherokee Health Systems’ Corporate Profile

Last Year:

73,953 patients 353,552 Services 23,720 New Patients

Number of Employees: 758

Provider Staff: Psychologists - 50 Cardiologist - 1 Psychiatrists - 7

Primary Care Physicians - 37 Nephrologist - 1 NP (Psych) - 10

NP/PA (Primary Care) - 50 Pharmacists - 12 LCSWs - 62

Community Workers - 41 Dentist - 2

Strategic Emphases

•Blended behavioral and primary care

•Go where the grass is brownest

•Outreach and care coordination

• Telehealth

•Training healthcare providers

•Value-based contracting

Healthcare analytics

The Scope of the Problem •Substance Use Diagnosis, of 157 patient intakes:• Alcohol “only” – 18

• Opioids – 138

• Stimulant only – 1

•Medical Co-Morbidities:• HIV – 1/92

• Hep C – 64/107

• Pregnancy – 16

• HTN – 33

• Chronic pain disorder – 43

•Behavioral Health Co-Morbidities• Mood Disorder – 127

• PTSD - 28

Identification of Substance Misuse• Screening

• Reporting

• Provider/staff referral

• Patient self-referral

Stage-matched Interventions• Access to treatment at the point of care

• Enhance motivation and facilitate care coordination

• Referral

• Reabsorption

•Long-term maintenance and monitoring

Medication Assisted TherapiesOpioid Use Disorder

• Methadone - not a federally licensed clinic but local resources available

• Naltrexone – available orally (daily dosing) and intramuscular (monthly dosing), payment challenges with IM form, limited use due to the acuity of clinic patients with OUD

• Buprenorphine – available orally as film or tablet and with/without naloxone, daily dosing, State grant for uninsured and covered by insurance with prior authorization, used in pregnancy as mono-product, anti-diversion strategies critical

Alcohol Use Disorder

• Acamprosate – no use in this clinic to date

• Disulfiram – available orally, daily dosing, expensive for uninsured compared to naltrexone

• Naltrexone – as above, frequent use with primary diagnosis of AUD with/without concomitant OUD

Addiction Medicine Healthcare Home•Addiction Medicine

•Behavioral Health

•Primary Care

•Psychiatry

•Pharmacy

•Care Management

Staff Roles and Responsibilities

•Addiction Specialist: overall responsibility, review referrals, conduct intake evaluations, treatment planning, DEA X-number

•Primary Care Provider: routine preventive and chronic health care, care coordination, medication safety

•Behavioral Health Consultant: review referrals, conduct IOP, directs behavioral needs, provides routine BHC care

•Pharmacist: TN CSMD report, medication safety and review

•Nursing: screen routine preventive and primary care health needs, lab test monitoring, clinic management, care coordination

•Community Health Coordinator: recovery environment review and action, care coordination, referral assistance

Data at One Year (as of 14 SEP 17)

•Unique Patients Assessed: 152

•Opioid Use Disorder: 137

•Alcohol Use Disorder only: 15

•Treatment Retention Rate, >30days: 78%Average 30-day retention=68%

Loveland D, Driscoll H. “Examining attrition rates at one specialty addiction treatment provider in the United States: a case study using a retrospective chart review.” Substance Abuse Treatment, Prevention, and Policy. 2014, 9:41.

Strategies for Success

•Open Access

•Group Medical Visit Model

•Workforce Development

Open Access •Intake clinic

• Walk-in

• Team of Staff-- BHCs, Therapists, Community Health Coordinators, and Peer Support Specialist

• Present continuum of A&D treatment options

•Triage for high priority patients

• Pregnant women

• Recent overdose(s)

• Recent hospitalization for drug-related medical or psychiatric condition

• Discharging from detox/inpatient A&D facilities

• Patient’s partners/family likely to impact a current patient’s recovery

Group Medical Visit Model•Routine component of care

• Join group 2-4 weeks after intake

• Group becomes their medication follow up visit

•3 hour group weekly

• 1 hour of “check-in”

• Progress, recent use, current medical and behavioral health needs

• 2 hours of curriculum

• Didactic education, Discussion, hands-on activities, goal-setting

•Co-facilitated by Behavioral Provider and Addiction Specialist

• Both providers present for “check-in”

• Pulled out for vitals + brief visit with Addiction Specialist

•Group attendance dramatically improved when services performed concurrently

Workforce Development•Continuing Education events for CHS providers

•Clinic visits for ongoing education and collaboration

•Real-time phone consultation

•APA Accredited Psychology Internship

•APPIC Postdoctoral Fellowship

•Training for Family Medicine residents

Lessons Learned•Rapid, imperfect implementation is okay. Patients always point the way.

•Complexity is the norm. All conditions are primary and require concurrent treatment.

•Rapid access, depth and breadth of services, continuity of care, and high level care coordination and communication are essential.

•This is a marathon, not a sprint.

•Practical barriers and resource needs complicate the path to recovery. Enhanced community-based outreach and support are needed.

Questions?

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