Integration with Primary care

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kim johnson
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Joined: 03/05/2012 - 17:35
Integration with Primary care

This is such a hotly debated topic that we decided to add a discussion topic all of its own. I have been doing interviews of leadership, medical and administrative, in practices where fully integrated behavioral health, including substance use disorders, is delivered. The ATTC is holding a forum in November to discuss the future of addiction treatment and the training and technical assistance needs that will arise in a fully integrated health care system. Some of the interesting things I have gathered in my interviews have been the loss of the concept of the 50 minute hour, more long term relationships with briefer treatment sessions, greater reliance on medication as the primary treatment rather than the assistance to treatment (a la MAT) and a greater need to be able to function as part of a team.

In November, we will be consulting with a handful of researchers and opinion leaders, but I am curious about the broader perspective. What is your experience of how integrating addiction treatment and primary care works and what are the training needs of the future work force?

michael boyle
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Joined: 03/06/2012 - 12:23

Kim is right that behavioral health sessions within primary care settings are briefer, usually 15-30 minutes rather than the"50 minute hour". The hour long sessions in mental health and substance abuse are based on tradition within our field and date back to psychoanalysis. There is a financial incentive for longer sessions as they can normally be billed at a higher rate. The tradition also makes the therapist's job easier seeing one patient per hour rather than 2-3. The focus on productivity and pace of work is very different in a primary care setting.

Within Federally Qualified Health Centers (FQHCs), there is also a different payment incentive. Medicare and Medicaid pay on a prospective cost, event mode. The payment is for a visit and is the same regardless of the time spent in the visit. Thus, hour long sessions have a financial disincentive.

I believe shorter sessions will require clinicians to be much more organized and focused. For example, they will need to rapidly assess progress, identify problems or barriers encountered and negotiate activities and homework to be accomplished by the patient. This may improve outcomes. Of course, these are only my opinions. What is needed are random clinical trials testing different session lengths and comparing outcomes.

Regarding the workforce, more licensed psychologists and social workers are needed as these licenses are usually required for billing in primary care. CMS requires these licenses for Medicare billing within a FQHC and most state Medicaid programs follow the lead of CMS.

shirsch
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Joined: 10/13/2014 - 12:37

It isn't just the therapist who has be organized but the client also and it demands that the person seeking help be somewhat self-directed. This is a problem - if someone was that self-directed, why would they need a therapist in the first place? Person growth takes time. We already have patients rushed through medical appointments with the assumption that within the 15 or 20 minutes they have with the doctor they have gathered enough guts to talk about pains and aches they have barely shared with their wives/husbands or partners. When are we going to remember that what "cures" folks is not the technology or elaborate labs but the relationship built between the doctor and patient. And I am sorry, that is going to take longer than 20 minutes once a year when your insurance company forces you to get a physical so your co-pays stay at some reasonable level.

Raymond
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Joined: 12/13/2012 - 17:28

Our experience suggests that significant workforce problems face us as we move to an integrated system. Clinicians are challenged by several features that typify work in a medical setting, including, as Michael points out, the need to adapt a brief intervention orientation that focuses on teaching, advising, and guiding patients to improved functionality. Outcomes will be measured by improved life functioning, not insight into etiology of problems. Clinicians will have to give up "ownership" of the patient and adapt to the team approach of shared collaboration in a PCMH environment. We have found great reluctance of clinicians to relinquish the 50 minute hour model that engages patients for long therapeutic relationships. In the new environment, the 50 minute session is going away. Disturbingly, university interns in our clinics tell us that their academic institutions are not even including these new models in their curricula. This resistance to change coupled with an under-supply of trained and qualified clinicians portends more challenges in the future and most likely will open the door to a surge in the use of technology based interventions. Time for the clinicians to get on board.

DrJohn
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Joined: 10/08/2014 - 13:57

I totally agree with the previous posts. In addition, the requirements of 42 CFR Part 2 significantly complicate integration of SUD intervention/treatment in the primary care environment, especially as concerns eHR. Although we have found a way around this (theoretically), it requires a significant investment to alter the eHR to accommodate this issue. For now, our BHCs enter mental health notes into the eHR, but keep a paper chart for all SUD notes. Not very integrated, and not very handy. I'd love to hear how others are dealing with this...

bradleym
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Joined: 10/09/2014 - 09:20

Brief sessions focused on teaching, advising and guiding the consumer to behavioral changes run the risk of ignoring the substantial body of research on how people change. Effective, evidence-based interventions including stages-of-change sensibilities, and motivational interviewing may be given short shrift, and this would be a disservice to the consumer. Also, the idea that medication would be the primary intervention carries a lot of negative aspects.

kim johnson
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Joined: 03/05/2012 - 17:35

What are those negative aspects, do you think? I'm really curious about what people think about this. Is addiction significantly different from depression in terms of how it would respond to a medication only or primarily medication protocol? Or are there parallels that you see that are problematic in the current model of how we treat depression that you wouldn't want to repeat with addiction?

AddictionProfCarol
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Joined: 10/11/2014 - 09:26

I mostly see differences in the populations with primary depression and primary addiction. I am concerned that shifting addiction counseling to the primary care setting will result in too narrow a focus on medication efficacy using a brief intervention approach without adequate integration of care using case management, co-location of addiction treatment with medical services and case monitoring - all shown to be important in treating addiction as the chronic disorder that it is (see Saits, Samet and Larson article at : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2756688/ )
I also think that primary care settings may eventually result in earlier intervention in addiction where the chronic care model is less needed, but, for now, people seldom become motivated to change addictive drug use early in the process - not as long as the drugs appear to be "working" for them. One other difference I see is that people with depression do not use (as often) the "escape" into dopamine and serotonin-changing (non-prescribed) drugs as addicts do (exception: alcohol, a poor "treatment") making them better candidates for prescription-drug interventions.

michael boyle
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Joined: 03/06/2012 - 12:23

I am replying to Bradleym's post on 10/9/2014. He is absolutely right on regarding the need to provide motivational interviewing and other motivational enhancement techniques for patients who are ambivalent. Years ago, Fred Osher developed the concept of stage of treatment to match interventions to an individual's stage of change. MI may be the desired approach initially whereas skill training is needed when people are at the action stage.

That said, years ago I saw a CBT treatment manual that had drink refusal training as some of the early sessions. The target population were people with low motivation for change in their drinking behavioral. I contacted on of the researchers and inquired as to the reason they provided the skill training in some of the initial sessions. He reported that many of the patients they worked with believed they could not refuse a drink. Providing the skills and having them practice in the real world environment actually provided motivation when they were able to demonstrate the ability to refuse a drink.

My question is whether motivational sessions could also be brief. It seems consistent hour sessions could be more than a patient would desire and potentially lead to their feeling they are being pushed which could increase resistance. Of course, I am sure a clinician who is highly skilled in MI can immediately sense this and back off.

kim johnson
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Joined: 03/05/2012 - 17:35

I was interviewing a physician recently and he said practically everything he does in motivating people to change behavior. I think he would say that you could easily do brief MI, but whether there are studies of it, I do not know.

bradleym
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Joined: 10/09/2014 - 09:20

My professional bias is in favor of emphasizing behavioral management of many conditions; we face a cultural bias in the other direction: I have condition xyz; what medication will fix it, without me making any sacrifices in my lifestyle preferences. This bias is manifest in our tolerance of direct-to-consumer advertising of prescription medications, and of research which is almost entirely sponsored by the manufacturer of the product being tested. Prochaska estimates that 70% of medical pathology is behaviorally based--nutrition, exercise (or lack of), etc. Now, admittedly it is hard to say exactly how you validate a figure like that empirically, but the sensibility it represents rings true. This is not to say medication has no role in management of the disease of addiction and recovery; I am advocating for emphasis in the direction of behavioral changes as inexpensive, accessible and long-lasting in their impact, and absent side effects. And such changes require constructive engagement in the change process, which often takes time and a collaborative approach on the part of the helping professional--along the lines of Miller/Rollnick"s motivational interviewing.

Marg Brawner
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Joined: 10/16/2014 - 16:28

The medical system is set up for a 'medicate first' approach, which isn't always the best approach, BUT In a dual diagnosis case, concurrent treatment with, for example, SSRIs for depression along with behavioral therapy has been effective. I would hate to see someone with depression go untreated medically. They are not likely to achieve success with behavioral therapy and thus abstinence without effective medical treatment for their clinical depression. Something like 70 percent of people who present with a substance use disorder suffer from a mood disorder, requiring medication.

Raymond
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Joined: 12/13/2012 - 17:28

To Bradley,s post, I am taking a wider view of how BH interventions in a PCP setting are framed. The intent is not to replace more substantial therapeutic engagement but to intervene earlier with folks to effect changes that won't require intensive treatment. In our work we've seen that about half of the interventions in the PCP setting provide remedial effect at that point of service. Patients whose condition requires more depth work are directed/referred/handed off to a BH specialty shop. It's much the same as a PCP managing another medical problem until he/she gets to point where more specialized care is needed (cardiologist, endocrinologist, etc). On the medication only (or primarily) question, I think meds only is a disservice to the patient, at least right now with the addiction medications we have. None of the pharma people advocate meds only. The adaptations that are necessary in human/social domains dictate that we do more with more traditional therapies to enable deeper change and extended periods of remission.

michael boyle
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Joined: 03/06/2012 - 12:23

I agree that the relationship between a doctor and a patient is crucial for engaging the patient and keeping them engaged. For personal growth, the relationship alone may be adequate. For serious mental and substance use illnesses, I believe more than a relationship in necessary. Even people who are "self-directed" and highly motivated need to learn new skills and behaviors. That said, some may gain these tools through the use of books or web sites.

I believe the development of new technologies including lab work will be crucial to quality behavioral healthcare as it is in other areas of medicine. An example is the treatment of cancer. The mapping of the human genome now allows identification of specific genetic factors associated with a cancer. Once the genetic abnormalities are known, the medications that have been shown to have positive results in patients that have the same genetic factors with the specific cancer can be identified. Physicians are guided on what meds are most likely to be successful. In the future, I hope the same lab work and studies will be done with behavioral health disorder such as schizophrenia. The current approach to the treatment of schizophrenia with psychotropic meds is trial and error. The psychiatrist selects a medication and dose and follows up to see if there are positive results. If the symptoms are not controlled, a different medication is tried. Unfortunately, some patients are prescribed multiple medications simultaneously contributing to negative side effects. Personalized medicine based on genetic testing may contribute to the identification of the best first line of treatment.

Other technologies delivered through computers, smart phones or tablets are demonstrating positive outcomes for screening and early intervention, treatment and recovery support. Usually these systems serve as clinician extenders. Their potential is to allow greater access and better outcomes at lower costs per episode of care.

If I have a serious illness, I would want access to these technologies not just talk therapy.

kim johnson
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Joined: 03/05/2012 - 17:35

Mike, I agree

Marg Brawner
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Joined: 10/16/2014 - 16:28

At Pfeiffer University we compiled the recent research on older adult.s and substance abuse. People don't realize how dire the situation is, especially the spike in psychoactive medication misuse and abuse among the elderly. Older adult substance abuse most likely to be detected in primary setting first using MAST-G then if positive SBIRT. Some form of opioid risk tool / benzodiazepine risk tool (CAGE-AID) essential. Hope this info could be useful to you in November forum.

michael boyle
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Joined: 03/06/2012 - 12:23

For screening tools in primary care settings, I would also suggest the AUDIT and DAST.

Marg Brawner
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Joined: 10/16/2014 - 16:28

Thanks for your comment. The gerontolgists we consulted indicated that AUDIT tends to miss active drinkers over the age of 65, and DAST (modeled after MAST) but its focus is more on illicit drug use and the intent of the items is readily apparent.

Marg Brawner
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Joined: 10/16/2014 - 16:28

I forgot to mention: the CAGE-AID is recommended: detects the use of prescription drugs other than prescribed.

Marg Brawner
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Joined: 10/16/2014 - 16:28

Maybe all primary care practices/settings could adopt the senior care model recommended by SAMHSA (annual alcohol/drug screening for 60+.) It would just take a few minutes to administer a short screen to detect alcohol and drug use (both illegal and prescription). As we already know, the primary care setting for those that see doctors is effective for early intervention, especially if nurses receive substance abuse training to spot signs and symptoms. Why wait until a person turns 60-years-old?

kim johnson
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Joined: 03/05/2012 - 17:35

That seems so logical.