Topic: Integration in the Field: Countyinitiatives (Riversidecounty, Mercedcounty And

SUMMARY REPORT

MEETING 15

Date: Wednesday, August 22, 2012

Time: 1:15PM – 2:45PM

Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Dept. of Alcohol and Drug Programs (ADP)

Topic: Integration in the Field: CountyInitiatives (RiversideCounty, MercedCounty and Los Angeles)

Presenters: -- Elizabeth Schaper

UCLA ISAP

-- Karen Kane

RiversideCounty

-- Manuel Jimenez

MercedCounty

-- Loretta Denering

Los AngelesCounty

Review of ILC Meeting 14

UCLA ISAP

The fourteenth ILC meeting, conducted on June 27, 2012, focused on the

growing prescription drug abuse problem. Special thanks to Beth Rutkowski who

gave a very informative presentation and responded to questions posed from

meeting attendees. Thank you all for your participation.

Logistics

Summary and materials discussed from the previous ILC meetings are available at Subsequent meeting materials will continue to be posted on this site.

The next ILC meeting will be held during CADPAAC on September 26, 2012 from 11:00AM to 12:00PM. Darren Urada from UCLA will be presenting.
All further meetings are scheduled to be held at 11:00AM (PST) on the 4th Wednesday of every month, unless otherwise noted.

ILC Meeting 15 Topic:

Integration in the Field: CountyInitiatives (RiversideCounty, Merced

County and Los Angeles)

Topic Introduction – Elizabeth Schaper, UCLA ISAP

The topic for today’s learning collaborative is to hear about the integration activities taking place in Riverside, Merced and Los AngelesCounty. We thank Karen Kane, Manuel Jimenez, and Loretta Denering for being willing to share their work and hope this will be a learning opportunity for those in the audience but also for the speakers. Questions and troubleshooting among the group are encouraged.

Integration Introduction

Elizabeth Schaper, UCLA ISAP

Summary

Areas of focus
Provide background and discuss the importance of behavioral healthcare integration
Facilitate understanding the key elements to moving toward integrated care
Describe three CA counties’ models of integration
Share practical strategies to integrating substance use, mental health, and/or primary care
Why is integrated care important?
27% of the population will experience a mental health or addictive disorder problem annually
Research findings consistently suggest that most people who seek behavioral healthcare do so from their primary care providers
Healthcare reform will result in an influx of patients with newly acquired SUD and MH treatment benefits seeking care in PC settings
What is “integrated healthcare”?
The collaboration of mental healthcare (MH), substance use disorder (SUD) treatment, and primary healthcare (PC) service providers to address a patient’s needs holistically and concurrently
Collaboration takes many forms along a continuum. Integration is more a process than a thing, a journey than a destination —it takes time, and it usually happens gradually. This continuum illustrates the steps organizations take as they integrate:
Coordinated services: are given by separate medical and behavioral health providers, and in separate settings.
Co-located services: occur where medical and behavioral health providers work separately, but in the same location.
Fully integrated service: occurs where medical and behavioral health providers are not only co-located, but they work together as a team to provide care that addresses both the physical and behavioral health needs of their clients concurrently.
Integration of services also follows a continuum
MinimalIntegration
Basic Integration at a Distance
BasicIntegrationOn-Site
ClosePartially-IntegratedServices
FullyIntegratedServices
Where can integrated care occur?
Primary care settings
Community health centers
Federally qualified health centers
Emergency rooms/trauma centers
Prenatal clinics/OB-Gyn offices
Medical specialty settings for diabetes, liver and kidney disease, transplant programs
Pediatric clinics
College health centers
Mental healthcare settings
Substance abuse treatment centers
What are the key elementsto successful integrated care?
Mission Integration – providers across disciplines embracing a common goal
Getting all the staff, regardless of discipline, ideologically together, embracing the importance of meeting a patient’s needs holistically. This would be reflected in a mission statement that highlights the treatment of behavioral health problems as part of the program’s overall improved health goals for patients
Physical Integration – medical and behavioral health providers working in the same immediate area
i.e. How close BH and PC service delivery are
Clinical Integration – seamlessly connecting clinical activities of PC and BH providers
How well clinic day-to-day operations facilitate connections between BH and PC care, for example the use of warm hand offs between providers for same-day contact.
Operations Integration – PC and BH providers practicing within a shared infrastructure
using the same billing sheets, sharing waiting areas and entrances for patients, imposing no role restrictions on support staff
Information Integration – PC and BH provider sharing clinically relevant information in real time
adhering to information sharing guidelines under HIPAA and 42 CFR, Part 2, which allow for the sharing of information on a “need to know” basis, allowing all providers access to patient information pertinent to the delivery of integrated care; document the histories and interaction of physical health, mental health and substance abuse disorders in one patient record, provided proper consent is obtained
Financial and Resource Integration – financing integrated services using a blended pot of health care and mental health care resources
What barriers can we anticipate to successful integration?
Differing priorities: For patients with mental health and substance use disorders, there are many challenges and issues that need urgent attention. It can be difficult to coordinate them all in one treatment plan.
Different philosophies: Different providers come from different orientations. For example, some substance abuse counselors may want abstinence from drugs to be the goal of treatment, whereas many PC clinicians prefer harm reduction. Also, some medical providers may want to focus services on treating symptoms of disease, while behavioral health may be more interested in changing clients’ behavior. Differences in approach can make coordination difficult.
Differences in training: Medical providers may not be trained or comfortable dealing with MH/SUD issues, and vice versa. Stigma regarding MHD and SUD can also hinder integration.
Funding: As mentioned earlier, though grantees have more flexibility, lack of specific BH funding streams make it difficult to integrate care. In many systems it is difficult for a physician to be reimbursed for behavioral health screenings or brief interventions.
Documentation: Different funding sources require different paperwork, which can become overwhelming. Also mentioned before, there are different systems in place to protect patients’ private health information. At times privacy restrictions can be a barrier to the sharing of information that is needed to integrate services.

RiversideCounty

Karen Kane

Program Administrator

Substance Abuse Services

Department of Mental Health

Summary

Three programs offering integrated services in Riverside were described.

1. Mental Health Services Integrated within Rubidoux Public Health Clinic (FQHC-Look Alike):

After months of planning, this integrated Public Health Clinic started last week in Rubidoux (just west of the City of Riverside).
This is a grant funded project, FQHC status was denied. They expect to get FQHC approval in the future.
Licensed Staff were needed for the program; hired two bi-lingual MFT’s. They could not find LCSW’s.
Psychiatrist started last Friday - three days/week (20 hours total).
It was clear during the planning process that the doctors did not understand what mental health (MH) providers do.
The program was created because their co-occurring disorders (COD) clients are dying at an average age of 48 years.
Many mentally ill individuals show signs of untreated health issues.
The goal was to identify and link MH clients to physical health care.
They also want to link physical health clients to mental health care, including prevention, e.g., post-partum depression information and education for pregnant women.
The Local MH Clinic identified those mental health consumers in the Public health catchment area;

-who had two or more physical health problems and who were not engaged with a primary health care provider and

-who needed management of integrated health problems.

Most of the clients served within the Mental Health Clinic were eligible for Medi-Cal.
Some MH clients did not want to move to a Public Health Clinic for services.
The CRAFT tool was used to screen patients for substance use. The MH clinicians were trained in using the tool. Patients receiving a certain score were referred to substance abuse treatment services.
The MH Clinician sees clients in an exam room in the public health clinic. Nurses from other doctors bring clients to the MH clinician if a doctor is prescribing a psychotropic drug. If there is an acute crisis, the clinician and/or psychiatrist will see someone immediately if they are available.
The program is tracking all services provided during the grant period so they can figure out how to bill under available funding later. They are learning how to do this so they will be prepared for 2014.
The grant from Riverside Health Foundation covers; Psychiatrist time, Nurse Practitioner time at Blaine St Clinic, and limited amount of physical health set-up costs. The plan was to bill Medi-Cal for lab services.
Charts are fully integrated at this site.
They have learned that the medical model at the Public Health clinic is very different from the MH model. They are two different work styles and languages. This has required patience, tolerance, and openness in order to merge the two cultures. Dysfunction existed in each system. “We know we have it – we just don’t talk about it. We don’t know all the hidden rules in the other the system.”

2.Blaine Street Mental Health Clinic:

Public Health provided a Nurse Practitioner (NP) who was bi-lingual and experienced in Public Health to work in the MH clinic.
They set up a primary health care exam room – the NP described the equipment needs.
It cost $35K for equipment & supplies- this was more than expected.
They needed to have a lab room for supplies and to collect specimens. This required specialized equipment including: a phlebotomy chair, more refrigerators, urine test cart, microscopes, slides, ear scopes, etc.
The focus was onbasic physical health care prevention and education services; birth control, STD education & testing, women’s reproductive health care (for women age 40 and older).
The NP had to get to know the MH clients and they needed to get to know her. It was critical to establish that relationship.
MH staff tended to screen out too many clients initially.
MH clients have high rate of obesity, cancer, high blood pressure, and diabetes. The clients need onsite services.
NP has a good way of talking to the clients; provides education and advocacy, which is necessary to provide coordinated care.
In the first two weeks of the added emphasis on physical health care there were two medical crises identified that the employees had not been aware of that required referral to the Emergency Room.
NP’s first approach was to teach the MH nurses about phlebotomy, about how to approach clients, etc. This increased their comfort level. The MH staff became more comfortable with physical health issues.
Clients did not want to switch to the new service initially. Clinicians found introducing the clients to the NP in the hall helpful – to allow an interaction. Once they met the NP, they were very likely to keep the next appointment. The NP is very skillful at developing a relationship, very caring.
The clinic is keeping the charts separate (one for MH and one for physical health); but the two are kept together – so they can both be pulled when the clinician or doctor sees the client. Both are used at the same time.

3.Suboxone Treatment with Primary Care Physician

Drug Manufacturer’s Protocol:

requires three months of Suboxone, on a step-down basis,
plus 3 months of simultaneous substance abuse counseling,
followed by one month of Naltrexone, if needed.

County Requires 4 month outpatient substance abuse treatment program.
Procedure in place:

Doctor identifies Drug Medi-Cal eligible clients in his private practice.
Doctor writes script that patient takes to a specific pharmacy.
Pharmacist calls the doctor prior to filling script for verification from the doctor that client is obtaining substance abuse treatment.
Doctor’s nurse checks with substance abuse clinic weekly to see if patient is keeping appointments. Sometimes, if there are problems, nurse visits clients at the treatment site.
Pharmacist calls the doctor to approve refill of Rx for each additional 30 days.
The doctor, pharmacist, and treatment center are working together.

Outcomes:
Treated 8 clients;
3 clients have completed the program.
No drop outs.
Only problem was a Registered Nurse who had trouble attending groups. She had an attitude problem. She is about to graduate.
One graduate completed our Perinatal program, graduated and is now a Peer Support Specialist. She has cleared all past legal issues, and plans to become a volunteer for our department.
Drugs clients were using:

1)Oxycontin and

2) Norcos

Merced County

Manuel Jimenez, MA, MFT

Alcohol & Drug Program Administrator

Summary

Community Outreach Program Engagement and Education (COPE)
The focus of COPE is to reach the underserved and racial disparate populations throughout Merced County
The primary focus is the development and continual engagement of collaborative system that relies on community based organizations.
COPE has further enhanced services by collaboration with agency partners, law enforcement, and other departments.
COPE clinicians partner with primary health clinics:
Livingston Medical Group—Hilmar Medical Group
Dos Palos Rural Health Center
Merced County serves about 256,000 clients. The County is beginning to co-locate services within two family friendly FQHC’s (the Livingston Medical Group and Family Care).
They will do screenings and refer patients (utilizing warm hand-offs).
The Family Care clinic is an alcohol and other drug (AOD) provider.
Currently they will be co-locating services (with plans to move into the FQHC facilities).
Family Care
Master Agreement with Mercy Medical Center
SAMHSASubstance Abuse Counselor
Livingston—Hilmar Medical Group
MOU—formalize structure
Blue Shield Grant—California Inst. for Mental Health
Total Integration
Integration with other FQHCs
Castle Family Health Centers
Golden Valley Health Centers

Merced County has staff co-located on site at a primary care facility to work with physicians, nurses and their patients.
About seven to eight months ago they received the support of their psychiatrists to integrate into rural clinics.
The AOD counselor is at the clinic 20 hours per week.
The program is using a Behavioral Health Screening Tool (it is much like the La Clinica form) and they have trained the physicians on how to use it.
The front desk staff gives out the screening tool to all patients seen in primary care.
The MH and substance use forms that they use are not in patient medical records. The charts are kept separate.
The procedure being implemented is as follows:
The patient is given the screening form
The physician reviews it
Patients that need follow-up are flagged
The AOD counselor is paged and the physician provides a warm hand-off
Sometimes the patient speaks with the AOD counselor in the exam room or they are taken into the counselor’s office.
Patients provide consent to release information.
The goal is to provide small groups at the clinic (group therapy and psych- education groups) in the future.
It’s been a long process to get the staff on board. The staff at the clinic was used to referring out for AOD services.
A considerable amount of time has been spent training the physicians on the signs/symptoms of substance use and how to use the screening tool.
The County also has probation co-located with the children and adult AOD judicial team- this provides a one stop shop for clients to see their probation officers before or after their treatment appointments.
Mental health and AOD staff are co-located at juvenile hall to provide AOD and MH services and facilitate a warm hand off when clients are released to community.

Los Angeles County

Loretta Denering

Summary

Telepsychiatry for Patients with Co-morbid Psychiatric and Substance Use Disorders

Telemedicine: “the practice of health care delivery, diagnosis, consultation, treatment and transfer of medical data and interactive tools using audio, video and/or data communication with a patient at a location remote from the provider.”
Telepsychiatry/Telemental Health is a potentially important application of telemedicine (Rost et al., 2002).
Telepsychiatry has been practiced within the University of California (UC) system since the late 1990’s and since 1996 UC Davis has provided over 5000 clinical consultations and has been awarded 10+ grants in this area.
Telepsychiatry allows the psychiatrist to meet with and monitor patients via a secured web-based application.
Telepsychiatry is accomplished though the use of special software and/or a freestanding mobile cart that includes a computer connect to the Internet, a camera and a microphone.
Studies thus far have demonstrated comparable levels of efficacy compared to routine live clinical visits
Targeting Unmet Needs
Research suggests that 33%-50% of patients in substance use disorder (SUD) rehabilitation programs often have co-morbid psychiatric problems (Drake et al., 2007).
Very few rehabilitation programs (and even fewer rural programs) have on-site psychiatrists (Hilty, 2008).
This project started in April 2011 is an innovative partnership between UCLA ISAP, the Los Angeles County Department of Public Health and the Los Angeles County Department of Health Services.
Telepsychiatry services are provided for patients admitted to the County operated Antelope Valley Rehabilitation Center (AVRC) in Acton, CA.
Background: UCLA/AVRC Telepsychiatry program
The AVRC is located in the high desert of LA County where access to psychiatric services is limited due to the remoteness of the facility.
Currently, UCLA provides psychiatric care to patients one day/week (4 hours).
Patients with severe and persistent mental illness (SPMI) and are eligible for services via the LA County Department of Mental Health (DMH) are transported to a DMH-operated clinic in Palmdale.
Patients in this project all have a DSM-IV-R SUD plus significant psychiatric co-morbidity, but do not qualify as (SPMI).
UCLA/AVRC Telepsychiatry Protocol
Patients are identified by the AVRC psychologist or LCSW as appropriate to receive telepsychiatry services.
Patients complete telemedicine information sheet, telemedicine consent form, and multi-consortium consent form. AVRC staff faxes via a secure line and mails hard copies to UCLA Neuropsychiatric Hospital.
Patient registration is processed and UCLA medical record numbers are issued.
Registration information is forwarded via secure line to ISAP psychiatrist.
AVRC mails copies of patients’ clinical information directly to ISAP psychiatrist.
ISAP psychiatrist conducts the session and completes dictations which are stored with the patients’ UCLA patient record.
Copies are sent via a secure line to the medical personnel at the Acton facility for placement in the patient’s AVRC file.
Prescriptions are written by the UCLA psychiatrist and filled at a local Acton pharmacy.

Clinical Activities To Date
As of August 1, 2012: 120 unique patients have been registered and 106 have had at least 1 session.
71 diagnosed with Major Depressive Disorder (MDD)
5 diagnosed with Bipolar Mood Disorder
38 diagnosed with Anxiety Disorders (Generalized Anxiety Disorder and Panic Disorder)
6 diagnosed with Psychotic Disorders (Drug-induced psychosis vs. Schizophrenia)
Using a low-cost medication formulary, psychotropic medications are prescribed.
So far, this project has resulted in a number of positive outcomes including: a reduced barrier to access for those in remote areas and an increase in efficiency for the AVRC and UCLA systems.
Next Steps
We hope that improved mental health outcomes will be noted as a result of the continuous care.
Other potential benefits include opportunities for enhanced cultural competency (i.e. increased interaction with traditionally underserved ethnic groups).
A report will be written in the next year to discuss SUD and mental health outcomes and results of the satisfaction survey.

Closing Remarks – Elizabeth Schaper, UCLA ISAP