Jack B. Stein, MSW, Ph.D. Division of Services Improvement Center for Substance Abuse Treatment

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1 Substance Abuse: The Missing Link in a Health/Wellness-Based Health Care System Jack B. Stein, MSW, Ph.D. Director Division of Services Improvement Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration ACMHA 2009 Santa Fe Summit ACMHA 2009 Santa Fe Summit March 12, 2009

2 H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment SAMHSA

3 Today s Topics Making the (Business) Case for Addressing Substance Abuse A Model Framework CSAT/SAMHSA Program Examples Suggested Next Steps

4 Making the (Business) Case 4

5 Economic Costs to Society Drugs and alcohol problems cost the nation an estimated $276 billion/year mainly due to lost productivity and healthcare costs (Harwood, et al. 1998). About 19.2 million U.S. workers (15%) reported using or being impaired by alcohol at work at least once in the past year (Frone, 2006)

6 Most People in Need of Drug Treatment Do Not Seek It Did Not Feel They Needed Treatment 95.5% 5% 4.6% Felt They Needed Treatment and Did Not Make an Effort 1.5% Felt They Needed Treatment and Did Make an Effort 20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use NSDUH/SAMHSA (2007)

7 Health Consequences of Substance Use HIV/AIDS Liver Cardiovascular Musculoskeletal Respiratory Gastro-Intestinal Kidney Prenatal

8 Substance Abuse Creates a Burden on Our General Medical Care System Medical conditions were found to be more common among substance abuse patients compared to nonsubstance abuse patients (Mertens et al., 2003). Substance dependent persons without primary p p p y medical care have a substantial burden of medical illness compared to age/gender matched US population controls (De Alba et al., 2004).

9 Greater Burden on Public Sector 83% in Private Pi Private 2010!! Pi Private 50% 23% 22% 50% 77% 78% Public Public Public 1986 All SA = $9.3B Public = $4.6 B Private = $4.6 B 2003 All SA = $20.7 B Public = $16.0 B Private = $4.7 B 2006 All SA = $23.6 B Public = $18.5 B Private = $5.2 B Source: Health Affairs, October 2008

10 Substance Abuse Treatment is Effective Reduces drug use, criminal justice involvement, and improves productivity. As effective as treatment for other chronic conditions (e.g., diabetes, high blood pressure, and heart disease). Cost effective: $1 invested in treatment saves $7 in future costs.

11 The Business Business Case Xerox Corporation achieved a 5 to 1 investment by enrolling workers in a wellness program that included reducing alcohol consumption. ChevronTexaco found that 75% of employees who entered the company EAP were able to retain their employment. Gillette Company saw a 75% drop in in-patient substance abuse treatment costs after implementing an EAP.

12 Toward a Recovery-Oriented Model of Care 12

13 What Do We Mean by Recovery from Substance Use? A process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. Source: CSAT National Summit on Recovery, 2005

14 Why a Recovery-Based Approach? Most clients undergo 3 to 4 episodes of care before reaching a stable state of abstinence ¹ Chronic ccare approaches, including self-management, age e family supports, and integrated services, improve recovery outcomes 2 Integrated and collaborative care has been shown to optimize recovery outcomes and improve costeffectiveness 3 ¹ Dennis, Scott & Funk, Lorig et al, 2001; Jason, Davis, Ferrari, & Bishop; 2001; Weisner et al, 2001; Friedmann et al, Smith, Meyers, & Miller, 2001; Humphreys & Moos, 2001)

15 A Traditional Course of Treatment for a Substance Use Disorder Severe 100 Sym mptoms Person s Entry into treatment Discharge Remission 0 Resource: Tom Kirk, Ph.D Time

16 A Traditional Service Response Severe 100 ymptoms Sy Remission0 Resource: Tom Kirk, Ph.D Acute symptoms Discontinuous treatment Crisis management

17 A Recovery-Oriented Response Severe 100 Sy ymptom ms Continuous treatment response Remission0 Promote Self Care, Rehabilitation Resource: Tom Kirk, Ph.D

18 Helping People Move Into A Recovery Zone Severe Symp ptoms Recovery Zone Improved client outcomes Remission Resource: Tom Kirk, Ph.D Time

19 Components of a Recovery-Based Care System

20 Recovery-Based Care System: Individual, d Family, and dc Community-centered Recovery Individualid Family V Community Wellness Health

21 Recovery-Based Care System: Comprehensive menu of services and supports recovery Recovery Services & Supports Family/ Alcohol/Drug Services Child Care Education Vocational Housing/ Transportation Spiritual Individual Family Community Mental Health Physical Health Care HIV Services Wellness Financial Legal VSO & Peer Support Case Mgt Health

22 Recovery-Based Care System: Interface of multiple systems Recovery Child Welfare and Family Social Services Services Housing Educational System Faith Community Indian Health Services Wellness Housing/ Transportation Spiritual Family/ Child Care Systems of Care Services & Supports Financial Individual Family Community Legal Case Mgt Health Insurance DoD & Veterans Affairs Addiction Services System Alcohol/Drug Treatment Vocational Mental Health VSO & Peer Support Health Care HIV Services Criminal Justice System Mental Health System Primary Care System Vocational Services Health

23 Recovery-Based Care System: Outcomes-driven approaches to care Cost Effectiveness Perception Of Care Retention Evidence-Based Practice Child Welfare and Family Services Social Services Housing Authority Faith Community Wellness Indian Health Services Educational Housing/ Transportation Spiritual Family/ Child Care Financial Health Insurance Recovery Systems of Care Menu of Services Individual Family Community Legal Case Mgt DoD & Veterans Affairs Abstinence Addiction Services System Alcohol/Drug Treatment Vocational Mental Health VSO & Peer Support Health Care HIV Services Criminal Justice System Mental Health System Primary Care System Employment Reduced Crime Vocational Services Safe & Drug-free Housing Health Access/Capacity Social Connectedness

24 Cost Effectiveness Perception Of Care Retention Recovery-Based Care System: Ongoing process of systems improvement Evidence-Based d Practice Social Services Housing Authority Wellness Child Welfare and Family Services Indian Health Services Family/ Child Care Recovery Systems of Care Services & Supports DoD & Veterans Affairs Abstinence Addiction Services System Alcohol/Drug Treatment Mental Health System Employment Vocational Educational Individual Mental Health Housing/ Family Reduced Primary Care Transportation Community Health Care Crime System Spiritual HIV Services Financial VSO & Peer Support Vocational Services Legal Case Mgt Safe & Drug-free Housing Health Insurance Criminal Justice System Access/Capacity Social Connectedness Ongoing Systems Improvement Health

25 Key Questions How to measure recovery? Which systemic components are most essential? Incentives to leverage systems change? Staffing and other organizational changes required? Utilization of peers as recovery coaches? Role of faith-based organizations in sustaining recovery? Effectiveness of various financing mechanisms (e.g., vouchers)?

26 CSAT Program Examples 26

27 Access to Recovery State-based program designed to promote recoverybased systems of care: Choice in providers vouchers Non-traditional providers (e.g., faith-based organizations) to provide clinical and recovery support services Grants awarded to 24 States and Tribal Organizations ( )

28 A New ROSC-Based Grant Opportunity Title: Grants to Expand Substance Abuse Treatment Capacity in Targeted Areas of Need-Local Recovery- Oriented Systems $5.1 million available 13 awards 4 year grants $ 400,000/grant See: grants.gov OR samhsa.gov

29 A Recovery- Oriented System of Care Should Focus on Both Upstream and Downstream Services

30 Traditional Substance Abuse Intervention High-Risk At-Risk Low Risk Abstainers Adapted from Babor,T,F., Higgins-Biddle,J.C., (2001), Brief Intervention for Hazardous and Harmful Drinking: A manual for use in primary care. p 33. WHO/MSD/MSB/01.6b World Health

31 Screening, Brief Intervention, and Referral to Treatment (SBIRT) Comprehensive, integrated approach to early intervention and treatment. Conducted din primary care and community health h centers, hospital emergency rooms, trauma centers, and other community settings. Utilize standardized tools that screen for alcohol, substance abuse and tobacco use.

32 SBIRT: Core Components Brief Treatment Cognitive behavioral work with clients who acknowledge risks and are seeking help Screen Identification of substance related problems Brief Intervention Raises awareness of risks and motivates client toward acknowledgement Referral to Tx Referral of those with more serious addictions

33 SBIRT Implementation Challenges Insufficient i ttraining, i organization, or reimbursement to screen, assess, and refer those with drug abuse disorders to services (McLellan & Meyers, 2004). Only 15% of health plans surveyed required any alcohol, drug, or mental health screening by primary care providers (Garnick, Horgan, et al. (2002).

34 SBIRT State Cooperative Agreement Awards 2003 Awards : California Cook Inlet Tribal Council Illinois New Mexico Pennsylvania Texas Washington 2006 Awards: Colorado Florida Massachusetts Wisconsin $3.5m $1.7m $3.5m $3.5m $3.0m $3.5m $3.0m $2.8m $2.8m $2.8m $2.4m 2008 Awards: Tanana Chiefs Conference $2.1 m West Virginia $2.2 m Missouri $2.3 m Georgia $2.5 m

35 To date, nearly 800,000 persons have been screening in SAMHSA s SBIRT initiative!

36 SBIRT: Outcomes at 6 Month Follow-Up SBIRT: Outcomes Intake 6 Month Follow-up 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 16.6% 95.2% 92.4% 42.0% 42.4% 35.9% 73.7% 73.4% 54.6% 51.2% No Subtance Use No Arrests Employed Social Housed Connectedness Clients reporting no substance use increased 153.8% Clients reporting no arrests increased 3.1% Clients reporting being employed increased 18.0% Clients reporting being socially connected increased 0.5% Clients reporting being housed increased 6.6%

37 Reimbursing for SBI: Major Policy Changes! HCPCS Codes (Medicaid) - H0049: Alcohol l &/or Drug Screening ($24) - H0050: Brief Intervention:15 mins. ($48) CMS G-Codes (Medicare) - G0396: mins ($29.42) - G0397: > 30 mins ($57.69) CPT Codes (Commercial Health Plans) : mins ($33.41) : > 30 mins ($65.51)

38 Bravo Eric and a host of other SBIRT proponents!

39 FY 08 Medical Residency Grants Natividad Medical Center (CA) University of California, San Francisco Yale University (CT) Access Community Health Network (IL) Children s Hospital Corp (MA) Albany Medical College (NY) Kettering Medical Center (Ohio) Oregon Health and Science University (OR) University of Pittsburgh (PA) University of Texas Howard University (DC)

40 Next Steps Cost offset and cost effectiveness studies Lessons learned from State-level health care reform initiatives (e.g., MA, VT, ME) Data on how states use Medicaid to support drug treatment Integration of services Electronic health records

41 Thanks!

42 Integrating Care Makes Sense/Cents Between 1998 and 2003, the number of patients diagnosed with a mental health/substance abuse disorder in community health centers increased from 210,000 to 800,000 (Druss, et al. (2006). Availability of medical care services in drug treatment clinics is associated with lower repeated emergency department use (Laine, et al. (2005). Integrated care patients had significant decreases in hospitalization rates, inpatient days, and ER use (Parthasarathy, et al. (2003).

ORGANIZATION OF AMERICAN STATES INTER-AMERICAN DRUG ABUSE CONTROL COMMISSION RECOVERY-ORIENTED SYSTEMS OF CARE

ORGANIZATION OF AMERICAN STATES INTER-AMERICAN DRUG ABUSE CONTROL COMMISSION FORTY-FOURTH REGULAR SESSION November 19-21, 2008 Santiago, Chile OEA/Ser.L/XIV.2.44 CICAD/doc.1687/08 13 November 2008 Original: