7/20/2010. Cherokee Health Systems Cherokee Health Systems

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1 The Implementation of SBIRT: Screening and Treatment of Substance Use Disorders in an Integrated dpi Primary Care Setting Suzanne Bailey, Psy.D. Behavioral Health Consultant Intensive Outpatient alcohol l& drug Program (IOP), Director Cherokee Health Tennessee Primary Care Association Nashville, TN July 29, 2010 Our Mission To improve the quality of life for our patients through the integration of primary care, behavioral health and substance abuse treatment and prevention programs. Together Enhancing Life 1

2 Cherokee Health : Merging the Missions of CMHC s and FQHC s Cherokee Health A Federally Qualified Health Center and Community Mental Health Center Corporate Profile Founded: 1960 Services: Primary Care Community Mental Health Dental Corporate Health Strategies Locations: 22 clinical locations in 15 Tennessee Counties Behavioral health outreach at numerous other sites including primary care clinics, schools and Head Start Centers Number of Clients: 54,009 unduplicated individuals served 21,326 Medicaid (TennCare) New Patients: 19,210 Patient Services: 419,537 Number of Employees: 585 Provider Staff: Psychologists 39 Master s level Clinicians 63 Pharmacists 9 Primary Care Providers 52 Psychiatrists 13 Dentists 2 Case Managers 38 2

3 The Imperative for Integration of Behavioral Health and Primary Care Stigma endures Indivisibility of mind and body Failure of mental health carve outs Behavioral health problems inflate medical costs and impede outcomes Poor health status of psychiatric patients It s got to come out, of course, but that doesn t address the deeper problem. 3

4 Blending Primary Pi and Behavioral Health Care Cherokee Health Clinical Model Cherokee s Blended Clinical Model Embedded Behavioral Health Consultant on the Primary Care Team Real time behavioral and psychiatric consultation available to PCP Focused behavioral intervention in primary care Behavioral medicine scope of practice Encourage patient responsibility for healthful living A behaviorally enhanced Healthcare Home 4

5 Meshing Treatment Cultures Pace Shdli Scheduling Lifespan vs episodic care Confidentiality Documentation ti Population vs case focus Identifying a Problem: Substance Abuse Prevalence in Primary Care % Prevalence in SMI Population Impact on Chronic Disease Management and Health Status Impact on Overall Healthcare costs 5

6 Prevalence in Primary Care Alcohol Use At Risk Abuse or Dependence Low Risk/Abstainers 30% 62% 8% The Georgia/Texas Improving Brief Intervention Project Blending Behavioral Health into Primary Care Limited training in substance abuse treatment in medical school PCP discomfort in treating substance use disorders. Lack of support network for substance abuse treatment in primary care 25% with substance use d/o seek formal treatment Murphy, K et al. (2009) 6

7 Integration: A Continuum of Care for Substance Use Disorders Screening Psychoeducation Monitoring Brief intervention Brief treatment In house IOP Inpatient Referral SBIRT Core Components 7

8 Coding for SBI Reimbursement Payer Code Description Fee Schedule CPT Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 Commercial Insurance CPT Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51 G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42 Medicare G0397 Alcohol and/or substance abuse structured screening and brief intervention services; $57.69 greater than 30 minutes H0049 Alcohol and/or drug screening $24.00 Medicaid H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00 BEHAVIORAL AND SUBSTANCE USE SCREENING & INTERVENTION IN PRIMARY CARE PRESCREEN Red Flag Questions for Depression and Substance Abuse Depression Screening V79.0 * + Depression or Alcohol/Drug? Annual Monitoring Alcohol/Drug Screening V65.42 * > 5 PHQ 9 CAGE AIDAID < 5 + Intervention Behavioral Health Annual Monitoring Intervention (99408*) Behavioral Health Resource List Annual Monitoring V Codes should be viewed as default codes for screening when a more accurate diagnosis is not available. Providers should use their own professional judgment in selecting appropriate diagnosis codes for all subsequent visits that include intervention services. 8

9 Interventions in Primary Care Education of Providers and Staff Behavioral Health Consultation Psychiatry Consultation Co Management Traditional Specialty Care Referrals to Supportive Community Resources Cherokee Health System s IOP Continuity of Care 8 weeks, 9 hours per week Cognitive Behavioral Treatment Motivational Enhancement Therapy Required AA/NA Attendance Required Individual Therapy Relapse Prevention 9

10 Impact and Cost Effectiveness Estimated net savings of $254 per person offered screening Medicalcare care costs only, cost effectiveness ration of $1,755 per QALY saved In top 4 most cost effective prevention recommendations of US Preventive Service Task Force recommendations Discuss daily aspirin use: men 40+, women 50+ Childhood immunizations Smoking cessation advice and help to quit adults Alcohol screening and brief counseling adults Solberg LI, et al. Primary care intervention to reduce alcohol misuse: ranking its health impact and cost effectiveness. Am J Prev Med. 2008;34(2) Treatment Impact Abstinence: 40.2% F/U vs. 15.1% intake No drug/alcohol related health or behavioral consequences: ces 83.4% F/U vs. 49.4% intake Employed or attending school: 45.0% F/U vs. 37.5% at intake Injected illegal drugs: 1.7% F/U vs. 3.5% at intake Had unprotected sexual contact with intoxicated person: 13.2% F/U vs. 28.5% at intake Drug use reduced by 67% at six month follow up Alcohol use reduced by 38% at six month follow up SAMHSA, 2009 Madras, B.K. et al. (2009) 10

11 Cost Savings Cost savings savings of $4 million for each $1 million spent on alcohol SBIRT implementation in primary care SAT produces savings 4 to 10 times > cost of care Medicaid Mdi id saves $2,000,000 for each 1,000 patients screened Madras, B.K. et al. (2009) Challenges Competing Priorities Limited access to A&D treatment resources Logistical Barriers Reimbursement Workforce 11

12 Lessons Learned Administrative, Clinical, Support Staff Buy In Have Champions at Every Level! Make Change Systematic and Organized Invest in Training Build the Right Team Build Support for Primary Care Integrate into Primary Care Flow All in One SBIRT Resource: Helpful Resources Screening and Treatment Resources: Center for Substance Abuse Treatment NIAAA Resources: Rethinking Drinking: Helping Patients Who Drink Too Much: A Clinician's Guide 12

13 Contact Information: Suzanne Bailey, Psy.D. 13

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