Integrating Primary Care for Addiction Treatment

Transcription

1 A23 These presenters have nothing to disclose Integrating Primary Care for Addiction Treatment By Donna Gallbreath, MD Senior Medical Director and Melissa Merrick, LCSW, CDCI Clinical Director of Behavioral Health Integration 12/11/18 9:30-10:45 AM #IHIFORUM

2 Disclosure: By Donna Gallbreath, MD, Melissa Merrick, Catherine Best, MD and Shelby Kuhn, ABHC today have no relevant financial or nonfinancial relationship(s) within the services described, reviewed, evaluated, or compared in this presentation. P 2 #IHIFORUM

3 Session Objectives P3 Develop integrated care systems that support primary care providers and behavioral health providers working to treat addiction Improve health outcomes through integrated care teams Illustrate the outcomes, benefits, and lessons learned in relation to treatment approaches implemented at two health systems #IHIFORUM

4 P4 Vision A Native Community that enjoys physical, mental, emotional and spiritual wellness Mission Working together with the Native Community to achieve wellness through health and related services

5 Goals Shared Responsibility Commitment to Quality Family Wellness P5

6 Customer-Ownership P6

7 Operational Principles P7

8 Core Concepts P8

9 P9 Southcentral Foundation s Approach to Care Integrated Care Teams Integrated Behavioral Health Trauma Informed Care

10 Trauma Informed Care P10 How does trauma affect the life of those seeking treatment? Adjusting to potential vulnerabilities a traumatized person may have Core Concepts #IHIFORUM

11 Integrated Care Team Roles P11 Behavioral Health Consultant Primary Care Provider Registered Dietitian Pharmacist Certified Medical Assistant Customer- Owner Nurse Case Manager Integrated Psychiatry Team Certified Nurse Mid-Wife Case Management Support Community Resource Support #IHIFORUM

12 Integrated Behavioral Health P12 Integrated Psychiatrists Behavioral Health Consultants Referrals #IHIFORUM

13 Using Behavioral Health Consultants P13 Screening in Primary Care Motivational Interviewing Brief Solution-Focused Therapy #IHIFORUM

14 Addressing the Opioid Epidemic P14 in Primary Care Prevent opioid misuse and abuse Resources for effective management of pain Promote safe prescribing practices Identifying substance use disorders Education for customer-owners System-wide approach Resources for recovery and medication-assisted treatment in primary care

15 Relationship Satisfaction It s All About Relationships P15 Good Community Relationships = Increased Demand for Behavioral Health Services Behavioral Health Services Requested

16 Continuum of Behavioral Health Care Substance Use Disorder Treatment Youth Dena A Coy Four Directions Alaska Women s Recovery Project SCF Detox Program TRAILS The Pathway Home Severely Mentally Ill Quyana Clubhouse Crisis / Supportive Rural Denaa Yeets Behavioral Urgent Response Team Willa s Way Behavioral Health Aides Community Health Centers Counseling / Therapy Fireweed Behavioral Health Clinic Primary Care Behavioral Health Clinic

17 Substance Use Disorder Services P17 Detox Services Residential Intensive Outpatient Outpatient Medication Assisted Treatment #IHIFORUM

18 Medication Assisted Treatment: Organizational Philosophy P18 Prevent further addiction, misuse and abuse Opiate guidelines in primary care for effective medication management Early identification of substance use disorders, including opiate misuse Promote safe prescribing practices Services are easy to use and barriers to care removed for substance use disorders Build out continuum of care across service lines; educating customer-owners Coordination of care is maximized; handoffs do not feel like barriers to customer-owner Resources are maximized; shared responsibility medication assisted treatment in primary care

19 Opioid Treatment at SCF: Spectrum of Medication Assisted Treatment Services P20 Medication Assisted Treatment & Primary Care Primary Care Provider, Registered Nurse Case Manager, Integrated Pharmacist Integrated Behavioral Health Behavioral Health Consultant Psychiatric Consult and Services Medication Assisted Treatment & Behavioral Health Specialty Services Residential, Intensive Outpatient, Outpatient Hospital Based Behavioral Health Services

20 Medication-Assisted Treatment P21 The use of medications with counseling and behavioral therapies to treat substance use disorders and prevent opioid overdose (SAMHSA, 2017).

21 Medication Assisted Treatment P22 Four Directions Integrated Behavioral Health Primary Care Provider Fluid movement between services depending on customer-owner needs

22 Referral From Primary Care P23 Severe Opioid Use Disorder Intravenous Users Community Referrals Currently on MAT Moderate Opioid Use Disorder Mild to Moderate Opioid Use Disorder Primary Care Physician Customer- Owner Behavioral Health Consultant / Chemical Dependency Counselor

23 Managed in Primary Care P24 Community referrals currently on MAT Milt to moderate opioid use disorder Life circumstances are stable: Primary care s limited structure meets need Successful on Vivitrol/Naltrexone Primary Care Physician Customer- Owner Behavioral Health Consultant

24 Pre-Induction Engagement P25 Attend behavioral health consulting / chemical dependency counseling visits Establish relationship with primary care provider Obtain screening labs Sign controlled substance agreement

25 Controlled Substance Agreement P26 Sets expectations regarding Medication use Medication misuse Urine toxin screens & pill counts Abstinence from other substances Alcohol Benzodiazepines Diversion

26 Induction P27 Rx Integrated Psychiatrist Registered Nurse Customer- Owner Pharmacist Primary Care Physician Day 1 1. Clinical Opioid Withdrawal Scale (COWS) mg Suboxone, based on COWS 3. Repeat COWS mg Suboxone, based on COWS 5. Repeat COWS Day 2 1. Clinical Opioid Withdrawal Scale (COWS) 2. Total day 1 dose of Suboxone 3. Repeat COWS mg Suboxone, based on COWS 5. Pharmacist-driven medication education

27 Follow-Up P28 Learning Circles Customer- Owner Integrated Psychiatrist/ Primary Care Provider Behavioral Health Consultant/ Chemical Dependency Counselor Registered Nurse

28 Stabilization Period P29 Four Directions Integrated Behavioral Health Primary Care Provider Fluid movement between services depending on customer-owner needs Customerowner Check-In s (12+ months) Urine Tox Provider Check-In s Pill Counts

29 P30 Lessons Learned Challenges Outcome Data

30 Lessons Learned P31 Logistical Challenges Provider receives training but does not prescribe Forgets or doesn t renew training Building in support and consultation for primary care providers Rural community challenges Medication storage Prescription timing In-person vs. telemedicine

31 Challenges of Behavioral P32 Health Integration Merging of behavioral services and medical services cultures Teaching Primary Care Provider s how to use behavioral health Promoting substance dependence as a chronic disease rather than mental weakness or moral weakness Helping behavioral staff adapt to a more problem focused, efficient and practical working environment Ensuring substance use disorder competency in addition to mental health competency

32 Challenges of Supporting P33 Primary Care Providers Understanding buprenorphine and addiction related regulations Addiction and behavioral health tips for primary care providers Ambulatory risk guidance for alcohol detox Ambulatory detox protocol (alcohol and opioids) Procedural and Surgical Guidelines for buprenorphine How to manage acute or chronic pain for those on buprenorphine

33 Prescribing Guideline Results P34 ANPCC Average Monthly QTY Dispensed #IHIFORUM

34 Tools P35 Data Mall Tools 3 Action Lists: 12 Month Snapshot FYI Controlled Medication Agreement Suboxone Action List Action List Contents Prescriber, who, what and quantity Recent Utox, BHC visit, utilization patterns, controlled med agreement Naloxone Dispensing

35 Outcomes Data for MAT P36 Percent of Primary Care Providers <1% 72% wavered went from Percent of Psychiatrists wavered 1% 94% went from Customer-Owners active in Medication Assisted Treatment in primary care <10 150

36 Following Opioid Rx Consultant Data P37 Consult Results on QTY Rate Customers with Consult 248 Consult Customers with Opioid Dispenses Pre-Consult Monthly QTY per Customer Post-Consult Monthly QTY per Customer Average Post-Consult Months Change in QTY Rate Consult Results on ED/FT Rate Customers with Consult 248 Consult Customers with ED/FT Visits Pre-Consult Monthly ED/FT Visits per Customer Post-Consult Monthly ED/FT Visits per Customer Average Post-Consult Months Change in ED/FT Rate -0.09

37 More outcomes P38

38 Disclosures: These presenters have nothing to disclose Integrating Primary Care for Addiction Treatment Aurora Behavioral Health Center, Aurora Sheboygan Memorial Medical Center, Sheboygan, WI December, 2018 Catherine Best, MD Shelby L. Kuhn, MSW, LCSW, SAC, CS-IT Kelly Grube, RN

39 Disclosures None of the presenters have relevant financial or nonfinancial relationships to disclose

40 Who we are

41 Sheboygan County 115,000 residents 89% identify as White/Caucasian 10% identify as Asian or Hispanic ethnicity 28% of residents report binge drinking in the past 30 days 19% treated for mental health conditions 5% considered suicide in the past year 16% of people report unmet medical needs due to cost barriers 174 total area providers 116 Aurora Providers 11 total BH providers (physicians, APPs) in the county 7 Aurora-employed BH providers

42 Aurora Sheboygan Memorial Medical Center 1 of 15 Legacy Aurora hospitals in Wisconsin Designated as Center of Excellence by Joint Commission: Stroke Hip Knee Spine Perinatal 135 Bed Hospital in Sheboygan County 20,000+ ED visits Psychiatric unit receives 5 counties of involuntary detention/hospitalization

43 Aurora Behavioral Health Center - Sheboygan Services provided: Partial Hospitalization Program Intensive Outpatient Program Medication Assisted Treatment Clinic Mental Health and Substance Use Disorders

44 Session Objectives Describe integrated care model that supports primary care providers and behavioral health providers working to treat addiction Improve health outcomes through integrated care teams Illustrate the outcomes, benefits, and lessons learned in relation to treatment approaches used by Southcentral Foundation and Aurora Healthcare in Sheboygan

45 Problem Statement Patients in Sheboygan County had limited access to medication assisted treatment (MAT) of addiction There were no Aurora physicians in Sheboygan County who prescribe buprenorphine Local wait times for first appointment to physicians prescribing MAT were 6 weeks or more Local wait times for behavioral health care access were 8 weeks or more

46 Current State The occurrence of opioid use disorder has reached epidemic proportions in Wisconsin

47 Current State Naloxone Dose Administration City of Sheboygan Fire, Year

48 Local Opportunity to Enhance Supports

49 Local Opportunity to Enhance Supports Aurora Behavioral Health Center opened an intensive outpatient program (IOP) to treat patients with substance use disorders Aurora has experienced challenges with recruitment of Addiction Medicine specialists to prescribe medication assisted treatment (MAT) for the center and broader community Although primary care physicians have been encouraged to prescribe MAT, there has been little interest or success in recruiting physicians to prescribe

50 Defining the Problem Poor access to MAT in Sheboygan County PCPs are reluctant to treat patients desiring MAT in their primary care office PCPs do not want to treat this patient population Lack of PCP experience in treating substance use disorder PCPs are reluctant to prescribe MAT in behavioral health center due to concern about loss of productivity Map of Buprenorphine-Authorized Programs/Physicians (SAMHSA)

51 Barriers to Access Challenges: Addiction Medicine Specialist recruitment Nationwide shortage of Addiction Medicine specialists Psychiatrists already in high demand; unable to expand practice and devote additional time to training Solution: Encourage primary care physicians to get training and treat patients with opioid addiction.

52 MAT in Primary Care Office Challenges: Lack of adequate facilities to treat this population Lack of nursing expertise to treat this patient population MAT can be diverted and abused in the absence of treatment protocols Solution: Create a model of MAT delivery by PCPs that does not involve costly modifications to existing offices or added training to primary care nurses.

53 Difficult Patient Population What Doctors Think Their Waiting Room Will Look Like: What Their Waiting Room Will Really Look Like: Solution: Create a model where a primary care physician acts as MAT prescriber for patient without being their PCP.

54 Experience Treating SUDs Challenges: PCPs lack experience in treating addiction Small numbers of these patients in individual practices; therefore rarely get comfortable treating them Inadequate access to the supplementary behavioral health support services that are needed Solution: Create a Behavioral Health Center where PCPs can prescribe MAT with comprehensive behavioral health support.

55 Compensation and Productivity Challenges: Time needed to complete training Limited to 30 patients in first year of waiver Developing a practice takes time Patients participate in behavioral therapies, which may limit initial access Attendance/attrition with patient population PCPs are concerned they will lose income due to low volume Solution: Create a compensation model that will incentivize PCPs wishing to prescribe MAT and support costs associated with training.

56 Expectations If we: Create a behavioral health center to provide medication assisted treatment of addiction Create favorable compensation models for PCPs Create RN model Create hospital based IOP Get more PCPs to prescribe Then we expect: Providers : will work with experienced staff will see higher volumes and attain proficiency sooner will work with developed protocols will have BH support and collaboration will have adequate facilities Providers may be more likely to consider participation RNs will work at top of license RNs will gain experience with managing patients with addiction Improved outcomes, better reimbursement Increased access for patients in need, closes the loop, increased compliance, improved communication

57 Implementation Plan Develop compensation model for PCPs prescribing MAT in ABHC Engage service line leaders in Primary Care, Behavioral Health, Pain Management Onboard specialty nursing staff Develop RN and MD MAT documentation templates Create workflows for outpatient buprenorphine induction Create treatment agreement contract

58 Treatment Agreement Safety is priority Safe storage Benzodiazepines Return to use/tolerance Pill counts, wrapper counts UDS and quantification levels Diversion, adulteration of urine specimens Attendance and participation in care

59 Intake Screen- Assessment Screening- Assessment Induction Day 1 Induction Day 2 Stabilization Maintenance Initial phone screen for imminence of medical need RN intake assessment to determine level of care Risk for communicable diseases Harm reduction behaviors POC Urine Drug Screen Treatment Contract Willingness to participate in group psychotherapy Schedule induction, ideally within 72 hours No opioid use for hours prior Medical Withdrawal

60 Day One Induction Screening- Assessment Induction Day 1 Induction Day 2 Stabilization Maintenance Patient presents in early withdrawal Assess COW scale, vitals MD completes admission history and physical Prescription filled Observe 1 st dose, 4mg unless otherwise indicated minutes later, reassess 2 nd dose, 4mg, if needed; 8mg typical maximum first-day dose Reassess minutes later Patient to return home with plan and telephone protocol/support, follow-up with RN visit next day Medical Withdrawal

61 Day Two Induction Screening- Assessment Induction Day 1 Induction Day 2 Stabilization Maintenance Nurse follow-up visit to establish dose COWS, vital signs Dose can be increased to 12mg Reassess min later Additional 4 mg available, if COWS indicates; maximum day 2 typically 16mg Phone support provided Patient initiates in Intensive Outpatient Program for behavioral therapy If symptoms are not managed by Day 2, clinic pathway can continue into Day 3 or 4 with maximum daily dose of 24mg Medical Withdrawal

62 Stabilization Screening- Assessment Induction Day 1 Induction Day 2 Stabilization Maintenance Medical Withdrawal Weekly visits during first month; every two weeks second month Response to treatment Risk of relapse Medication treatment Compliance with treatment agreement Unmet physical health needs, health maintenance topics, referral for primary care provider Patient encouraged to attend peer support recovery groups Treatment individualized based on short and longterm goals: Patient completes IOP Encouraged to attend traditional outpatient counseling Goal to maintain abstinence Create recovery-supportive environment

63 Maintenance Screening- Assessment Induction Day 1 Induction Day 2 Stabilization Maintenance Medical Withdrawal MD visits every 1-2 months Increase frequency of visits, if relapse or increase in symptoms Monitor risk of relapse, return to use, alternative substance use Consider transition back to PCP Health Promotion Smoking cessation Management of Hepatitis C Access to naloxone Contraception Care Pathway for Pregnant Women Prenatal care Neonatal assessment prior to delivery

64 Medical Withdrawal Screening- Assessment Induction Day 1 Induction Day 2 Stabilization Length of treatment is individualized, can be indefinite Decision to taper is a joint decision by patient and clinician Taper slowly: monitoring and frequent assessment Prepare patient for withdrawal symptoms Recovery is the top priority: continue to work with patient Maintenance Medical Withdrawal

65 Results MAT patients treated at Aurora Behavioral Health Center Sheboygan, April October Buprenorphine Naltrexone Transferred Patients Discharged Patients 10 0

66 Results Employment Status 90 Day Sobriety 13% 6% 31% 56% Employed at Admission 94% Gained Employment during Tx Unemployed Achieved 90 days continuous sobriety Less than 90 days Based on current patients, admitted with untreated OUD, treated with buprenorphine for at least 90 days; N=16

67 Insights Our model has improved access to medication assisted treatment of substance use disorder by encouraging primary care physicians to prescribe MAT in a behavioral health center Provides opportunity for provider to become competent with consistent patient volumes Provider surrounded by behavioral health expert teams: RN, case manager, clinical social work, psychiatric consult Primary care is well-suited to provide this care Population is particularly suited for treatment of the whole person With support, we hope that our model can be replicated in other communities and with additional providers

68 Lessons Learned Do not delay induction until behavioral therapies are available Flexible, individualized care is necessary Learning to define what is success? Newer data supports induction of buprenorphine in nontraditional settings and opportunities for more flexible care

69 Future Directions Expand Primary Care access to training opportunities Expand access and support for Primary Care to provide care in behavioral health hub or primary care setting with behavioral health support Emergency Department Induction Inpatient Induction Home induction

70 Questions?