ATTC White Paper 1: Integrating Substance Use Disorder and Health Care Services in an Era of Health Reform

2015·2.4 MB·English

ATTC WHITE PAPER:
INTEGRATING SUBSTANCE USE DISORDER AND HEALTH
CARE SERVICES IN AN ERA OF HEALTH REFORM
MARCH 2015
ATTC
Advancing the Integration
of Substance Use Disorder
Services and Health Care
Prepared by:
ATTC Technology Transfer Workgroup: Stanley Sacks, PhD, and Heather J. Gotham, PhD, (Co-Chairs) with
Kim Johnson, PhD, Howard Padwa, PhD, Deena Murphy, PhD, and Laurie Krom, MS
Copyright © 2015 by the Addiction Technology Transfer Center (ATTC) Network
Coordinating Office.
This publication was prepared by the Addiction Technology Transfer Center (ATTC) Network
under a cooperative agreement from the Substance Abuse and Mental Health Services
Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT). All material
appearing in this publication except that taken directly from copyrighted sources is in the
public domain and may be reproduced or copied without permission from SAMHSA/CSAT
or the authors. Citation of the source is appreciated.
At the time of publication, Pamela S. Hyde, JD, served as the SAMHSA Administrator. Daryl
W. Kade, MA, served as Acting CSAT Director.
The opinions expressed herein are the views of the authors and do not necessarily reflect
the official position of the Department of Health and Human Services (DHHS), SAMHSA
or CSAT. No official support or endorsement of DHHS, SAMHSA or CSAT for the opinions
described in this document is intended or should be inferred.
Corresponding Author: Heather J. Gotham, PhD, School of Nursing and Health Studies,
University of Missouri-Kansas City, [email protected]
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Table of contents
Acknowledgements ......................................................... 4
Executive Summary ........................................................ 5
Integrating Substance Use Disorder and Health
Care Services in an Era of Health Reform ..................... 8
1. Integration in the Era of Health Care Reform ........... 10
2. Models of Integrated Care ....................................... 15
3. Interventions ............................................................ 22
4. T echnology Transfer/Implementation Support
and Guidance .......................................................... 32
5. Summary and Conclusions ...................................... 36
References .................................................................. 37
Appendix ...................................................................... 45
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Acknowledgements
This report has not been published elsewhere nor has it been submitted simultaneously for
publication elsewhere.
The work reported in this manuscript was supported by the following cooperative agreements
from the Substance Abuse and Mental Health Services Administration (SAMHSA): TI024236
(ATTC Network Coordinating Office), TI024251 (Northeast and Caribbean ATTC Regional
Center), TI024226 (Mid-America ATTC Regional Center), and TI024242 (Pacific Southwest ATTC
Regional Center).
Views and opinions are those of the authors and do not necessarily reflect those of SAMHSA
or CSAT.
The authors wish to express their appreciation to Dr. Barry Brown, Dr. Michael Dennis, and
Renata Henry for their thorough review, insightful comments and invaluable assistance in the
preparation of this manuscript. We also acknowledge the substantial contributions of Maureen
Fitzgerald, Jan Wrolstad, and Molly Giuliano for their editorial and graphics assistance.
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Executive Summary
Integrating Substance Use Disorder and Health projects that have an impact nationwide. At the
Care Services in an Era of Health Care Reform is the regional/state level, ATTCs reach deep into local
first in a series of white papers produced as part communities and are able to customize services
of the Addiction Technology Transfer Center to meet the needs of a particular area.
(ATTC) Network’s initiative, “Advancing the ATTC expertise in implementation science/
Integration of Substance Use Disorder Services technology transfer strategies combined with
and Health Care.” The main goals of this white the complimentary national and regional
paper are to emphasize the need for better reach of the various Centers situates the ATTC
integration of substance use disorder (SUD) Network in an ideal place to promote and facili-
and health care services and describe an array tate efforts to integrate SUD services and health
of effective models, interventions and imple- care. A number of ATTCs have already begun
mentation strategies for treating SUDs in health such work, examples of which are provided
care settings, highlighting efforts of the ATTC throughout the paper. For a comprehensive list
Network. The target audience for this document of the Network’s integration projects, please
includes all those concerned with the integration visit: http://www.attcnetwork.org/advanc-
of SUD and health care: the SUD, mental health, ingintegration/index.aspx.
and health care workforces; policy makers; state This paper is divided into five sections.
officials; health and behavioral health treat- Section 1 discusses two major influences on
ment administrators; physicians, nurses, social integration, a growing body of research evidence
workers, psychologists, and peer workers; and for the effectiveness of integration and health
third party payers. care reform, including the Affordable Care Act
The ATTC Network is the Substance Abuse (ACA). Health care reform and the ACA are
and Mental Health Services Administra- destined to have a powerful influence on the
tion’s (SAMHSA) most experienced program delivery of health care services nationwide,
to provide workforce development and to including treatment for SUDs and the training
promote the adoption and implementation of the SUD workforce. Sections 2 and 3 respec-
of research-based interventions in the SUD tively examine a variety of effective models of
field. The ATTC Network employs a full array integration and evidence-based clinical interven-
of technology transfer techniques, including tions that can be utilized in health care settings.
product development, academic educa- Section 4 describes strategies for implementing
tion, training, technical assistance and skills integrated care in health care environments.
building, online and distance learning, coaching Each section reviews key research in support of
and implementation support/guidance, to help integration and illustrates selected ATTC activ-
individuals, organizations and systems prepare ities in that area. Section 5 provides a summary
for, make, and sustain change. and conclusions. The paper can serve as a
Comprised of ten Regional Centers that resource for those who are pursuing the integra-
align with the ten Department of Health and tion of SUD and health care services.
Human Services (HHS) regions, four National
1. Integration in the Era of
Focus Area Centers and a Network Coordinating
Health Care Reform
Office, the ATTC Network has both a national
reach and a targeted regional/state emphasis. The Substance Abuse and Mental Health
At the national level, the Network collaborates Services (SAMHSA) – Health Resources and
and partners with many national SUD and Services Administration (HRSA) Center for
behavioral health care organizations to produce Integrated Health Solutions defines integrated
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care as “the systematic coordination of general
and behavioral health care. Integrating mental
SAMHSA’s ATTC Network is the “go
health, substance abuse, and primary care
to” resource as states, providers, and
services [that] produces the best outcomes and
the SUD treatment workforce embark
proves the most effective approach to caring for
on change under the ACA. The
people with multiple health care needs” (2015).
Network has the standing, resources,
The momentum for the integration of SUD
processes, and experience to train the
and health care services is being driven by (a)
SUD workforce and guide the integra-
a growing body of research evidence showing
tion of SUD services with mental health
better patient outcomes from integrated
services, and (b) policy changes resulting from and primary health care services.
health care reform.
Research increasingly shows that integrating
SUD and health care services improves patient
outcomes. Successful integration efforts indicate patient experience of care, improving the health
that SUDs are common and should be addressed of the population, and decreasing the per capita
in the same way as other common diseases, cost of care (Berwick, Nolan, & Whittington,
via screening, a focus on harm reduction and 2008), the ACA incentivizes coordinated and
symptom relief, use of evidence-based practices, integrated care with the use of evidence-
and, as needed, chronic disease management. based practices that lead to improved clinical
The benefits of integrated care extend to patients, outcomes.
caregivers, providers, and the health care system. For the SUD treatment and recovery
The integration of SUD services and primary services fields, health care reform is projected
care can lead to improved physical and mental to change the number and characteristics of the
health (Madras et al., 2009), reduce levels of patient population receiving services, the struc-
substance use (Gryczynski et al., 2011; Madras ture and nature of providers and services, and
et al., 2009), and result in cost savings for health to promote the integration of SUD and primary
care (Babor et al., 2007). care services (Patient Protection and Afford-
“The Affordable Care Act and its imple- able Care Act, 2013). Unfortunately, early signs
menting regulations, building on the Mental suggest that the integration of SUD treatment
Health Parity and Addiction Equity Act, services is not receiving adequate attention in
will expand coverage of mental health and health care settings. (Lardiere, Jones, & Perez,
substance use disorder benefits and federal 2011; NORC, 2011; Sacks & Chaple, 2013;
parity protections in three distinct ways: 1) SAMHSA, 2010a, b).
by including mental health and substance use A variety of challenges may impede the
disorder benefits in the Essential Health Bene- progress of integration, including needs to
fits; 2) by applying federal parity protections define and develop appropriate services;
to mental health and substance use disorder cultivate staff support; identify strategies for
benefits in the individual and small group implementing change; train the SUD, mental
markets; and 3) by providing more Americans health, and medical workforces; bring payers to
with access to quality health care that includes the table; and transcend the currently bifurcated
coverage for mental health and substance systems of SUD and mental health care. On
use disorder services” (Beronio, Po, Skopec, the other hand, as integration moves forward,
& Glied, 2013). It includes coverage for SUDs it creates opportunities for the current SUD
in recognition of their prevalence and role workforce to work in new settings. This paper
in causing or contributing to other serious outlines recommendations for areas of change
health conditions (Buck, 2011; McLellan, 2014). needed for the SUD treatment community to be
Through the Triple Aim of improving the prepared to integrate services.
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2. Models of Integrated Care Promoting dissemination and implemen-
tation of evidence-based practices for SUD
Several reports suggest that health care
treatment is the primary focus of the NIDA/
programs can be categorized by the level of
SAMHSA-ATTC Blending Initiative (Martino
collaboration/integration in their clinical service
et al., 2010). Using recently completed NIDA
models (Collins, Hewson, Munger, & Wade,
research, “blending teams,” comprised of
2010). Thus, the organization of service programs
NIDA researchers, clinical treatment providers,
can be arrayed descriptively across levels of
and ATTC Network staff design user-friendly
integration, suggesting points on a continuum
tools or products and introduce them to treat-
from less to more integration and from less to
ment providers. The Network uses the NIDA/
more integrated programs, such that coordinated
SAMHSA Blending products for medication-as-
care precedes co-located care, which precedes
sisted treatment, motivational interviewing,
integrated care (Collins et al., 2010; Treatment
technology-assisted care, and contingency
Research Institutes, 2010). Section 2 describes
management/motivational incentives in its
useful models for conceptualizing the integration
training, technical assistance, and technology
of behavioral health and health care services (see
transfer/implementation activities.
also the SAMHSA-HRSA CIHS website: http://
www.integration.samhsa.gov/integrated-
4. Technology Transfer/Implementation
care-models). Patient-centered medical homes,
Support and Guidance
FQHCs, and the newly developing certified
community behavioral health clinics are three Changing practice patterns, routines, and
settings that have begun integrating services. treatments is difficult. Integrating SUD treat-
The ATTC Network has been actively bringing ment services and health care is subject to all
health and SUD treatment players to the table to the complexity and difficulties that attend
accelerate integration efforts across the country. any organizational change initiative. Recent
The Appendix provides a convenience sample advances in implementation science have
of some current real-world examples that delineated conceptual models and principles
emphasize the integration of SUD and health that help to change treatment practices (see for
care services. example, Damschroder et al., 2009). The ATTC
Network places a unique emphasis on tech-
3. Interventions
nology transfer and implementation support/
Regardless of the model of integration applied, guidance to achieve lasting changes in practice.
evidence-based practices must be used to meet Section 4 describes these scientific/conceptual
the goal of improving quality of care. During advances and the related products and methods
the past 30 years, a substantial body of rigorous the Network employs to accomplish change.
study has led to the development and valida-
5. Summary and Conclusions
tion of numerous evidence-based treatments
for SUDs (e.g., medication-assisted treat- This paper focuses on: 1) the need for better
ment, motivational interviewing, contingency integration of SUD and health care services; and
management). A number of effective clinical 2) a description of effective models, evidence-
practices are compatible with the existing based interventions, and implementation
structure and functioning of primary or other strategies that are useful in treating SUDs in
health care services. Section 3 of this white health care settings, highlighting efforts of the
paper describes evidence-based SUD treatment ATTC. SAMHSA’s ATTC Network is uniquely
interventions that may be easily integrated with situated to facilitate and accelerate SUD and
other health care services, analyzes the research health care service integration at the state,
evidence for each, and presents an overview regional, and national levels.
of the Network’s activities in supporting and
guiding the use of these interventions.
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Integrating Substance Use Disorder
and Health Care Services in
an Era of Health Reform
ATTC Technology Transfer Workgroup: Stanley
Sacks, PhD, and Heather J. Gotham, PhD,
(Co-Chairs) with Kim Johnson, PhD, Howard
Padwa, PhD, Deena Murphy, PhD, and Laurie
Krom, MS
Introduction
Integrating Substance Use Disorder and Health
Care Services in an Era of Health Care Reform is
the first in a series of white papers produced
as part of the Addiction Technology Transfer
Center (ATTC) Network’s initiative, Advancing
the Integration of Substance Use Disorder
Services and Health Care. The main goals of
this white paper are to emphasize the need for
better integration of substance use disorder
(SUD) and health care services and describe
an array of effective models, interventions and
implementation strategies for treating SUDs
in health care settings, highlighting efforts of
the ATTC Network. The target audience for
this document includes all those concerned
with the integration of SUD and health care: uals, organizations and systems prepare for,
the SUD, mental health, and health care work- make, and sustain change.
forces; policy makers; state officials; health and Comprised of ten Regional Centers that
behavioral health treatment administrators; align with the ten Department of Health and
physicians, nurses, social workers, psycholo- Human Services (HHS) regions, four National
gists, and peer workers; and third party payers. Focus Area Centers and a Network Coordi-
The ATTC Network is the Substance Abuse nating Office, the ATTC Network has both a
and Mental Health Services Administra- national reach and a targeted regional/state
tion’s (SAMHSA) most experienced program emphasis. At the national level, the Network
to provide workforce development and to collaborates and partners with many national
promote the adoption and implementation SUD and behavioral health care organiza-
of research-based interventions in the SUD tions (e.g., NAADAC, the National Council
field. The ATTC Network employs a full array for Behavioral Health, Faces and Voices of
of technology transfer techniques, including Recovery, the American Association of Addic-
product development, academic educa- tion Psychiatrists, the American Society of
tion, training, technical assistance and skills Addiction Medicine, the International Certifi-
building, online and distance learning, coaching cation and Reciprocity Consortium) to produce
and implementation guidance, to help individ- projects and activities that have an impact
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nationwide. At the regional/state level, ATTCs of health care services will be highlighted.
reach deep into local communities and are able Look for the “Spotlight on ATTC Integration
to customize services to meet the needs of a Work” examples that provide these selected
particular area. illustrations. For a comprehensive list of the
One of the unique features of the ATTC Network’s integration projects, please visit:
Network is its ability to bring locally tested http://attcnetwork.org/advancingintegration/
efforts to scale nationally. Due to the structure index.aspx.
of the Network, ATTCs are able to develop This paper is divided into five primary
and test projects locally in organizations, states sections. Section 1 discusses two major influ-
and regions, and then bring them to scale ences on integration: the growing body of
nationally through cross-ATTC collaboration. evidence for the effectiveness of integration,
One example of this process is the soon-to-be and health care reform, including the Afford-
released hepatitis C virus (HCV) initiative, able Care Act (ACA). This section also examines
“HCV Current,” a national campaign to train the ACA’s powerful influence on health care,
medical and behavioral health professionals on SUD treatment, and workforce development.
HCV. Beginning work at the local level, ATTC Sections 2 and 3 respectively examine a variety
Regional Centers identified the needs of their of effective models of integration and clinical
regional workforces and sought the expertise interventions that can be utilized in health
of regional stakeholders. This local model, in care settings. Section 4 describes strategies for
which the needs and expertise of each region implementing evidence-based SUD practices in
were leveraged, is now being brought to scale health care environments. Each of these sections
nationally through a cross-ATTC workgroup. reviews representative research in support of
Workgroup members developed online and integration and illustrates selected ATTC activ-
in-person training curricula and resources to ities in that area. Section 5 presents a summary
increase knowledge of HCV among medical and conclusions. The paper can serve as a
and behavioral health professionals. Through resource for those who are pursuing the inte-
national and regional training of trainer events, gration of SUD and health care services.
experts across the country
will be trained to deliver the
curricula. It is anticipated that
“HCV Current” will increase
the capacity of medical and
behavioral health professionals
to screen for and appropriately
address HCV among patients.
ATTC expertise in
technology transfer strategies
combined with the national
and regional reach of the
various Centers situates the
ATTC Network in a favorable
place to promote and facilitate
efforts to integrate SUD services
and health care. A number of
ATTCs have already begun
such work. Throughout this
paper, specific activities of the
ATTCs to facilitate integration
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1. Integration in the Era of Health Care Reform
The SAMHSA – Health Resources and Services health (Friedmann, Hendrickson, Gerstein,
Administration (HRSA) Center for Integrated Zhang, & Stein, 2006; Gourevitch, Chatterji,
Health Solutions defines integrated care as “the Deb, Schoenbaum, & Turner, 2007; Laine et al.,
systematic coordination of general and behavioral 2000; Madras et al., 2009) and reduce levels of
health care. Integrating mental substance use (Gryczynski et
health, substance abuse, and al., 2011; Madras et al., 2009),
primary care services [that] and can result in cost savings
produces the best outcomes Research is increasingly for health care (Babor et al.,
and proves the most effective showing that integrating 2007; Parthasarathy, Mertens,
approach to caring for people SUD and health care Moore & Weiner, 2003).
with multiple health care services improves patient More specifically, inte-
needs” (2015). grating SUD services into
outcomes. Successful
The momentum for the health care can help improve
integration efforts indi-
integration of SUD and access to much needed
cate that SUDs are
health care services is being treatment services for many
common and should be
driven by (a) a growing body who could benefit from
addressed in the same
of research evidence showing SUD services but do not
way as other common
better patient outcomes from receive them. Of the 22.7
diseases, via screening,
integrated services, and (b) million Americans who need
a focus on harm reduc-
policy changes resulting from specialty treatment for SUDs,
health care reform (the ACA, tion and symptom only 2.5 million—just under
its implementing regulations, relief, use of evidence- 11%—actually receive these
and the Mental Health Parity based practices and, as services (SAMHSA, 2014a).
and Addiction Equity Act). needed, chronic disease Many of the 20.2 million
As these forces coalesce to management. people who need but do not
move integration forward, receive SUD services appear
the current SUD specialty in medical settings for phys-
care system will need to ical or mental health issues
expand and adapt. This section highlights that are related—directly or indirectly—to their
research evidence for integration, the impact of substance use (Ernst, Miller, & Rollnick, 2007).
health care reform, and challenges and oppor- Over 7.5 million individuals receive emergency
tunities for the SUD workforce. room treatment for problems related to alcohol
use (McDonald, Wang, & Camargo, 2004), and
approximately 22% of all patients in health care
Evidence for Integrating SUD
settings have a substance use condition (Treat-
and Health Care Services ment Research Institute, 2010). Consequently,
medical settings are ideal places to identify
The Integration of SUD individuals with SUDs, engage them in under-
Services into Health Care standing the need for treatment, and begin
providing services (Babor et al., 2007; Cantor et
The benefits of integrated care extend to al., 2014; Cherpitel & Ye, 2008).
patients, caregivers, providers, and the health The integration of SUD services into health
care system. Research demonstrates that the care can also help prevent risky drinking and
integration of SUD services and primary care drug use from developing into more serious
can lead to improved physical and mental problems. Approximately 68 million Amer-
10