Substance Abuse Resource Guide: Managed Care and Prevention

52 Pages·1998·3 MB·English

by  Center for Substance Abuse Prevention

,*prill998
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Prevention
Substance Abuse Resource Guide
wmmmmm
Managed and
Prevention
Whenwedialogaboutthehealthandwell-
beingofthiscountry,wequitenaturallytalk
aboutprevention.Buttodaywemustalsotalk
aboutmanagedcare.AstheleadFederal
agencyforsubstanceabuseprevention,CSAP
cannotaffordtoseparatepreventionfrom
managedcare.Bringingthemtogetherwill
assistindevelopingaseamless,qualityhealth
caredeliverysystem.
Preventionandmanagedcareorganizations
agreethatsubstanceabuseisadevastating
problemthatadverselyimpactsuponour
children,familymembers,communities,and
ourcountry.Wecancollaboratewiththis
mutualagreement.
Thefieldofpreventionhascomeofageandis
readytomoveintonewalliancesandcollabo-
rationsthatwillreinforcetheimportanceand
Studies, Articles,
credibilityoftheprofession.Theinformation
& Reports
inthisresourceguidewillhelpprevention 1
professionalsunderstandthattheirskillsand Agencies, Groups & Organizations
leadershipareessentialtocompletethe Interested in Prevention and
evolutionarycyclefrommanaginghealthcare
coststomanagingthehealthofourcitizens. Managed Care 23
Managed Care Glossary
NelbaR.Chavez,Ph.D. ofTerms 35
Administrator Healthcare Acronyms 45
SubstanceAbuseandMentalHealthServices
Administration
KarolL.Kumpfer,Ph.D.
Resource Center
CSAP
Director, -''/,-
n CenterforSubstanceAbusePrevention .,'..;
SubstanceAbuseandMentalHealthServices Washington, DC 20013-73&
0O0 Administration
4-
OoN S.DEPARTMENTOFHEALTHANDHUMANSERVICES
MS623

MvH2D?^o|
and
Studies, Articles,
Reports
JournalArticles
The Partnership for Community grassroots grantmaking approach is to
A combat the biggest health problems in
Health in the Lehigh Valley: local communities, as determined by the
Model for Healthcare Reform residents of that community. Kaiser then
Watkins, S.H. makes a grant to a broad-based coalition
or a well-established community service
Lehigh VolleyMagazine, pp. 14-18, 43 pp.
organization.
(Available from Lehigh Valley Magazine,
242 Uncas Street, Bethlehem, PA 1 8015- Kaiser makes an initial assessment of the
1237:610-691-8833) socio-medical needs of a community, as
determined by the residents of the
T community. This approach has been
he Partnership for Community used successfully in the South and is
Health in the Lehigh Valley is unique in currently being tried in Washington,
that it is the only healthcare reform DC. Based on the results of the South
effort of a partnership of healthcare and DC, Kaiser plans to move on to the
providers that is not affiliated with the Northeast and Midwest.
health insurance industry. It is being
used as a national model for healthcare Managing Managed Care: Steps
reform. The partnership began in 1992
with nine area medical centers with to Thriving with Managed Mental
three goals in mind: 1) to assess the Healthcare Arrangements
community's health needs in 1993; 2) to Durban, C.L; Durban, P.K.; etal.
form a cooperative managed care plan
EmployeeAssistance: Solutions to the
for 50,000 low income residents or the
Problems
Lehigh Valley; and 3) to develop a
coordinated system of health and 4(10): 28-30, May 1992
human services for children and
families. So far this Partnership has been 1 he effects of managed care on
successful and the goal is to extend employee assistance programs (EAP's),
beyond the seven hospitals and into the private practice providers, and
community.
institutional providers are discussed.
EAP's need to conduct a professional
Rx: Social Reconnaissance assessment, be willing to adapt, learn
new skills to be effective in a managed
Foundation News care environment, educate members on
31(4): 24-29, July/August 1990 ethical beliefs and values, work on
prevention practices to ensure that the
Docial reconnaissance is a new EAP will not be taken over by an
approach to grantmaking implemented insurance company or other
by Kaiser's Health Promotion Program, organization, provide substantial
and being copied by organizations all outcome data to managed care
over the country. The goal of this providers that make them accountable
for clinical decisions they make, and
Managed Care Page
1
seek support from and collaboration will have short-term, low-consequences
with other EAP providers. Private relapses and will rapidly return to
practice providers should diversify, recovery, whereas 60 percent of
perhapsby teaching and providing relapsers will have long-term, high-
consultation in their practices, to solidify consequences relapses that require
a broader source of revenue and costly treatment. Fifty-three percent of
satisfaction. Providers must learn to be chemically dependent patients do
more cost effective while providing recover. The recovery and relapse rates
quality clinical services, and they may for chemical addiction improved
need to put more emphasis on goal- significantly since the introduction in
directed, problem-solving orientation; 1935 of abstinence-based recovery
empowering clients; retraining in short- methods. Relapse prevention therapy is
term therapy techniques; and improving the chances of recovery for
redirection into intermittent relapsers. Many managed care providers
psychotherapy. Private practice are establishing cost control strategies
providers also may need to retool their that refuse to pay for repeat treatments
marketing strategies. It is suggested that with methods that have failed. It is
hospitals and other institutional suggested that what is needed is the
providers take the following steps to widespread implementation and
thrive through managed care's influence support of specialty treatment programs
on mental health services: (1) enter the for relapse prone people.
market at all points of continuum care;
(2) be geographically diverse; (3) cut Social Science Theory in Health
costs to the bone; (4) eliminate or de- Education: Time For a New
emphasize boutique service; (5) examine
the medical staff and make sure practice Model?
patterns are in line with the payor's Goodman, R.; Burdine, J.; et al.
philosophy; (6) create a seamless Health Education Research
interface for patients, families,
employers, insurers, physicians, and 8(3): 305-314, 1993
managed care utilization review
personnel; (7) adopt a data-driven In the health education field there is a
approach to mental health and difference between the way theory is
substance abuse treatment; (8) taught and the way it is used in practice.
continuously measure outcomes in all Also, there is a question as to how
mental health and chemical dependency theory should actually be used. The
services. academic perspective on theory and the
current use of theory in health
education practice are explored using
Penny-Wise, Pound Foolish? examples. Then an ecological planning
Gorski, T.T. approach for health education practice is
Addiction and Recovery explored. In conclusion, suggestions for
strengthening health education practice
12(3): 24-25, May/June 1992
are proposed.
JLvelapse prevention is of serious Grassroots Participation in
concern to managed care providers
Healthcare Reform
responsible for containing the cost of
chemical dependency treatment, since Cranshaw, R.
47 percent of patients treated in private Annuals of Internal Medicine
treatment programs will return to 120(8): 677-681, 1994
chemical use within the first year
following treatment; 40 percent of these
Page 2 NCADI, P.O. Box 2345, Rockville, MD 20847-2345
c
oncerned citizens have responded to systems. An overview of the changes in
the healthcare crisis by developing the both areas during the past few decades
health decisions movement. American shows technological advances in
Health Decisions, a national consortium medicine that add small increments to
of 21 State organizations, leads a grass health at a high cost, and relatively few
roots discussion network of community resources are distributed to broad public
meetings committed to education and health promotion or disease prevention
consensus on the ethical, technological, programs. Continuing the present
legal, and economic issues of health approach to medical care not only
policy. The movement is described here, perpetuates a system that does more
and potential roles for physician and more for fewer and fewer people,
cooperation and participation in forging but it denies the reality of the
functional, community-based health transformation in the distribution of
policy are delineated. illness and disability in the country. As
the population ages the healthcare
system must address treating long-term
A New Approach to Alcoholism chronic conditions and be more
Del Toro, M.; Lorsen, D. A; etal. responsive to prevention services. The
I.
integration of medicine and public
Journal ofMental HealthAdministration
health requires assigning responsibility
21(2): 124-135, 1994
for public health in a reformed system;
defining roles of the public and private
1 he authors of this article describe in sectors for public health matters;
detail an approach to alcoholism fulfilling the public health mandate;
detection which brings together determining if the implementation work
chemical dependency, mental health, accomplishes its goals; and raising funds
and primary care services. The article to pay for public health services. An
mentions alcoholism prevention, but the integrated system is the country's best
context is primarily early intervention. hope not only for improving the health
They do, however, include identification of all citizens, but for closing the "health
of patients with emotional/behavioral gap" between socioeconomically
problems in order to provide crisis- disadvantaged groups and the rest of
oriented intervention. The project model the population.
included a masters level social worker
with community resources, as well as
HMO, Collaboration in the Carolinas:
those within the to provide the
services necessary. The conclusion of the An In-depth Look at American
authors is that placing this team in the College of Healthcare Executives'
primary care facility is advantageous to Healthcare Demonstration Project
both the patient and the medical team.
Crystal, B.
Healthcare Executive
The Integration of Public Health 1 0(1 ): 1 7-20, January/February 1 995
and Medicine
Rundall, T, G. In 1992 the American College of
Frontiers ofHealth Services Management Healthcare Executives started the
10(4): 3-24, Summer 1994 Healthcare Leadership Demonstration
Project to identify and mobilize
T community healthcare leaders who
he author examines President could work together to influence
Clinton's American Health Security Act healthcare policy and delivery in their
and other efforts to integrate medical communities, also known as the
care and public health service delivery Carolinas Project. It is comprised of two
Managed Care Page 3
pilot projects: the Midlands Partnership 1 his article is an extensive discussion of
tor Community Health in Columbia, SC the merits of worksite health promotion
and the Partnership for Community in the context of health reform and the
Health of Robeson County in rapid changes in the healthcare system.
Lumberton, NC. The goals, successes, Wnile the article is in the Journal ofthe
obstacles, and future goals are discussed. American MedicalAssociation and,
therefore, is focused on physicians, it
also focuses on employers and employee
The Effect of Retirement on assistance plan administrators. The
Mental Health and Health article only occasionally references
Behaviors: The Kaiser substance abuse directly, but rather
Permanente Retirement Study focuses the discussion on smoking
cessation, health risk appraisal, and
Midanik, L.T.; Soghikion, K.; etal.
stress management. Substance abuse is
Journal ofGerontology referenced within this context. The
50(1): S59-S61. 1995 authors have reviewed the history of
worksite health promotion programs
and their limitations. They outline a
1 o assess the short-term effect of large number of programmatic
retirement on mental health and health
behaviors of members of an HMO, aged challenges to integrating such programs
with the medical care system, but do not
60-66, the authors compared mental
view those challenges as
health and health behaviors of members
who actually retired (N=275). insurmountable. Some of the challenges
they note are: access to hard-to-reach
Controlling for age, gender, marital populations, integration of health
status, and education, the authors found promotion into corporate benefit plans,
that retired members were likely to have protecting employee privacy and job
lower stress levels and to engage in security, developing more
regular exercise more often than those comprehensive approaches to worksite
who did not retire during the study wellness, addressing the health
period. Retired women were more consequences of the current
likely to report no alcohol problems as environment of downsizing, and
compared to women still active in the improving methods for evaluating the
labor force. health outcomes and cost-effectiveness
of these programs.
There were no differences between the
groups on self-reported mental health
status, coping, depression, smoking, Prevention and Managed Care:
alcohol consumption, and frequency of Opportunities for Managed Care
drunkenness. These findings
Organizations, Purchasers of
underscore the importance of assessing Healthcare, and Public Health
positive benefits associated with
Agencies
retirement and call for further
evaluation of whether these benefits Morbidityand Mortality WeeklyReport
persist over time. 44 (No. RR-14): 1-12, 1995
MMWR
(Available from Series, Mailstop C-
Integration of Medical Care and 08, CDC, 1 600 Clifton Road, NE, Atlanta,
Worksite Health Promotion GA 30333; 404-332-4555)
Stokols, D.; Pelletier, K. /?.; etal.
Journal oftheAmerican Medical 1 he rapid, extensive changes in the
healthcare system in the United States
Association
provide public health agencies with new
273(14): 1136-1142, 1995
opportunities for prevention-oriented
Page 4 NCADI, P.O. Box 2345, Rockville, MD 20847-2345
relationships with the private healthcare activities at the community level. Lastly,
system. Managed care organizations the article includes a series of tables
(MCO's) are rapidly becoming a major listing the critical elements for
source of healthcare for the beneficiaries prevention; criteria to examine primary
of both employer-funded care and of the and secondary prevention issues; and
publicly funded programs, Medicaid critical intervention strategies aimed at
and Medicare. In addition, MCO's predisposing, enabling, and reinforcing
represent organized care systems that factors. This discussion is focused on
often focus their efforts on defined health maintenance organizations and
populations and are accountable for other managed care organizations and
desired outcomes, including prevention managers.
activities. In recognition of the potential
role of managed care in prevention, in
January 1995, the Centers for Disease The Ups and Downs for Children
Control and Prevention (CDC) formed a with Chronic Illnesses
Managed Care Working Group to Smyth, M.; Haas, D.; et al.
develop recommendations for CDC for Managed Care Quarterly
fostering the incorporation of
prevention practices into managed care. 3(4): 91-95, 1995
This report presents these G
recommendations and approaches for children with chronic illnesses have
their implementation, as well as the same basic need for preventive care
background and case examples. as their healthy peers. In Michigan, a
Medicaid Physician Sponsor Plan was
Primary and Secondary established to provide that care for this
special population. Incentives and
Prevention Services in Clinical barriers for both physicians and families
Practice: Twenty Years' were identified as well as the
Experience in Development, advantages to providing care in a
Implementation, and Evaluation managed care delivery system.
Thompson, R. S.; Taplin, S. /-/.; etal.
Journal oftheAmerican Medical Use of Medical Care After a
Association Community-Based Health
273(14): 1130-1135, 1995 Promotion Program: A Quasi-
Experimental Study
1 his article reviews the 20-year history Cousins, A/7.; McDowell, I.
of the Group Health Cooperative of American Journal ofHealth Promotion
Puget Sound's development and
10(1): 47-53, 1995
provision of clinical preventive services.
It is often touted as a model of managed
care and prevention, including 1 he purpose of this study was to assess
substance abuse prevention, although the effects of health promotion on the
the only clear connection to substance use of medical care services in a
abuse prevention is smoking cessation community setting. A quasi-
programs. The approach used by the experimental, multiple time points, case-
Cooperative is population-based, comparison group design was used in a
targeting the individual level of primary community health center in Ottawa,
care and multiple infrastructure levels of Canada. The sample used was 520
care, resulting in a synthesis of clinical volunteer participants in a health
medicine and public health approaches. promotion program and 932 matched
It uses demonstration projects, comparison subjects. The health
coalitions, or policy development promotion program consisted of a
Managed Care Page 5
weekend workshop on health behaviors, the data; 5) translating the analysis to
lifestyle assessment, and identification policy; 6) communicating the findings;
of weekly goals for change. This was and 7) supporting continued efforts.
followed by 18 months or support (5
group sessions, weekly telephone calls,
The Social HMO's: Meeting the
and optional individual sessions).
Computerized data on healthcare use 6 Challenge of Integrated Team
months before, 18 months during, and 6 Care Coordination
months after the program was obtained Macko, P.; Dunn, S.; et al.
from Ontario's Universal Health
Journal ofCase Management
Insurance Plan (OHIP). These data were
used to determine the number and 4(3): 102-106, Fall 1995
system costs of visits made by
participants and comparisons. When
JTour social health maintenance
controlling for baseline differences organizations (social HMO's)
through analysis of covariance, program implemented care coordination
participants were found to have higher programs in 1985 to integrate acute and
costs and more visits for ambulatory long-term care for aged Medicare
care during the first year (p<.01) and beneficiaries. The team approach to care
second year (p<.05) of follow-up. coordination has been the key concept
Participants used significantly more of the model at all four sites. Team
diagnostic services than comparisons members include the primary care
during both years of follow-up.
physician, the care coordinator,
Participants were also more likely to use inpatient and medical office staff,
more counseling and psychotherapy geriatric nurse practitioners, home care
services in year 1 (relative risk, 1.53; 95 nurses and social workers, contracted
percent confidence interval, 1.28, 1.81) community-based care staff, and, at
and year 2 (relative risk, 1.57; 95 percent
confidence interval, 1.31, 1.89). No tdehsrcereiobfesthheoswitecsa,rveoclouontredeirnsa.toTrhsiswoarrtkicle
differences were found between
with the healthcare teams in the social
participant and comparison groups in HMO's.
visits for medical consultations and
assessments or preventive services. In
conclusion, no evidence shows that this Awakening the Sleeping Giant:
health promotion program reduced use Mainstreaming Efforts to
in the population over the 2-year follow- Decrease Tobacco Use in an
up period. HMO
McAfee, T.; Wilson, J.; et al.
Taking the Pulse of the HMO
Practice
Community
9(3): 138-143, September 1995
Felix, M.; Burdine, J. N.
Healthcare Executive VJroup Health Cooperative (GHC) of
10(4): 8-11, July/August 1995 Puget Sound is developing, within a
framework of quality improvement, a
1 his article discusses the seven comprehensive population-based
components of designing and approach to decreasing the prevalence
implementing a population-based of tobacco use. Broad organizational
community health status assessment. support has been obtained, centralized
The seven steps are: 1) selling the idea; support is being integrated with clinic-
2) developing a methodology; 3) level activity, local ownership of
outcomes encouraged with
gathering information; 4) interpreting is
empowerment of healthcare teams, and
Page 6 NCADI, P.O. Box 2345, Rockville, MD 20847-2345
support for community and policy- Tobacco Use Prevention and
based activities is being provided. Reduction
GHC's smoking prevalence has
decreased from 25 percent to 15.5 Yox, S. B., (Ed.)
HMO
percent over the past decade, while the Practice
State of Washington's prevalence 9(3): 123-127, September 1995
declined from 23.7 percent to 21.8
percent.
1 his article is a report on the meeting
on tobacco use and prevention and
HMO
Health Plans Helping Smokers reduction sponsored by The
Group and the Centers for Disease
Kotke, T. Control and Prevention. The meeting
HMO
Practice focused on designing plans that would
9(3): 128-133, September 1995 improve HMO delivery systems and
developing strategies that would impact
1 obacco use is the leading cause of laws and policy regarding tobacco
control. Summaries of other conference
preventable mortality in the United
participants' presentations and
States. Therefore, healthcare
recommendations are included.
organizations have an important role to
play in the control of tobacco use both
among their plan members and in the Behavioral Medicine, Clinical
communities that they serve. To be Health Psychology, and Cost
effective, they need to adopt a policy
Offset
that all tobacco users will be identified
and provided with advice to quit Friedman, /?.; Sobel D., etal.
smoking (or chewing) at each contact Health Psychology
with a healthcare professional. This 14(6): 509-518, November 1995
same policy ought to be adopted for
parents of pediatric patients. The policy
can be implementeaby defining tobacco Behavioral medicine interventions, if
use as a "vital sign" and periodically correctly combined with primary
assessing implementation rates with a medical care, can result in significant
chart review. Patients who express an healthcare cost savings, according to an
interest in quitting should be supported article published in a recent issue of
through individual or group follow-up. Health Psychology. According to the
To make clinical interventions more authors, recent attempts at medical cost
effective, to counteract tobacco savings have tended to limit patient
promotion that is directed at youth, and access. However, this supply side
to protect the health of non-smokers, perspective overlooks the potential
HMOs will want to support local and savings from reducing demand for
regional tobacco control coalitions that services, say the authors.
are taking action against tobacco For example, research has shown that
promotion and are promoting smoke- up to 74 percent of medical complaints
free public areas. brought to internists have no—
diagnosable organic etiology rather, a
variety of psychosocial factors were
involved. Careful application of
behavioral interventions in such cases
can reduce costs by eliminating the need
for expensive and needless medical
testing, while providing better outcomes
for patients.
Managed Care Page 7
The authors identify six "pathways" by physician counseling and use of the
which behavioral medicine nicotine patch. The cost involved in the
interventions can save money. use of the nicotine patch included extra
time for counseling (5 minutes at U.S.
$80/hr) and the actual cost of the patch
Bridge Over Troubled Waters
($112/mo for 2 mos.). Future quit rates
Novotny, T. £.; Nitzkin, J. L were taken from the Centers for Disease
American Journal ofPreventive Medicine Control and Prevention and quality-
12(4): 1-2, 1996 adjusted life years (QALY) saved were
calculated. The main findings
confirmed quit rates at 1 year were 2.5
1 his special supplement to the percent for no intervention, 4.0 percent
American Journal ofPreventiveMedicine is with physician counseling alone, and 7.9
dedicated to collaborative research percent with physician counseling plus
among schools of public health, State the nicotine patch. The cost of each
and local health departments, and QALY saved depended on the age and
community-based organizations. It is ranged from $4,390 to $10,943 for men
believed that such a collaboration could and from $4,955 to $6,983 for women.
be important in sustaining the science Cost effectiveness was more sensitive to
base of public health practice in this new the baseline quit rate, the physician-
environment. Collaborative counseling-only quit rate, and the
arrangements could serve as the discount rate. The addition of the
"bridge" necessary for threatened nicotine patch to physician counseling
agencies and programs to cross over the for smoking cessation in primary care
"troubled waters' of privatization and settings was relatively cost-effective.
diminishing governmental support.
Effect of Managed Care Felt in
Cost-Effectiveness of the Every Medical Field
Transdermal Nicotine Patch as an Marwick, C.
Adjunct to Physicians Smoking
Journal oftheAmerican Medical
Cessation Counseling
Association
Franks, F. K. 276(10): 768-769, 1996
Journal oftheAmerican Medical
Association /\s managed care organizations
275(16): 1247-1251, 1996 (MCO's) become commonplace in the
field of medicine, physicians not only in
1 he objective of this article is to patient practice but also in medical
education, clinical research, and public
determine the incremental cost-
health are grappling with the challenge
effectiveness of the transdermal nicotine
patch in helping adults in primary care they present. The task is hardly started,
settings stop smoking. The design used it will not be easy, and it will not be
is a decision analysis model from the accomplished overnight. This is the
overall message from several forums
perspective of the payer with
effectiveness data taken from two meta- that have addressed the impact of
managed care on the future of medical
analyses of the effectiveness of physician
counseling for smoking cessation; practice. Among these aspects were the
following:
nicotine patches were included in one
meta-analysis and excluded in the other. Education: Teaching hospitals are
The main cost and outcome measures developing ways to instruct students in
are listed by: quit rates with patch, the skills they will need to practice in a
physician counseling alone, and managed care environment.
MD
Page 8 NCADI, P.O. Box 2345, Rockville, 20847-2345