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Substance Abuse Resource Guide: Managed Care and Prevention PDF

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,*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

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