SUMMARY REPORT

MEETING 10

Date: Wednesday, February 22, 2012

Time: 11:00am-12:00pm

Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Dept. of Alcohol and Drug Programs (ADP)

Topic: Project Care: Integrating Primary Care and Behavioral Health Services in Kern County

Presenters: --Lily Alvarez-Overview of Project Care

Behavioral Health Administrator

-- Darren Urada- Evaluation Plan

UCLA Integrated Substance Abuse Programs

Review of ILC Meeting 9

UCLA ISAP

  • The ninth ILC meeting, conducted during the CADPAAC Quarterly Meeting on January 25, 2012,showcased Vivitrol: A Medication for Treating Alcohol and Opiate Dependence. Special thanks to presenters John Viernes, Desiree Crevecoeur-MacPhail and Kathy Jettwho described their programs and experiences and responded to questions posed in an open forum from meeting attendees. Thank you all for your participation. A summary from this meeting has been posted on the UCLA ILC webpage:

Logistics

  • Summary and materials discussed from the previous ILC meetings are available at Subsequent meeting materials will continue to be posted on this site.
  • All further meetings are scheduled to be held at 11:00AM (PT) on the 4th Wednesday of every month, unless otherwise noted.
  • The next ILC meeting will be held on March 28, 2012 from 11:00AM to 12:00PM during the CADPAAC Quarterly Meeting. UCLA has invited Mady Chalk, PhD to present.

ILC Meeting 10 Topic:

Integration of Mental Health & Substance Use Disorders into Primary Health Care: Models of Co-Located and Integrated Services

Topic Introduction – Valerie Pearce Antonini, MPH,UCLA ISAP

  • The topic for today’s learning collaborative is to hear about the integration activities taking place inKern County. We thank Lily Alvarez and Darren Uradafor being willing to share their work and hope this will be a learning opportunity for those in the audience but also for the speakers. Questions and trouble shooting among the group are encouraged.

Kern County

Lily Alvarez

Behavioral Health Administrator

Kern County Mental Health

Darren Urada, PhD

UCLA ISAP

Summary

Lily Alvarez discussed Kern County’s demographics, goals of behavioral health integration, and implementation of the integration project (Project Care). Darren Urada later presented the evaluation plan and early evaluation results.

Kern County Project Care

  • What does Kern County look like?
  • Kern County is very large; the system must be organized in a way to deliver services to reach outlying areas
  • County is approximately 8500 square miles – it takes 5 and ½ hours to span the county
  • Bakersfield industry consists of oil and agriculture
  • Unemployment rate 32% in one community
  • Kern County is very diverse; 80%-90% Hispanic in certain valley communities while some communities are the opposite with 60%-70% White
  • Mental Health system of care consists of crisis and residential services (five clinics, 31 physicians, 8 contracted providers)
  • Substance abuse system of care consists oftraditional outpatient care in regional areas with inpatient care handled in Bakersfield (14 clinics including inpatient and methadone)
  • FQHCs; 27 in Kern County
  • KCMH is working with FQHC partners to implement SBIRT type model in fiveFQHCs and one hospital
  • What MHSA opportunities are provided?
  • Integration
  • Workforce
  • Two services in same day
  • Address both MH and SUD
  • Time
  • Spoken Goals:
  • Universal Screening: the goal is to screen all adults clients coming to the clinics
  • 3 Instruments: PHQ9, GAD7, and/or Audit-C
  • Brief Interventions: SUD assessment, MH solution centered treatment (Assist model, Motivational Interviewing techniques)
  • Technology via health registries: search engines for homogenous populations, based off i2i model
  • Unspoken Goals:
  • Develop value for SAS: raise importance of position since they can bring a lot to primary care
  • Develop the blood pressure cutoff for SUD
  • Close the gap between primary and specialty care
  • Demonstrate how to overcome security and privacy issues
  • Build capacity for 2014
  • What is the Model?
  • Universal screening
  • Brief consultation in the exam room
  • Brief interventions (6-10 visits)
  • Integrated case conferencing (physician, psychiatrist, behavioral health staff)
  • Use data to monitor progress
  • Anticipated Barriers and Proposed Solutions
  • Being in the forefront; creating a learning environment (safe environment where people can discuss and share)
  • Competition; monthly provider meetings
  • Physician involvement; contractual requirements for case conferencing
  • Trainings have involved a night session with dinner and CMEs for physicians (realize physicians don’t have the time available)
  • New practice standards; technology transfer through events
  • Clinics have ¼ million encounters per year (60,000 patients)
  • Current Barriers
  • Fear of recognizing the SUD patient (universal screening is scary to some)
  • Filing in the medical record (where and what)
  • Charting in the medical record
  • New categoryin the medical record that has limited access
  • Clinics using different systems; goal is to exchange information at some point (paper/pencil is the first step)
  • Health Information Exchange
  • 42 CFR Part 2 requires: individual consent, specificity of info exchanged, prohibits of re-disclosure (SUD is protected)
  • Between primary and specialty care: diagnosis, lab results, and medications are exchanged
  • UCLA and Evaluation
  • Prevalence of disorders in primary care
  • Baseline with Dual Diagnosis Capability in Health Care Settings (DDCHCS) tool (measure of integration)
  • The pipe line using i2i data
  • Perception and attitudes of staff in the clinic
  • Prevalence Preliminary Results
  • Prevalence of Depression: 42%
  • Prevalence of Thought Disorders: 2%
  • Prevalence of Anxiety: 43%
  • Prevalence of alcohol and drug: 13%
  • 95% Hispanic (80% prefer Spanish)
  • DDCHCS Integration Measure: Baseline (completed 2011)
  • Follow up planned 2012
  • Scores based on 1-5 measure: 5= DD advanced, 3= DD capable, etc.
  • A score of 5 is not necessary/desirable in all cases
  • The three sites scored a 3 on average
  • Administrative Data: “Patient Pipeline”
  • “Filtration” system for screened patients
  • The goal is to see what happened with patient population:

All patients>screened>positive screen>referred for assessment>assessed>positive assessment> either referred on-site (received intervention) or referred off-site (received treatment or no show).

  • Staff Perceptions & Attitudes
  • Adapted from surveys developed by the Integrated Behavioral Health Project (
  • Multiple survey versions were used (BH provider, PC provider, and Line Staff) to assess attitudesand perceptions of staff
  • Primary Care providers (physicians, nurse practitioners) highly value BH care, they are satisfied with the communication level with BH staff, but are not as comfortable administering BH care
  • BH staff under-rated the value of their services, felt communication with physicians was poor (they want more time to meet/discuss patients), and they were more enthusiastic about expanding services

Discussion:

Q:We are working on a project involving SBIRT screening in an FQHC and we are having a hard time working with confidentiality issues. Which staff are responsible for screenings -FQHC’s staff or County staff?

A:Our 5 FQHC clinics have contracts with Kern County Mental Health. Grant funds pay for an MFT and SUD counselor at each clinic; they are contracted employees. All patients consent to release information and consent to treatment. It does get tricky and we rely on our County Council.

Q:Where in the clinic “flow” will the BH screening occur?

A:Each clinic has their own culture. In most clinics paperwork (including screening) is filled out in the lobby. In some sites the forms are filled out in the exam room. In one clinic the client is given the questionnaires in the lobby, the nurse or doctor would score it, and if the doctor felt SUD counseling is necessary the SUD counselor is pulled in right then and there and a brief intervention is given and a follow up is offered. Some clinics feel hiring a dedicated front office staff is necessary to make sure the screenings get done.

Q:With respect to the surveys do the MD’s value SUD screening scores themselves or just BH services in general?

A:We will have to look into that in the next round of surveys- that is a good idea for the future.

Q:How did you (Lily) get the level of cooperation from the FQHC’s?

A:A RFI was sent out to all the FQHC’s and we responded to ones that showed interest. From the get-go the clinics have been engaged. The design of the project was very good- which helped as well. I think continued support from the FQHC’s was gained with our monthly provider meetings and UCLA’s involvement. They felt like they were on the “cutting edge” of the industry. The clinics are all very gracious to be a part of the project and see value in the work they are doing.

Q:Are people doing diagnosis codes (ICDR Codes)?

A:We are not in the billing world right now since we have grant funds; but we are learning about this and tracking it so that we will be prepared. I can say that the current system provides disincentives to use SU diagnosis codes.

Closing Remarks – Valerie Pearce Antonini, UCLA ISAP

  • Thanks again to both Lily Alvarez and Darren Urada for sharing today. It is always helpful to hear from the people actually working on integrated care. Thank you for volunteering your time and sharing with the group.
  • The next ILC Meeting is scheduled on March 28, 2012 (during CADPAAC).
  • Please remember to reference the website which holds all information and materials disseminated from the ILC:

APPENDIX 1 – ATTENDEES

COUNTYPARTICIPANTS

MEDIUM

Kern (Lily Alvarez)

LARGE

Los Angeles (Wayne Sauseda, Yolanda Codero)

Orange County (Bill Manov)

Santa Cruz (Alice Gleghorn)

Ventura (Janet Kaplan)

San Bernardino (Dianne Sceranka)

Riverside (Karen Kane)

ORGANIZATION PARTICIPANTS

CiMH (Gale Bataille)

BAART (Valerie Woolsey)

ADP Participants

Craig Chaffee

Jonathan Graham

Cathy Phoenix

Gladys Mitchell

Rich Rohus

Trinidad Perez

Alice Trejor

Vishaal Pegany

Theresa Gulley-Reed

Marcia Yamamoto

UCLA Participants

Desiree Crevecoeur-MacPhail

Darren Urada

Valerie Pearce Antonini

Brandy Oeser

Diego Ramirez

APPENDIX 2– Agenda and Relevant Materials

  • Overview of Meeting 9
  • Introductions
  • Topic discussion – Project Care: Integrating Primary Care and Behavioral Health Services in Kern County.
  • Lily Alvarez – Overview of Project Care
  • Darren Urada – Evaluation Plan
  • Q and A

Materials for this meeting

  • PPT Presentation – Lily Alvarez and Darren Urada

Copies of materials can be found at UCLA ISAP’s ACA Resources Website: