How Behavioral Health Organizations Can Positively Impact Communities Effected by Prescription Drug Abuse

Doug Leonardo, LCSWExecutive Director

Tracey Kaly, LMHCClinical Services Manager

Learning Objectives

1) Learn about state/local prescription drug abuse data related to mortality rates, neonatal abstinence syndrome and pain clinic monitoring.

2) Learn a minimum of 3 ways a behavioral health center can support their local community.

3) Learn some of the steps needed to develop an integrated care model to provide behavioral health services onsite in specialty care sites (e.g.; pain management clinics, health clinics, primary care offices and hospitals).  

Agenda

1) Who We Are

2) State and Local Data Trends

3) Supporting Your Local Community

4) Building an Integrated Care Model

Who We Are

• BayCare - large community-based non profit health care system in Florida

• Located in Tampa Bay Region• Network of hospitals and outpatient facilities • 22,000 team members• We are the behavioral health service provider for the

BayCare Health System• Full continuum of adult and children's behavioral

health services• Services provided in 5 counties in Tampa Bay area

Addiction

…a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing the development and manifestations. It is characterized by behaviors that include one or more of the following:– Impaired control over drug use– Compulsive use– Continued use despite harm– Craving

(American Society of Addiction Medicine, 2001)

State Data 10 Year Trend Upward in Prescription Drug Abuse

FY 01-02 FY 02-03 FY 03-04 FY 04-05 FY 05-06 FY 06-07 FY 07-08 FY 08-09 FY 09-10 FY 10-110.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Ten Year Trend Analysis of Drug of Abuse

AlcoholMarijuanaCrack/CocaineHeroinOther OpiatesMethamphetaminePrescription Other Drugs

Fiscal Year

% o

f Tot

al A

dmis

sion

s

Florida counties with high rates of opiate overdoses

Florida counties with high rates of benzodiazepine overdoses

State Data Overdoses – Opiates and Benzo’s

State Data Hospitalizations and Emergency Department Visits for Unintentional Rx Drug Poisonings

12.3

23.8

15.2

23.8

0

10

20

30

2006 2007 2008 2009 2010

Rate

per

100

,000

pop

ulati

on

Opiate Poisoning Tranquilizer Poisoning

Source: Agency for Health Care Administration Emergency Department and Inpatient Hospital Datasets

Florida Poison Information Center Tampa

Oxycodone Suspected Suicides

205

260

302

227

305 294

368

430

583

668

0

100

200

300

400

500

600

700

800

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber

Year

326%Increase

January 20, 2011

Florida Poison Information Center Tampa

602

761809

919

1523 1525

1284

1054

1432

1590

0

200

400

600

800

1000

1200

1400

1600

1800

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Num

ber

Oxycodone Cases 264% Increase

January 20, 2011

State Data Drug Overdose Deaths 2003 - 2009

Death rates for all substances increased with the exceptionof heroin and cocaine. Heroin decreased 62.2% Cocaine decreased 10.8%

Death rates for prescription drugs increased 84.2%. 7.3 to 13.4 per 100,000

Substance specific death rates. Oxycodone rose 264.6% Alprazolam rose 233.8% Methadone rose 79.2% Ethanol rose 81.4%

Source : MMWR July 8, 2011/60 (26);869-872

Prescription Drug Monitoring Program (PDMP)

Florida lacked a system for monitoring drug prescriptions until Governor Scott signed a bill into law on June 3, 2011;

The law strengthens reporting requirements to a prescription drug database, increases penalties for overprescribing, tracks wholesale distribution of specific controlled substances, bans most doctors who prescribe narcotics from dispensing them and provides funding to support law enforcement and state prosecutor efforts;

Attorney General Pam Bondi has made prescription drug abuse her top priority;

98 of the top 100 doctors dispensing Oxycodone nationally are in Florida – concentrated in the Miami, Tampa and Orlando regions.

Prescription Drug Monitoring Program (PDMP)

The state of Florida has established a program that will improve patient quality of care and reduce controlled prescription drug abuse and diversion.

The PDMP will reduce the chances for patients to repeatedly and illegally divert prescription drugs.

Overall the program will dramatically reduce doctor and pharmacy shopping.

Local Data - Pasco County Prescription Drug Abuse Becomes Priority

Parents began calling local substance abuse coalition (ASAP) to get involved;

Legislators asking for community members to get involved; Law enforcement was highlighting the prescription drug related

crimes: (impaired driving, stolen property, drug trafficking, pill mills, etc.);

Detoxification unit seeing unprecedented number of admissions for prescription drug dependency (specifically females aged 18 to 40);

FYSAS indicated increase in prescription drug use by students;

Pill mills and drug trafficking arrests increased significantly in Pasco County;

Pain Management practitioner reached out to local provider and coalition to become part of the solution.

Local Data - Pasco County Lethal Level of Drug Present at Death

According to the Medical Examiner, there were 103 deaths from Oxycodone alone in 2010. District 6, which consists of both Pasco and Pinellas Counties identified higher amounts of prescription drugs tracked by the Medical Examiner at the time of death then any other district in the State of Florida. Primary drug of choice is Oxycontin (30 mg), followed by Xanax.

Pasco County is higher than Pinellas County in per capita drug-related deaths.

Primary route of delivery; crushing and inhaling, followed by an equal amount of oral and injection.

Approximately 80% obtain from “friends” who sell off the streets and approximately 20% steal from a parent or family member who is prescribed.

Local Data Pasco County

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0

40

80

120

160

200

2005 2006 2007 2008 2009 2010

FloridaCoun

ties

Trends in Newborn Withdrawal diagnoses, 2005 - 2010

Pasco (+2,840%)

Pinellas (+595%)

Florida (+433%)

Pasco County has the Highest Rates of Diagnoses of Newborn withdrawal per 1000 live births in the State of Florida. Source: DCFPinellas and Pasco Counties ranked 1 and 2 respectively in the state of Florida for the number of substance exposed newborns. Pasco saw a 2,840% increase from 5 in 2005 to 147 in 2010 and nearly doubled the from 2009 to 2010 (75 to 147 respectively). Data obtained from the Florida Agency for Health Care Administration (AHCA)

Local Data - Pasco County

63.2% of the 399 women ages 18 - 40 (child bearing age) that entered treatment, reported a prescription drug as their primary drug of choice in Pasco County (BayCare Behavioral Health 2009 - 2010).

4.1% of Pasco County high school students report past 30-day use of prescription pain relievers (2010, Florida Youth Substance Abuse Survey).

In 2008 in Pasco County, there were 159 ER visits for an Opioid related incident. There were 86 overdoses of Benzodiazepine and 20 overdoses involving other tranquilizers (2008 Agency for Healthcare Administration).

The number of female inmates in Pasco Sheriff’s County jails that are pregnant and have substance abuse problems with prescription drugs is increasing.

59% of Pasco residents feel that there is not enough enforcement of prescription drugs (2010 Pasco Alcohol Policy and Prescription Drug Use Survey).

Supporting Your Local Community:What Can I Do As a Provider?

Gather data to prioritize the public health problem related to prescription drugs;

Start a local Initiative with rapid action planning; Join learning collaboratives and list serves; Leverage grants and other funding initiatives; Educate policy makers, funders, providers,

individuals, families and communities about the public health issue and advocate for policies to reduce morbidity and mortality rates;

Explore with local community the recovery supports for supportive housing, activities of daily living, phone outreach, peer mentors, recovery coaches wellness centers, etc.;

Focus on what happens BEFORE and AFTER primary treatment with greater emphasis on the physical, social and cultural environment in which recovery succeeds or fails;

Supporting Your Local Community:What We Did as a Provider

Leverage collaborative initiatives to combat epidemic (coalition’s, stakeholders, specialty clinics, legislators, law enforcement, etc.).

Frame your system of care with a focus on integrated care partnerships (FQHC, health clinics, primary care, specialty care clinics, hospitals, emergency departments, etc.);

Collaborative Initiatives

1. In 2010 we created a Prescription Drug Initiative to address the growing number of individuals seeking treatment for prescription drug use, increased deaths related to prescription drug use, increased substance exposed newborns and the increased number of unauthorized pain management clinics in Pasco County.

2. Focus was to review, research and make recommendations on how to address the increasing prescription drug problems within our community.

3. Committee was composed of law enforcement, treatment providers, parents, judiciary, pain clinics and community partners.

4. One of the recommendations from that effort was the development of a proposed innovative project to assist Pasco County in the epidemic fight against prescription drug use.

5. The proposed project would harness six environmental strategies that would bring about community change that was adopted as a useful framework by the Community Anti-Drug Coalitions of America (CADCA).

Provide Information - Enhance Skills - Provide Support - Change ConsequencesChange Physical Design - Enhance Access

Collaborative Initiatives

Provide Information

Change Physical Design

Enhance Access

Change Consequences

Provide Support

Enhance Skills

Eliminating Prescription

Drug Abuse in Communities

Collaborative Initiatives

Sample Description of ActivitiesProvide Information Community Forums, Marchman Act training, prescription drug tool kits and social

norms marketing campaign, etc.Enhance Skills Prescriber training, parent and youth summit, student and faculty training,

motivational interview training, screening and intervention training, community education, etc.

Provide Support Prescription drug information line, medication disposal pill drop boxes, Rx drug

safes, etc. Change Consequences Pain clinic best practices, pain clinic compliance, pain clinic drug screenings,

enhance drug court Ambassador Program, etc.Change Physical Design Intelligence Led Policing enforcement activities, Take Back events, etc.Enhance Access Outreach, care management, community education, substance abuse screening

tools, expanded treatment capacity, etc.

Integrated Care Partnerships

“Integrated care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their medical care providers.”

“It allows patients to feel that, for almost any problem, they have come to the right place.”

Alexander Blount, Ed.D.

Why do Integrated Care?

To strengthen collaboration between behavioral health and health care; To reduce cost and utilization factors; To improve outcomes, access to care and engagement; To integrate population based care into system redesign; To prepare for payment reform and overall system redesign; Because with reform primary care and behavioral health services must be available in all clinical settings; Because behavioral health settings must have streamlined access to medical services; Because all healthcare settings must have care coordination capability in the continuum based on case mix and severity; Because it is the right thing to do.

How do I get started?Building an Integrated Model Establish administrative and clinical leadership “buy-in”; Create a sense of urgency; Establish an Integrated Care Initiative; Complete an environmental scan - readiness assessment; Benchmark the perception of healthcare professionals

regarding integration; Design and deploy strategically (PCP, FQHC, Hospitals, ED,

Pain Clinics, etc.); Identify and address funding/financial barriers; Develop and revise business modeling/practices; Seek partners who bring needed expertise or consultation; Commit on transformation from volume to value.

Qualities of an Integrated Model

1) Culturally competent2) Stepped care approach 3) Shortened sessions4) Condensed treatment pathways5) Multiple delivery formats

Benefits of an Integrated Model

More likely to keep appointments Treat person where they feel

comfortable Focus on preventative care Offset medical cost On site behavioral services available Better communication Better outcomes Mind/body connection Whole person approach

Measure, Measure, Measure

Develop metrics (satisfaction, efficacy, productivity, cost, access, utilization,

capacity, health indicators, etc.)

Key Findings and Challenges ofIntegrated Care

Not one size fits all (cultural tailoring, developing common language, variance in population based needs, training, etc.);

Quality outcomes and measurement are vital (future pay structure, integrated record, reliable data, etc.);

Care management/coordination imperative (break down silos, use skills with care management, cross train, home based practice, patient education coaching, focus on raising health of population, etc.);

Payment alignment and reimbursement is challenging (transforming from fee for service model to delivering model of brief care, internal and external barriers, minimal current state flexibility, minimal consultation reimbursement/care management/ telephone contact, pursuit of cost offset not immediate, etc.);

Access and the ability to ramp immediately based on the unmet demand by primary care is urgent (physician demands, access to care, multiple primary sites, psychiatric evaluation requests, etc.);

Changing the system of care is essential (finding the right staff, brief stepped care approach, pathway driven model, limited short sessions with focus on triage, group preventive care with focus on at risk patient, linkage to specialty care clinics for diversion of high risk patients, emphasis on early identification, etc.);

Key Findings and Challenges of Integrated Care

Cultural competencies are critical (recognizing differences, assessments/screenings/interventions are appropriate, linkage to community support services, etc.);

Sustainability is crucial. Data and Outcomes (integrated electronic health record, measurement

moving from encounters to overall health outcomes, increased productivity for physicians, patient/family satisfaction will be driver of long term market differentiation, change in care being based on managing health of population. physician satisfaction, quality of life increased, identifying and documenting added values, payment for those of us that deliver, etc.).

Staff Model Integration

Level 4

Deep IntegrationCo-Located

Level 3

Basic IntegrationCo-Located

Level 2

Basic CollaborationAt-a-Distance

Level 1

Four Level Integration Model

Separate Sites2 Front DoorsReferral to BH Clinic

Staff Model

Integration

Deep Integration

Co-Located

Basic Integration

Co-Located

Basic Collaboration

At-a-Distance

ACCESS

Single SiteSeparate ReceptionOn Site Paper Referral

Single SiteSame ReceptionWarm Handoff ReferralSpecialty Care Referrals

Single SiteOne ReceptionOne Visit for All NeedsSpecialty Care Referrals

2 Prescribers2 Separate Treatment PlansLicensed Clinician At A DistancePhone Consultation for Staffing

Staff Model

Integration

Deep Integration

Co-Located

Basic Integration

Co-Located

Basic Collaboration

At-a-Distance

SERVICES

2 Prescribers with Psych. Phone Consult2 Treatment Plans with Information Sharing Licensed Clinician On SiteInformal On Site StaffingPatient Prevention Materials DistributedScheduled Appointments for BH On Site

2 Prescribers with On Site Psych. Consult2 Treatment Plans with Integrated GoalsLicensed Clinician On SiteMulti Disciplinary Treatment Team StaffingPatient Prevention Groups Same Day Appt. as Primary AppointmentReferrals Made to Case Management

1 Prescriber 1 Treatment Plan Fully IntegratedLicensed Clinician in Staff Model1 Treatment TeamPatient Prevention - Wellness GroupsIntegrated Care Manager On SiteIn Home Clinical Services AvailableIntegrated Appointment with PC

Traditional Clinical PathwaysTraditional Therapy ModelsMotivational Interviewing

Staff Model

Integration

Deep Integration

Co-Located

Basic Integration

Co-Located

Basic Collaboration

At-a-Distance

VALUE ADDED PRACTICES

Specialized Clinical PathwaysBrief Therapy Model (15 - 30 minute sessions)Motivational InterviewingScreening Tools On Site (e.g. PHQ9, CAGE)

Integrated Clinical PathwaysBrief Therapy and SBIRT Model (4-8 sessions)Motivational InterviewingOn Site Clinician Conducts ScreeningsJoint Monitoring Health ConditionsPsychiatric Training

Integrated Clinical/Critical PathwaysBrief Therapy Model and SBIRT ModelMotivational InterviewingCare Management ModelCare Manager Conducts ScreeningsTeam Monitoring Health Conditions Psychiatric TrainingPatient Centered Medical HomeManage Multiple Chronic Conditions

Try to avoid this……

What’s Next?

QUESTIONS

Contact Information

Doug Leonardo, LCSWTracey Kaly, LMHC

BayCare Behavioral Health8132 King Helie Blvd.New Port Richey, Florida 34653

douglas.leonardo@baycare.orgtracey.kaly@baycare.org