Integrating Addiction and Primary Care Services
Becky Vaughn, MSEd, CEO, State Associations of Addiction Services (SAAS), and Aaron Williams, MA, Director of Training and Technical Assistance for Substance Abuse, CIHS
Few people know that individuals living with substance use disorders often have physical health problems ? like lung disease, hepatitis, HIV/AIDS, cardiovascular disease, and cancer that affect their quality of life and life expectancy. Research shows that these individuals have:
- Nine times greater risk of congestive heart failure.
- 12 times greater risk of liver cirrhosis
- 12 times the risk of developing pneumonia.
Substance use disorders can also complicate the management of other chronic disorders. For example, substance use disorders, depression, and other medical comorbidities are associated with poor adherence to medications for type 2 diabetes. Evidence also suggests that addressing substance use and physical health together improves both physical health and substance use conditions. Yet, 54% of addiction treatment programs have no physician.
In recent years, a number of changes to the healthcare system have made the integration of primary care and addiction treatment a more viable option for many service providers.
Passage of the Affordable Care Act and Mental Health and Substance Use Parity Laws
Addiction treatment is one of the 10 categories of essential health benefits specified in the Affordable Care Act, providing more people with access to treatment and services. It is estimated that more than 16 million additional people will now seek healthcare services, many of them with substance use disorders. The Affordable Care Act also incentivizes and promotes improved care coordination between providers (the health home is one model) and the use of multidisciplinary teams of providers to address individuals’ total healthcare needs in a more efficient and cost-effective way.
Advances in Addiction Treatment Medication
In recent years, the Food and Drug Administration has approved new medications for the treatment of substance use disorders. These include buprenorphine to treat opioid addictions, acamprosate to treat alcohol addiction, and extended-release naltrexone to treat alcohol or opioid addiction. Research has found these new medications to be safe and highly effective in helping individuals achieve and sustain recovery and applicable in both behavioral health and primary care settings.
They also give providers additional tools to fight addiction by expanding the range of treatment options available for individuals with opioid, alcohol, and other drug addictions, provided treatment programs have appropriate staff to administer and monitor the use of these medications. However, lack of funding and limited insurance reimbursement for medications and provider services is still a barrier to widespread use.
Considerations for Integrating Addiction and Primary Care
As the healthcare system continues to evolve and further advances are made in the development of medications to treat addictions, providers that offer a wider array of integrated healthcare services and that coordinate care effectively between multiple providers will be in high demand. This evolution in care delivery will reduce the need for stand-alone treatment providers. However, several issues still need attention, including:
Licensing and credentialing standards for working in integrated care settings.
Further development of electronic information management tools that allow for more robust sharing of healthcare information, which currently vary by state.
Yet, despite these hurdles, the healthcare landscape offers opportunities for addiction treatment programs to provide comprehensive care to the people they serve in a way that can lead to reduced addiction problems and improved overall healthcare. Similarly, the incorporation of addiction treatment offers mental health and primary care settings important opportunities to improve health outcomes. However, these benefits will only be realized by those providers who are ready and willing to explore new opportunities. These models are improving patient outcomes and the bottom line of financial statements for providers across the country — clearly well worth the effort.
Note from the Editor: CIHS has released a new document, Innovations in Addictions Treatment: Addiction Treatment Providers Working with Integrated Primary Care Services, to help addiction treatment and primary care providers learn about existing integration programs.
The Stanley Street Treatment and Resources (SSTAR) was founded over 35 years ago to provide the Fall River, Massachusetts community with inpatient alcohol detox, outpatient alcohol treatment, and education to people convicted of DUIs. However, beginning in the late 1980s, SSTAR began to watch as the HIV/AIDS epidemic began to grow in their community, claiming the lives of many of the people they served who did not receive adequate healthcare. As a result, SSTAR’s leadership made the decision to begin offering healthcare, and opened its health center doors in 1996. They are now classified as a 330 Federally Qualified Health Center (FQHC), and in March 2012 they opened a second health center and soon after were awarded a SAMHSA Primary and Behavioral Health Care Integration (PBHCI) grant.
SSTAR now provides chronic illness case management for diabetes, hypertension, asthma, chronic pain, and HIV/Hepatitis C Virus through a collaborative care model, with significant physician involvement and regular multidisciplinary team meetings to discuss the care provided.
SSTAR’s integration model is designed to reach two main goals. First, they aim to provide better, more focused medical care for people with substance abuse-related diseases. In addition, they seek to provide those services within a private setting that allows for more seamless sharing of information — with proper consents — between substance use and primary care providers, given that both addiction treatment and healthcare services are provided by the same organization. Individuals enrolled in addiction treatment at SSTAR must receive their primary care onsite. SSTAR hopes that by normalizing screening and treatment for substance use within general healthcare that they will decrease stigma around substance abuse issues in their community.
Onsite healthcare has allowed SSTAR to use new medications for addiction treatment that have been approved over the last decade. SSTAR has a robust program to administer these medications, where they provide tobacco, opioid, and alcohol dependence medications to individuals when appropriate. In particular, SSTAR considers the use of buprenorphine for opioid dependence a priority because of high rates of opiate abuse in their community and a number of other factors including:
- Inpatient and/or methadone maintenance programs had been the only options available.
- Limited availability of other treatment programs.
- Employed individuals unable to commit to an inpatient program.
To address community needs, SSTAR has provided buprenorphine since 2004. They now serve 525 individuals in the opiate treatment program, which has evolved into a financially sustainable program. As part of their commitment to the use of buprenorphine as part of treatment, they require as a condition of employment that every one of their physicians obtain a DEA waiver for the provision of buprenorphine.
Over the years, SSTAR has seen notable improvement in service delivery marked by reduced wait times for treatment and treatment dropout rates. Overall, SSTAR has found that their efforts to integrate care have been well worth the effort.
Beginning to integrate services with a primary care provider can seem daunting at times. The following questions may help your organization begin redesigning its addiction services delivery systems to support integrated primary care and/or integrated mental health services.
What is the vision and mission of your agency?
Does it need to change?
Is integration a part of your vision and mission? Different types of integration option (examples will differ by setting):
- Treat substance abuse issues only
- Treat substance abuse with primary care Treat all substance abuse and mental health without primary care
- Treat all substance abuse and mental health with primary care
Have you developed a strategic plan related to integration?
Is your governing board engaged and knowledgeable about integration?
Do you understand the primary care and/or substance use needs of the population you are serving?
Do your administrative policies (e.g., confidentiality, billing and reimbursement, ethics) support integration?
What changes could better integrate clinical and business processes?
How will your current service delivery model compete when new and/or integrated services are provided by other primary care and specialty behavioral health providers in your area?
What will be the impact of the federal healthcare law on your current and future business plan?
Do you have existing relationships (formal or informal) with other service providers in mental health and primary care?
Is there potential to build on those relationships?
What existing resources (e.g., community coalitions, prevention programs) in the community can be leveraged across systems?
Do you have access to a variety of levels of care through medical partners so patients can be moved along the continuum of care, as appropriate?
Do you have the staff and other resources to treat primary care and substance-related disorders?
Does your program have staff with a range of expertise and/or competencies related to integrated care (e.g., case management, care coordination, wellness programming)?
Is your facility licensed to provide services for substance-related disorders and/or primary care services?
How difficult and time consuming would adding additional licenses be? Do you have a primary care clinic within your agency or an effective working relationship with a primary care provider organization in your community?
Are you familiar with the regulations related to licensing a primary care clinic or know where to find this information?
Does your program demonstrate integrated components, even if these elements are informal and not part of the defined program structure (e.g., informal staff exchange processes, as-needed use of case management to coordinate services)?
Do you have professional staff capable of providing billable primary care or mental health services?
What additional investments in people and equipment would be required?
How much money does your organization need to make in order to support your integrated care vision (key elements: number of consumers seen; how often are they seen per year; payer mix; reimbursement per visit)?
Are you able to bill diverse payer groups (i.e., Medicaid, Medicare, private insurance)?
Are you familiar with how to join provider networks of major payers?
Clinical Supports Questions
Are you using a certified electronic system?
Can your system generate patient data registries for staff to use to support integration?
Can you generate a coordination of care document (CCD)?
Does your clinical record support documentation of physical health-related services?
Can your system generate an electronic bill after the completion of a documented event?
CIHS’s new Innovations in Addictions Treatment: Addiction Treatment Providers Working with Integrated Primary Care Services shares the perspectives of integrated addiction and primary care programs to inform efforts nationwide.
Did you miss CIHS’ March webinars on Health IT for Primary and Behavioral Healthcare Integration and Suicide Prevention Tools for Primary Care Providers? You can access them on the website, along with a host of webinars on a range integrated health topics.
New Integration Framework Helps Providers Evolve Integration Efforts
Primary and behavioral healthcare integration is widely recognized as an effective way to improve physical and behavioral health outcomes among people living with mental illnesses and addictions, as well as to lower the cost of care associated with this complex patient population. To continue to improve outcomes, provider organizations must understand where they are on the integration continuum. CIHS’ new tool, A Standard Framework for Levels of Integrated Healthcare, helps them do just that. The six-level framework begins with collaboration and moves through increasingly sophisticated levels of integration.
Early Implementation Experiences of Integrating Primary Care into Community Behavioral Health Settings
A Psychiatric Services article describes the characteristics and early implementation experiences of community behavioral health agencies that received SAMHSA’s Primary and Behavioral Health Care Integration (PBHCI) grants to integrate primary care into programs for adults with serious mental illness. The article indicates that early implementation experiences of PBHCI grantees may inform other programs that seek to integrate primary care into behavioral health settings as part of new, large-scale government initiatives such as specialty mental health homes.
Medicaid.gov Introduces New Health Home Resources Center for States
The Health Home Information Resource Center on Medicaid.gov offers a variety of technical assistance services to states and a resource library of continuously updated materials. States may use the resource center to request one-on-one technical assistance, access peer-learning opportunities, and find resources to guide their health home design and implementation.
AHRQ Announces New Funding Opportunity
AHRQ announced a new funding opportunity — AHRQ Patient Centered Outcomes Research Institutional Mentored Career Development Program (K12) — that would support the career development of post-doctoral and junior research and clinical doctorate faculty scholars in comparative effectiveness research methods applied to person-centered outcomes. Letters of intent are due by June 7, 2013.
Funding for Substance Abuse Treatment for Minority Women at High Risk for HIV/AIDS
SAMHSA will award up to 35 grants of approximately $520,000 per year for three years for the Substance Abuse Treatment for Racial/Ethnic Minority Women at High Risk for HIV/AIDS program. Community-based organizations, FQHCs, and FQHC look-a-likes are eligible applicants. The program aims to expand substance abuse treatment and HIV services for target populations that have substance use or co-occurring substance use and mental disorders and are living with or at risk for HIV/AIDS. Applications must be submitted by May 14.
New Funding to Improving Health and Reduce Premature Mortality in People with Mental Illness
The National Institute of Mental Health announced the availability of funding to support effective interventions to reduce common modifiable health risk factors for people with severe mental illness. This funding opportunity will support research project grants for up to five years for rigorous effectiveness testing of innovative services interventions designed to reduce the prevalence and magnitude of common modifiable health risk factors related to shortened lifespan in adults with mental illnesses, as well as in children and youth with serious emotional disturbances. Non-profit agencies are eligible to apply and letters of intent are due October 7, 2013.
Safeway Solicits Applications from Nonprofit Agencies
The Safeway Foundation invites grants applications from non-profit agencies whose mission aligns with the Safeway’s four priority areas — hunger relief, education, health and human services, and/or assisting people with disabilities — to apply for grants to support community-based employment and job coaching organizations focused on serving people with disabilities. First-time funded organizations will typically receive a grant ranging between $10,000 and $25,000.
Tips from Former Smokers Campaign
The CDC has launched the second round of its Tips From Former Smokers campaign. The campaign features individuals with a wide range of tobacco-related health conditions. The ads will run for at least 12 weeks through various media outlets nationwide. Visit their website for information on how you can leverage the campaign with their free resources, which include ads, sample press releases, Spanish-language materials, website badges and buttons, and more.
CA Releases Comprehensive New Integration Toolkit
Partners in Health: Mental Health, Primary Care and Substance Use Inter-agency Collaboration Tool Kit was developed by the Integrated Behavioral Health Project and sponsored by the California Health Services Authority’s Statewide Stigma and Discrimination Reduction Initiative. The 337 page tool kit aims to help primary care and behavioral health settings forge collaborative relationships. It includes job descriptions, sample agreements and contracts, screening instruments and evaluation measures, operational forms, strategies and prototypes for integrating mental and physical services, practical advice, issues to consider when brokering agreements, mutual role descriptions, and much more. Though the focus is on California counties, much of the tool kit can be generalized.