Moving Beyond Screening to Prevent Mental Illness and Substance Use
eSolutions: August 2014
Feature article: Moving Beyond Screening to Prevent Mental Illness and Substance Use
Provider Profile: Positive Parenting - Othello Family Clinic
Quick Tips: 5 Evidence-Based Kernels for Prevention
Featured resource: HIE paper
Moving Beyond Screening to Prevent Mental Illness and Substance Use: What can be Achieved in Primary Care?
Sarah M. Steverman, PhD, MSW, Consultant, and David L. Shern, PhD, Senior Science Advisor, Mental Health America
The Affordable Care Act required preventative services with an A or B rating (per the U.S. Preventive Services Task Force) to be covered and available at no cost to the individual, which includes screening for alcohol misuse and depression by primary care providers. Beyond identifying mental health and substance use problems early, mounting research demonstrates a lot can be done – by providers, policy makers, community members, and other stakeholders – to prevent mental health and substance use problems.
To keep these health issues from developing in the first place, primary and behavioral health care providers can be involved in primary prevention efforts. Primary prevention is any activity – intervention, program, policy, or systems change – that stops or slows the development of a mental health or substance use disorder before it begins. It is distinguished from secondary prevention, which is the early recognition and treatment of diagnosable illness early to shorten its duration and prevent significant morbidity, and tertiary prevention, which is focused on the management of chronic illnesses to restore function, promote quality of life, and lessen disability associated with the illness.
A 2009 Institute of Medicine report on prevention among young people distinguishes three levels of primary prevention – universal, selective, and indicated.
- Universal prevention strategies are aimed at a population regardless of the presence of risk or symptoms.
- Selective prevention interventions are for individuals, families, and populations that have elevated risk for developing a mental health or substance use problem but do not yet exhibit any symptoms or problem behaviors.
- Indicated prevention interventions are for individuals and families experiencing signs of a mental health or substance use condition but who do not yet meet criteria for diagnosis. Indicated prevention interventions are intended to prevent those problems or symptoms from turning into a diagnosable disorder.
What evidence-based interventions are available for primary prevention?
Primary prevention interventions have demonstrated short and long term benefits. SAMHSA includes many evidence-based primary prevention strategies in the National Registry for Evidence-based Programs and Practices. Many of these are designed to be administered in schools or other community settings, but community health centers can also implement primary prevention programs. In fact, community health centers are well-positioned to identify what prevention strategies would be most useful for the population they serve.
The Good Behavior Game (GBG) is an example of a universal prevention program. It promotes pro-social behaviors to youth in first or second grade to improve classroom behaviors and support effective learning. Long term follow-up of GBG participants indicates that it reduces risk for a myriad of later life problems, including substance use, tobacco use, and mental health conditions. It can be administered to every first grader in a given school district, regardless of the presence of risk factors or problem behaviors.
Home visitation programs like the Nurse-Family Partnership (NFP) are typical of selective interventions. NFP helps young, new mothers who are from economically disadvantaged circumstances with parenting, attachment, and child development during the first few years of their child's life. Like GBG, NFP has also demonstrated long term benefits for both moms and their offspring. Positive Parenting Program (Triple P) is an example of an indicated prevention program, providing parenting strategies to families with children exhibiting problem behaviors.
What types of prevention programs work in a clinical setting?
Triple P's parenting strategies are examples of primary prevention that can be administered during regular primary care visits. Trained pediatric and family practice providers can offer brief parenting strategies and written resources when a concern for a child’s behavior is identified during routine clinical encounters. Trained providers can also recommend additional clinical sessions with the parents to provide further parenting strategies to help prevent and/or ameliorate problem behaviors.
Providers that encounter families with concerns regarding problem behaviors, symptoms of mental health conditions, or substance use can provide computer-based resources to parents. Another program, Parenting Wisely, provides resources and strategies for parents of children ages 3-18 and is available in English, Spanish, and French. Providers can consider recommending this program to gain parenting, communication, and discipline strategies outside the clinical setting.
Additionally, many prevention interventions are administered in group settings, which can be held in various community locations – schools, recreational centers, houses of worship – as well as community health centers. For instance, through participation in a series of group sessions, Incredible Years strengthens parent-child relationships, prevents harsh discipline, and assists parents in promoting their child's healthy development. The Wellness Initiative for Senior Education (WISE) is a curriculum based educational group targeted at older adults in six weekly sessions to promote positive aging and prevent substance abuse.
What else can community health centers do to promote prevention in their communities?
In addition to administering or hosting prevention programs for their clients, health centers can play an integral role in community public health efforts. There are 5,000 drug free coalitions in the United States who welcome the perspective of primary and behavioral health care providers. If your health center has not already formed relationships with the local public health authority, determine what types of data they are collecting and be aware of trends regarding risk factors, prevalence of chronic illnesses, and other demographic issues to help inform clinic priorities. Lastly, health center staff can partner with non-profit hospitals in your area to perform needs assessments and direct charity care funding toward needed population level prevention efforts.
One of the persistent problems of implementing prevention interventions in primary care relates to an historical inability to bill for these services when they involve delivering interventions to individuals who are not the identified beneficiary (e.g. parents of children with problem behaviors). Read how one provider has begun to address these problems in Washington state, where Medicaid provides funding for the brief interventions and targeted counseling of Triple P, in this month’s provider profile.
What strides are primary and behavioral health care providers in your community taking toward prevention of chronic conditions? Share your story with us, email integration@theNationalCouncil.org.
Based on an interview with Dr. Ellen Aduan, Othello Family Clinic, Columbia Basin Health Association
The only pediatrician at Othello Family Clinic, an FQHC that is part of the Columbia Basin Health Association, Dr. Ellen Aduan sees up to 25 patients per day. She often encounters frustrated parents who need some assistance to manage their child's behavior. Two years ago, Dr. Aduan and a few other providers from the Columbia Basin Health Association participated in a training to learn how to help stressed parents relate to their children through improved parenting strategies and to promote the healthy development of her patients.
Triple P is an evidence-based system of parenting education and support that consists of five levels of increasing intensity, ranging from universal prevention to treatment. Level 1, Universal Triple P, involves a public education campaign designed to reach a broad audience with messages about positive parenting. Level 2, Brief Primary Care Triple P, allows a trained individual to provide a brief consultation during a clinical encounter to parents with specific concerns about their child's behavior. Level 3, Primary Care Triple P, consists of brief (15-30 minute) in-person or telephone consultations to assist parents whose children are having mild behavior difficulties. Up to four sessions are available along with tip sheets and resources to reinforce parenting strategies. Levels 4 and 5 are for parents of children with more serious behavioral problems, and involve intensive support from behavioral health specialists in individual and group settings.
Levels 4 and 5 are utilized in behavioral health settings as reimbursable services for children who already have a behavioral health problem. However, given its preventive nature and requirements that services meet medical necessity criteria for a diagnosable problem, providers could not be compensated for providing Levels 2 and 3. To overcome this barrier, Washington State, the Division of Behavior Health and Recovery, the Washington Health Care Authority, Seattle Children’s Hospital, and the Division of Public Behavioral Health and Justice Policy at the University of Washington worked to create a Medicaid CPT code so providers can bill for Levels 2 and 3 interventions. Grant funds provided Triple P training for primary care providers in Levels 2 and 3, and only those providers that have gone through the training are able to bill Medicaid for the service.
At the recommendation of the Director of Quality Improvement, Dr. Aduan attended the training with other providers from Columbia Basin Health Association. She saw a need to provide parents with evidence-based parenting strategies, and found the two-day training and certification process manageable, despite her constrained schedule. Dr. Aduan uses Level 2 strategies during regular wellness checkups when parents express concerns or she notices a behavior that could benefit from brief strategies. A nurse colleague who also attended the Triple P training often follows up with families by telephone. Dr. Aduan also suggests Level 3 consultations when she believes parents could benefit from more in-depth help.
School personnel with training in Triple P periodically refer families to the clinic for Level 3 consultation, for which she is able to bill Medicaid. Additionally, providers at the region's behavioral health specialty clinic, Integrated Health Care Services, are trained on Triple P Level 4, so providers at Othello Family Clinic can refer families for whom the Level 3 intervention was not sufficient and who need further help to them.
While she is motivated to use Triple P in her practice, Dr. Aduan has found some challenges with the program. She has such short visits with her patients, it is often difficult to insert Level 2 strategies and tips into her clinical encounters without running into the next scheduled appointment. Level 3 generally works best when parents come seeking the information, but the clinic lacks marketing to inform parents that the service is available.
When Dr. Aduan suggests to parents that they might benefit from services offered in Level 3, they are often hesitant, assuming they are being judged as bad parents. But once they understand the evidence supporting the intervention, they are generally willing to give it a try. Many parents have given Dr. Aduan positive feedback, that implementing the strategies has led to changes in their children and improved behavior.
What programs do you or your partner agency offer for prevention of mental illness, addiction, and other chronic health conditions? Share your strategies, email firstname.lastname@example.org.
The Promise Neighborhoods Research Consortium, funded by the National Institute on Drug Abuse, offers evidence-based kernels – simple, proven behavioral interventions to improve health and development, family life, and educational outcomes; treat substance abuse; or reduce violence. Recommend these kernels to clients to try at home or implement them in your center to promote health, productivity, and staff satisfaction.
- Recommend reduced TV time for children and teenagers.
- Recommend parents give their children meaningful roles at home – tasks they can complete and feel good about contributing to the family.
- Recommend verbal praise to improve parent-child relationships, workplace relationships, and reduce marital conflict.
- Recommend the use of direct praise notes in the workplace, family, or school to improve mental health, cooperation, and productive.
- In groups, encourage soft team competition to support a greater community good.
Visit our Wellness Strategies page for further resources, initiatives, and strategies focused on whole health and wellness.
CIHS worked with the National eHealth Collaborative to explore the Current State of Sharing Behavioral Health Information in Health Information Exchanges. The collaborative created a final report that outlines challenges and opportunities for integrated primary and behavioral health care providers participating in an HIE and shares case studies from 11 states.
CMS released an informational bulletin to highlight the use of FDA-approved medications in combination with evidence-based behavioral therapies (Medication Assisted Treatment (MAT)), to help persons with substance use disorders (SUDs) recover in a safe and cost-effective manner. The bulletin provides background about MAT, examples of state-based initiatives, and resources to help ensure proper delivery of these services to the nearly 12 percent of Medicaid beneficiaries over 18 who have a SUD.
Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT), funded by SAMHSA’s Center for Substance Abuse Treatment (CSAT), released a new buprenorphine waiver training and five new clinical online modules and case vignettes on developing a behavioral treatment protocol, management of opioid withdrawal, motivational interviewing, pain management, and SBIRT. Providers’ Clinical Support System for Opioid Therapies (PCSS-O), also funded by CSAT, also released a new online module, Opioids for Pain Treatment in Persons with Addiction.
Using key trauma-informed principles, treatment improvement protocol (TIP) 57, Trauma-Informed Care in Behavioral Health Services, addresses trauma-related prevention, screening, assessment, intervention, and treatment issues and strategies. It includes key information to help practitioners and administrators become trauma aware and informed, and implement science-informed intervention strategies.
SAMHSA’s BHbusiness Plus offers mental health and addiction providers an opportunity to spend three months focused on improving business operations. Receive robust guidance and resources around topics like third-party billing, services costing, strategic business planning, and much more. Apply online by September 5 for an October start date.
Health and Human Services Secretary Sylvia Mathews Burwell announced as much as $360 million to test innovative care models for 39 recipients spanning 27 states and the District of Columbia. These models are designed to deliver better health care and lower costs under the Health Care Innovation Awards program.
Health Information Technology (HIT) makes it possible for individuals to access their health information online and also supports care coordination among health care providers. But how else can centers use HIT to support the integration of behavioral health in primary care? In case you missed it, check out the recording of Making Apps and Web-based Technology Part of your Integrated Team to hear how one health center uses new behavioral HIT tools in their integrated behavioral health care services, review the types of tools available to safety-net providers, learn how to ensure IT tools support your clinical outcomes goals, and get tips for implementing them into your clinic workflow.