Access to Best Practices for CoOccurring Disorders: Research and Practice Partnerships Constance Weisner, DrPH, MSW Stacy Sterling, MSW, MPH Sujaya Parthasarathy, PhD Jennifer Mertens, MA Charlie Moore, MD, MBA University of California at San Francisco and Division of Research, Northern California Kaiser Permanente Conference on Complexities of Co-Occurring Conditions: Harnessing Services Research to Improve Care for Mental Health, Substance Use, and Medical/Physical Disorders, June 24, 2004, Washington, DC From studies funded by the National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, Center for Substance Abuse 1 Treatment, and Robert Wood Johnson Foundation Broadening the research focus in improving access and utilization of best practices Asking new research questions develop
questions in collaboration with clinicians Studying the implementation process the variety of stakeholders that influence adoption of, and access to, best practices 2 Sources of Research Questions Generates research intervention study Research literature Intervention Policy issues evaluated Clinical concerns Health Plan Clinicians Program (CD & MH) Primary Care
Consumers Purchasers/ employers Accreditation bodies Health policy Stakeholder concerns Program change shape implementation implemented 3 Sterling & Weisner, (2002) Closing the Loop: A Model to Address the Transfer of Research to Practice OVERVIEW Importance of access Screening, assessment, and integrated services Conceptual model and application
4 Research Supporting Integrated Services Assessment: Many individuals entering CD and MH treatment have co-occurring problems. (Rounds-Bryant et al., Grella et al. 2001; Rao, 2000; Greenbaum et al., 1996) Screening: These co-occurring problems could be identified earlier before they are severe. (Samet et al., 2001) Integrating services: Providing services that address those problems is related to outcomes. (McLellan et al., 1998, 1993; Willenbring & Olson, 1999) 5
Setting Kaiser Permanente Medical Care Program of Northern California Sacramento Vacaville Vallejo Oakland Non-profit, group practice prepaid HMO 3.2 million members (35% of commercially insured population) Carved-in psychiatry and chemical dependency services 6 Adolescent Chemical Dependency Treatment Sample 419 adolescents (143 girls, 276 boys) and parents
4 facilities Age ranged from 13 to 18 years Ethnicity: 9% Native American/Asian 16% African-American 20% Hispanic 49% White Treatment intake, 6-month, and 1-, 3-, & 5 years Response rate: 6-month 91.4%; 1-year 92.1% 7 Psychiatric Conditions of Adolescents
Entering CD Treatment (in %) Intakes (419) Matched Controls (2007) p-value Depression 24.0 0.3 <.0001 Conduct Disorder with ODD 17.0 0.2 <.0001
1.2 0.1 <.01 37.0 2.0 <.0001 1+ Psychiatric Conditions 8 ARE PSYCHIATRIC SERVICES RELATED TO OUTCOME? 9 Role of Dual Treatment: Logistic Regression
Predicting Abstinence at 6 Months Receiving mental health services while in chemical dependency services was related to better alcohol and drug outcomes at 6 months. 10 An Adult Example: 5-Year Abstinence when Psychiatric Services Provided For those who still had psychiatric problems at 12 month follow-up: 2 or more hours/year over the 5 years O.R. = 5.5* *P<.05 Controlling for age, gender, type of dependence, abstinence goal, readmission, # of 12step meetings, recovery-oriented social support, treatment intensity 11 Are Medical Services Related to Outcome? 12 An Adult Example: CD Patients and Matched Health Plan Members:
Medical Conditions* CD Patients (N=747) Matched Members (N=3,690) 25.6% 11.2% 9.2% 12.1% 5.8% 3.8% Hypertension 7.2% 3.4% Asthma 6.8% 2.6%
Acid-related Disorders 5.5% 2.1% Arthritis 3.9% 1.3% Injury and Overdoses Lower Back Pain Headache *all p<.001 Mertens, Lu, Parthasarathy, Moore, Weisner. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: Comparison to matched controls. Archives of Internal Medicine. 13 Randomized Adult SAMC Group: Logistic Regression Predicting
Abstinence at 6 Months: Independent Variable O.R. 95% C.I. Integrated Care (vs. Usual Care) 1.90 (1.22, 2.96) Controlling for baseline alcohol and drug severity Weisner C, Mertens J, Parthsarathy S, Moore C, Lu Y. (2001). Integrating primary medical care with addiction treatment: A randomized controlled trial. JAMA 286(14):1715-1723. 14 Medical Costs 12 Months after Treatment for Randomized CD Patients with Psychiatric & Medical Conditions $350.00
Integrated Care Independent Care $300.00 $250.00 $200.00 $150.00 $100.00 $50.00 $0.00 Med SAMC Subgrp *p<.05; **p<.01 Psych SAMC Subgrp Parthasarathy S, Mertens J, Moore C, Weisner C. (2003). The utilization and cost impact of integrating substance abuse treatment and primary care. Medical Care. 15 Sources of Research Questions Generates research intervention study Research literature Intervention
Policy issues evaluated Clinical concerns Health Plan Clinicians Program (CD & MH) Primary Care Consumers Purchasers/ employers Accreditation bodies Health policy Stakeholder concerns Program change shape implementation implemented 16 Sterling & Weisner, (2002)Closing the Loop: A Model to Address the Transfer of Research to Practice Research Practice Model
CD & MH Directors/Chiefs Groups: Business case: outcomes & cost Parity legislation Identifying next generation of research questions Survey of pediatricians Clinicians Development of assessment for MH and CD clinics PC & ER physicians Results to their professional organizations Identifying next generation of research questions Assessment in MH and CD clinics Readiness to change AOD use in MH clinics Dual Diagnosis Best Practice Committee Concept & development of liaison model Core competencies, care guidelines
Training Identifying next generation of research questions Dual diagnosis continuity of care, utilization & cost 17 Conclusions A wide variety of stakeholders influence access Demonstrating both outcome and cost is important in improving access Integrating research and practice can lead to better understanding how to study and address access 18
COLLABORATORS Kaiser Permanente Clinics Oakland Sacramento San Francisco Stockton Vacaville Vallejo
Felicia Chi, MPH Steve Allen, PhD David Pating, MD Bill Brostoff, MD Christine Waters, MD Agatha Hinman, BA Georgina Berrios, BA Tom Ray, M.A. Wendy Lu, MPH Cynthia Campbell, PhD Derek Satre, PhD Carolynn Kohn, PhD Melanie Jackson, BA Cynthia Perry-Baker, BA Lynda Tish, BA Barbara Picchoto, BA 19
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