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ATTC Messenger January 2015: Integration of SUD Services and Healthcare: The Role of the ATTC Network

January 2015

Integration of SUD and health care services: The role of the ATTC Network

Heather Gotham, PhD
MidAmerica ATTC

Stan Sacks, PhD
Northeast and Caribbean ATTC

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines integrated care as “the systematic coordination of general and behavioral health care, integrating mental health, substance abuse, and primary care services [that] produces the best outcomes and proves the most effective approach to caring for people with multiple health care needs.” (SAMHSA, 2014). Research demonstrates that the integration of substance use disorder (SUD) services and primary care can lead to improved physical and mental health (Madras, et al., 2009), reduce levels of substance use (Gryczynski et al., 2011; Madras et al., 2009), and result in cost savings for health care (Babor et al., 2007), including for patients with co-occurring SUD and health problems (Parthasarathy et al., 2003). The benefits of integrated care extend beyond patients to caregivers, providers, and the health care system.

For more than 20 years the ATTC Network has contributed to the development of the SUD services workforce. Currently, the Network consists of 10 Regional Centers, 4 National Focus Area Centers, and a Network Coordinating Office. The Network enjoys active working relationships with all Single State Agencies (SSAs) and SAMHSA Regional Administrators, and functions at the state, program, and staffing levels. The Network has both a targeted regional/state emphasis and can enlarge its impact through coordinated, network-wide activities. It is ideally situated to provide leadership and support as the field embarks on efforts to integrate SUD treatment and health care.

As the major resource for training and technical assistance in the SUD treatment field, the Network offers a full array of skills training, academic education, online and distance learning, curricula, conferences, workshops, and publications. Training and other resources to foster integration are available in a variety of formats and media.

However, the Network goes well beyond traditional dissemination, which primarily supports getting the word out about evidence-based practices for SUDs. The ATTC Network has a unique emphasis on technology transfer and implementation support (The Change Book, ATTC 2000, 2010; the ATTC Technology Transfer Model, ATTC Technology Transfer Workgroup, 2011a, 2011b), using more in-depth strategies aimed at helping organizations prepare for, make, and sustain change. Through these state-of-the-art efforts, the Network is accelerating the use of effective treatments and models for patient care.

The ATTC Network has a vital role in helping the SUD treatment field promote the integration of SUD treatment with mental health and health services. The following are five examples of ATTC work in this area. These examples come from a soon-to-be-released White Paper developed by the ATTC Network Technology Transfer Workgroup and co-authors, titled “Integrating Substance Use Disorder and Health Care Services in an Era of Health Reform.”

National SBIRT ATTC: Helping an FQHC Implement SBIRT

In addition to its work promoting the implementation of SBIRT at the national level, the National SBIRT ATTC has worked with specific healthcare groups. One example is its association with an FQHC in Youngstown, Ohio. ONE Health Ohio’s CEO Ron Dwinnells has been on a mission to implement SBIRT into the clinic, and the National SBIRT ATTC assisted this process by providing technical assistance and training. During an initial meeting, the National SBIRT ATTC provided consultation to the physician director and his staff as they were in the beginning stages of implementing SBIRT. Discussions included the specific SBIRT model and processes that would be used in the clinic (e.g., who conducts the screening? Which screening tools to use? How to effectively get patients referred to treatment?). After this initial meeting, the National SBIRT ATTC provided an all-staff training, including physicians, nurses, dentists, medical assistants, receptionists, and other support staff, so that everyone had at least a basic understanding of the rationale for SBIRT and the process that would be used. Dwinnells and One Health Ohio conducted an evaluation, showing that SBIRT did not significantly increase doctors’ average time with patients, and that rates of identification of substance use issues were higher in clinics where SBIRT was implemented.

Pacific Southwest ATTC: Napa County SBIRT Implementation Initiative

In 2013, the Pacific Southwest ATTC partnered with the Napa County Health and Human Services Agency, Mental Health Division, in a project focused on SBIRT program development and implementation for staff working in substance use disorder, mental health, and primary care treatment settings

Training: Pacific Southwest ATTC-affiliated trainers provided 10 full-day Motivational Interviewing (MI) and SBIRT trainings to more than 250 Napa County-affiliated providers. Key populations trained included physicians, nurse practitioners, physician assistants, psychologists, MFTs and LCSWs, interns, and certified alcohol and drug counselors. The training focused on the use of MI, screening, and brief intervention implementation throughout the county’s integrated behavioral health system (comprised of a mental health services division, alcohol and drug abuse services, and a fully functioning Federally Qualified Health Center (FQHC). The desired outcome for the training was the development of concrete skills to better screen/identify, treat, and refer patients at risk for mental health and substance use disorders within the behavioral health care system

Implementation: Following the initial round of training, Pacific Southwest ATTC staff conducted two full-day site visits with key Napa County HHSA leadership to finalize a pre-screening instrument, discuss necessary clinic flow changes, design a fully articulated SBIRT implementation manual, decide upon data measures and documentation procedures, and develop data dashboard and summary report templates. SBIRT implementation began in the integrated care campus in fall 2013 and efforts are ongoing. Refresher trainings were provided in summer/fall 2014 for new clinical staff.

Central Rockies ATTC: Behavioral Health Care Integration with Primary Care Subcommittee

The Central Rockies ATTC is working at a regional level to accelerate the implementation of integrated care. They have convened the Behavioral Health Care Integration with Primary Care Subcommittee that includes twelve representatives from the six states in Region 8 (CO, MT, ND, SD, UT, WY). The Subcommittee members represent state-level SSA and integrated mental health and substance use disorder treatment offices, substance abuse treatment organizations, primary care providers, and integrated SUD/MH/primary care service providers.

The Subcommittee developed a work plan that focuses on two major topics: workforce development and integrated models. Related to workforce development, the Committee sees a major need to identify ways to help prepare the SUD workforce to work in integrated settings, such as through a learning collaborative or other training and technical assistance that the Central Rockies ATTC will provide.

In addition, the Committee recognized that another need is to disseminate information to SUD and MH providers about integrated models and ways that SUD providers can begin the integration process. This will include pulling together examples of integrated care provision in the region, as well as developing a road map of steps that States can take to facilitate integration quickly, such as by focusing on Medicaid populations and blending SUD and MH into primary care (e.g., via SBIRT). As the Committee further develops their plan, the Central Rockies ATTC will provide training and technical assistance at the region, state, and provider levels.

Mid-America ATTC
A Changing Health care Landscape: Can Your Organization Weather the Storm?

The Mid-America ATTC currently serves the HHS Region 7 states of Iowa, Kansas, Missouri, and Nebraska. The Mid-America ATTC collaborated with the State Associations of Addiction Services (SAAS) to create this model program. “A Changing Health care Landscape: Can Your Organization Weather the Storm?” was designed to facilitate state discussion of health care reform and integration of substance use disorder services into healthcare settings. The program included the following components:

Securing buy-in from state leadership: The Mid-America ATTC met with state leaders in Iowa, Kansas, Missouri, and Nebraska to gain SSA Director support for state-specific “Can Your Organization Weather the Storm?” events.

Assessing readiness for health care reform: State-licensed SUD treatment program executive leaders were invited to complete a free, confidential, online tool to assess their readiness for health care reform. Developed by SAAS, the Provider Readiness and Capabilities Assessment (RCA) generated an automatic health care reform readiness assessment. Treatment program leaders were encouraged to complete the RCA in advance of their state’s “Can Your Organization Weather the Storm?” and bring it along to the event to compare their scores with those aggregated across the state.

Changing Healthcare Landscape: Can Your Organization Weather the Storm” events held in each state.  Each event included presenters from organizations such as the National Association of County Behavioral Health and Developmental Disabilities Directors, Advocates for Human Potential, and SAAS. The events featured a presentation on the RCA results, with comparisons of the data aggregated across the state to a national data set of 500 organizations, across six key areas: 1) general management, 2) marketing, 3) information technology and data management, 4) clinical and human resources, 5) finance, and 6) provider network organizations. Focus groups and discussion sessions were held for in-depth conversations about what actions to take based on the RCA results.

Follow-up technical assistance: The Mid-America ATTC provided follow-up TA in each state targeting the readiness areas of most concern to providers.

Northeast and Caribbean ATTC
Integration of Behavioral Health and Primary Care Services in FQHCs

Staff from NDRI, which houses the Northeast and Caribbean ATTC (NeC-ATTC), worked on a project to integrate behavioral health (SUD and mental health) and health care services in FQHC settings in New Jersey. After a site visit, the FQHCs received a written report of their program capability to deliver integrated care. The NeC-ATTC offered two full-day, special implementation support and guidance trainings on the integration of addiction, mental health, and primary care services in these FQHCs. The special sessions provided feedback on progress to date, identified staff to carry out the work going forward, and developed plans for making further improvements. Ongoing technical assistance and implementation support, a peer-to-peer learning community, and a six-month follow-up assessment followed these sessions. The FQHCs successfully achieved more than the 5 to 7 changes initially proposed. In addition, their capability scores increased substantially, demonstrating that it is possible to achieve significant gains in the integration of SUD, mental health, and medical services in the relatively short period of time of six months (Sacks and Chaple, 2014).

In summary, The ATTC Network is the “go to” resource as states, providers, and the SUD treatment workforce embark on change under the ACA. The Network has the standing, resources, processes, and experience to train the SUD workforce and guide the integration of SUD services with mental health and primary health care services.

For more information, visit the ATTC Network webpage: Advancing the Integration of Substance Use Disorders and Health Care