A recent Substance Abuse and Mental Health Services Administration (SAMHSA) announcement about the Advisory, Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update, states:
“Opioid misuse is a significant problem in the United States. According to the 2014 National Survey on Drug Use and Health, 914,000 people age 12 or older used heroin in the past year and 4.3 million people currently engage in nonmedical use of pain relievers.
Medication-assisted treatment (MAT) is an important part of an effective response to opioid use disorder and has been found to reduce morbidity and mortality, decrease overdose deaths, reduce transmission of infectious disease, increase treatment retention, improve social functioning, and reduce criminal activity.
This Advisory reviews current information on the use of sublingual and transmucosal buprenorphine for MAT of opioid use disorder. Topics include new formulations of buprenorphine, the effectiveness and safety of buprenorphine treatment, contraindications and cautions (including medication interactions), informed consent and treatment agreements, treatment monitoring, and indications of diversion and misuse.”
In addition, SAMHSA has just released the Opioid Overdose Prevention Toolkit — Updated 2016. This resource is intended to equip health care providers, communities and local governments with material to develop practices and policies to help prevent opioid-related overdoses and deaths. It specifically addresses issues for health care providers, first responders, treatment providers, and those recovering from opioid overdose.
This is part of a targeted initiative to address opioid-drug related overdose, death, and dependence announced a year ago by the U.S. Department of Health and Human Services.
Additional Academy Portal information on Opioids, previously covered, includes a commentary on treating addiction with behavioral health in primary care clinics, by Alexander Blount of the NIAC.
The National Alliance on Mental Illness (NAMI) has released State Mental Health Legislation 2015: Trends, Themes and Effective Practices, its third annual report on state legislation enacted during 2015. This report is intended to serve as a source of ideas for state leaders and a tool for advocates who share a desire to strengthen mental health care systems that for too long have been fragmented and existing in perpetual crisis.
The report organizes legislation and regulatory action in 2015 into 11 topical areas. While not exhaustive, measures listed in Appendices 1 through 23 represent much of the meaningful action on mental health issues at the state level during 2015. The topical areas are:
- State Mental Health Budgets
- Medicaid and Medicaid Expansion
- Insurance Parity
- Children and Youth
- First Episode Psychosis: Early Intervention
- Inpatient and Crisis Care
- Civil Commitment and Court-Ordered Treatment
- Criminal Justice
- Suicide Prevention
- Housing and Employment
NAMI notes that state mental health budgets are a matter for concern, and they provide an analysis of trends.
The report is available at: NAMI 2015 State MH Legislation
Vikram Patel, PhD, delivered a TED talk at TEDGlobal2012 encouraging the training of laypeople to deliver mental health services to help meet the worldwide mental health workforce shortage. Patel, trained as a psychiatrist in Britain, highlighted the gap between mental health needs and service provision for people with mental health problems — “the vast majority of these individuals do not receive the care that can vastly improve their lives.” This is a major problem in developed countries and is an even greater problem in developing countries. Patel explains that there is a gulf between the knowledge we have about mental health and what to do with that knowledge. In developing countries, where mental health professional are in short supply, alternative resources may need to be considered. Three experiments are highlighted in which lay persons were trained to deliver psychotherapy with positive outcomes. Patel makes the case that “in order for us to achieve health for all, we will have to involve all in that particular journey.”
View the TED Talk:
Read the associated blog post:
Integration of substance use disorder (SUD) treatment services are not getting adequate attention in health care settings, a new white paper suggests. The Addiction Technology Transfer Center (ATTC) Network released “Integrating Substance Use Disorder and Health Care Services in an Era of Health Care Reform” in March 2015. Current momentum for the integration of SUD and health care services stems from policy changes resulting from health care reform, as well as from growing evidence demonstrating improvements in patient outcomes form integrated services. Research shows that SUDs are common among patients in health care settings and should be treated in manner similar to other common diseases. This ATTC Network paper emphasizes the need for better integration of SUD and health care services and describes a variety of effective models, evidence-based interventions, and implementation strategies for treating SUDs within health care settings. The paper also highlights the work of the ATTC Network. The ATTC Network is the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) program designed to promote both workforce development and implementation of evidence-based SUD interventions. “The Network is an essential resource as states, providers, and the SUD treatment workforce embark on change under health care reform.” One such resource discussed was The ATTC/NIATx Network of Practice, an online learning community with SUD integration implementation instructions and additional resources to assist providers. The authors conclude that 1) there is a need for better integration of SUD and health care services; 2) there is an array of effect approaches for integration including models, interventions, and implementation strategies; and 3) SAMSHA’s ATTC Network is a key resource for guiding the SUD and health care services integration process.
Link to the white paper:
Link to The ATTC/NIATx Network of Practice:
A recent Journal of the American Medical Association Viewpoint article argues that developing quality measures for assessing and rewarding high quality integrated behavioral health care could promote widespread adoption of an integrated care model. Patients with behavioral health issues, such as serious mental illness and substance abuse, use more medical resources than other patients, particularly when these patients have comorbid medical conditions. Effective models of care exist that integrate physical and behavioral health services and have demonstrated improvements in patient outcomes and cost reduction. One model discussed in the article is collaborative care model, which has demonstrated cost savings in low-income, high-risk patient populations compared to traditional models. Despite cost-saving and patient outcome benefits associated with integration, these models have yet to be implemented on a large scale. One barrier to widespread implementation is the lack of systematic incentives, payment, and improvement strategies designed to reinforce best practices and outcomes for integrated care patients – key to this process is the development of valid quality measures. The article’s authors, Matthew L. Goldman, MD, MS, Brigitta Spaeth-Rublee, MA, and Harold Alan Pincus, MD, from Columbia University Medical Center, Department of Psychiatry, build the case that “developing and validating a set of robust quality measures that targets this high-cost/high-need patient population and is tied to new payment mechanisms can play a powerful role to encourage more cost-effective care.” Current quality measures tend to be rather limited in scope and do not address behavioral and physical health integration. The authors conclude that best practice and outcomes measures for integrated care “can increase accountability across health care settings, diminish disincentives to serve and treat […] complex patients, broaden dissemination of research-proven models that improve patient outcomes and enhance the efficiency of the health care system as a whole.”
Read the Viewpoint article:
For additional information on collaborative care models, view the following brief:
The Collaborative Family Healthcare Association (CFHA) posted a series of four stories on their blog that highlight developments in the field of behavioral health and primary care integration. The series covers a wide range of topics, including health care policy, delivery, and financing. Multiple members of the National Integration Academy Council (NIAC) and AHRQ Academy Team are featured in the series.
In the first blog post, “The Wild West and Healthcare Innovation: Colorado’s Frontier Legacy Continues,” Benjamin Miller, PsyD, (Academy Principal Investigator), describes a State Innovation Model grant that will allow Colorado to integrate behavioral health into 400 primary care practices through payment.
Neil Korsen, MD, MSc, (NIAC), and Becky Boober, PhD, co-authored the second blog post, which details some of the many efforts being made across Maine to advance integration of primary care and behavioral health. Almost 50 percent of primary care practices in Maine offer some level of integration largely as a result of two organizations, the Maine Health Access Foundation and Maine Quality Counts.
Christine Borst, PhD, and Cathy Hudgins, PhD, LMFT, relay their experiences with integration in North Carolina in the third blog post of the series. Borst describes the Center of Excellence for Integrated Care (COE), a program of the North Carolina Foundation for Advance Health Programs. COE is committed to helping develop and advance integrated care across the state by systematic training, assistance, and capacity-building to contracted entities. Hudgins lists a number of federally funded programs for integration in North Carolina. Both Borst and Hudgins contributed to a list of the top 10 lessons they learned as “practice transformationists.”
The final blog post outlines the experiences of Robin Henderson, PsyD, leading up to the passage of Oregon Senate Bill 832, which defines integrated care, behavioral health homes, and behavioral health clinicians. Henderson acknowledges that CJ Peek (NIAC) and Benjamin Miller provided “invaluable editorial guidance” in defining integrated care through their work for the AHRQ Academy. The new law will remove some of the financial and regulatory barriers that previously hindered provision of integrated primary care and behavioral health in Oregon.
Access the CFHA Blog: http://www.cfha.net/blogpost/689173/CFHA-Blog
A broad gap exists between behavioral health (BH) needs of low-income Californians and BH treatment, a recent report finds. The report from Blue Shield of California Foundation discusses the results of a survey, which measured low-income Californians self-reported needs for and barriers to BH assistance. The results found that 3 out of 10 survey respondents had a time in the past year when they have felt the need to talk with a health care professional about their BH; however, only half of these individuals actually talked with one about these issues. Barriers identified included stigma, cultural, and language barriers, as well as not knowing where to get help. The findings also highlight a mismatch between patient interest in receiving Services at a primary care (PC) facility and current availability of these services, with three-quarters indicating that it was “highly important” that their facilities provide BH services, but only half reporting that these services were available. The survey results demonstrated strong support for interest in integrated care among low-income Californians, with the majority indicating a strong preference for receiving BH services in the same setting as their PC. Sixty percent reported a preference for discussing BH issues with a professional at their PC facility, rather than off site.
The report provides several recommendations for how to bridge the gap between BH needs and services based on the survey results. A few of these recommendations include:
- Integrating BC specialists into PC practices;
- Making patients more aware of BH resources; and
- Having health care providers routinely ask patients about their emotional well-being.
The authors explain that:
“By inviting patients to discuss their behavioral health needs within the primary care setting, primary care providers may vastly improve the chances that their patients will seek help. By strengthening and deepening their relationships with their patients, providers and healthcare facilities have the potential to dramatically enhance health treatment for low-income Californians.”
The Blue Shield of California Foundation research report findings add additional support to previous research on the benefits of integrated BH services in PC settings, particularly as a way to reduce stigma and increase ease of access by providing care within a PC clinic.
Read the Blue Shield of California Foundation report:
View the Health Affairs article on bridging the gap:
The Affordable Care Act (ACA) was signed into law 5 years ago. In the time since its passage, the ACA has increased the number of Americans with health insurance, increased access to affordable health care, and may be contributing to slowing the rate of increase in health care spending.1 In addition, the ACA has transformed the delivery of health care,1 including changes that advance primary care and behavioral health integration. Among the post-ACA initiatives enabling opportunities for transformation through the integration of primary care and behavioral health are:
- State Innovation Models (SIMs) – Provides Federal dollars and technical assistance to help states and private payers provide better care at lower costs
- State Plan Amendments (SPA) – Sixteen states have agreements with the Federal Government that relate to the integration of primary care and behavioral health within Medicaid and the Children's Health Insurance Program CHIP administration
- Independence at Home Demonstration (IAH) – An Innovation Center program to test the effectiveness of delivering team-based comprehensive primary care services at home to high-need Medicare beneficiaries
- Medicaid Innovation Accelerator Program (IAP) – Technical assistance program launched that supports states in accelerating payment and delivery system reforms for Medicaid beneficiaries relating to issues such as substance use disorders and mental and physical health integration
- Comprehensive Primary Care Initiative (CPCI) – A program that supports innovative health care payment and organization models, including some that focus on care-coordination and chronic disease management
- Multi-Payer Advance Primary Care Practice Demonstration (MAPCP) – A demonstration program that provides a monthly care management fee for Medicaid beneficiaries who receive care from patient-centered medical homes.
For additional information, view the following resources:
- ACA Payment and Delivery Reform Systems at 5 Years – An issue brief from the Commonwealth fund
- Summary of Select Affordable Care Act Payment and Delivery System Reform Provisions – A supplemental table describing ACA reforms from the Commonwealth Fund
- The Affordable Care Act at 5 Years – A New England Journal of Medicine article
- Healthcare Integration in the Era of the Affordable Care Act – A report from the Association for Behavioral Health and Wellness
1Blumenthal D, Abrams M, Nuzum R. The Affordable Care Act at 5 Years. N Engl J of Med. 2015 Jun 18; 372(25): 2451-8. PMID: 25946142
A study, published in Pediatrics in March of 2014, revealed a significant level of unmet need for care coordination among parents of children with a mental health condition. Care coordination is a way of connecting children with special health care needs and their families to critical services and resources. This type of care has been linked to lower health care costs, better health outcomes, and it helps families to use the health care system more efficiently. Coordinated care is especially important for children with mental health conditions because their families often have greater difficulty accessing specialty care for their child’s health problems.
The study’s authors analyzed data from the 2007 National Survey of Children’s Health to get a better understanding of the frequency of need for coordinated care and to identify factors that related to this need being unmet. The research sample included more than 7,500 children from ages 2 to 17 years with a diagnosis of depression, anxiety, attention-deficit/hyperactivity disorder, or conduct disorder who had received two or more types of preventive or subspecialty health care services in the last year. The need for care coordination was assessed with a single question: “During the past 12 months, have you felt you could have used extra help arranging or coordinating the child’s care among different health care providers or services?” A large proportion of parents (43%) reported a need for care coordination. Among the parents expressing a need for this type of care, 41% indicated that this need was not met. The authors then looked at sociodemographic, clinical, and parent psychosocial characteristics, to understand which factors may be linked to having an unmet need. They found that parents of children with an anxiety disorder, parenting stress, low income, and public or no insurance were more likely to have unmet need. Whereas, those who reported social support and family-centered medical care seemed be less likely to have unmet coordinated care needs.
This study highlights the need for care coordination among children with mental health conditions and their families, particularly those with anxiety. The study authors concluded from these results that “delivery of family-centered care and enhancing family supports may help to reduce unmet need for care coordination in this vulnerable population.” In a Culture of Health blog post from the Robert Wood Johnson Foundation (RWJF), the first author, Nicole M. Brown, MD, from the RWJF Clinical Scholars Program, commentated that the findings also point to a “need for more training for physicians to help us recognize and diagnose anxiety and other mental health conditions earlier” in order to help connect children and their families to appropriate mental health services.
Link to the article:
Link to blog post with Nicole Brown, MD discussing the study:
Until 2010, Federal agencies defined health disparities very generally as “differences in health among different population groups.” The term was originally coined not merely to describe “all possible health differences among all possible groups of people” but rather to refer specifically to the poorer health outcomes experienced by socially disadvantaged people. Thus, in 2010, Healthy People 2020 clarified the meaning of health disparity by defining it as
“. . . a particular type of health difference that is closely linked with economic, social, or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”
Health equity is defined as
“the principle underlying a commitment to reduce—and, ultimately, eliminate—disparities in health and in its determinants, including social determinants. Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions.”
These explicit definitions of health disparities and health equity ensure that allotted resources are used for intended purposes.
In addition, the definitions of health disparities and health equity emphasize health differences specifically with regard to economic/ social disadvantage for many reasons:
- First, a large body of evidence associates “economic/social disadvantage with avoidable illness, disability, suffering, and premature death.”
- Second, economic/social disadvantage can be mitigated by social policies such as new minimum wage laws and anti-discriminatory housing and employment practices.
- Moreover, “health is needed for functioning in every sphere of life” and should therefore be fairly distributed.
- International human rights principles call for everyone to have a fair chance at health, well-being, long life, and social and economic opportunity and declare health disparities as discriminatory and inequitable.
Health disparities and health equity are interrelated. Health disparities are the way in which we measure progress towards health equity or social justice in health. A reduction in health disparities means greater health equity, and achieving greater health equity requires that we selectively improve the health of the economically/socially disadvantaged without worsening of the health of others.
Read the related article: http://www.publichealthreports.org/issueopen.cfm?articleID=3074