pam hyde samhsa

9/7/2010

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Behavioral Health 2010:Ch ll d O t itiChallenges and Opportunities

Pamela S. Hyde, J.D.SAMHSA Administrator

Annual NPN Research Conference

Denver, Colorado • September 2, 2010

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FULL OF CHALLENGES…FULL OF OPPORTUNITIESA Day in the Life of American Adolescents

U.S. Adolescents (12‐17) on an average day in 2008…

● 508,000 drink alcohol

● 641,000 use illicit drugs

● > than 1 million smoke cigarettes

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Adolescents who used illegal substances for the 1st time on an average day in 2008:

● Approximately 7,500 drank alcohol for the 1st time

● Approximately 4,360 used an illicit drug for the 1st time

● Around 3,900 smoked cigarettes for the 1st time

● Nearly 3,700 used marijuana for the 1st time

● ~ 2,500 abused pain relievers for the 1st time

Current illicit drug use 2009 appears higher than 2008 – all ages

alcohol & tobacco use unchanged; perceived risk of harm declined

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A NEW SAMHSA NATIONAL REPORT:DRAMATIC PATTERN SHIFTS IN ADMISSION TO SUBSTANCE ABUSE TREATMENT AMONG PREGNANT TEENS BETWEEN 1992 AND 2007

The proportion of pregnant teen admissions for marijuana abuse more than doubled from 19.3% in 1992 to 45.9% in 2007

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Marijuana has surpassed alcohol as the primary substance of abuse cited in admissions for pregnant girls

The proportion of pregnant teen admissions for methamphetamine use has more than quadrupled, from 4.3% in 1992 to18.8% in 2007

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BEHAVIORAL HEALTH THREADS THROUGH AMERICA’S HEALTH

Mental Illness affects one in four families

Almost ¼ of all adult stays in U.S. community hospitals Involved mental or substance use disorders

Up to 83% of people with serious mental illness are overweight or obeseg

People with serious mental illness have shortened life‐spans, on average living only until 53 years of age

44% of all cigarettes consumed in the U.S. are by individuals with a mental illness or substance use disorder

64% of antidepressants are prescribed by primary care offices, hospitals, outpatient programs or surgical offices

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3rd leading cause of death among all youth 15‐24 years old

1.8 times higher among American Indian/Alaska Native adolescents and young adults age 15‐34

Over 1.1 million Americans attempted suicide and over 8 million i l id d i id

SUICIDE: NATIONWIDE6

seriously considered suicide

More than 33,000 suicides occurred in the U.S., equaling 91 suicides per day; one suicide every 16 minutes

Approximately 90% of individuals who die by suicide had a mental disorder, and 40% had visited their primary care doctor within the month ‐ the question of suicide was seldom raised

Alcohol use is a factor in approximately 30% of all suicide deaths

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Mission: To reduce the impact of substance abuse and mental illness on America’s communities

Roles:

SAMHSA’s DIRECTION

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● Voice and leadership

● Funding ‐ service capacity development

● Information/Communications

● Regulation and standard setting

● Improve practice

Strategic initiatives

Provide focus

● Budget planning

● Program development (New RFAs)

Align resources

SAMHSA’s STRATEGIC INITIATIVES HELP TO:

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Align resources

● Block Grants, formula grants, discretionary grants, contracts

● Human capital/program management

Create consistent message

A work in progress

● Public input/open government

SAMHSA’s STRATEGIC INITIATIVES

1. Prevention of substance abuse and mental illness

2. Trauma and justice

3. Military families

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4. Health insurance reform implementation

5. Health information technology

6. Housing and homelessness

7. Data, quality, and outcomes

8. Public awareness and support

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SA/MI prevention; emotional health development

● Prevention Prepared Communities

● Tobacco use among persons with MI/SUDs

● Disabling impacts of mental illnesses

STRATEGIC INITIATIVE NO. 1:PREVENTION OF SUBSTANCE ABUSE AND MENTAL ILLNESS

SAMHSA’s Strategic Initiatives

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Underage drinking/Alcohol policies

Suicide

● Youth

● Tribal communities

● Military‐connected individuals

Prescription drug abuse/misuse

2009 IOM REPORT

Common risk and resiliency factors

●Build emotional health in young children

●Prevent substance abuse, adolescent depression, conduct disorders

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disorders

Signs evident 2‐4 years before disorder

Intervene earlier, consistently and across multiple institutions

●Parents, teachers, clergy, community, health practitioners

Coordinate/collaborate at policy levels

PREVENTION WORKS!

Widespread decreases in SU over the past several years in U.S. were encouraging ‐ Illicit drug use may be ↑ and perceived risk of harm stagnating

Cost‐benefit ratios for early treatment & prevention SA/MI programs range from 1:2 to 1:10 meaning $1.00 in investment yields $2.00 to $10 00 savings in health costs criminal & juvenile justice costs

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$10.00 savings in health costs, criminal & juvenile justice costs, educational costs, lost productivity, etc.

Project Success—1 of 58 substance abuse prevention interventions listed on National Registry of Evidence‐based Programs and Practices (NREPP):

● 37% decrease in alcohol, tobacco and other drug use (ATOD) after year one

● Of the students using ATOD at pretest, 23% stopped ATOD use

● At second year follow‐up, students who reported using ATOD at pretest, 33.3% reportedly stopped using alcohol, 45.0% reportedly stopped using marijuana, and 22.9% reportedly stopped using tobacco

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SAMHSA’s Safe School/Healthy Students Grant Program:

● Bullying ↓5%

● Fighting ↓8%

● Verbal Abuse ↓11%

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PREVENTION WORKS!

↓

● Alcohol Use (past 30 days) ↓11%

● Cigarette Use at School ↓19%

● Feeling Unsafe at School ↓7%

Preventive intervention for adolescents can reduce the incidence of depressive disorders by 23%

Almost one quarter (24%) of pediatric primary care office visits involve behavioral and mental health problems

Public health approach to trauma

Trauma informed care and screening; trauma specific service

STRATEGIC INITIATIVE NO. 2: TRAUMA AND JUSTICE SAMHSA’s Strategic Initiatives

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Prevention & diversion from juvenile justice and adult criminal justice systems

Reduce impact of violence and trauma on children/youth

Improve access to care

Suicide prevention

Improve quality of care

Knowledge of military culture

STRATEGIC INITIATIVE NO. 3: MILITARY FAMILIES – GUARD, RESERVE, AND VETERAN


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Knowledge of military culture

Promote emotional & psychological health

Build and support resilience

Streamline policies & resources

● ↑Partnerships

● ↑Prevention for families

● ↓Homelessness

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Affordable Care Act

Medicaid/Medicare

STRATEGIC INITIATIVE NO. 4: HEALTH REFORM SAMHSA’s Strategic Initiatives

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Parity

Block Grants

Primary Care/Behavioral Health Integration

IMPACT OF AFFORDABLE CARE ACT

MAJOR DRIVERS

● More people will have insurance coverage

● Medicaid will play a bigger role in MH/SUD than ever before

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● Focus on primary care and coordination with specialty care

● Major emphasis on home and community based services and less reliance on institutional care

● Preventing diseases and promoting wellness is a huge theme

WHAT’S IN AFFORDABLE CARE ACT FOR BEHAVIORAL HEALTH?

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COVERAGE 32 million newly insured – expands Medicaid to 133% FPL ‐ estimated 16 million

new enrollees • 4‐6 million Medicaid are likely to have significant MI/SUD service needs (6‐10

million total)

High risk pools for those with pre‐existing conditions (2010)

Youth covered through parents insurance until they turn 26 years old (2010)

Expanded options in home and community‐based services for individuals with mental health and substance use disorders supports recovery orientation● 1915i● Money follows the person extension● Section 10202—increased FMAP for HCBS services● Special need plans

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$370 billion spent on individuals with Medicaid and Medicare ‐ 60% of these individuals have a ID or MH/SUD

39% of individuals served by SMHAs have no insurance (CMHS)

IMPACT OF AFFORDABLE CARE ACT: MEDICAID

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(CMHS)

61% of the individuals served by SSAs have no insurance

Services for some of these individuals are purchased with BG Funds

Many will be covered in 2014 (or sooner) – most likely by the expansion in Medicaid

SERVICES● Allows state Medicaid programs to establish health homes for those with chronic

illnesses – states must consult/coordinate with SAMHSA re: MH/SUD prevention & treatment

● Grant dollars will be for community prevention, wellness, and support services not paid for through insurance benefit plans


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● Parity required in essential benefits plans offered through exchanges and in private health plans that choose to offer MH/SUD

● Grants to community MH programs for co‐locating primary and specialty care services

● Establishes CLASS Program – voluntary, self‐funded long‐term care insurance program for people currently employed – flexible funds for support services to people with disabilities including Mental illness

● Establishes a “Medicaid Emergency Psychiatric Demonstration”

FOCUS ON PRIMARY CARE

● 5 different medical home initiatives to focus on coordinating primary and specialty care

● Enhanced federal incentives (Medicaid and Medicare) for


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● Enhanced federal incentives (Medicaid and Medicare) for these initiatives

● Significant grant funds to educate primary care

FOCUS ON HOME AND COMMUNITY BASED SERVICES

● Expansion of Medicaid to additional HCBS services and for individuals in institutional care (PRTFs/IMD 65+)

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TRAINING & RESEARCH Increased patient‐centered health research

Training grants for behavioral health workforce

Training on MH/SUD for primary care extender


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SUPPORT FOR WORKFORCE DEVELOPMENT Funding for residencies for behavioral health included with other

disciplines (HRSA)

Loan repayment programs

Push towards more national certification standards and re‐licensure/re‐certification

Primary care/behavioral health integration ‐‐ bidirectional

Prevention research programs and national prevention plans

Coverage of preventive services in private insurance and Medicare including SBIRT, without cost‐sharing and with a financial incentive to do the same in Medicaid

WHAT’S IN AFFORDABLE CARE ACT FOR PREVENTION?PREVENTION?

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financial incentive to do the same in Medicaid

Prevention Trust Fund (2010)

Allows Medicare payments for annual wellness visits including assessment and recommendations to address MH conditions or risks

Establishes a national public/private outreach and education campaign re: prevention

The Affordable Care Act requires health plans to cover a number of preventive services related to behavioral health without cost sharing (for plans effective on or after 09/23/10)

Adults● Alcohol misuse screening and counseling● Tobacco use screening & cessation interventions● Depression screening● HIV screening for those at higher risk

WHAT’S IN AFFORDABLE CARE ACT FOR PREVENTION?PREVENTION?

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● HIV screening for those at higher risk● Obesity screening and counseling

Pregnant Women● Special, pregnancy‐tailored counseling for tobacco cessation and avoiding alcohol use

Children● HIV screening for those at higher risk● Sexually transmitted infection prevention and counseling for adolescents at higher risk● Alcohol and drug use assessments and screening for depression for adolescents● Behavioral assessments for children of all ages● Developmental screening (under age 3) and surveillance (throughout childhood) ● Autism screening for children at 18 and 24 months● Obesity screening and counseling

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National Prevention, Health Promotion and Public Health Council

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Prevention and Public Health Fund

SAMHSA’s ROLE IN MOVING IMPLEMENTATION OF AFFORDABLE CARE ACT FORWARD

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Prevention and Public Health Fund

Education and Outreach Campaign

Incentives for Prevention of Chronic Diseases in Medicaid

School‐Based Health Centers include MH/SUD

Maternal, Infant, and Early Childhood Home Visiting Program

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Community Transformation Grants


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g gGrants to Accredited Programs and MH

Organizations for training BH Professionals

gEvaluation of Community‐Based Prevention and

Wellness Programs

Technical Assistance for Employer‐Based Wellness Programs

Pediatric Health Care Workforce

Consultation regarding health homes

● Start date: 5 months and counting

● States amend Medicaid state plan


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● 90% match initially—big incentives for states

● Definitional work on services and providers

● Protocol for states to request/receive TA from states

● SMD letter

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Developing quality measures for HCR

Primary care/behavioral health integration (both directions)


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(both directions)

● Expansion of current sites

● Proposed expansion of 15 more sites

● TA center

● Interface with CMS and health homes

Home Visiting Program

● Major focus on families that have or are at risk of having an SUD


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● Immediate ‐ responses to initial RFA submitted

● SAMHSA active participant in work group

● SSAs must sign off on application

Specific work regarding post‐partum depression (HRSA

has lead)

i ! i ! i !


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Prevention! Prevention! Prevention!

● Regulations

● Focused strategies for adding services to USPSTF

Health information technology changes

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WHAT WORK HAS BEEN DONE?

Identifying services that comprise a “good” and “modern” mental health and addiction system—foundational work

● From prevention to recovery

Identifying BH Measures that will be in the first round of meaningful use

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y g gmeasures for EHRs

● Initiation and Engagement of Other Drug Dependence Treatment

● New Episode of Depression

Prevention Trust Fund (2010 $$ for Primary Care/BH integration)

Prevention Task Force report

Home Visiting RFA—significant focus on addictions

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Work plans for each provision where SAMHSA has responsibility

● Primary care behavioral health initiative

● COE for depression

● Post‐partum depression

Review of Policies and Regulations (28)

WHAT WORK HAS BEEN DONE?

Review of Policies and Regulations (28)

● High risk pools

● Prevention

● Grandfathering of plans

● Medicare payment regulations

● SMD letters

Work with HHS on web portal www.HealthCare.gov

Working meeting with CMS regarding parity

WHAT WORK REMAINS?

Developing additional services that can be used for the exchange (prevention,

recovery, support services for children and families)

Supporting states, providers, individuals and families to understand the changing

environment

R d f t t

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● Roadmap for states

● Dealing with addiction services gap

● Cross association provider infrastructure support

● Lessons learned from 6 states

● HCR basics

Developing quality measures for BH that can be used for us and other purchasers

SAMHSA is active participant in all HHS health care reform workgroups

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Preparing field to expand access

● Capacity to provide MH/SU services (workforce)

● Accessing and developing strategies to improve infrastructure

(data, HIT)

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WHAT WORK REMAINS?

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● Facilitating linkage with primary care and other providers

Review current block grant spending

● Different services to support individuals/families in recovery &

resiliency

● Use for services and individuals not covered by Medicaid and/or

commercial insurance

General

● Role as payer expanding

● Role in preparing state Medicaid programs now for expansion in

2014 ( ll b fi l )

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ROLE OF STATES IN AFFORDABLE CARE ACT IMPLEMENTATION

2014 (enrollment, benefit plans, payments, etc.)

● Role in HIT is expanding

● Role in high risk pools unfolding

● Role in insurance exchanges unfolding through HHS

● Role in evaluating state insurance markets and weighing against

possible benefits of new exchanges

State substance abuse and mental health agencies

● New kind of leadership required with and by state

agencies – (Medicaid, insurance commissioner, HIT

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ROLE OF STATES IN AFFORDABLE CARE ACT IMPLEMENTATION

g ( , ,

coordinator)

● Change in use of block grant dollars (moving demos to

practice)

● Supporting communities selected for discretionary

grants

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ROLE OF PROVIDERSIN AFFORDABLE CARE ACT IMPLEMENTATION

Develop partnerships with primary care and other specialty care systems—identify what roles they can play in or as medical homes

I th i i f t t

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Improve their infrastructure

● Operations (e.g. billing)

● Electronic health records

● Compliance

Developing a competent workforce including use of peers or recovery coaches

BH provider adoption/implementation of EHRs

EHR standards and quality measures

STRATEGIC INITIATIVE NO. 5: HEALTH INFORMATION TECHNOLOGY

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EHR standards and quality measures

Privacy/confidentiality issues

Engage state HIT leaders

Prevent homelessness

Create permanent stable housing

STRATEGIC INITIATIVE NO. 6: HOUSING & HOMELESSNESS

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Implement supportive housing services

Focus on families and persons who are experiencing chronic homelessness

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Integrated approach – single SAMHSA data platform

Common data requirements for states to improve quality and outcomes● Trauma and military families

STRATEGIC INITIATIVE NO. 7:DATA, QUALITY, AND OUTCOMES


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● Prevention billing codes

● Recovery measures

Common evaluation and service system research framework● For SAMHSA programs

● Working with researchers to move findings to practice

● Improvement of NREPP as registry for EBPs

SAMHSA COLLECTS AND REPORTS

General population data

State level data

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Community level data

Program level data

Treatment services data

Emergency departments and mortality data

INFORMATION IN…

National Survey on Drug Use and Health (NSDUH)

Drug Abuse Warning Network (DAWN)

Drug and Alcohol Services Information System (DASIS)

Treatment Episode Data Set (TEDS)

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Treatment Episode Data Set (TEDS)

National Survey of Substance Abuse Treatment Services (N‐SSATS)

Alcohol and Drug Services Study (ADSS)

Drug Services Research Survey (DSRS)

CSAT Substance Abuse Information System (SAIS)

CMHS TRACS and CSAP Prevention Data System

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INFORMATION OUT…

Substance Abuse & Mental Health Data Archive (SAMHDA)

SAMHSA Office of Applied Studies (OAS) Reports

SAMHSA’s National Clearinghouses (NCADI & NMHIC)

S b Ab T F ili L

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Substance Abuse Treatment Facility Locator

NREPP – National Registry of Evidence‐based Programs and Practices (164 current interventions)

EBP Toolkits

Knowledge Application Programs (KAP)

Treatment Improvement Protocols (TIPs)

Understanding of and access to services

Cohesive SAMHSA identity

● SAMHSA branding

● Consolidation of websites

STRATEGIC INITIATIVE NO. 8: PUBLIC AWARENESS AND SUPPORT

SAMHSA’s 10 Strategic Initiatives

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● Consolidation of websites

● Common fact sheets

● Single 800 #

Consistent messages – communications plan for initiatives

● Use of social media

Tools to improve policy and practice

↑Social inclusion and ↓discrimination

People

● Stay focused on the goal

Partnership

SAMHSA PRINCIPLES

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Partnership

● Cannot do it alone

Performance

● Make a measurable difference

pam hyde samhsa

Health & Medicine