The Valley Specialty Center – part of the Santa Clara Valley Health & Hospital System

Santa Clara Valley Health and Hospital System

Department of Alcohol & Drug Services

Integrated Care Projects Update

Santa Clara County—Quick Facts• Population: 1.8 million (larger than SF)

White 37%Asian 30%Hispanic 26%Black 3%

• Foreign Born: 40% (One of 10 U.S. counties where more than 50% of residents speak a language other than English at home)

• Income: $75K median, 10th in US, but . . . .

< $25K 13%$25-45K 15%$45-100K 37%> $100K 35%

28% of families earn less than local poverty threshold

Governance and Organization

ValleyMedicalCenter

Drug &Alcohol

PublicHealth

MentalHealth

ValleyHealthPlan

Voters

Board of Supervisors

Health and Hospital Committee

Santa Clara Valley Health and Hospital System

Department in Santa Clara Valley Health and Hospital System

Safety-net system for County of Santa Clara VMC has 574 licensed beds 9 Valley Health Center Clinics 3 Urgent Care Clinics 17 Network Neighborhood Clinics

One in four Santa Clara County Residents are served by SCVMC

Greater than 220,000 unduplicated patient count (increase of 60% in 10 years)

Busy Emergency Department (24 beds) seeing 70,000 visits

700,000 Ambulatory Clinic visits yearly

Two projects were initiated in 2010 that incorporated the core components of screening, brief intervention treatment, and referral (SBIRT). Moorpark Medical Home: A pilot project within one of three similar primary care settings that will demonstrate that when substance abuse services are integrated with primary medical care both medical and substance use outcomes are improved.

Alexian Integrated Care Project: Integrate the DADS addiction medicine division with the Valley Health Homeless primary care program at Alexian. DADS is also planning to conduct pilot studies on an array of various addiction medicines in addition to those being used for opioid addiction. These would include naltrexone, acamprosate, odansetron, topiramate, and disulfiram.

Project GoalsAs a result of both initiatives, DADS is planning to see: 1) medical and substance use problems both show better

improvements when treated in an integrated way; 2) patient compliance with their medical care plan and

substance abuse treatment plan will improve; 3) a decrease in over-utilization of limited medical

services; and 4) demonstrated cost offsets and savings through the

health system as a result

Partnership Development Process

Moorpark Medical Home • Regular planning meetings were held in order to co-develop

the logistics with medical clinical staff.• Screener form development processes occurred to integrate

into the medical system• Securing permanent office space for the addiction specialist• Selection of a screening test and a substantial training for the

medical staff on the importance of routine screening for SUDs in all patients. CAGE-AID is the screening tool being used.

• Addressing 42 CFR issues that can impede integration

CAGE-AID QUESTIONNAIRE Patient Name _____________________________ Date of Visit __________________

When thinking about drug use, including illegal drug use and the use of prescription drugs other than prescribed,

QuestionsYes No

 Have you ever felt you ought to cut down on your drinking or drug use?

Have people annoyed you by criticizing your drinking or drug use? Have you felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?  

Reviewed By: _____________________________ Date: __________________

Disposition:

Moorpark Patient Flow Through Primary Care and Referral

SCREENINGAdministering the CAGE-AID:Screen all patients for SUDs using the CAGE-AID. Patients can self administer the screen, although be mindful of language/reading concerns. Offer assistance.Inform patients that this is now being asked of all patients in order to help accomplish their healthcare goalsPlace completed screen in patient chart for physician review in exam room

CAGE-AID Action Steps: Physician reviews results of positive screen with pt and clarify/confirm quantity, frequency, and duration of use.

Patient education about use and medical dxExplain how health problems can be caused by or exacerbated by drug/EtOH use.

Monitor and review use patterns at f/u visits

Score 2: Probable SUDs or at-risk use.Physician reviews and discusses w/ pt and

refers for assessment

Assessment and ASAM level of care (LOC) placement. If LOC 0.5 - 1.0, use brief intervention/brief tx on site at Moorpark

If LOC > 1, consider referral to DADS system of care

Score 1: Possible SUD.Physician reviews and discusses w/ pt

Score >2: Suspected high SUDs.Physician reviews and discusses w/ pt and

refers for assessment

Brief Intervention/Brief Tx (ASAM 0.5—1.0)

At-risk use unchanged or

increasing, refer for

Refer to treatment admission in DADS

(ASAM > 1)Pt refuses treatment

Continued follow-up and relapse prevention for SUDs

Successful brief intervention (may need to be repeated as circumstances change).

Brief intervention unsuccessful

Motivation interviewing and watchful waiting

MOORPARK DADS REFERRAL FORM  Pt alt contact #______________ CAGE-AID score____________ Referring physician (please print)_________________________ Date of referral______________ PCP (if different from referring provider above):_________________________________________ Referring Clinic:______ Moorpark Care Team Reason for Referral (check all that apply): ___Worsening of patient’s medical condition (s) due to ongoing substance abuse ___Difficulty adhering to treatment plan due to substance or prescription abuse ___New relapse/near-relapse of substance abuse, request help connecting to programs ___Obtain prior and/or current treatment plan from substance abuse program ___Request assistance communicating with treatment program ___Other: Chronic conditions:   Current meds (list here or attach printout from ELMR):   FAX TO DADS LCSW:_ For DADS use: Please circle: Date form rcvd:___/____/____Y N DADS release form attached 1st attempt contact pt__/__/___

2nd attempt contact pt_ _/__/__

  

Outcomes

Moorpark Medical Home DADS established a data dashboard to document outcomes compared to the non-medical home settings.

Measures include: # of patients, % SUD screened, % assessed and diagnosed, % received patient education and brief intervention, % referred to DADS for treatment, % referred to the continuous recovery model post treatment and the number active in post treatment. Preventative Care and Patient Satisfaction will also be measured.

SANTA CLARA COUNTY DEPARTMENT OF ALCOHOL & DRUG SERVICES DASHBOARD

Data collected continuously but reported on a quarterly basis Bi-monthly Report # ____ From ______ to ______

CLINICAL QUALITY: Addiction Care Preventive Care • # of pts Tobacco education

• % screened for SUDs Information given pts • % referred for assessment TB test• % pt education or Brief Intervention • # Referral to SUD tx

PATIENT EXPERIENCE: Patient Satisfaction• Pt satisfaction survey: Overall quality of care - % rated as “excellent”• Chronic disease Self-Efficacy Scales

Partnership Development Process

Alexian Integrated Care Project • Regular planning meetings were held in order to co-

develop the logistics with medical clinical staff.• Addressing 42 CFR issues that can impede

integration• Minor construction needed to assist integrating both

programs and an increase in patient capacity

  

Outcomes

Alexian Integrated Care Project Based in part on the Primary Care Behavioral Health model, the Alexian Health Clinic is a fully integrated model where behavioral health is a routine part of the medical care.

Effective collaboration for the Alexian Health Clinic and the Valley Health Homeless Project (VHHP) will improve the quality of care for patients of both programs and will include:• Increased accessibility to needed care through patient referrals

(i.e. methadone patients needing primary medical care , VHHP Suboxone patients needing transition to methadone, etc.);

• Consultations by Addiction Medicine staff with VHHP and vice versa to patients in common;

  

Outcomes

Alexian Integrated Care Project • In-service trainings on addiction medicine including screening,

MI and addiction clinical practice;• VHHP/AMT participation in regular case conference meetings

(42 CFR federal confidentiality guidelines restrictions would apply);

• Patient education series on substance abuse, co-occurring medical conditions, preventive health care, and medical comorbidities provided;

• VHHP representative in weekly AMT clinic management team

  

Barriers

Moorpark Medical Home • Time and place to conduct screening and brief intervention is

problematic. • MDs can’t do the full SBIRT, but they can do SRT (screening, referral to

treatment). Therefore, it is essential to bring in support behavioral health staff to conduct the pieces in between.

• To save some time, patients can complete the CAGE-AID on their own and the MD can review it with them during the exam.

• There are no data fields to capture patient information for SUDs in current medical databases. 42 CFR can be a barrier to accomplish this.

• During the process of selecting or modifying electronic medical records, and/or modifying procedures stay compliant with privacy regulations, it is important to manually collect data as soon as possible.

• Selecting the data measures and collecting data remains challenging (both projects)

Plans for Sustainability

Moorpark Medical Home and the Alexian Integrated Care Project

1) Test out a billing system using LCSW staff who can bill FQHC for Medi-Cal clients.  This is a very high reimbursement rate that may support the full cost of the SUD staff. 

2) If cost savings can be identified as a result of integrating and treating SUDs, such as reduction in hospitalizations or use of ED for medical care, this would help justify the investment in Tx of SUDs.  

3) Integration, if successful, identifies that primary care settings are the appropriate place to identify and initiate treatment for SUDs, and this will shift responsibility to the primary care system, thus increasing the likelihood that the services will continue.  If they see value, and recognize their responsibility, they may decide they own it.  

4) As we get increased Medi-Cal reimbursement from the MCE waiver, and ultimately from health care reform in 2014, the SUD services may have their own reimbursement stream.

Project Contacts:

Mark Stanford, Ph.D. Division Director DADS Addiction Medicine Division(408) 885-4078

Kakoli Banarjee, Ph.D. DADS research and Development(408) 792-5683