Access to Best Practices for Co-Occurring Disorders: Research and Practice Partnerships

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Access to Best Practices for Co-Occurring
Disorders Research and Practice Partnerships
Constance Weisner, DrPH, MSWStacy Sterling, MSW,
MPHSujaya Parthasarathy, PhDJennifer Mertens,
MACharlie Moore, MD, MBA University of
California at San Francisco and Division of
Research, Northern California Kaiser
PermanenteConference 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
Treatment, and Robert Wood Johnson Foundation
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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

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Sources of Research Questions Research
literature Policy issues Clinical concerns
Generates research intervention study
Intervention evaluated

• Health Plan
• Clinicians
• Program (CD MH)
• Primary Care
• Consumers
• Purchasers/employers
• Accreditation bodies
• Health policy

Program change implemented
Stakeholder concerns shape implementation
Sterling Weisner, (2002) Closing the Loop A
Model to Address the Transfer of Research to
Practice
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OVERVIEW

• Importance of access
• Screening, assessment, and integrated
  services
• Conceptual model and application

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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)

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Setting
Kaiser Permanente Medical Care Programof
Northern California
Sacramento

• Non-profit, group practice prepaid HMO
• 3.2 million members (35 of commercially insured
  population)
• Carved-in psychiatry and chemical dependency
  services

• Vacaville

• Vallejo

• Oakland

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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

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Psychiatric Conditions of Adolescents Entering
CD Treatment (in )
Intakes (419) MatchedControls (2007) p-value
Depression 24.0 0.3 lt.0001
Conduct Disorder with ODD 17.0 0.2 lt.0001
Conduct Disorder 11.0 0.2 lt.0001
ADHD 10.0 0.7 lt.0001
Anxiety 6.4 0.3 lt.0001
Eating Disorders 1.2 0.1 lt.01
1 Psychiatric Conditions 37.0 2.0 lt.0001
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ARE PSYCHIATRIC SERVICES RELATED TO OUTCOME?
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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.

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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
• Plt.05
• Controlling for age, gender, type of
  dependence, abstinence goal, readmission, of
  12-step meetings, recovery-oriented social
  support, treatment intensity

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Are Medical Services Related to Outcome?
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An Adult Example CD Patients and Matched
Health Plan Members Medical Conditions
CD Patients (N747) Matched Members (N3,690)
Injury and Overdoses 25.6 12.1
Lower Back Pain 11.2 5.8
Headache 9.2 3.8
Hypertension 7.2 3.4
Asthma 6.8 2.6
Acid-related Disorders 5.5 2.1
Arthritis 3.9 1.3
all plt.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.
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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.

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Medical Costs 12 Months after Treatment for
Randomized CD Patients with Psychiatric Medical
Conditions
plt.05 plt.01
Parthasarathy S, Mertens J, Moore C, Weisner C.
(2003). The utilization and cost impact of
integrating substance abuse treatment and primary
care. Medical Care.
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Sources of Research Questions Research
literature Policy issues Clinical concerns
Generates research intervention study
Intervention evaluated

• Health Plan
• Clinicians
• Program (CD MH)
• Primary Care
• Consumers
• Purchasers/employers
• Accreditation bodies
• Health policy

Program change implemented
Stakeholder concerns shape implementation
Sterling Weisner, (2002)Closing the Loop A
Model to Address the Transfer of Research to
Practice
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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

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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

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COLLABORATORS

• 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

• Kaiser Permanente Clinics
• Oakland
• Sacramento
• San Francisco
• Stockton
• Vacaville
• Vallejo