Erin Hultgren, a Bernstein Fellow and Program Manager at Gaston Family Health Services (GFHS) is currently assisting with a behavioral health initiative that will improve and expand the delivery of substance abuse services and Medication-Assisted Treatment (MAT) to underserved populations with opioid use disorders. This initiative is funded by the Health Resources & Services Administration (HRSA) through their recent Substance Abuse Service Expansion, which awarded a total of $94 million in funding to health centers across the United States. GFHS was one of seven centers in North Carolina and one of 271 centers across 45 states to be awarded.
The additional grant money will enable GFHS to expand behavioral health and substance abuse services to serve its patient panel as well as extending services to both pregnant women and people living with HIV/AIDS and opioid addiction. Through its history of collaborative work with the Gaston County Health Department (GCHD), GFHS will work with GCHD and other community partners to identify pregnant and parenting women and HIV+/AIDS patients who need a more integrated approach to their opioid addiction including primary care, behavioral health, MAT and counseling services. Identification is only the first step. The ultimate goal of GFHS is to not only identify these patients, but also provide them with the integrated care they need to achieve and sustain recovery.
Additionally, GFHS will enhance their existing integrated model by:
Increasing the number of patients screened.
Connecting identified patients to treatment.
Hiring additional behavioral health providers to connect patients with access to MAT treatment.
Providing training and education for providers on best practices for opiate prescription.
Working with patients and community members on the availability and use of opioid antagonists.
As the HIV program manager for GFHS, Erin’s primary role in this initiative is to increase screening and education regarding the availability of testing and treatment for patients with or at risk of HIV/AIDS and Hepatitis C, both associated with opioid use disorders. Erin will work with behavioral health staff to update risk assessments to include questions regarding sexual health, HIV and Hepatitis C risk. Since integration and coordination of services is key to success, Erin will coordinate services between GFHS and health departments in the area to ensure patient’s have access to HIV testing and clinical services regardless of ability to pay. Although she’s new to the work of opioid addiction, she believes that an integrated care approach is the best way to provide support for these substance abuse issues.
“As we move forward, I think collaboration and communicating between partners will be our largest challenge and biggest asset,” she says. “Education will be critical – educating primary care providers, working with ERs, changing protocols, etc. Opioid addiction has far-reaching consequences and it will take all players at the table to conquer this public health crisis.”
For more information about Gaston Family Health services and their unique integrated care approach, visit http://gfhs.info.
The Center of Excellence for Integrated Care (COE) is a program of the Foundation that works with health providers across the state to integrate primary care and behavioral health services. COE’s model of integrated care is well-suited for substance abuse issues, which can harm both the mental and physical well-being of a patient. COE Director Cathy Hudgins says that “integrated care provides those struggling with addiction an opportunity to be treated as a whole person.”
The COE helps organizations develop their ability to provide integrated health care. One of their longstanding partners is Family Service of the Piedmont (FSP) in Guilford County.
The primary care provider for FSP is Anthony Steele. Steele is a nurse practitioner with a certificate in family medicine and psychiatry. He has spent 16 years serving individuals with addiction. He says he’s a “one-stop-shop” for patients because he has the training to address their physical and mental health in one setting. In the time that the COE has been working with FSP, Steele has assisted in building exemplary integrated care services.
We asked Steele a few questions to understand how he uses the integrated care model to help patients suffering from addiction.
When did you realize that you wanted to work with addiction?
I was done with inpatient healthcare. I needed to do something different. When I came in 16 years ago I knew nothing about addiction. But guess who were the best educators? My patients. They were the ones who taught me about the disease. They even taught me how to change my language when speaking to clients. I had to really adjust. Because when you’re looking at a patient and you’re calling him or her an addict, it’s one of those things that just makes them cringe. ‘No, I’m not just an addict. My name is John,’ or, ‘my name is Suzie.’
I also had to work on my perception and how I addressed individuals. I had to look at them as a patient and as a client. This is someone’s son. This is someone’s daughter. This is someone’s brother. In treatment we always want to keep people alive. Every day you see someone alive is a success. Then you work on developing tools to help them stay alive. You work on helping them build resources and you meet them where they are. Within the first month of working with addiction I became engrossed with learning about the disease process and I thought if not me, then who?
What’s encouraging about your work?
When I have a patient come in who’s been using 10 bags of heroin a day and then within a week of treatment, they are looking at me in the eye, they are taking a bath, and they are beginning to see changes in their life. When you see a pregnant mother who’s been using every drug under the sun get stabilized and she’s now able to have a normal labor and delivery. When I see those patients, I know this is where I need to be.
How does integrated care help you serve individuals with addiction?
We look at the whole picture. We do a comprehensive assessment when people come in. We have screening tools that look at depression, anxiety, trauma, addiction history, and physical health issues. When a patient comes in, they have bared their souls to us, and it’s a judgment-free zone. It just makes sense for us to treat the mind, the body, and the soul. If a patient is struggling with opioid addiction, but also high blood pressure and diabetes, I’m not going to ignore those physical issues. I’m not going to send them to another primary care doctor that doesn’t know them or who may prescribe other medications that could get the patient into trouble. It’s important to be mindful of not causing a relapse.
If we don’t begin to address the fragmentation of care, then our opioid addicted individuals will continue to be stigmatized. We need providers that know a patient’s history, won’t judge them, and will meet me where they are. Some of these patients don’t have their basic needs being met. When you add addiction on top of that, their addiction takes precedence over food and shelter. That’s why we help clients get their cravings under control, and then we work on the other aspects of life. Let’s get you gainfully employed. Now let’s work on relationships with your family so you can be supported on that road to recovery. Instead of disconnecting the head from the body, my goal is to connect it all together.
[box type=”bio”] “If we don’t begin to address the framentation of care, then our opioid addicted individuals will continue to be stigmatized.”[/box]
How does addiction tie in with other health issues?
People who have addictions have the same chronic medical issues that anyone else has, but they might be highly elevated because they aren’t typically treated. If you look at most statistics, more than one in five adults have a co-occurring mental health and substance abuse issue. And so it just makes sense to figure out how to treat them in a collaborative perspective.
One thing I’ve noticed is that dental care is much needed and sought after. A patient who’s addicted to opioids, one of their side effects is dry mouth. If you have dry mouth you aren’t producing enough saliva, and then bacteria grows and your teeth decay. But if you’re in active addiction, you’re not going to be worrying about brushing your teeth. It’s a perfect storm for dental problems. If I have dental issues, they effect my self-esteem, and now I have self-doubt, now I’m depressed, now I’m isolated. And it continues that cycle of relapse and recovery, relapse and recovery. Oftentimes our patients are also IV drug users which opens up the risk for Hepatitis C transmission with potentially shared needles. They may not know or have any symptoms, so they keep sharing needles, snorting drugs with dollar bills and having unsafe sex.
Why do you think that integrated care for opioid addiction isn’t more widely used?
Sometimes I think it’s a comfort level. Most medical programs don’t give you a lot of training in substance abuse and mental health. In primary care you maybe get one to two week’s rotation in substance abuse, and that’s it. You’re taking on the responsibility of something you really don’t know much about. And sometimes in primary care, if you don’t ask about addiction, you don’t have to deal with it. Some primary care providers do want to deal with it, but guess what? They are limited in terms of where they can refer patients. The amount of money that’s available for substance abuse treatment compared to all the other diseases is a drop in the bucket. If I’m a primary care provider and I screen for addiction, where can I get this patient into treatment? The hospital is limited and here in Guilford County we only have one in-patient detox facility, which is also limited. I think there might be 15 beds.
In your opinion how do we better address this epidemic?
We’ve got to do a better job with screening and treatment. You really need to meet the patient where they are. But once we screen for it, we also need funding to cover the cost of these patients who need this service. We have to stop ignoring the issue. Because it’s here, and it’s prevalent. Until we take a very hard look at this disease, we are going to continue these vicious cycles of chronic relapse and people dying on the streets. Most people look at it as a character flaw. We in the addiction world know that it’s not. This is a disease of the brain that needs to be dealt with like any other disease. You don’t tell your diabetic, ‘you’re obese so we aren’t going to treat you.’ No. You work with that patient where they are. Oftentimes with our addicted individuals, we just don’t have that same tolerance.
Psychologist Neftali Serrano remembers when the concept of integrated care—the combination of behavioral health and primary care—clicked with him.
Dr. Serrano was working in a health center, down the hall from the primary care physicians. He only had two or three patients a day. “I was open for business and had no one coming in,” he said.
Out of that futility, he said he started spending time with providers instead of sitting alone in his office. This evolved to walking into exam rooms and working with patients directly.
“Within 30 seconds, patients were opening up about their behavioral health issues and getting to things that would usually take hour long visits or even a series of visits,” said Serrano.
Dr. Serrano said he connected faster to patients in a primary care setting. “They trusted their primary care doctors and they extended that trust to me,” he said.
Dr. Serrano now works with the Center of Excellence for Integrated Care, a program of the Foundation that trains health care professionals and providers to treat behavioral and physical health in one setting.
[box type=”bio”] “They trusted their primary care doctors and they extended that trust to me.”[/box]
Integrated care can work especially well among the aging population. Two out of three Americans aged 65 and over have chronic illnesses, which are often coupled with mental health distress. The Centers for Disease Control and Prevention estimates that 20 percent of adults over 55 have a mental health concern. Decreased mobility, isolation and health complications can cause anxiety, depression, and severe cognitive impairment among our aging community members.
Integrated care can offer older adults a safe place to get help with these behavioral health issues.
“Some older adults are not as willing or able to go outside the walls of a primary care office to see a therapist,”” said Dr. Serrano. “Having a behavioral health consultant right there is a more culturally appropriate way to deliver care for folks who are more comfortable with primary care.”
[box type=”bio”] Integrated Care can offer older adults a safe place to get help with behavioral health issues.[/box]
Initial research trials among the elderly combined psychiatric therapy with primary care, and proved to be very successful, said Dr. Serrano. For example, cardiovascular health, a common concern for the elderly, can improve by treating depression. “There are clear links between heart health and depression,” said Dr. Serrano.
Another advantage of integrated care is the free flow of patient information. The patient’s medical history is on hand, and can better inform the behavioral therapist, instead of having to start from the beginning with every patient.
Integrated care can also help primary care physicians make better assessments for their patients. For example, depression is often masked by physical health issues. Patients with vague pain may be suffering from isolation or loneliness.
“Oftentimes primary care doctors will do a whole lot of work to address the physical problems but fail to address the root issues,” said Dr. Serrano.
There is also a certain threshold a patient must meet for referral to a mental health therapist. Many people that need behavioral health assistance may not have acute behavioral health issues, but would benefit from the input of a therapist in their primary care office.
Dr. Serrano said it will take a lot of broad training across specializations to prepare the medical profession for an older population. Mental health professionals in particular, according to Dr. Serrano, will need to reconfigure their mindset and work-flow. “Mental health professionals are more accustomed to sitting in an office by themselves than working on a team,” he said.
The Center of Excellence for Integrated Care (COE), a program of the Foundation, helps providers make this adjustment. They have practical training programs on all aspects of integrating the silos of behavioral health and primary care in any setting where health care is delivered. COE is also dedicated to reducing the stigma associated with behavioral health issues. Accessing therapy through a primary care doctor can help reduce any discomfort of feeling of shame about needing help. The integrated approach to elderly care is important to recognize and replicate as our population continues to age.
Most healthcare providers agree that mental health affects physical health and vice versa. However, integrating the two is not easy. Providers aren’t trained to address both the mind and the body in one setting. As we transition towards value-based reimbursement, there’s a greater incentive to improve quality for patients. The Center of Excellence for Integrated Care (COE) is an example of a creative approach to improving patient outcomes.
The imminent changes to our healthcare system will result in a workforce that operates differently—and that’s where COE steps in. Housed in the NCFAHP, this small team provides the tools and training for integrating mental and physical health. “And we have our eyes on oral health specialists and pharmacists too.” says Associate Director Christine Borst.
The COE team works in a broad range of settings, and not just traditional healthcare sites. “North Carolina is one of the most diverse states in the nation when it comes to putting teams together to meet the patient where they seek services,” says Director Cathy Hudgins, “This can be a school-based clinic, a mental health or substance abuse clinic, homeless shelters, migrant worker camps and church basements.”
COE breaks down the cultural and educational barriers between health sectors. This type of workforce development, dubbed cross-training, is crucial to better patient outcomes. “It’s been exciting to work with universities,” said Borst, “Conducting trainings early on is really helpful for developing that multidisciplinary lens.”
In a healthcare practice with established workflows, cross-training requires a colossal team effort. “We work with everyone in the office, from the front desk ‘eyes and ears’ of the clinic, to the physicians and therapists in the back,” said Borst, “Regardless of what kind of specialist you are, it’s essential to work together as a team and develop a mindset of integration.”
Every care site is different. Some have a behavioral health therapist in-house; others have close connections to one. Some have no partnerships or experience with behavioral health. Borst gave the example of smoking cessation or diabetes diagnosis. “These issues really require a behavioral health intervention,” she said, “And not every clinic has the resources to provide that.” Tailoring training to meet the needs of a care setting is part of COE’s work. Every practice and every community has its assets, and COE works to create partnerships around those assets.
The biggest hurdle for integrating care is payment reform. “Everyone wants to know how to pay for it,” said Borst. COE provides some direction on navigating the billing process, but it will take policy reform to dictate how behavioral health integration will be properly reimbursed.
Effective workforce training to integrate the siloes of care is an important step towards fully implementing value-based care. “There’s a method to our madness,” Borst said, “Laying a strong foundation for a multidisciplinary approach is the first step.”