Integrating Mental Health and Substance Abuse Care With HIV/AIDS Prevention. John Anderson, PhD Bob Bongiovanni, MA Leigh Fischer, MPH Jeff Basinger

Transcription

1 Integrating Mental Health and Substance Abuse Care With HIV/AIDS Prevention John Anderson, PhD Bob Bongiovanni, MA Leigh Fischer, MPH Jeff Basinger

2 Who Am I and Where do I work? John Anderson, PhD Senior Director APA Office on AIDS What is APA? What is the BSSV Program?

3 Goals of this Presentation Explain why it is critical to address mental health and substance abuse issues of participants in HIV prevention programs Describe how the state of Colorado addressed these issues from the perspective of the health department, a capacity-building assistance (CBA) provider, and a community-based HIV/AIDS service organization Provide a broad overview of critical steps that community-based organizations (CBOs) can take to address mental health and substance abuse issues Inform you about where you can go for technical assistance and training in this area.

4 Scope of the Problem HIV Cost & Services Utilization (HCSUS) Study - Bing & colleagues (2001) examined mental health and substance abuse in a nationally representative probability sample of adults receiving HIV care. Identified those who screened positive for mental health or substance abuse disorders in the past 12 months. Nearly 50% screened positive for MH disorder. Nearly 40% reported illicit drug use other than marijuana. More than 12% screened positive for drug dependence. Bing, E.G., Burnam, A., Longshore, D., Fleishman, S.A., Sherbourne, C.D., & Shapiro, M. (2001). Psychiatric disorders and drug use among HIV-infected adults in the United States. Arch Gen Psych, 58,

5 Comparison with Other National Samples Bing, E.G., Burnam, A., Longshore, D., Fleishman, S.A., Sherbourne, C.D., & Shapiro, M. (2001). Psychiatric disorders and drug use among HIV-infected adults in the United States. Arch Gen Psych, 58,

6 So WHY does this matter? Increased HIV risk behaviors. Inadequate engagement of health care services. Poor adherence to treatment regimens. Negative impact on quality of life. Intervention programs are unlikely to work unless these problems are addressed.

7 Bob Bongiovanni, MA Current Job Manager of HIV Care and Treatment (Part B) for Colorado Previously served as HIV Prevention Manager

8 How should a public health department integrate HIV and substance use services? Colorado has been moving toward an integrated model since The public health approach to behavioral health is unfamiliar in the U.S. Long held assumptions must be confronted. HIV service providers can and should screen and intervene early.

9 A Public Health Approach to Behavioral Health Public Health Approach Target populations or at risk groups; prioritize broad threats to public health (such as HIV transmission). Intervene at the earliest opportunity. Provide the least intensive intervention necessary to prevent problems or reverse problems while they are sub clinical. Mostly delivered by trained health educators. Settings convenient to the clients. Facilitate help seeking behaviors. Clinical Approach Clients must seek out services on their own; prioritize clients with the most severe diagnoses. Provide care based on diagnoses. Match the intensity of the service to the severity of the diagnosis. In general, more is better than less. Mostly delivered by credentialed professionals. Health care settings. Rely on the severity of the problem or court order to motivate clients into care. Tucker, J, Donovon, D., and Marlatt, G. Changing Addictive Behaviors: Bridging Clinical and Public Health Strategies New York: Guilford Press. Page 11.

10 The Challenge of Flawed Assumptions The major substance abuse issue associated with HIV risk is injection drug use. Mental illness and substance use are relatively rare among PLWH/A and those at risk. PLWH/A and at risk persons need to bottom out before they will seek help. The solution is a referral to clinical services. Substance use is part of gay life. People with mental health or substance use problems are adequately served by standard HIV prevention and care strategies.

11 The Reality Considering the prevalence of behavioral health problems among PLWH/A and those at risk, IDU is the tip of the HIV risk iceberg. There are evidence based strategies to encourage help seeking, long before bottoming out. Behavioral screening and early intervention models are appropriate for HIV settings (such as SBIRT).

12 The Colorado Experience Developed and implemented a training for all contractors and other interested agencies. Integrated mental health and substance use screening questions in individual level interventions. Released funding to integrate screening, brief intervention and referral to treatment into eight different HIV care and treatment settings. Plan to expand SBIRT into more HIV prevention settings.

13 Leigh Fischer, MPH Program Manager SBIRT Colorado Peer Assistance Services What is SBIRT Colorado? Peer Assistance Services, Inc.

14 What is SBIRT? Screening: To identify people at risk for a condition that wouldn t otherwise be detected Brief Intervention: Short motivational conversation for those who screen positive Referral to Treatment: For those who have more serious problems

15 Source: SAMHSA (2006). Results from the 2005 National Survey on Drug Use and Health.

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17 Brief Intervention Brief conversation focused on behavior change Education about risk Motivational interviewing techniques Goal setting is key component

18 Payer Code Description Fee Commercial CPT Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 CPT Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51 Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42 G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69 Medicaid H0049 Alcohol and/or drug screening $24.00 H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

19 6 infectious disease clinics Data Collected 2 AIDS Services Organizations 2,500 clients screened 46% = no/low risk 17% = brief intervention for alcohol/drug 14% = brief intervention for tobacco 23% = referral to therapy or treatment Source: Peer Assistance Services, Inc. (2010). Data collected from Ryan White/SBIRT Collaborative Project sites: June 2008 March 2010.

20 Successes Improved, systematic service delivery Stronger relationships with clients Greater collaboration and communication among staff Increased attention to tobacco use Decrease in use and increase in treatment Source: OMNI Institute (2010). Evaluation of SBIRT Implementation in Colorado HIV Clinics and Community Organizations.

21 Client Perspectives Positive = moderate risk or higher on SBIRT screening Negative = low or no risk on SBIRT screening Source: OMNI Institute (2010). Evaluation of SBIRT Implementation in Colorado HIV Clinics and Community Organizations.

22 Build buy-in Recommendations I thought I knew Establish clear processes and protocols Bridge communication with referral resources Integrate with retention and adherence efforts Source: OMNI Institute (2010). Evaluation of SBIRT Implementation in Colorado HIV Clinics and Community Organizations.

23 Jeff Basinger Executive Director, NCAP Northern Colorado AIDS Project, Fort Collins, CO The Ryan White Regional Service Provider serving 8 counties of north east Colorado with medical case management for PLWH/A; HIV/HCV prevention and testing; MH counseling and SBIRT screenings.

24 Goals for MH/SA Services: Address disproportionate rates of substance use and mental health issues among HIV+ populations, and those at highest risk of acquiring HIV when resources allow. Incorporate Early Intervention Services. Provide yearly SA screenings for case management clients with medical case managers doing pre screenings and referring those needing interventions to SBIRT. Integrate SA and MH programs by streamlining process with medical case management and referrals to MH/SA services. Improve health outcomes, and reduce HIV infections.

25 The Beginnings: Conversations in 2007 between NCAP and CDPHE were beginning to address the gap in MH/SA services in ASOs. Using Interim Mental Health Standards from CDPHE, NCAP secured private funding to launch MH services. NCAP collaborated with Mapleton Mental Health Center at the Boulder Community Hospital for clinical supervision. In 2008 CDPHE allocated Ryan White funding to MH/SA services and NCAP piloted SBIRT and continued MH services. In 2009 MH/SA services were combined into one Behavioral Health contract with Ryan White funding from CDPHE.

26 Surprises! Getting SBIRT Health Educator aligned with medical case management, prevention and counseling services. Getting all of staff aligned with SBIRT and counseling services. How to collect and report data in systems not built to collect this information. Moving clients perception of these services from wariness to acceptance and being beneficial. Funding for care and treatment of PLWHA supports these services, yet there isn t support for prevention funding.

27 MH/SA Services at NCAP Today: All medical case management clients receive annual SBIRT screenings and CDQ. Brief interventions and referrals to treatment are provided as needed. More integration and efficiency between SA and MH services. More communication and collaboration with other systems/closer connections with community. Improved individual client outcomes and tracking. Evaluation of efficacy of MH/SA services in an ASO setting with client satisfaction tools and better data collection.

28 Tips: Have the internal capacity, space, qualified staff and standards of practice. Your procedures need to remain malleable as changes are to be expected. Identify other resources as partners to ease the burden on a fledgling program. Have a strong referral network. Have a plan for tracking/evaluating the program before implementing. It is ok to start a program without having all the pieces in place at the beginning.

29 Important to Remember that Mental Health and Substance Abuse Problems Exist Along a Continuum Higher Distress Lower Mental & Substance Use Disorders Health

30 Integrative Triage Model Screening Leads to more in-depth assessment and intervention Brief Intervention Raise awareness & motivate client to acknowledge issues Brief Treatment Psychoeducational, self-management & skills-building interventions for less serious clients Referral For those with more serious problems

31 Screening and Referral Sounds Simple Enough People don t want to be labeled as crazy so they under report symptoms. I could not put my family through another painful event It would kill my mama HIV was bad enough.. Now I had mental problems I felt horrible all the time Ms. Alfonso, she asked the right questions.getting treated for my depression changed my life. 28 year old Hispanic woman, South Florida

32 Screening Instruments Substance Abuse and Mental Illness Symptoms Screener (SAMISS) A 16 question instrument developed from existing reliable and valid scales. Easily administered and it screens for both mental illness symptoms and substance use problems. Client Diagnostic Questionnaire (CDQ) Designed specifically to assess depression, anxiety, PTSD & substance abuse. Separate modules, one for each disorder. Each module starts with 1 2 questions determining initial criteria. If initial symptoms are affirmed, further questions are asked within the diagnostic category. Takes 15 to 20 minutes. More information is available at:

33 What s Next? Discuss the findings Explore the level of distress Raise awareness & motivate client to acknowledge issues Who gets referred for what kind of treatment? Frame the benefits of treatment

34 Mental Health Resources (

35 Substance Abuse Treatment Resources (

36 Clinical Guidelines for Mental Health & HIV/AIDS NY State Department of Health Depression Anxiety Neurocognitive Disorders Seriously Mentally Ill Suicidality and Violence Trauma and PTSD

37 Mental Health & Substance Abuse Service Referrals: Steps to Reduce Structural Barriers Develop and maintain referral resource guide. Nurture strong working relationships with the agencies providing the services. Identify key contacts from these agencies. Have formal written agreements to outline the roles and responsibilities of each agency. Track referrals made and completed. Identify and address barriers to successful referrals initially and on ongoing basis.

38 For Information About Technical Assistance and Training: BSSV Program American Psychological Association 750 First Street, NE Washington, D.C Phone: Fax: