Evaluation, Training, and Technical Assistance for Substance Use Disorder Services Integration (ETTA)

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1 Evauatio, Traii, a Tchica Assistac or Substac Us Disorr Srvics Itratio (ETTA) 2013 Rport Darr Uraa, Ph.D., Vari P. Atoii, M.P.H., Bray Osr, M.P.H., Chry Truya, Ph.D., Eis Tra, B.A., Jry J. Ao, M.A., MIS/M., Ka Darr, B.A., Dio Rairz, B.A., Jssica Haa, B.S., Richar A. Rawso, Ph.D. UCLA Itrat Substac Abus Proras Prpar or th Dpartt o Hath Car Srvics Caioria Hath a Hua Srvics Acy Uivrsity o Caioria, Los As, Itrat Substac Abus Proras

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3 Tab o Cotts Excutiv Suary...1 Prac...5 Chaptr 1: Data Aaysis: Urstai th Chai Fi o SUD Srvics...9 Chaptr 2: Hath Car Ror a th Itratio o SUD Srvics with Mta Hath a Priary Car...31 Chaptr 3: Stratic Pai or Wororc Dvopt: Prpari th AOD Wororc or 2014 a Byo Chaptr 4: Traii a Tchica Assistac Activitis Chaptr 5: Rport Cocusios a Rcoatios Appics...165

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5 Excutiv Suary Chaptr 1: Srvics Data Aaysis: Urstai th Chai Fi o SUD Th icras covra o substac us isorr (SUD) srvics as part o ow-ico hath proras at to prpar Caioria or hath car ror i ot a to icras cooriatio btw hath car a spciaty car srvics i th or o rrras. By xtsio, it ay b assu that th 2014 Mi-Ca xpasio a hac SUD bit ay ot, o thir ow, rsut i bttr cooriatio. Rathr, partrships to b activy pursu. Currty, a rativy sa ubr o proras hav stabish such partrships. Patits rrr ro hath car to spciaty SUD tratt t to b Whit, a, a tri toxiicatio or acoho us. Fa a Hispaic patits ar urrprst. Data o AB 109 cits (ors who ar bi trasrr ro th stat priso syst to couty systs) is spars a o qustioab accuracy, but thir ubrs appar to b risi rapiy. Itii AB 109 cits t to b a, upoy, a thaphtai usrs. Vry ow rot o AB 109 cits i Mi-Ca is o particuar cocr. Bits shou b susp uri icarcratio rathr tha triat to avoi aps i covra, a Mi-Ca outrach a rot orts shou b tart at soo-to-b ras iats. Data Iicator Rports or outpatit a thao-aitac prorac asurt hav b poy. Dvopt o asurs or rsitia tratt a toxiicatio ar bi cosir i th utur. Dru Mi-Ca ata a CaOMS-Tx tratt ata ca pottiay b prouctivy us to pror prorac asurt, itiicatio o SUD hot spots, cost aayss, a rau tctio. Chaptr 2: Hath Car Ror a th Itratio o SUD Srvics with Mta Hath a Priary Car I orr to vauat a assist with Caioria s orts to itrat SUD, ta hath (MH), a priary car srvics, ioratio was coct throuh itratur rviws, wbiars, corcs, a cosutatios with stahors a itratio xprts. Withi th stat, UCLA couct survys, ocus roups, a vauatios o itratio piot iitiativs; aciitat othy tis o th Caioria Itratio Lari Coaborativ; a att othr ari coaborativs i our orts to athr a shar th ost currt rsourcs o itratio. Fro ths activitis, w hav ocut coo barrirs a aciitators, as w as y ssos ar ro coutis throuhout th stat. Th i has a prorss i vopi toos a shar soutios or supporti itratio. Currt stratis or achivi itratio icu vic-bas practics (such as scri, bri itrvtio, a rrra to tratt Excutiv Suary 1

6 [SBIRT] a icatio-assist tratt [MAT]), w oraizatioa os, a via iovatios with tchooy. Proisi os a practics cotiu to r, but urthr rsarch is to tri whthr ths approachs ca iprov quaity a outcos, whi ctivy ruci costs. Barrirs prsist with rar to hath car ror iptatio, spciicay ao patit/cosur coitiaity a ata shari practics, ctroic hath rcors (EHR) iptatio, wororc vopt s, iaci itrat srvics. Thr is currty a trous opportuity at ha i which to r-vauat currt poicis a ruatios that cou hac a bttr aciitat a itrat hath car syst i Caioria. Ao coutis wori o itratio, practics a ui stratis vari. Lssos ar ro coutis ar hihiht i this chaptr. Cutivati ratioships ao itratio partrs, ivri stro arship, a achivi sta buy-i wr iportat actors i th succss o svra iitiativs. Thr cotius to b hih itrst i or traii throuhout th stat. A rat a o wor rais aha across th ras o poicy, rsarch, traii, a tchica assistac. Rcoatios at th poicy v to ss th ubr o pottia iicutis provirs ac icu: Dru Mi-Ca crtiicatio xpasio to icu priary car provirs (PCPs), iti th rstrictio o sa-ay physica a bhaviora Mi-Ca srvic bii, aowi crtiicatio o rasoaby siz rsitia aciitis or Mi-Ca riburst, a aowi PCPs to b pac i rsitia tratt proras. I aitio to cotiu ivstt i rsarch, traii, a tchica assistac, urthr rcoatios icu cotiui ivovt i coaborativ orts a piot projcts. Chaptr 3: Stratic Pai or Wororc Dvopt: Prpari th Acoho a Dru (AOD) Wororc or 2014 a Byo As SUD a MH itratio orts ro out i Caioria, it is car that th wororc wi rquir a broa a ivrs st o sis. As SUD itratio ur hath car ror is sti vovi, th wororc cssary to ipt SUD srvics outsi o th spciaty syst rais ucar. Th oa is to prpar our currt AOD wororc or th typs o sttis a practic chas that wi occur i SUD tratt ivry, icui chas i rcovry a prvtio srvics brouht orth by hath car ror. Rcoatios icu: 1. A cocrt wororc pai ort shou b iitiat i which y stahors a wororc xprts wor i cocrt with th Dpartt o Labor Wororc Ivstt Boar (WIB). 2. A sris o tis shou b cov to provi a oru or a rviw o th critica issus that wi tri SUD wororc s as w as iscussios a pa vopt. 3. A trasitio pa shou b crat to stabish a cousor crtiicatio irastructur i which thr is a si cousor crtiicatio/ics aiistr by th Stat o Caioria. 4. Th SAMHSA carr ar or SUD cousi shou b ipt i Caioria. 2 Excutiv Suary

7 5. Th stat shou xpa xisti traii a tchica assistac srvics to sur that th SUD wororc vops capacity i aras that ar critica to provii coprhsiv a vic-bas SUD tratt. Ths activitis shou b si to prpar two istict wororcs o that wi cotiu to wor as SUD provirs i spciaty tratt sttis a aothr that wi vov ito Itrat Bhaviora Hath (IBH) provirs i ica sttis. Chaptr 4 - Traii a Tchica Assistac Ovr th past yar, UCLA provi traiis a tchica assistac to aciitat itratio across th stat. This icu i-prso traiis, wbiars, tchica assistac to coutis, a tchica assistac or th Caioria Istitut or Mta Hath s Car Itratio Coaborativ. Traii a tchica assistac s rat to itratio prsist throuhout th stat. Cocusios Th ssos ar throuhout this rport support a coo cocusio: O thir ow, th uch-aticipat hac SUD bits a xpa isur popuatio i 2014 wi ot sur aquat SUD tratt capacity or itratio. I a ubr o barrirs ar ot ovrco, th hac SUD bits wi ot b us to thir pottia. Both th CMSP/Path2Hath a LIHP xprics sust that ay tratt proras currty ac th irastructur a sta traii to bi Mi-Ca a isurac. Furthror, th CMSP/Path2Hath xpric ostrat that i th cais procss is prciv as too copicat or uriab, bits ay ot b us. I sar coutis, such as thos srv by CMSP/Path2Hath, th costs o buii a aitaii a bii irastructur ay outwih th payts that ca b obtai by srvi a rativy sa ubr o iiviuas. UCLA s currt CATES traii sris proposs o soutio: th oratio o provir twors to shar th costs o bii irastructur as w as, pottiay, ctroic hath rcors, arti, a othr aiistrativ xpss across ay proras. I priary car, such oraizatios, ow as Maat Srvics Oraizatios (MSOs) or Ipt Practic Associatios (IPAs), ar coo. Itratio aso hos th prois o ai SUD tratt accssib to or patits throuh priary car. Howvr, proras to activy pursu partrships with priary car. As scrib i Chaptr 1, a vry sa ubr o tratt proras currty rciv a outsiz proportio o rrras ro hath car provirs. Ths proras a thir priary car partrs ar ostrati that such partrships ca b succssu, but th ubr o proras that hav ta this stp has, so ar, b iit. Byo rrra arrats, SUD srvics ca aso b itrat ito priary car. A ubr o itratio iitiativs hav r arou th stat to attpt this (s Chaptr 2). Fro Excutiv Suary 3

8 ths ivrs iitiativs, a w cosy rat a rcurri ssos hav r, icui th to ucat sta o th iportac o itratio a to cariy ros, th iportac o havi a chapio physicia to proot itratio, a th to obtai buy-i ao th participats. Ev i ucatio, a chapio, a buy-i ar prst at th rou v, howvr, thr ar ipits to itratio at th poicy v. Ths barrirs icu Mi-Ca rstrictios o sa-ay bii or two srvics (Chaptr 2) a th ac o a aquaty trai wororc whos srvics ca b riburs i priary car sttis (Chaptrs 2 a 3). Without arssi ths probs, actios such as activati SBIRT bii cos wi iy ai to hav th sir ct. To ovrco ths barrirs, traii a tchica assistac wi cotiu to pay a iportat ro i aciitati th i s prorss. To asur this prorss a iprov practics a poicyai, th coctio a us o vai a riab ata wi b critica. I cocusio, Caioria is cotiui to a prorss towar itratio, but urthr prparatios ar sti to prpar th stat or 2014 a byo. 4 Excutiv Suary

9 Prac Darr Uraa, Ph.D. Toay ss tha 11% o iiviuas who substac abus tratt rciv it ro th currt couity-bas spciaty tratt syst (Substac Abus a Mta Hath Srvics Aiistratio, 2012). O oa o hath car ror a rat isatio, 1 is to cha this by tai th tratt o substac us isorrs (SUDs) out o its currt sio a itrati it with th broar hath car syst, which rachs a uch arr portio o th popuatio. As a rsut, th SUD tratt i ow acs th ost siiicat a swpi chas that it has xpric i cas (Havorso, 2010). Itratio with priary car is asib (Erst, Mir, & Roic, 2007; Maras t a., 2009), a proiss bttr outcos or patits (Babor t a., 2007; Butr t a., 2008; Parthasarathy, Mrts, Moor, & Wisr, 2003; Saitz t a., 2003, 2010; Sat, Fria, & Saitz, 2001; Saxo t a., 2006; Wisr t a., 2001; Wibri & Os, 1995, 1999). Such itratio wi aso pay a criticay iportat ro i bi th cost curv o ica xpss. Micai patits with SUD hav ary twic th ica costs o patits without SUD (Boy t a., 2010), but itrat ica a SUD tratt has b show to ruc costs by as uch as 54% ao patits with chroic ica coitios, whi aso iprovi car (Parthasarathy t a., 2001, 2003). At th sa ti that ths hath car chas ar occurri, aothr raatic cha is tai pac i th or o criia justic rait, bttr ow as AB 109, 2 which is ovi owr-v ors ro th stat to th 58 coutis. This is chai th popuatio that s a ss tratt at th couty v. Hath car ror a AB 109 ar ot just two ipt chas, but actors that wi itract. Priiary ata susts that SUDs ar a priary rivr o vioatios i th AB 109 popuatio. Whi ths iiviuas ay b ab to accss SUD srvics or raiy i 2014 u to th Mi-Ca xpasio, this wi oy occur i suicit tratt capacity is avaiab a i ths iiviuas o ot os thir hath car bits as a rsut o icarcratio. This rport, prouc by th UCLA Itrat Substac Abus Proras (rrr to as UCLA i this rport) as part o a itracy art with th Dpartt o Hath Car Srvics (orry th Dpartt o Acoho a Dru Proras), ss to xpor ths issus. Chaptr 1 wi xpor th atst ata o patits tri th spciaty SUD tratt syst ro hath car a AB 109 rrras. It aso proposs xt stps i trs o prorac a outco asurt, a us o ata to ior poicyai. 1 Patit Protctio a Aorab Car Act o 2010 (ACA), th Arica Rcovry a Rivstt Act (ARRA) o 2009 a th Mta Hath Parity a Aictio Equity Act (MHPAEA) o AB 109 rrs to Assby Bi 109, which was pass by th isatur a si by Gov. Brow i Rait isatio copris both AB 109 a AB 117, but th oriia a AB 109 has rai i coo us. Prac 5

10 Chaptr 2 iscusss currt orts to itrat SUDs withi th hath car syst its, both atioay a across th stat. Chaptr 3 iscusss th critica ro that wororc vopt wi pay i suri ivry o appropriat SUD srvics. Chaptr 4 iscusss th traii a tchica assistac activitis UCLA has a i a pas to a i to hp arss th stat s s. Chaptr 5 suarizs y iis a rcoatios ro this rport. For urthr ioratio, s or cotact: Darr Uraa, Ph.D. Pricipa Ivstiator: Evauatio, Traii, a Tchica Assistac (ETTA) Projct UCLA Itrat Substac Abus Proras S Istitut or Nuroscic a Hua Bhavior Sata Moica Bv., Suit 200, Los As, CA [email protected] 6 Prac

11 Rrcs Babor TF, McR BG, Kassbau PA, Griai PL, Ah K, Bray J. (2007). Scri, Bri Itrvtio, a Rrra to Tratt (SBIRT): towar a pubic hath approach to th aat o substac abus. Substac Abus. 28(3):7-30. Butr M, Ka RL, McApi D, Katho, R.G., Fu, S.S., Haor, H., & Wit, T.J. (2008) Itratio o ta hath/substac abus a priary car. Evic Rport / Tchooy Asssst. 173: Erst D, Mir WR, Roic S. (2007). Trati substac abus i priary car: a ostratio projct. Itratioa Joura o Itrat Car.7:36. Havorso, A. (2010). Ipti Hathcar Ror: First Stps to Trasori Your Oraizatio A Practica Gui or Lars. Movi Forwar Aiac. Rtriv ro: Maras BK, Copto WM, Avua D, Stbaur T, Sti JB, Car HW. Scri, bri itrvtios, rrra to tratt (SBIRT) or iicit ru a acoho us at utip hathcar sits: Copariso at ita a 6 oths atr. Dru a Acoho Dpc. 2009;99(1-3): Parthasarathy SP, Mrts JMA, Moor CMDMBA, Wisr CD. (2003). Utiizatio a Cost Ipact o Itrati Substac Abus Tratt a Priary Car. Mica Car. 2003;41(3): Parthasarathy S, Wisr C, Hu TW, Moor C. (2001). Associatio o outpatit acoho a ru tratt with hath car utiizatio a cost: rvisiti th ost hypothsis. Joura o Stuis o Acoho. Ja 2001;62(1): Saitz R, Aor DP, Brsti J, Ch DM, Sat J, Paai T. (2010). Scri a Bri Itrvtio or Uhathy Dru Us i Priary Car Sttis: Raoiz Ciica Trias Ar N. Joura o Aictio Mici. 2010;Pubish Aha o Prit: /ADM.1090b b1096b1067. Saitz R, Horto NJ, Suiva LM, Mosowitz MA, Sat JH. (2003). Arssi acoho probs i priary car: a custr raoiz, cotro tria o a systs itrvtio. Th scri a itrvtio i priary car (SIP) stuy. Aas o Itra Mici, 138(5): Sat JH, Fria P, Saitz R. (2001). Bits o ii priary ica car a substac abus srvics: patit, provir, a socita prspctivs. Archivs o Itra Mici, 161(1): Saxo AJ, Mat CA, Soa KL, t a. (2006). Raoiz tria o osit vrsus rrra priary ica car or vtras i aictios tratt. Mica Car. 44(4): Substac Abus a Mta Hath Srvics Aiistratio (2012). Rsuts ro th 2011 Natioa Survy o Dru Us a Hath: Tabs: Dpc, Abus, a Tratt. Rtriv ro: DtTabsPDFWHTML2011/211DtaiTabs/Wb/HTML/NSDUH- DtTabsSct5pTabs1to ht#Tab5.23A Wisr C, Mrts J, Parthasarathy S, Moor C, Lu Y. (2001). Itrati priary ica car with aictio tratt: a raoiz cotro tria. JAMA. 286(14): Wibri ML, Oso DH. (1999). A raoiz tria o itrat outpatit tratt or icay i acohoic. Archivs o Itra Mici, 59(16): Prac 7

12 Wibri ML, Oso DH, Biisi J. (1995). Itrat outpatits tratt or icay i acohoic : rsuts ro a quasi-xprita stuy. Joura o Stuis o Acoho. 56(3): Prac

13 Chaptr 1: Data Aaysis: Urstai th Chai Fi o SUD Srvics Darr Uraa, Ph.D. Th icras covra o substac us isorrs (SUD) srvics as part o ow-ico hath proras at to prpar Caioria or hath car ror i ot a to icras cooriatio btw hath car a spciaty car srvics i th or o rrras. By xtsio, it ay b assu that th 2014 Mi-Ca xpasio a hac SUD bit ay ot o thir ow rsut i bttr cooriatio. Rathr, partrships to b activy pursu. Currty, a rativy sa ubr o proras hav stabish such partrships. Patits rrr ro hath car to spciaty SUD tratt t to b Whit, a, a tri toxiicatio or acoho us. Fa a Hispaic patits ar urrprst. Data o AB 109 cits (owr-v ors who ar bi trasrr ro stat to couty systs) is spars a o qustioab accuracy, but thir ubrs appar to b risi rapiy. Itii AB 109 cits t to b a, upoy, a thaphtai usrs. Vry ow rot o AB 109 cits i Mi-Ca is o particuar cocr. Bits shou b susp uri icarcratio rathr tha triat to avoi aps i covra, a Mi-Ca outrach a rot orts shou b tart at soo-to-b ras iats. Data Iicator Rports or outpatit a thao-aitac prorac asurt hav b poy. Dvopt o asurs or rsitia tratt a toxiicatio ar bi cosir i th utur. Dru Mi-Ca ata a CaOMS-Tx ata ca pottiay b prouctivy us to asur prorac, itiy SUD hot spots, aayz costs, a tct rau, which ay b usu to poicyars. I. Itrouctio Two ajor poicy chas i Caioria hav th pottia to raaticay cha th ubr a typ o iiviuas accssi SUD srvics i th ar utur. Th irst is hath car ror. Caioria has put ito pac bri to ror poicis i prparatio or chas xpct i 2014, but itt is ow about th ct ths poicis hav ha o SUD tratt. Th sco poicy cha urway is criia justic rait (AB 109) 3 which is rsuti i icras ubrs o iiviuas with SUD bi ivov i th criia justic syst at th couty v. Thr has b o statwi vauatio o th ct o AB 109 o th ubr a charactristics o iiviuas si SUD srvics, howvr. This chaptr provis iitia ata o iiviuas rrr to spciaty car ro hath car or AB 109, as w as a iscussio o what ca b o to iprov th accuracy o th ata o ths popuatios i th utur. 3 AB 109 rrs to Assby Bi 109, which was pass by th isatur a si by Gov. Brow i Rait isatio icu both AB 109 a AB 117, but th oriia a AB 109 has rai i coo us. Chaptr 1 9

14 Currty th bst sourc o ata avaiab to asur th ubr a charactristics o iiviuas accssi spciaty SUD srvics statwi is th Caioria Outcos Masurt Syst, Tratt (CaOMS-Tx). CaOMS-Tx capturs ata at aissio, ischar, a aua upats (whr rvat), or a patits tri pubicy u tratt or toxiicatio aciitis or SUDs a a ics thao proras i th stat (Dpartt o Acoho a Dru Proras [ADP], 2012). CaOMS-Tx is th oy statwi sourc o patit outco ata or SUD tratt. It thror pays a ctra ro i currt orts to ipt tratt prora prorac a outcos asurs. W wi provi a upat o th status o ths asurs. Wh Mi-Ca xpas to covr a arr popuatio i 2014, ata systs us i th aiistratio o Dru Mi-Ca ca pottiay bco a sco iportat sourc o ioratio o SUD srvics. W thror wi iscuss pottia utur uss o Mi-Ca ata i traci a iprovi SUD srvics, ithr ao or i cojuctio with CaOMS-Tx ata. Fiay, w wi prst a xap o how CaOMS-Tx ca b us to a spciic poicy rcoatios. I this cas, w ocus o a stat poicy rquiri patits to ai toxiicatio irst bor bi aitt to thao aitac tratt. W bi th chaptr by itiyi our objctivs oow by scribi th thos us to arss ach objctiv. W icu tai iis a ssos ar raw ro our ivstiatios, a cos th chaptr with a suary a rcoatios. II. Objctivs This chaptr arsss th Dpartt o Hath Car Srvics (DHCS) / UCLA cotract Doai 1, tit Data Aaysis : Urstai th Chai Fi. Bow ar th two objctivs itii ur this oai. 1. Exai how ooi poicy chas ar acti who rcivs SUD tratt a how accss, srvics, costs, a quaity o car ar bi act. Ma rcoatios to iprov poicis, practics, a ata quaity. 2. Ri prora prorac a patit outco asurs. III. Mthos Th iis scrib i this chaptr ar bas o aayss o ata ro CaOMS-Tx. UCLA obtai this ata ro ADP (ow DHCS) o Fbruary 21, Th iis rport hr ar scriptiv i atur. Irtia statistics ( siiicac ) ar ot rport bcaus ths statistics ar appropriat or trii whthr iis i a sap ar iy to b ou i th arr popuatio, but CaOMS-Tx ata sstiay rprsts th popuatio o aissios to pubicy u tratt proras, ot a sap. Furthror, 10 Chaptr 1

15 v i irtia statistics wr to b appi, th vry ar ubr o cass i CaOMS-Tx wou rsut i statistica siiicac v or ircs that ar vry sa a o itt to o ra-wor siiicac. Thror, iis icu tabs a raphs o asurs o ctra tcy such as ias a as (avras), a rqucis (couts) that th rar ca xai or ircs, a w itiy ircs o pottia ra-wor iportac whr rvat. W xai patit ubrs a charactristics or rrras ro hath car a ro AB 109 i particuar, a copar ths to o-hath car rrras a o-ab 109 rrras, rspctivy. W aso iscuss th iptatio o prorac a outco asurs or tratt proras a coutis bas o CaOMS-Tx ata, a iscuss pottia utur uss o CaOMS- Tx ata i associatio with Mi-Ca ata. IV. Fiis Th iis ar oraiz i th oowi orr: A. Ipact o Poicy Chas a SUD Itratio with Priary Car a Rrras ro th Hath Car Syst B. Ipact o AB 109 o SUD Tratt C. Prora Prorac a Patit Outco Masurt 1. Prorac a outco rports bas o CaOMS-Tx 2. Propos ways DHCS ca us Dru Mi-Ca a CaOMS-Tx ata or prorac a outco asurt a to ior poicyai 3. Mthao toxiicatio poicy xap usi CaOMS-Tx A. Ipact o Poicy Chas a SUD Itratio with Priary Car a Rrras ro th Hath Car Syst Rrras ro Hath Car SUD srvics covra was ot associat with chas i aissios to spciaty SUD srvics i th iv iu a ar coutis provii SUD covra throuh th Low Ico Hath Prora or th 35 sar coutis participati i th Couty Mica Srvics Pa. Lar/Miu Siz Low Ico Hath Prora Coutis Th Low Ico Hath Prora (LIHP) was crat throuh a Micai waivr ot rrr to as Caioria s bri to ror. LIHP provi th opportuity or Caioria coutis to xpa Mi-Ca i ways that rsb th Mi-Ca xpasio xpct to occur i 2014 u to th Aorab Car Act (ACA). Howvr, oy iv coutis (Kr, Sa Fracisco, Sa Mato, Sata Cara, a Sata Cruz) provi a SUD bit as part o thir LIHP prora, a ths wr ray ai at arrowy i popuatios (or or o LIHP iptatio, s Chaptr 2). Sti, it was pausib that wh ths coutis xpa thir Chaptr 1 11

16 Ju 2010 Au 2010 Sp 2010 Oct 2010 Nov 2010 Dc 2010 Ja 2011 Fb 2011 Mar 2011 Apr 2011 May 2011 Ju 2011 Ju 2011 Au 2011 Sp 2011 Oct 2011 Nov 2011 Dc 2011 Ja 2012 Fb 2012 Mar 2012 Apr 2012 May 2012 Ju 2012 Ju 2012 Au 2012 Sp 2012 Oct 2012 Mi-Ca popuatios a provi SUD covra, priary car iht provi iit srvics osit a rr patits i or itsiv car to spciaty provirs i th couity, ai to icrasi ubrs o patits rrr ro hath car sourcs to spciaty SUD car. Howvr, i raity, rrras ro hath car ros oy sihty i ths iv coutis. I th yar prior to LIHP iptatio (Juy 1, 2010 Ju 30, 2011) proras i ths iv coutis avra a tota o 79.5 hath car rrras pr oth. I th oowi yar (Juy 1, 2011 Ju 30, 2012) thy avra 83.2 pr oth. Ovr ha o ths rrras cou b trac bac to a si ica toxiicatio prora i Sa Fracisco Couty whos activitis wr support by couty ra us a ha itt to o with LIHP, accori to th couty aiistrator (Aic Ghor, prsoa couicatio, 7/16/2013). Excui this prora, th irc arrow to 37.4 rrras pr oth i th yar prior to LIHP a 39.7 i th yar atr. CMSP/Path2Hath Coutis A siiar story r i Couty Mica Srvics Pa (CMSP) coutis. O Jauary 1, 2012, CMSP/Path2Hath ba iit covra o SUD srvics, but this os ot appar to hav asuraby icras rrras ro hath car provirs to spciaty SUD provirs. I act, th avra ubr o aissios i th six oths oowi th iitiatio o covra actuay ro 46.8 to 42.0 i th coparab prio i th prior yar. This as ss i iht o th chas coutis rport i usi this bit. For urthr ioratio about CMSP/Path2Hath, s Chaptr 2. A Coutis Hath car rrras to spciaty car SUD srvics hav ot ris sic th passa o th ACA or iptatio o CMSP or othr LIHP proras. Th ubr o rrras has ropp sihty sic 2010, but this cosy oows a rop that occurs across a rrra sourcs, susti that ost variatios ovr ti ay b urat to hath car ror. S Fiur Fiur 1.1. Rrras ro Hath Car to Spciaty SUD Srvics by Moth Chaptr 1

17 Charactristics o Hath Rrra Patits S Tab 1.1 or tai statistics. Copar to othr cits, hath car rrras ar: Mor iy to b Whit (58.7% vs. 50.2%), cosistt with th FQHC popuatio, which is 58.6% Whit (HRSA, 2012) Lss iy to b Hispaic (23.2% vs. 36.7%). This is owr tha th FQHC popuatio, which is 62.1% Hispaic (HRSA, 2012) As iy to b a (63.7% vs. 62.4%). Howvr this is hihr tha th FQHC popuatio, which is 41.0% a (HRSA, 2012). Mor iy to rport acoho as thir priary ru (45.5% vs. 22.0%). Liy to us thir priary ru or ot (ia 15 ays out o th ast 30 vs. 4 ays). Mor iy to tr o-hospita rsitia toxiicatio (35.5% vs. 9.2%) or rsitia tratt (24.8% vs. 17.9%) a ss iy to tr outpatit tratt (35.0% vs. 64.8%). Or (ia a o 39 vs. 31) Lss iy to b ro i schoo at aissio (10.1% vs. 21.0%). Mor iy to rport ot bi i th abor orc at aissio (69.8% vs. 58.0%) Mor iy to b hoss (32.0% vs. 17.9%) Mor iy to b a vtra (7.5% vs. 2.9%) As iy to b a Mi-Ca biciary (36.7% vs. 38.1%) Mor iy to rport a isabiity (35.9% vs. 18.3%), particuary a ta o (24.0% vs. 10.4%) Mor iy to copt tratt (43.8% vs. 37.8%) a or iy to copt tratt a rciv a rrra or urthr srvics (34.8% vs. 23.3%). Ths ar both iy u to th hihr us o toxiicatio i th hath car rrr roup. Liy to sp ss ti i th prora (ia 20 ays vs. 62 ays). This is aso iy u to th rativy hih us o short acoho toxiicatio srvics ao th hath car rrr roup. O th basis o aissios (as oppos to uiqu patits), ary ha ar or o-hospita rsitia toxiicatio (49.4%). Ths rrras wr hihy coctrat. I th ast six oths o 2012, 46 rsitia o-hospita toxiicatio proras rport si patits. O ths, oy two proras (4.3%) coct or tha ha o th hath car rrras to ths proras (57.8%). Ths two proras wr Bar Pacs, Ic., i Sa Fracisco Couty a Tarzaa Tratt Ctr i Los As Couty. UCLA attpt to ar or about why ths proras wr succssu i attracti rrras ro hath car sourcs. Accori to th couty aiistrator (Aic Ghor, prsoa couicatio, Juy 16, 2013), Bar Pac was vop with th oa o vopi a couity-bas atrativ to xpsiv hospita-bas icay aa toxiicatio. It has u ica stai, a typicay has ay stays, osty or acoho or opiat issus. Thr wr iicutis tti th ics rw rcty u to rstrictios o ica srvics i rsitia sttis (or or o this barrir to itratio, s Coo Barrirs a Chas, Chaptr 2). Chaptr 1 13

18 Tab 1.1. Charactristics o patits rrr ro hath car. No-Hath Hath Car Rrra Car Rrra Uiqu Patits,Ju 2011-Ju ,026 3,536 Fa 37.5% 36.2% Rac Arica Arica/Bac 15.2% 15.0% Asia/PI 2.9% 2.2% Whit 50.2% 58.7% Othr 31.8% 24.1% Ethicity: Hispaic 36.7% 23.2% Priary Dru Rout o Aiistratio Ora 28.8% 54.3% Soi 49.1% 29.9% Ihaatio 4.7% 4.1% Ijctio 17.0% 11.1% Srvic Moaity Outpatit Itsiv 4.7% 3.2% Outpatit Dtoxiicatio 3.4% 1.6% Outpatit Tratt/Rcovry 64.8% 35.0% Rsitia Dtoxiicatio (o-hospita) 9.2% 35.5% Rsitia Tratt/Rcovry 18.0% 24.8% Ero i Job Traii at Aissio 2.3% 2.4% Ero i Schoo at Aissio 21.0% 10.1% Epoyt Status Epoy Fu Ti 7.3% 6.1% Epoy Part Ti 6.5% 4.2% Upoy, ooi or wor 28.2% 19.8% Not i th abor orc 58.0% 69.8% Priary Dru Acoho 22.0% 45.5% Cocai/Crac 5.8% 6.1% Hroi 16.8% 10.4% Marijuaa/Hashish 22.6% 10.2% Mthaphtai 25.4% 17.7% Othr 7.4% 10.2% Dischar Status Copt 37.8% 43.8% Lt bor coptio / satisactory 18.8% 20.3% Lt bor coptio / usatisactory 41.3% 35.4% Dath 0.2% 0.0% Icarcratio 2.0% 0.5% Ha HIV Tst 69.9% 69.8% Livi Arrat at Aissio Hoss 17.9% 32.0% Mi-Ca Biciary 38.1% 36.7% SUD Micatio Prscrib 16.4% 13.4% Prat at Aissio 1.8% 2.0% Triatio o parta rihts 3.8% 3.1% Vtra 2.9% 7.5% Disabiity 18.3% 35.9% A* A at irst us o priary ru* Days priary ru us, ast 30 ays, Aissio* 4 15 Days priary ru us, ast 30 ays, Dischar* 0 3 Days i tratt* Nubr o prior aissios* 1 1 Days o socia support, aissio* 0 0 Days o socia support, ischar* 5 7 * ia 14 Chaptr 1

19 Tarzaa Tratt Ctr oprats a priary car aciity that rrs patits to thir SUD proras or toxiicatio a tratt. Accori to its chi oprati oicr, th prora aso wors with svra oca rcy roos a both pubic a privat ciics (A Sa, prsoa couicatio, Juy 17, 2013). No-toxiicatio rrras t to b or outpatit ru-r (24.4%) a o-tr rsitia tratt (22.2%). Ths rrras wr sowhat coctrat as w. Excui rsitia o-hospita toxiicatio proras, thr wr 959 proras that rport patits i th ast six oths o O ths, just two (0.2%) ciics (Tarzaa Tratt Ctr i Tarzaa a Epir Rcovry Ctr i Ri) accout or 14.4% o th hath car rrr aissios statwi. Epir Rcovry Ctr (Shasta Couty) rport ori a partrship with a oca Fray Quaii Hath Ctr (Shasta Couity Hath Ctr). Epir rquirs that patits b o icatio a stab bor oi thr. Patits cotiu to rciv icatios ro thir prscribi physicia whi Epir provis socia o tratt. Epir rports that th icatios s to hp or iiviuas with o ru-us historis, a that th ratioship with th hath ctr has b rat, bcaus ach si bivs i what th othr os. For or ioratio o Tarzaa Tratt Ctr, s th prior iscussio o toxiicatio proras. SBIRT O Fbruary 1, 2013, th Ctrs or Micar a Micai Srvics provi uiac to stats o sctio 4106 o th Aorab Car Act, which scribs ictivs or prvtativ srvics, icui scri, bri itrvtio, a rrra to tratt (SBIRT). Support or SBIRT i ica sttis ay aciitat rrras to tratt. I a six-stat SAMHSAsposor stuy o SBIRT i ica sttis (Maras t a., 2009), 22.7% o patits scr positiv or risy/probatic us, a 3.7% wr rco or rrra to spciaty tratt. I oy 1/10 th o Caioria s popuatio o 38 iio (i.., 3.8 iio) ar scr ach yar a 3.7% o ths (about 140,000) ar rrr or spciaty car (as i th SAMHSA stuy), th rsuti ubr o w rrras ro ica sttis wou xc th tota ubr o uiqu cits pr yar s by th currt syst (137,562 i FY ). I othr wors, i SBIRT is succssuy proot i Caioria, th currt spciaty tratt syst wi to uro a raaticay substatia xpasio. Thr ar a ubr o Caioriaspciic barrirs to succssu SBIRT iptatio, howvr, icui: 1. Rstrictios o sa-ay bii that wi prcu priary car provirs ro tti pai or SBIRT i ost cass, sic thy wou typicay s th patit or aothr srvic o th sa ay. 2. Shortas o bhaviora hath prso to provi SBIRT i priary car sttis. Provirs ar uiy to scr or SUD i thy o ot hav th prso to provi srvics or support to ica sta wh SUD is itii. Currty oy psychiatrists, psychooists, a LCSWs ca bi Mi-Ca i a Fray Quaii Hath Ctr (FQHC) stti, a FQHCs rport that thy ar uab to i ouh prossioas with ths Chaptr 1 15

20 rs a othr quaiicatios (.., biiuais) to i ths positios. Aowi othr sta typs (.., LMFTs) to bi Mi-Ca i ths sttis wou hp to arss th prob. For or o this issu, s Chaptrs 2 a 3. Lssos Lar I suary, icras covra o SUD srvics i a o its i ot appar to a to icras cooriatio btw hath car a spciaty car srvics. By xtsio, it ay b assu that th 2014 Mi-Ca xpasio a hac SUD bit ay ot, o thir ow, rsut i bttr cooriatio. Ista, partrships wi hav to b activy pursu. Th ost coo hath car rrras ar currty patits who ar Whit, a, a tri toxiicatio or acoho us. It wi b iportat to oitor this as or iiviuas ai covra throuh privat isurac or Mi-Ca i 2014, a to xai why or iority a a patits ar ot bi succssuy rrr or spciaty SUD srvics. Currt oraphics ar icosistt with th act that th vast ajority o ray quaii hath ctr patits i Caioria ar a (63.2% o patits 15 64) a ar brs o racia/thic ioritis (77.7%; Hath Rsourcs a Srvics Aiistratio, 2011). It ay b that hath ctrs ar attpti to trat ths patits osit or that cuturay a iuisticay appropriat srvics ar uavaiab i th couity. A rativy sa ubr o proras ar ruary rcivi rrras ro hath car. Whr rrras ar occurri, it has b u to cocrt orts by th rcivi prora to vop ratioships with th rrri oca hath car provirs. Fiay, i SBIRT is succssuy proot i Caioria, th currt spciaty tratt syst wi to uro a raaticay substatia xpasio. Howvr, thr ar a ubr o Caioria-spciic barrirs that wi to b vauat i orr to aciitat a succssu SBIRT iptatio. B. Ipact o AB 109 o SUD Tratt CaOMS-Tx Data Aayss Th tru ubr o statwi AB 109 aissios is iicut to asur. ADP Buti provi protocos to itiy AB 109 cits ctiv Octobr 1, Howvr, acota rports ro couty aiistrators sust that i so coutis this ioratio is iicut to rcor i CaOMS-Tx u to th structur o th rrra syst. For xap, i probatio ss a AB 109 cit to a ctraiz asssst ctr, that ctr ot rrs th prso to a tratt prora without otiyi th prora that it is a AB 109 cit, a th cits thsvs ot o ot ow or thi o thsvs as a AB 109 rrra. Thus, wh th prora ass th cit what thir rrra sourc was, th aswr ay b rcor as a srrra or assi to so othr rrra sourc. Participats i th CADPAAC ata a outcos coitt who wr ab to viw CaOMS-Tx rports o th ubr o AB 109 rrras a copar th to thir oca probatio rports stat that th CaOM-Tx ubrs 16 Chaptr 1

21 Oct 2011 Nov 2011 Dc 2011 Ja 2012 Fb 2012 Mar 2012 Apr 2012 May 2012 Ju 2012 Ju 2012 Au 2012 Spt 2012 Oct 2012 Nov 2012 Dc 2012 Ja 2013 Aissios (urcout*) wr too ow. I suary, th ovra ubr o AB 109 cits i th stat is uow, but is crtaiy hihr tha th ubrs rport hr. Dspit th act that th absout ubrs ar aost crtaiy iaccurat, oth-to-oth ircs i rport aissios ca sti b iorativ. I so coutis ar uab to rport aissios, or xap, th statwi ubrs wi b ow but th ircs i th raii coutis ovr ti ay rct ra chas i th AB 109 popuatio. Th cha i AB 109 aissios is show i Fiur 1.2. Whi so o th icras ay rct icrasiy or accurat us o th CaOMS-Tx AB 109 rporti chais, th ubrs sust aissios ar risi quicy a approxiaty iary ovr ti. Itrstiy, this pattr is cosistt with th icrasi ubr o AB 109 activ post-ras couity suprvisio ors i th stat (Chi Probatio Oicrs o Caioria, 2013) Fiur 1.2 CaOMS AB 109 Aissios* by Moth *ADP Buti provi CaOMS-Tx protocos to itiy AB 109 cits ctiv Octobr 1, Howvr, i so coutis provirs ar uab to rport AB 109 rrras u to a ac o aquat rrra ioratio. Ohr coutis hav ou ur-rporti wh rcocii CaOMS ata with probatio ata. Thror whi th tr is o itrst, th absout vs o aissios abov ar haviy ur-rport. W wr aso ab to xai AB 109 cit charactristics by ocusi o uiqu cits that i hav a AB 109 rrra ot at aissio, a copar th to cits that i ot hav this siatio (s Tab 1.2). Not that it is iy that th o-ab 109 ata actuay icus a uow ubr o AB 109 cits or th rasos scrib abov, which as th ircs btw th AB 109 a o-ab 109 popuatios ay actuay b sihty arr tha thos rport hr. 4 4 W o ot biv th rvrs occurs vry ot, howvr. O ar couty that copar thir CaOMS ata to a probatio ist rport that ss tha 2% o cits itii as AB 109 via CaOMS wr ot o th probatio ist. Chaptr 1 17

22 Tab 1.2. Charactristics o itii AB 109 cits. No-AB 109 AB 109 Uiqu Patits, Nov 2011-Oct ,945 4,141 Fa 37.9% 16.8% Rac Arica Arica/Bac 15.3% 15.6% Asia/PI 2.8% 4.0% Whit 50.3% 48.3% Othr 31.7% 32.1% Ethicity: Hispaic 36.3% 37.6% Priary Dru Rout o Aiistratio Ora 29.8% 15.8% Soi 48.4% 59.6% Ihaatio 4.7% 5.6% Ijctio 16.9% 18.2% Srvic Moaity Outpatit Itsiv 4.9% 1.6% Outpatit Dtoxiicatio 3.6% 0.1% Outpatit Tratt/Rcovry 63.5% 54.0% Rsitia Dtoxiicatio (o-hospita) 10.3% 3.0% Rsitia Tratt/Rcovry 17.8% 31.2% Ero i Job Traii at Aissio 2.2% 2.2% Ero i Schoo at Aissio 20.7% 3.5% Epoyt Status Epoy Fu Ti 7.4% 6.7% Epoy Part Ti 6.4% 6.5% Upoy, ooi or wor 27.5% 43.2% Not i th abor orc 58.6% 43.6% Priary Dru Acoho 22.8% 13.8% Cocai/Crac 5.5% 8.2% Hroi 16.9% 12.2% Marijuaa/Hashish 22.4% 12.9% Mthaphtai 25.0% 50.5% Othr 7.4% 2.4% Dischar Status Copt 35.8% 30.6% Lt bor coptio / satisactory 19.2% 16.0% Lt bor coptio / usatisactory 42.9% 50.0% Dath 0.1% 0.0% Icarcratio 1.9% 3.4% Ha HIV Tst 69.6% 83.2% Livi Arrat at Aissio Hoss 18.9% 25.1% Mi-Ca Biciary 38.8% 8.8% SUD Micatio Prscrib 16.6% 1.0% Prat at Aissio 1.8% 0.6% Triatio o parta rihts 3.7% 5.0% Vtra 3.0% 3.6% Disabiity 19.1% 14.4% A* A at irst us o priary ru* Days priary ru us, ast 30 ays, Aissio* 5 0 Days priary ru us, ast 30 ays, Dischar* 0 0 Days i tratt* Nubr o prior aissios* 1 1 Days o socia support, aissio* 0 0 Days o socia support, ischar* 6 14 * ia 18 Chaptr 1

23 Copar to othr participats, itii AB 109 cits ar: Siiar i rac a thicity Mor iy to b a (83.1% vs. 62.0%) Lss iy to b aitt to toxiicatio (3.1% vs. 10.3%) a or iy to b i rsitia tratt (31.2% vs. 17.7%). Lss iy to b ro i schoo (3.5% vs. 20.7%). Mor iy to b upoy ooi or wor (43.2% vs. 27.5%). Mor iy to rport thaphtai as thir priary ru (50.5% vs. 25.0%), ss iy to rport arijuaa (12.9% vs. 22.4%) or acoho (13.8% vs. 22.8%). Lss iy to copt tratt (30.6% vs. 35.8%), sowhat or iy to b ischar u to icarcratio (3.4% vs. 1.9%). Mor iy to hav rciv a HIV tst (83.2% vs. 69.6%). Mor iy to b hoss at aissio (25.1% vs. 18.9%). Lss iy to b a Mi-Ca biciary (8.8% vs. 38.8%) Lss iy to rciv icatio as part o thir tratt (1.0% vs. 16.6%). Mor iy to hav ha parta rihts triat (5.0% vs. 3.7%). Or (ia a 36 vs. 31). Siiar i rar to ti spt i tratt (ia 42 ays vs. 44 ays) Th AB 109 popuatio oos siiar to th prvious Propositio 36 paro popuatio (Evas, Hutr & Uraa, 2009) i trs o oraphics a th hih us o thaphtai. O particuar cocr is thir ow rot i Mi-Ca. This os ot appar to b u to a ac o pts, as AB 109 cits actuay ha sihty or chir (avra 1.05 vs. 0.92), a wr chir ivi with soo s (avra 0.21 vs. 0.27). This susts thr ay b a atrativ xpaatio, such as osi Mi-Ca bits as a rsut o thir ivovt with th criia justic syst. Ors ot hav thir bits triat whi icarcrat, which ca caus probs wh th iat is ras a ss hath car. I Massachustts, this to a 22% uisur rat ao SUD patits v as th ra popuatio joy a ss tha 3% uisur rat. Suspi rathr tha triati Micai bits or ors a aii Micai outrach a rot orts at iats ar rco soutios (Cuar & Cha, 2012). At this writi, AB 720 (Sir), which wou rquir asurs ao ths is, ha pass th Assby a has b rrr to th Sat Appropriatios Coitt. Othr AB 109 ata ro arou th stat Dspit AB 109 bi th bist pa xprit i or history, th stat provi o ui to vauat its ovra ct (Ptrsiia & Syr, 2013). Rsarch o its ratioship to SUD is thror spars. Hr is ata that UCLA was ab to i: Frso (Pr, Ow, Taahashi, Ow, & Huhs, 2012) rport that two o th top iv oss that to participatio i AB 109 wr ru a cotro substac possssio. Thy aso rport that th ost coo raso or aiur to copy with o or or coitios o suprvisio was substac abus (38%). Chaptr 1 19

24 Atr aayzi AB 109 couty pas, a ta ro Staor (Abarba, McCray, Nwha, & Syr, 2013) rport that ost pas (83%) tio ipti couity SUD tratt as part o thir iptatio o AB 109, but oy 36% provi ay tais about th SUD tratt thy wou provi. Th Caioria Mta Hath Pai Couci (2013) rport th prcta o AB 109 us coutis spt o SUD srvics ra ro 0% to 9%. Mta Hath srvics ra ro a aitioa 0% to 19%. Couty rprstativs xprss surpris at th v o substac us isorr s ao th AB 109 popuatio. Sa Mato Couty Probatio rport a isparity btw thir ruar probatio popuatio a th rai popuatio with 90% o th attr rporty havi substac abus probs. A 2012 CADPAAC survy o couty acoho a ru (AOD) prora aiistrators ou that th AOD aiistrator was ivov i thir couty s Couty Couity Corrctios Partrship, which iscusss AB 109 iptatio i 47 o th 51 coutis. I 24 o ths coutis, acis wr provii SUD tratt outsi o th syst ovrs by th AOD aiistrator, with this ost rquty occurri throuh th couty s probatio partt. Oriiay UCLA ha propos to aayz CaOMS-Tx ata i cojuctio with th CADPAAC survy or a w survy o AB 109 iptatio. Howvr, u to th chas i itiyi AB 109 cits usi CaOMS-Tx, a particuary variatios i CaOMS-Tx rporti by couty, it wou b pratur to o so. Iprovi itiicatio o AB 109 cits ay b a or prouctiv irst stp. Lssos Lar Avaiab ata sust that AB 109 aissios to SUD tratt ar risi, but th xact ubr o iiviuas is uow. Asi ro courai coutis to provi accurat CaOMS-Tx ata, which ay ot b possib i so cass, thr ar two othr possib thos o obtaii or accurat ata: 1. I thory, it wou b possib or th 58 couty probatio partts to provi ists o currt AB 109 ors to DHCS or to UCLA. UCLA cou th r ths ists with th CaOMS-Tx atabas to tri how ay pop o ths ists ar i SUD tratt. This wou rquir coopratio ro th probatio partts, howvr (.., Chi Probatio Oicrs o Caioria). 2. A sco optio wou b to coura couty AOD aiistrators to obtai this ioratio at th oca v, th copar it to thir ow tratt ists. Acotay, so o th arr coutis aray o this. UCLA cou th coct th rsuti or couts via survy to prouc a statwi ubr. Bas o a siiar ort that UCLA ipt or th Substac Abus a Cri Prvtio Act (SACPA, aa Prop. 36) vauatio, this is possib but is iy to prouc icosistt couty rsposs that wi rquir so stiatio. 20 Chaptr 1

25 C. Prora Prorac a Patit Outco Masurt Prorac a outco rports bas o CaOMS-Tx Ovr th past yar, UCLA cotiu to wor with th Dpartt o Acoho a Dru Proras a th CADPAAC ata a outcos coitt to ri prorac a outco asurs. Th Dpartt has ow ro out Data Iicator Rports (DIRs) or outpatit proras a or arcotic tratt proras that wr party bas o th prviousy propos ashboars. Iitia provir bac has rporty b positiv. Upat vrsios o th ashboar asurs UCLA prviousy propos or rsitia a toxiicatio oaitis ar icu bow. Ths hav aso b circuat to th ata a outco coitt brs, a iscussios about pottia rvisios hav bu. At th rqust o ADP, UCLA aso prouc a couty-v ashboar that icorporats ts ro th toxiicatio a rsitia vrsios (s bow). Th ubrs i th ashboars bow ar ra, a bas o statwi ubrs. Wh poy, ths ashboars wou actuay cotai prora- or couty- v ata. Th statwi asurs rat ix rsuts, with a ubr o asurs ai ro th prior yar (r Xs i th i cou). For th ost part, ths chas wr sa. Couty Lv Dashboar Exap Couty: A Rporti Prio: 7/1/2011 6/30/2012 Prorac Masur Patits trasrr ro tox to tratt withi 14 ays o ischar Patits trasrr ro rsitia to outpatit, itsiv outpatit, or ay-car rhabiitativ withi 14 ays o ischar SCORE (%) Copariso with Prvious Rport Copariso with Stat Bchar % Iprov? % Goa t? 19.4% 20.7% X 8.8% 8.1% Patits rporti priary ru abstic* at ischar 57.7% 62.0% X Riabiity o abstic ioratio (% o ischars with ata) 52.7% 54.3% X *Abstic is i as 0 ays us withi th ast 30 prior to ischar itrviw. Ovr 20% Ovr 8% Ovr 60% Ovr 55% Dashboar upat: Riabiity o abstic ioratio was a to provi cotxt or th abstic asur. X X X Chaptr 1 21

26 Prora Lv Dashboar or Dtoxiicatio Proras Prora Na: Dtox Prora X Couty: A Prora Sub-Catory: A Rporti Prio: 7/1/2011 6/30/2012 (Icus: Rsitia-Hospita a No Hospita, Outpatit, NTP) Nubr o Dischars: 28,152 (statwi ata us or this xap) Prorac Masur Patits trasrr to tratt withi 14 ays o ischar SCORE (%) Copariso with Prvious Rport Prv % Iprov? 19.4% 20.7% X Patits who copt tox 48.8% 48.3% Patits NOT r-tri tox withi 14 ays o ischar 96.4% 96.3% Copariso with Stat Bchar Tart % Ovr 20% Ovr 50% Ovr 95% Goa t? X X Dashboar upat: Th iiat rop outs asur was ropp bcaus this asur was rati ubrs that wr too ow to b iorativ. Prora Lv Dashboar or Rsitia Tratt Proras Prora Na: A Couty: A Nubr o Dischars: 28,360 Rporti Prio: 7/1/2011 6/30/2012 Prorac Masur SCORE (%) Copariso with Prvious Rport Prv % Iprov? Patits i tratt at ast 30 ays 62.0% 64.2% X Patits trasrr to outpatit, itsiv outpatit, or ay-car rhabiitativ withi 14 ays o ischar 8.8% 8.1% Patits rporti priary ru abstic* at ischar Riabiity o abstic ioratio (% o ischars with ata) *Abstic is i as 0 ays us withi th ast 30 prior to ischar itrviw ** Sa-ay aissio a ischar 77.9% 80.9% X 66.6% 72.6% X Copariso with Stat Bchar Tart % Ovr 60% Ovr 8% Ovr 80% Ovr 70% Goa t? X X Not: Th prorac ashboar or short-tr rsitia wou b th sa, but without th patits i tratt at ast 30 ays asur. Dashboar upat: Th iiat rop outs asur was ropp bcaus this asur was rati ubrs that wr too ow to b iorativ. 22 Chaptr 1

27 Mthao toxiicatio poicy xap usi CaOMS-Tx Opioi toxiicatio tratt is prov to b ictiv i achivi o-tr abstic ao opioi-pt iiviuas (Dhaa t a., 2009). I aitio to ra critria or opioi aitac tratt iibiity, Stat o Caioria poicis rquir two ai attpts at opioi toxiicatio. CaOMS-Tx a its prcssor, th Caioria Acoho a Dru Data Syst (CADDS), ca b us to tri whthr th ata support this poicy or sust a to rvisit it. W aayz CADDS a CaOMS-Tx ata covri th prio Jauary 1, 1991, to March 31, 2012, covri a sap o 237,709 uiqu iiviuas a 857,030 tratt pisos. Th ai outcos a asurs us wr: Succssu coptio o opioi toxiicatio tratt (thao or buprorphi) Duratio o opioi aitac tratt Duratio o ti to iitiatio o aitac tratt oowi toxiicatio. Rsuts A tota o 112,211 iiviuas accss oy opioi-toxiicatio tratt (259,168 pisos), a 125,498 iiviuas accss opioi-aitac tratt. Ao iiviuas vr accssi aitac tratt, th ajust os o succssu opioi toxiicatio ci with ach succssiv attpt (vs. irst attpt: 2 attpt, Ajust Os Ratio:0.66; 3r attpt: 0.51; 4th attpt: 0.44; 5th attpt: 0.44; 6th attpt: 0.36). Furthr, si or utip prior attpts at toxiicatio ha o siiicat associatio with subsqut aitac tratt uratios (vs. o prior toxiicatio attpts: 1 3 toxiicatio attpts: Ajust Hazar Ratio: 0.98; 4 prior toxiicatio attpts: 0.99). Suary Dtoxiicatio has o siiicat associatio with subsqut aitac tratt rttio. Ths iis sust a to rvisit currt Stat o Caioria poicis aati two usuccssu opioi toxiicatio attpts or aitac tratt iibiity. Lssos Lar Th statwi asurs rat ix rsuts, with a ubr o asurs ai ro th prior yar (r Xs i th i cou). For th ost part, ths chas wr sa. As xt stps, w rco a ocus o th vopt o rsitia tratt a toxiicatio DIRs. Th ata a outcos coitt has a oa o copti a rsitia DIR by th o Sptbr 2013 or poyt bii i Octobr. Foowi this, DIRs wi hav b poy or th ajor oaitis icu i CaOMS-Tx. I CaOMS-Tx cou vr b xpa to covr w oaitis, it wou b avataous to th i to hav prorac a outco asurs o cotiui car, i particuar, a sobr ivi, i possib. Chaptr 1 23

28 I aitio, UCLA has itii svra possib stratis to iprov prorac a outco asurt by utiizi both Dru Mi-Ca ata a CaOMS-Tx ata tothr. Dru Mi-Ca ata a CaOMS-Tx ata ca pottiay b us prouctivy to asur prorac, itiy SUD hot spots, aayz costs, a tct rau. I DHCS wr to authoriz 5 aayss usi CaOMS-Tx a Dru Mi-Ca (DMC) ata, icui th us o protct hath ioratio ro both atasts, it is thorticay possib to prouc a ubr o aayss that wou bit th Mi-Ca prora. It is iportat to ot that UCLA i ot hav accss to th DMC ata at th ti o this writi a was uab to vriy crtai acts about th ata, so athouh th oowi ias ar thorticay possib, vriicatio wi b to sur that practica issus such as ata covra, issi/urport ata, a ata quaity wou ot itrr with ths pas. Assui aquat quaity o DMC ata, patit itiirs (a, at o birth, sx, aii arss) cotai i CaOMS-Tx ca b atch to th sa subscribr variabs cotai i DMC ata usi triistic aoriths or probabiistic atchi sotwar (.., Li Ki). Havi achiv this i btw CaOMS-Tx a DMC subscribr ioratio, th atch ata cou th b i to ata ro DMC cai is raw ro DMC 837 P cais trasactios by usi th cit ix ubr cotai i both th subscribr a cais ata. Th atast cou th b stripp o itiirs (-itii) a th rsuti DMC cais- CaOMS-Tx atast cou pottiay b us or a ubr o aayss, xaps o which ar scrib bow. Prorac Moitori: Th Hathcar Ectivss Data a Ioratio St (HEDIS) is a too us by or tha 90% o Arica's hath pas to asur prorac o iportat isios o car a srvic. Atothr, HEDIS cosists o 75 asurs across 8 oais o car (Natioa Coitt or Quaity Assurac (NCQA), 2013). Ao th HEDIS asurs ar Iitiatio 6 a Eat 7 o Acoho a Othr Dru Dpc Tratt. Masuri ithr Iitiatio or Eat rquirs coutr-v ata, which appars to b avaiab i th DMC cais ata. Micai HMOs rport 39.2% iitiatio a 11.9% at i 2011 (NCQA, 2012). Both rprst cis ro th prior yar. Usi DMC ata wou aow DHCS to oitor iitiatio a at ao th popuatio o DMC provirs, icui -or-srvic provirs. Usi DMC ata i cojuctio with CaOMS-Tx ata wou ab DHCS to oitor th iitiatio a at asurs i cojuctio with CaOMS-Tx patit outcos ata. Not that oi so wou rquir us o both atasts to prouc provir-v asurs, but th two atasts wou ot cssariy to b i at th patit v. 5 Sctio 1902 (a) o th ra Socia Scurity Act (42 U.S.C. 1396a (7)) rstricts DHCS ro iscosi protct ioratio othr tha or purposs that ar ircty coct with th aiistratio o th Mi-Ca Prora. 6 Iitiatio o AOD Tratt. Th prcta o pop who iitiat tratt throuh a ipatit AOD aissio, outpatit visit, itsiv outpatit coutr, or partia hospitaizatio withi 14 ays o iaosis. 7 Eat o AOD Tratt. Th prcta o pop with a iaosis o AOD us or pc who iitiat tratt a ha 2 or or aitioa srvics withi 30 ays o th iitiatio visit. 24 Chaptr 1

29 Hot spotti (Brr, 2013): Hot spotti ca b us to itiy whr patits ar coi ro (rsitia arss) a to copar that to whr th srvics ar (aciity arss). This ca b us to itiy whr hp is ost, icui tratt, prvtio, a outrach srvics. For xap, Brr rat th ap o Ca, NJ, bow, showi that patits ro 6% o th city bocs (i r) accout or 37% o hathcar costs, a two spciic buiis ha particuary hih costs. Fiur 1.3 Hot Spotti Exap Sourc: Icu with prissio. Brr s oraizatio aso couct a siiar stuy usi Mai s Micai ata (Ca Coaitio o Hathcar Provirs, 2013), thrby stabishi th asibiity o usi stat Micai ata or hot-spotti aayss. I appi to DMC ata, or (v bttr) Mi-Ca ata or ray, w ay i siiary coctrat pattrs o srvic utiizatio a costs i Caioria. Itiyi ths patit hot spots wou provi ioratio o whr prvtio a outrach orts ay hav th ratst ipact i itrvi with iiviuas bor thy vop SUDs or to rach out to thos who ar i o tratt. Itiyi spots with hih coctratios o rsits that us SUD srvics (ro DMC subscribr ata), spciay thos who hav poor outcos (ro CaOMS-Tx) a o tratt proras arby (ro DMC ata or CaOMS-Tx+Mastr Provir i), ca provi vauab ioratio o whr Chaptr 1 25

30 w proras ar. Patits ar or iy to rop out o tratt i thy ar uab to accss it covity, a ropouts hav wors hath a cost outcos tha tratt coptrs. Thror, hot-spotti ay b hpu i achivi th trip ai o bttr car, bttr hath, a ruc costs. Cost Aayss: With suicit ti a rsourcs, it ay b possib to copar costs pr uit o outco, ajusti or patit charactristics (.., oraphics, ru us, priary ru) ta ro CaOMS-Tx. For xap, o cou tri or a 33-yar-o Hispaic a with aiy th ru us, 10 yars o us, a two prior tratt pisos, which oaity (.., outpatit, itsiv outpatit, or rsitia tratt) proucs th ratst ructio i ru us pr oar spt. I a Mi-Ca ata (as oppos to DMC oy) ca b obtai, w cou stuy th associatio btw oaitis or varyi ths o stay o ovra ica costs. By usi DMC a CaOMS-Tx ata tothr, it is thorticay aso possib to itiy iiviua proras that provi th ratst ba or th buc i orr to stuy th as o proras that ay b ab to provi proisi practics or issiatio to othr proras. Frau Dtctio To protct th ctivss o th thos iscuss, tais o th procurs propos i this sctio hav b ov to a sparat rport. Thr ar a ubr o this DHCS aaysts or UCLA via cotract cou o to pursu rau usi DMC ata aaysis. Sic a Dru Mi-Ca proras ar currty bi r-crtii, this wou b a ia ti to iitiat a piot aaysis prora that itiis a ist o outir proras that cou b xai or cosy uri th rcrtiicatio procss. I this ist provs hpu a succssuy itiis rauut proras, orts cou b xpa. I ths thos ar succssu, it is iy that proras wi cha thir thos i rspos, a DHCS sauars wi thror to cotiuay vov to p up as w. V. Chaptr Suary a Rcoatios Suary A utitu o ata aaysis orts wr couct to arss th oowi objctivs: 1. Exai how ooi poicy chas ar acti who rcivs SUD tratt a how accss, srvics, costs, a quaity o car ar bi act. Ma rcoatios to iprov poicis, practics, a ata quaity. 2. Ri prora prorac a patit outco asurs. Outcos rva ovra that icras covra o SUD srvics i a o its i ot appar to a to icras cooriatio btw hath car a spciaty car srvics. By xtsio, it ay b assu that th 2014 Mi-Ca xpasio a hac SUD bit ay ot, o thir ow, rsut i bttr cooriatio. Ista, partrships wi hav to b activy 26 Chaptr 1

31 pursu. Currty, a rativy sa ubr o proras ar ruary rcivi rrras ro hath car sourcs u to cocrt orts by ths proras to vop ratioships with oca hath car provirs. Patits rrr ro hath car to spciaty SUD tratt t to b Whit, a, a tri toxiicatio or acoho us. This ay cha as or iiviuas ai covra throuh privat isurac or Mi-Ca i Furthr rsarch is to tri why a a Hispaic patits ar urrprst. A rviw o SBIRT iptatio i a six-stat SAMHSA-sposor stuy rva ata that cou iicat a ajor ipact to Caioria s currt SUD spciaty tratt syst, i SBIRT is succssuy proot i Caioria. Howvr it is iy that th currt spciaty syst wi to uro a raaticay substatia xpasio. Thr ar a ubr o Caioria-spciic barrirs that wi to b arss i orr to aciitat a succssu SBIRT iptatio. Data o AB 109 cits is spars a currty o qustioab accuracy, but sust that th ubr o AB 109 cits tri tratt ay b risi rapiy. Vry ow rot o AB 109 cits i Mi-Ca is o particuar cocr. Bits shou b susp uri icarcratio rathr tha triat, a Mi-Ca outrach a rot orts tart at soo-to-b ras iats ar. Data Iicator Rports or outpatit a thao aitac prorac asurt hav b poy, a vopt o asurs or rsitia tratt a toxiicatio ar xt. Iitia provir bac has rporty b positiv. Dru Mi-Ca ata a CaOMS-Tx ata ca pottiay b prouctivy us to asur prorac, itiy SUD hot spots, aayz costs, a tct rau, which ay b usu to poicyars. Rcoatios Exaii ioratio ro th Uior Data Syst to tri whthr th ubr o patits trat or SUD icras withi hath ctrs uri ths ti prios. It is possib that SUD srvics actuay i icras ovra, but that this occurr i priary car sttis that o ot rport to CaOMS-Tx. UCLA has rqust this ioratio ro th Hath Rsourcs a Srvics Aiistratio (HRSA), but at this writi, th ata was ot avaiab yt. Cotiu orts to trai a provi tchica assistac to iprov ata try procsss a ata quaity. Cosir atrativ thos o obtaii or accurat AB109 ata: 1. I thory, it wou b possib or th 58 couty probatio partts to provi ists o currt AB 109 ors to DHCS or to UCLA. UCLA cou th r ths ists with th CaOMS-Tx atabas to tri how ay Chaptr 1 27

32 pop o ths ists ar i SUD tratt. This wou rquir coopratio ro th probatio partts, howvr (.., Chi Probatio Oicrs o Caioria). 2. A sco optio wou b to coura couty AOD aiistrators to obtai this ioratio at th oca v, th copar it to thir ow tratt ists. Acotay, so o th arr coutis aray o this. UCLA cou th coct th rsuti or couts via survy to prouc a statwi ubr. Bas o a siiar ort that UCLA ipt or th Substac Abus a Cri Prvtio Act (SACPA, aa Prop. 36) vauatio, this is possib but is iy to prouc icosistt couty rsposs that wi rquir so stiatio. Whthr or ot AB 720 bcos aw, UCLA rcos th practic o suspi rathr tha triati bits whr possib. Asi ro iprovi avaiab ata o AB 109 aissios to SUD tratt, it wi b iportat to sur that this popuatio wi actuay b ab to rciv tratt by suri thy o ot os Mi-Ca bits, shou thy b icarcrat. To iprov rrra practics btw SUD a priary car provirs, it is rco that vopi partrships b coura at th syst v. Currty, a rativy sa ubr o proras ar ruary rcivi rrras ro hath car sourcs. SBIRT iptatio orts cou b siiicaty ipact i th oowi barrirs wr vauat: Rstrictios o sa-ay bii a iib wororc. Cotiu to vop a poy prorac ashboars. Eorts towar asurt o rsitia tratt a toxiicatio ar urway. Dtoxiicatio has o siiicat associatio with subsqut aitac tratt rttio. Ths iis sust a to rvisit currt Stat o Caioria poicis aati two usuccssu opioi toxiicatio attpts or aitac tratt iibiity. Utiiz both Dru Mi-Ca ata a CaOMS-Tx ata tothr to iprov prorac a outco asurt. Dru Mi-Ca ata a CaOMS-Tx ata ca pottiay b us prouctivy to asur prorac, itiy SUD hot spots, aayz costs, a tct rau. 28 Chaptr 1

33 Rrcs Abarba, S., McCray, A., Nwha, K. & Syr, J. (2013). Raii th Rvovi Door: A Aaysis o Caioria Coutis AB Iptatio Pas. Rtriv ro: s%20or%2058%20coutis%20(1).p Brr, J. (2013). Hot Spotti - Ias or psychiatrists wori with hih utiizrs o hath car. Prstatio at th Natioa Couci or Couity Bhaviora Hath Corc, Las Vas, NV. Apri 9, Powrpoit avaiab at: Caioria Mta Hath Pai Couci (2013). AB 109 Iptatio. Th First Yar: How Four Caioria Coutis Mt th Cha o th 2011 Pubic Saty Rait i Thir Couitis. Rtriv ro: FINAL.p Ca Coaitio o Hathcar provirs (2013). MaiCar Hospita Utiizatio Aaysis or Cubra, Kbc, a Pobscot Coutis, FY2009 & FY2010. Rtriv ro: Chi Probatio Oicrs o Caioria (2013). Caioria Rait Dashboar. Rtriv ro: Cuar, A.E. & Cha, J. (2012). As rouhy 700,000 prisors ar ras auay, about ha wi ai hath covra a car ur ra aws, Hath Aairs, 31(5), Doi: /htha Dpartt o Acoho a Dru Proras (2012). Th Caioria Outcos Masurt Syst Tratt (CaOMS Tx): CaOMS Tx Data Coctio Gui. Fi vrsio 1.1, Sacrato: Caioria Dpartt o Acoho a Dru Proras. Dhaa, I; Maai, M; Siviotti, M; Kopp, A; Qurshi, O; Juuri, D. (2009). Prscribi o opioi aasics a rat ortaity bor a atr th itrouctio o o-acti oxycoo. Caaia Mica Associatio Joura 181(12): Evas, E., Hutr, J., & Uraa, D. (2009). Charactristics o Propositio 36 ors. I Evauatio o th Substac Abus a Cri Prvtio Act 2009 Rport Prpar or th Dpartt o Acoho a Dru Proras, Caioria Hath a Hua Srvics Acy. Los As: UCLA Itrat Substac Abus Proras. Rtriv ro: p Hath Rsourcs a Srvics Aiistratio (2012) Caioria Data. Rtriv ro: Maras, B.K., Copto, W.M., Avua, D., Stbaur, T., Sti, J.B., & Car, H.W. (2009). Scri, bri itrvtios, rrra to tratt (SBIRT) or iicit ru a acoho us at utip hathcar sits: Copariso at ita a six oths. Dru a Acoho Dpc, 99(1-3): Doi: /j.ruacp Natioa Coitt or Quaity Assurac (2012). Th Stat o Hath Car Quaity Wb.p Chaptr 1 29

34 Natioa Coitt or Quaity Assurac (2013). HEDIS & Prorac Masurt. Rtriv ro: Pr, L., Ow, B., Taahashi, Y., Ow, J., & Huhs, E. (2012). Masuri 109 I Frso Couty. Rtriv ro: Ptrsiia, J. & Syr, J. (2013). Looi Past Th Hyp: 10 Qustios Evryo Shou As About Caioria s Priso Rait. Caioria Joura o Poitics a Poicy 2013; 5(2): DOI /cjpp Stphso DK. (2008). Guii or physicias wori i Caioria Opioi Tratt Proras. Caioria Socity o Aictio Mici Chaptr 1

35 Chaptr 2: Hath Car Ror a th Itratio o SUD Srvics with Mta Hath a Priary Car Vari P. Atoii, M.P.H., Bray T. Osr, M.P.H., Chry Truya, Ph.D., Darr Uraa, Ph.D., Jry J. Ao, M.A., MIS/M Eis Tra, B.A., Ka Darr, B.A., Dio Rairz, B.A., a Jssica Haa I orr to vauat a assist with Caioria s orts to itrat SUD, MH, a priary car srvics, ioratio was coct throuh itratur rviws, wbiars, corcs, a cosutatios with stahors a itratio xprts. Withi th stat, UCLA couct survys, ocus roups, a vauatios o itratio piot iitiativs; aciitat othy tis o th Caioria Itratio Lari Coaborativ; a att othr ari coaborativs i our orts to athr a shar th ost currt rsourcs o itratio. Fro ths activitis, w hav ocut coo barrirs a aciitators, as w as y ssos ar ro throuhout th stat. Th i has a prorss i vopi toos a shar soutios or supporti itratio. Currt stratis or achivi itratio icu vic-bas practics (such as scri, bri itrvtio, rrra to tratt [SBIRT] a icatio-assist tratt [MAT]), w oraizatioa os, a tchooy. Proisi os a practics cotiu to r, but urthr rsarch is to tri whthr ths approachs ca iprov quaity a outcos whi ctivy ruci costs. Barrirs prsist with rar to hath car ror iptatio, spciicay ao patit/cosur coitiaity a ata shari practics, ctroic hath rcors (EHR) iptatio, wororc vopt s, a iaci itrat srvics. Ao coutis wori o itratio, practics a ui stratis vari. Lssos ar ro coutis ar hihiht i this chaptr. Cutivati ratioships ao itratio partrs, ivri stro arship, a achivi sta buy-i wr iportat actors i th succss o svra iitiativs. Thr cotius to b hih itrst i or traii throuhout th stat. A rat a o wor rais aha across th ras o poicy, rsarch, traii, a tchica assistac. Rcoatios at th poicy v to ss th ubr o pottia iicutis provirs ac icu: Dru Mi-Ca crtiicatio xpasio to icu priary car provirs (PCPs), iti th rstrictio o sa-ay physica a bhaviora Mi-Ca srvic bii, aowi crtiicatio o rasoaby-siz rsitia proras or Mi-Ca riburst, a aowi PCPs to b pac i rsitia tratt proras. I aitio to cotiu ivstt i rsarch, traii a tchica assistac, urthr rcoatios icu cotiui ivovt i coaborativ orts a piot projcts. Chaptr 2 31

36 I. Itrouctio Itrati substac us isorr (SUD) srvics (i.., prvtio, scri, itrvtio, a tratt) with hath car srvics is asib, is associat with bttr patit outcos a ruc ovra hath car utiizatio costs, a is rporty w urway i ay couity hath ctrs a othr ica sttis throuhout th Uit Stats. Howvr, athouh thr is ap ocutatio o bhaviora hath itratio, which by iitio icus both SUD a ta hath srvics, th ajority o th ocutatio ocuss o th itratio o ta hath srvics ito hath car sttis, a thr is itt ocutatio o th atur o itrat SUD a hath car srvics a bst practics or SUD srvic itratio with both ta hath a physica hath car srvics. Bas o bac ro stahors, particuary u to th currt stat o aairs atioay a statwi arou th iptatio o th Aorab Car Act a othr hath car ror rat poicis (scrib i th Prac), it is car that coutis ar i o tchica assistac a traii o topics rat to SUD itratio. W bi th chaptr by itiyi our objctivs oow by scribi th thos us to arss ach objctiv. W icu tai iis a ssos ar raw ro our ivstiatios, a cos th chaptr with a suary a rcoatios. II. Objctivs This chaptr arsss th ADP/UCLA cotract Doai 2, tit Hath Car Ror a th Itratio o SUD Srvics with Mta Hath a Priary Car. Bow ar thr objctivs* itii ur this oai that ar arss withi Chaptr Coct a issiat cutti ioratio o th itratio o SUD srvics with ta hath a priary car srvics 2. Cooriat a aciitat a itractiv oru (i.., Lari Coaborativ) with coutis a othr y stahors to iscuss SUD itratio barrirs a practica os 3. Couct cas stuy/piot vauatios *Not: raii objctivs ur cotract Doai 2 ar arss i Chaptrs 3 a 4. III. Mthos Th iis i this chaptr hav b athr by coucti utip ivstiativ thos a activitis i a ort to obtai a wi scop o ata a ioratio o th broa a copx topic o itratio. Activitis icu: itratur rviws, participati i atioa a statwi wbiars, atti itratio-ocus corcs, cosuti with y stahors a itratio xprts, coucti survys a ocus roups, aciitati th Caioria Itratio Lari Coaborativ, a vauati piot itratio iitiativs with sct coutis withi Caioria. 32 Chaptr 2

37 IV. Fiis Du to th various ivstiativ thos utiiz withi this chaptr, th iis ar oraiz i th oow way. Th cotract oai objctivs ar ot bow i orr to cary itiy whr to i th spciic outcos: A. Cocptua Rviw: Itratio o SUD srvics with ta hath a priary car srvics (Objctiv A) Why itrat car? Dii itrat car A rawor or itrat car: A upat Tai itratio : Fii a coo aua How itratio ca b achiv Evic-bas practics (EBPs) Oraizatioa os Usi tchooy to aciitat itratio Proisi practics/proras ro th i Coo barrirs a chas HCR iptatio Coitiaity: HIPAA a 42 CFR Hath IT: EHRs, EMRs, itroprabiity Fiaci, bii, a ruatios or itrat car, icui poicy chas Wororc iitatios i bri (u rviw i Chaptr 3) B. What is happi i Caioria (Objctivs B a C) 2012 Itratio Survy: a upat ro 2010 Caioria Itratio Lari Coaborativ (ILC) Goas a objctivs Mthos Topic suaris Couty cas stuy suaris Piot vauatios Othr statwi vauatios A. Cocptua Rviw: Itratio o SUD srvics with ta hath a priary car srvics Why itrat car? Bcaus iiviuas with SUD t to hav poorr hath outcos, ot associat with cooccurri chroic coitios, vopi bttr approachs to arss thir s is cssary. Micai patits with SUD hav ary twic th ica costs o patits without SUD (Boy t a., 2010), a Parthasarathy t a. (2003) ou a 54% ica cost savis wh patits with chroic ica coitios rciv itrat ica a SUD car. Aitioa rsarch Chaptr 2 33

38 has show that rat or poory cooriat car is ot associat with ativ outcos a hihr tratt costs ao SUD patits (Crot & Parish, 2012). I th ia rport subitt by UCLA or th Evauatio Srvics to Ehac th Data Maat Syst i Caioria projct (ECAL, FY ), it was show that: Substac us isorrs (SUDs) ar coo a costy; SUDs ar a ajor rivr o hath costs, spciay or Micai; SUD tratt srvics ca cut hath car costs; Most Caiorias who SUD srvics o ot rciv th; Scri a ary itrvtios ar o way to arss substac isus withi th broar hath car syst; a I spit o pottia bits o SUD itratio with priary car (PC), such itratio is ai bhi th itratio o ta hath (MH) srvics with PC. Cosistt with th trip ai o hath car ror propos by Brwic, Noa, a Whittito (2008), itrat car has th pottia to iprov patit car, hac hath outcos, a ruc costs. Th Aorab Car Act (ACA) a othr rct isatio hav crat w opportuitis or iprovi SUD tratt a prvtio by iti barrirs to accssibiity, crati w riburst a iaci chaiss, a hpi to bui th irastructur or bttr car ivry. Parity a th icusio o ta hath, SUD, prvtativ, wss, a chroic isas aat srvics as part o th 10 catoris o sstia hath bits that hath pas ust covr provi urthr support to this oa. Aitioa opportuitis hav co i th or o a icras phasis o wss a rcovry, car cooriatio, who-prso hath, a prso-ctr hath car. With th rapi approach o 2014 a th xpasio o th Micai popuatio, ioratio is to tri th status o SUD/PC itratio. I th past yar, thr has b uch activity i th vopt o itratio-rat tooits, rports, a wbsits. Rsourc wbsits icu th SAMHSA-HRSA Ctr or Itrat Hath Soutios (CIHS; which houss usu atrias a hosts ruar wbiars o topics rati to itrat bhaviora hath, a th Acy or Hathcar Rsarch a Quaity (AHRQ) Itratio Acay ( which cocts a copis pubish a upubish itratur o th topic o itratio. Th Stat Ror(u) wbsit ( provis a way or aiistrators, rsarchrs a provirs ro irt stats to couicat with o aothr o hath ror vopts, icui ipacts o bhaviora hath a car cooriatio. Th Natioa Couci or Couity Bhaviora Hath ( cotius to host rvat a iorativ wbiars o topics rvat to itratio. Now or tha vr, a wath o atioa rsourcs a support is avaiab or thos wori o itratio. Shari o soutios a ssos ar is aso hpi to pav th way or or itratio projcts to achiv succss. Th coctiv issiatio o procurs, worows, chcists a ors wi accrat th procss o itratio so that ach oraizatio ot rivt 34 Chaptr 2

39 th wh. Staar tpats a toos ca b aapt a taior to ach oraizatio s uiqu s. Dii Itrat Car A upat rawor or itrat car As th i cotius to ov orwar i ipti SUD/MH a hath car itratio, tai rawors hav b vop a ri i rspos to th prousio o irt itratio os that xist. Th SAMHSA-HRSA Ctr or Itrat Hath Soutios (CIHS, 2013) ras a issu bri scribi a Staar Frawor or Lvs o Itrat Hathcar, which aapts a prvious rawor propos by Dohrty, McDai, a Bair (1996), icorporati wor ro Bout (2003) a Cois, Hwso, Mur, a Wa (2010). Th w rawor copasss six vs o bhaviora hath a hath car itratio, ur a cotiuu rai ro cooriat car to co-ocat car a iay itrat car. This rawor riorcs th act that iiviuas si priary car o ot hav isoat probs iit to oy SUD or oy ta iss, but ot hav issus that co-occur. Hc, th rawor copasss bhaviora hath a is at to icu both SUD a ta hath srvic itratio. Prviousy, th rawor copris iv vs (Dohrty t a., 1996) rai ro iia coaboratio to cos coaboratio i a uy itrat syst. Whi th irst thr vs o th o rawor ar rtai, th wr rawor as urthr rit as practics approach hihr vs o itratio (SAMHSA-HRSA Ctr or Itrat Hath Soutios [CIHS], 2013). I aitio, thr ar carr iitios o y ts that ti tothr vs at ach itratio sta. Ths six vs o coaboratio/itratio ca b us by oraizatios to itiy thir currt sta o itratio. This ioratio wou th b hpu i ori oas or rachi th xt sta, or aocati rsourcs to iprov quaity at th currt v o itratio. Fiay, it shou b ot that ach v cos with its ow st o avatas a wasss, scrib i th SAMHSA-HRSA CIHS rport. A staar rawor wi cotribut a basis or itratio or oraizatios, but this approach, by o as, shou b cosir o siz its a. Suary scriptios o ach v oow. Cooriat Car Lv O: Miia Coaboratio. At this v, car is at its ast itrat accori to th rawor. Couicatio btw bhaviora hath provirs a priary car provirs is ow a thy oprat i sparat aciitis with sparat systs. Lv Two: Basic Coaboratio at a Distac. Prioic couicatio btw provirs irtiats this v ro th irst, athouh physica a systs sparatio is aitai. Bhaviora hath a priary car provirs ay couicat occasioay about shar patits a viw ach othr as rsourcs i provii cooriat car. Chaptr 2 35

40 Co-Locat Car Lv Thr: Basic Coaboratio Osit. Cosr proxiity u to co-ocatio o bhaviora hath a priary car provirs aows or or rqut couicatio btw th. Provirs ay bi to i part o a arr ta, a rrras ar or iy to b succssu u to ruc istac btw provirs i th sa aciity. Howvr, bhaviora hath a priary car systs ar sti pt sparat. Lv Four: Cos Coaboratio with So Syst Itratio. Bhaviora hath a priary car provirs bi to shar so systs, ai to ratr itratio. Icrasi cosutatio a coaboratio occurs btw provirs as thy ar ach othr s ros a shar ioratio to hp patits with utip copx hath issus. Itrat Car Lv Fiv: Cos Coaboratio Approachi a Itrat Practic. By this v, bhaviora a priary car provirs couicat rquty a ruary a hav start to uctio or as a ta, activy si soutios to itrat car or or o thir patits. Crtai barrirs sti xist, but wor is bi o to crat a or uy itrat syst (such as throuh a itrat ica rcor). Lv Six: Fu Coaboratio i a Trasor/Mr Practic. Practic cha is this v; systs a pop ar b tothr so that thy oprat as o si practic a ar rcoiz as such by both provirs a patits. Th hath syst appis pricips o who hath i trati thir tir patit popuatio. Tai Itratio : Fii a coo aua I orr to copass th broa ra o itratio activitis occurri i SUD, MH, a priary car sttis, th wori iitio o itratio us throuhout this rport icus ay typ o routi or staar SUD/MH scri, rrra, itrvtio, or tratt couct i a priary car stti; ay priary car srvics couct i a SUD/MH stti; biirctioa rrras; a/or th icusio o SUD/MH priary prvtio or rcovry support srvics i priary car sttis. To bttr scrib spciic xaps o itratio, othr trs ar rquty poy, but cousio sti xists rari coo trs surroui th cocpt o itratio. Th ra tr itratio ot tas a wi varity o ors, a siiar rat trs ca a irt this pi o th cotxt a who is usi th tr. For istac, Butr t a. (2008a) scrib th trs itrat car a coaborativ car i itrchaab trs, both o which riv ro ary rsarch couct by Way Kato a coaus, who brouht tothr utip acts o car to hp trat prssio (Kato t a., 1995). Usi a istictio propos by Strosah (1998), th irc ca b usuy cocptuaiz as 36 Chaptr 2

41 bhaviora hath wori with priary car i coaborativ car, costrast with bhaviora hath wori withi a as a part o priary car i itrat car (Cois t a., 2010). Bcaus itratio ivovs brii tothr cotributios ro irt is a prspctivs, cossus o basic triooy wou ai ths roups i wori with o aothr. A cossus-bas xico o trs rati to bhaviora hath a priary car itratio pubish by th Acy or Hathcar Rsarch a Quaity (AHRQ) attpts to i this (P & Natioa Itratio Acay Couci [NIAC], 2013). Accori to this xico, th y t o itrat car is th prsc o osit tas wori tothr, with othr iportat cosiratios bi oraizatioa itratio a ia to couity rsourcs. Th pubicatio aso ists various atitus o itratio to cosir, proposi that itratio ca appy to proras, systs, tratt a payt, a o which shou iay b ai i orr to srv patit s ost ctivy. Oc a coo cossus ca b rach about th iitios o ths trs, thy ca b us a bttr urstoo across iscipiary bouaris. Th irt cuturs a aua us by th irt is that ar itrati ar ot cit as a barrir (s Coo Barrirs a Chas). How itratio ca b achiv Evic-bas practics (EBPs) As provirs cotiu wori o itrati bhaviora hath a priary car, vicbas practics (EBPs) ca pay a iportat ro i th procss by brii rsarch-support itrvtios ito ciica practic to hp iprov outcos (Gasr-Ewars & Rawso, 2010). Th sct xaps o EBPs scrib i this sctio ar cooy us i itratio iitiativs, as thy ar w suit or ivry i priary car a othr sttis outsi o spciaty car. Th suaris provi hr hav b riv ro rct rports a tooits. Scri, Bri Itrvtio, a Rrra to Tratt (SBIRT) For ay itratio proras, scri, bri itrvtio, a rrra to tratt (SBIRT) is a y practic copot us to arss probs with substac us a othr hath bhavior issus. Th procss o SBIRT is si to icorporat th oowi stps or itrat prvtio a car: (1) assss iiviuas or SUD probs usi staariz toos, (2) itiy th v o tratt, (3) icras iiviua awarss a otivatio or bhavior cha throuh bri covrsatio, a (4) provi a rrra to spciaty car i th v o tratt is svr ouh. O o th avatas o SBIRT is that it ca b provi i a varity o hath car sttis; SAMHSA s SBIRT Iitiativ, spai svra stats across th atio, has ostrat th ctiv itratio o SBIRT or SUD i sttis such as FQHCs, HIV a STD ciics, sior ctrs, triba ciics, a spciaty hath ciics, to a a w (Substac Abus a Mta Chaptr 2 37

42 Hath Srvics Aiistratio [SAMHSA], 2013). SAMHSA ou that SBIRT to siiicat ructios i both substac us a its associat hars, a that SBIRT ca b cooicay viab a sustaiab (SAMHSA, 2013). Th U.S. Prvtativ Srvics Tas Forc rcos scri a bri cousi itrvtios or auts a 18 or or or acoho isus (USPSTF, 2013). SBIRT provis th opportuity to itiy a hp patits with substac us probs i priary car sttis that ay othrwis o uarss. As a practica ai to ths itratio orts, SAMHSA-HRSA Ctr or Itrat Hath Soutios provis a wi copiatio o rsourcs or us i couity hath sttis ( Appropriat sctio o istruts pays a ro i th aout o ti it tas to aiistr th scri procss. Tai ito cosiratio th asurt proprtis o th istruts as w as th ti costraits o oprati i a priary car virot, th AUDIT, AUDIT-C, a si-it scrs wr rco or us i scri or th spctru o acoho isus i priary car (AHRQ Coparativ Ectivss Rviw Nubr 64, Juy 2012). Othr vaiat scri istruts that ar cooy us ar th CAGE a th ASSIST (SAMHSA, 2013). Wororc a riburst or SBIRT ca b aothr barrir to its ass iptatio. For urthr iscussio, s th Coo Barrirs a Chas Sctio. Motivatioa Itrviwi (MI) Motivatioa Itrviwi (MI) is a cousi approach us to proot bhavior cha throuh xpori a rsovi abivac. It ca b us to hp patits with MH, SUD, iabts, a othr chroic coitios by icrasi thir awarss a otivatio to a positiv bhaviora chas rari thir hath. Th procss is oa-riv a coaborativ; it ocuss o patits ow vaus, bis, a wishs rathr tha bi ictat top-ow by th provir (Roic & Mir, 1995). Bri MI itrvtios ca b ivr throuh SBIRT i hath car sttis, a vic supports th us o MI with patits who hav bhaviora hath issus (Bar & Habri, 2002; Britt, Huso & Bapi, 2004; Mir & Roic, 2002; Roic, Mir, & Butr, 2008). MI itrvtios hav aso b show to ruc hazarous rii ao prss auts i outpatit psychiatric sttis (Satr, Ducchi, Lichtachr, Stri, & Wisr, 2013). To urthr coura th us o MI i hath car sttis, th ctiv traii o provirs i MI sis is iportat. Rsarch o MI traiis has ray yi positiv outcos a has ocus o isoati irt copots o succssu traii a succssu iptatio o MI as part o routi ciica practic (Maso, Loio, & La, 2009; Söru, Maso, Ruba, & Nis, 2011). 38 Chaptr 2

43 Micatio-Assist Tratt (MAT) Us o icatio-assist tratt (MAT) or aictio shows rat prois or th itratio o aictio tratt srvics ito priary car. Th Arica Socity or Aictio Mici (ASAM) has rcty pubish a copiatio o rports o th currt stat o MAT or opioi pc, icui systatic rviws cary ostrati th ctivss o thao, buprorphi, a atrxo or opioi pc (Arica Socity o Aictio Mici (ASAM), 2013). O ths rus, atrxo a buprorphi ar currty th ocus o uch itrst rati to SUD a hath car itratio bcaus ui thao, thy ca b prscrib by physicias i oic sttis. This provis a way or patits to rciv SUD tratt i th sa pac thy rciv othr ica car. Dspit th vic i support o MAT, ow aps about its bits a appropriat us, issus with icatio costs a riburst, a th or ratr wororc traii a cotribut to its ur-utiizatio. I orr to bra throuh so o ths barrirs, cotiu orts towar ucatio a traii ar. I aitio, ratr MAT aoptio ca b aciitat by ui th poicis a ica irastructur to support it (Kus, Abraha, & Osr, 2011; Roa, Abraha, & Kus, 2011). Oraizatioa os Ur hath car ror, w oraizatioa os ar ri a aii proic as ways to trasor car so that is bttr itrat, or coprhsiv, a or rsposiv to th s o patits. Exaps o ths os ar hath hos, patit-ctr ica hos (PCMHs), a accoutab car oraizatios (ACOs). Hath Hos a Patit-Ctr Mica Hos Th priary car hath ho o was vop as a way to arss th s o patits with utip copx coitios. A provisio o th ACA crat a optio o stabishi hath hos, which provi hac Micai riburst or srvics to iiviuas with chroic coitios, icui ta hath or SUD. Car is oraiz to b hoistic a tabas, with a xpicit ocus o th itratio o bhaviora hath a priary car. Ur ACA provisios, thr is aso a optio to crat bhaviora hath-bas hath hos or patits with srious ta iss or SUDs (SAMHSA-HRSA CIHS, May 2012). Bhaviora hath hos ca b vauab i srvi th s o ths patits bcaus ay ay aray rciv th ajority o thir car i bhaviora hath sttis rathr tha priary car. Rarss o thir ocus, hath hos ust sur that th u array o srvics is avaiab a cooriat, which ay iprov both outcos a cost or hath-ho patit popuatios. A siiar cocpt, th patit-ctr ica ho (PCMH) is ot xcusiv to Micai a thror ca srv a broa popuatio. Accori to th Natioa Coitt o Quaity Assurac ( which provis rcoitio to PCMHs that t its pubish st o staars a critria, a PCMH is i as a hath car stti that aciitats Chaptr 2 39

44 partrships btw iiviua patits, a thir prsoa physicias, a wh appropriat, th patit s aiy. Hath ioratio tchooy (hath IT), patit ristris, a hath ioratio xcha pay a ro aciitati car i th PCMH, a a car ivr ais to b cuturay a iuisticay appropriat. I a PCMH, a priary car provir os ot oprat ao but wors as part o a ta cooriati car or th patit s who hath s. Th Uivrsity o Misota has vop a parai cas o th PCMH to hp urthr cariy what aturs ar iportat i ii what thy ar (P & Otah, 2010): - Patits/citizs itiyi a accssi a priary car practitior a ta as irst cotact or a w hath cocr or ooi hath/iss s - Routiy acti ro a patit-ctr (hc who-prso) oritatio - Aii or popuatio hath outcos - A practic ta taior to th s o ach patit a situatio - Carryi out practic-bas car cooriatio / car aat - Cooriati with th hath car ihborhoo o othr tas, practics, a couity rsourcs shap arou th s o spciic patits - Patits activy participati i quaity iprovt (QI) a practic vopt uctios co-crati th practic a shapi its prorac - Dostrati capacity or cotiuous ari a practic iprovt - Support by a sustaiab busiss o a aiistrativ / arship ait - Accoutab to achivi a spciic st o ciica, xpric, a iacia outcos appropriat to th popuatio ur th car o th practic Accoutab Car Oraizatios (ACOs) Th cocpt o th accoutab car oraizatio (ACO) oriiat ur Micar i orr to iprov quaity a ruc costs or th chroicay i throuh bttr car cooriatio ( ACOs ar ar twors o hath provirs, octors, a hospitas that cotract tothr to provi cooriat car to thir patit popuatio. Throuh various shar savis arrats, ACOs ar ab to shar i ay cost savis thy rat with Micar, athouh crtai arrats ivov or ris a cou tai iacia osss to th ACO. I cotrast with hath hos a PCMHs, ACOs ar sti ary Micar bas, athouh th ACO cocpt is bii to ai th itrst o corcia hath pas. Th thr-yar CMS Pior ACO ostratio projct is si to aow ACO Piors to tst out w payt os to s whthr thy ca ruc costs whi iprovi quaity o car. It provis ictivs or payrs a provirs to support ratr car cooriatio a ruc ucssary spi, whi aowi a partis who ar accoutab or th cost a quaity outcos to shar i th possib savis that rsut. Thirty-two Piors si up to participat i th prora, but i icui two i Caioria t th prora or atrat arrats atr th irst yar, citi cocrs about iacia ris ( 40 Chaptr 2

45 ACOs rai a hot topic u to thir prois o iprovi car whi ruci costs. Bcaus o thir phasis o itrati srvics, thy provi a pottia opportuity or bhaviora hath. A ar boy o vic supporti thir us has ot yt b vop, but ovr ti a st o bst practics ay r. Usi tchooy to aciitat itratio Thr ar ay ways that tchooy ca b us to aciitat itratio. Nw tchoois a th ass poyt o xisti tchoois xpas th abiity o provirs to ot oy shar ioratio with ach othr across iscipis, but aso to oitor a trac patits a couicat iportat vopts with patits rari thir hath. Opi th is o couicatio throuh tchooy ca hp icras patit at as w as put patits i ratr cotro o thir hath. Thath: Tici a Tpsychiatry Thath has th pottia to trasor car by xpai th sttis ro a to which it ca b ivr. Coucti tpsychiatry via vio corci ca b asib a has a varity o bits, icui icras accss to car a aciitatio o spciaty cosutatio (Hity, Mars, Urss, Yows, & Nsbitt, 2004). Bcaus o ths bits, it is a attractiv ia or oraizatios itrati SUD a PC srvics, particuary cosiri th opportuity to us thath or cosutatio with bhaviora hath spciaists. Thath ca aciitat provir iscussio about shar patits i aitio to its us i couicati with a ucati patits ro aar. Rsarch rviws show prois or th bits o viocorci a thath, but iportat iitatios ust b acow. Vio corci ca hp icras accss to psychiatric srvics or patits i rura aras, but oy crtai roups o patits bit ro thath, whras th bits ar ucar or othrs. Bor rcoi thath or a patits, or rsarch is to tri which roups wou b ost hp by thath a which wou b bttr srv throuh traitioa ac-to-ac car (Nora, 2006). Furthror, costs p o th typ o tchooy us a how uch us is xtract ro th iitia ivstt i quipt; a bra-v poit shou b aticipat i orr to sur iacia asibiity (Hyr & Gaur, 2003; Nora, 2006). Hath Ioratio Tchooy (HIT) a Ectroic Hath Rcors (EHRs) Us o hath ioratio tchooy a EHRs is xpai (Ar-Misti, Bats, & Jha, 2013; DsRochs t a., 2013; Hsiao t a., 2013), aciitat by ui ro th ra Maiu Us prora, which ors ictivs or provirs to trac a shar ciica ioratio, icui so bhaviora hath ts itrouc i Sta 2 (Tai t a., 2012). Th procss o ipti a itrati a EHR ca b iicut (s Coo Barrirs a Chas sctio). Howvr, th uy uctioa itratio o SUD a hath car srvics is iicut i ot ipossib without itratio o th ica rcor syst. Hath IT aows Chaptr 2 41

46 bttr aat a traci o patit ata, which ca ot oy hp iprov iiat patit car, but aso aows oraizatios to vop a ajust o-tr quaity iprovt proras. Proisi Practics/Proras ro th Fi Provirs across th coutry hav b piot-tsti proisi practics to itrat ta hath a SUD srvics with priary car. Dspit barrirs, so hav b ab to ctivy itrat irt srvics. Ioratio o various itratio iitiativs has b obtai ro corcs a wbiars att throuhout th yar, with th hihihts prst hr. For a u isti o ths corcs a wbiars, s Appix 2A. This sctio provis suaris o proras that ar xaps at utip irt vs o itratio, iscusss what uiqu or y iovatios ar us by ths proras, why thy ar show to b proisi, a iitia outcos that support thir icusio. I so cass, ipt vauatios a rpicatio o ths os wi b to bttr stabish vic or th. Uivrsity o Washito TEAMcar Mo TEAMcar is a itrvtio vop by th Uivrsity o Washito to provi cooriat car or patits with chroic isas. Patit-ctr utiiscipiary ta-bas approachs ca hp ovrco ay barrirs ac by iiviuas with utip chroic hath coitios, ai to or cost-icit car a iprov patit outcos. For patits with prssio, iabts, a/or coroary hart isas, th TEAMcar itrat uti-coitio coaborativ car prora, ryi o cooriat car aat btw th patit, th priary car provir, a bhaviora a ica hathcar spciaists (Kato t a. 2010, Cichaowsi 2011, Vo Kor t a., 2011, Davyow t a. 2013, Kato t a., 2012, McGror t a. 2011, Li t a. 2012), ca a to iprov quaity o i, ruc isabiity rat to activitis o aiy ivi (Vo Kor t a. 2011), a ructios i a outpatit costs (Kato t a. 2012). Giv that TEAMcar has ostrat icacy or coorbi ra ica a bhaviora hath coitios i a couity-bas stti, this iovativ o ay b a ctiv approach to provii cooriat car or th tratt o co-occurri substac abus a chroic ica coitios, which r so o th ost costy, chroicay ursrv, a chai patits i th hath car syst. Furthr rsarch is to tri whthr this a othr xisti os o itrat car ar ctiv or th tratt o SUD. VA Mo or Trati SUD a Coorbi Chroic Pai Misus o prscriptio opiois is a ajor pubic hath prob rsuti i substatia orbiity a ortaity. Th Vtras Aairs (VA) ciics i Phiaphia, PA (Wir, 2007), a Abuqurqu, NM (Pa, 2012), hav ta stps to provi or patit-ctr a itrat srvics to arss th ica a psychiatric coitios that uri prscriptio opioi isus bhaviors a copicat thir tratt (Gaahr, 1999; Jw, 2011). Thy hav stabish spciaiz proras that hav brouht tothr ica, psychiatric, SUD, a pai 42 Chaptr 2

47 spciaists to oitor a trat patits rcivi chroic opioi thrapis. Ths iitiativs hav show proisi rsuts, icui iprov patit ahrc to opioi tratt pas (Mhai 2009; Wir 2007), succss i tti opioi-pt patits to bi a aitai buprorphi tratt (Pa, 2012), ructios i patits rcy roo utiizatio, ructios i th ubr o uschu priary car visits, savis i pharacy costs, iprov priary car physicia oitori o patits rcivi opioi thrapis, a hih provir satisactio (Wir, 2007). SBIRT Iitiativ: Oro Mo As part o SAMHSA s atiowi SBIRT Iitiativ, which has to th auch o svra piot SBIRT traii proras across th coutry, SBIRT Oro has vop a o to trai rsit physicias to us SBIRT or tcti a arssi probs with acoho a substac isus i priary car. By wori cosy with th stat Micai prora a Micar itriaris, Oro Hath a Scic Uivrsity (OHSU) was ab to obtai riburst or SBIRT srvics (s Appix 2A, Wbiar 28). Aothr iportat copot to th prora s iptatio si is aiu itratio o th SBIRT procss ito th EMR syst or or strai ocutatio a bii (Much, Jarvis, Bovra, Hara, Hays, & Wi, 2012). OHSU has provi traii to rsit physicias i sv priary car rsicy ciics a is pai to trai aost 400 utur priary car physicias o th SBIRT approach. Th oa o th iitiativ has b to vop usab curricua a spra th aoptio o SBIRT traii i rsicy proras (Pri, Kowachu, Myrs, & Sa, 2012). As a rsut, SBIRT Oro s curricua a atrias, icui scri ors, ciic worows, ciic toos, a riburst o a ostratio vios, hav a b a ry avaiab o th prora s wbsit. Whi a stro cas has b a or th iportac o icorporati SBIRT traii ito rsicy proras (Much, Jarvis, Hays, Varsoot, & Wi, 2013), utur rsarch a outcos ata ar to ju th succss o this tchiqu. Issus to cosir ar whthr th approach wi rai sustaiab without rat support, a whthr th SBIRT traii curricua vop throuh th iitiativ wi b us to ipt siiar proras across th coutry (Pri t a., 2012). Tarzaa Tratt Ctr Th Tarzaa Tratt Ctr (TTC), bas i Los As Couty, Caioria, provi a prstatio o a wbiar sayi thy ai to provi car that is patit-ctr, ta-bas, a cooriat. As a SUD provir that has itrat coprhsiv srvics, icui MH a priary car, TTC rports provii o poit o accss or its patits hath car a bhaviora hath s. Throuh ra, stat, a ouatio rats; Micar a Mi-Ca -or-srvic a aa car; cotracts with coutis; a aa car cotracts with a Chaptr 2 43

48 ajor privat isurac carrirs, TTC rports bi ab to rciv ribursts or its ay itrat activitis (s Appix 2A, Wbiar 38). Bay Ara Aictio Rsarch a Tratt (BAART) Th Bay Ara Aictio Rsarch a Tratt (BAART) prora is a coprhsiv SUD srvic provir that has wor to provi MAT, priary car, a ta hath srvics to patits throuh its 20 ciics ocat i 5 stats. I th Southast BAART ciic ocat i Los As, patits ar uivrsay scr or thir SUD/MH/PC s. Priary car a SUD tratt is ha i-hous, whi patits ar rrr to a arby ta hath ciic or urthr vauatio a car throuh ora arts. BAART rports bi ab to ruc th iihoo o patits ai throuh th cracs u to isjoit car a thrby ruc ucssary rcy roo us a hospitaizatios by provii couity-bas cooriat car (s Appix 2A, Wbiar 23). Missouri CMHC Hath Ho Bii i 2012, Missouri ba iptatio o th Couity Mta Hath Ctr (CMHC) Hath Ho o. Th objctiv o this systs-v cha is to iprov patit xprics a hathcar outcos ao Micai iib patits with a MH coitio or SUD a at ast o othr chroic ica coitio (s Appix 2A, Wbiar 40). Th Hath Ho o ris o a ta o provirs, icui th Hath Ho irctor, urs car aars, th PCP, a bhaviora hath spciaists to provi coprhsiv car aat. Ovr th cours o th irst yar o iptatio, Missouri s CMHC Hath Hos rport ructios i ubrs o hospitaizatios, a cost savis i ruc ER aissios a Micai spi. Accori to th Dirctor o Missouri s Dpartt o Mta Hath, ys to th succss o this prora hav icu stro couicativ twors, EMR iptatio, a rcoitio o th aout o tchica assistac a traii rquir or th provirs (Pars, Foy, Graha 2013). Sau Faiy Hath Ctr Th Sau Faiy Hath Ctr i Coorao is a FQHC itrati bhaviora hath ito priary car. As a NCQA-rcoiz patit-ctr ica ho, th Sau o icus such copots as co-ocatio, tas utiizi both PCPs a BHPs who accpt shar rsposibiity or patits, a a shar ica rcor syst btw PCPs a BHPs, whri both ca accss ach othr s prorss ots (Auxir, Fary, & Sirt, 2011; s Appix 2A, Wbiar 4). Th bhaviora hath provirs hav stro raist traii bacrous a ar o ca to provi srvics to physicias a patits. Its sourcs o ui icu th Mta Hath Expasio Grat ro HRSA; partrship with a oca hath 44 Chaptr 2

49 istrict; partrship with oca ta hath ctrs; coitt o its ra oprati us; rats ro privat ouatios; aocatio o pr br, pr oth (PMPM) rvu; a traii proras (post-ocs, itrs, stuts, tc. as a way to provi car at owr cost whi aso icrasi ucatioa opportuitis or worrs). Coo Barrirs a Chas As part o UCLA s ooi orts, w ar ocuti y barrirs to itratio that hav b xprss i wbiars a iscussios with stahors. Ovr th ast yar, hath car ror iptatio, coitiaity, hath ioratio tchooy, wororc issus, iaci, a ruatios hav r as aras o particuar cocr. HCR iptatio Traitioay, bhaviora hath practitiors hav oprat ur uatay irt srvic ivry procsss copar to thir priary car coutrparts, ot crati iscocptios o ach party s srvic ivry ro a vau to th patit. Ths traitioa sios o car aso cotribut to coo iscocptios about th atur o SUD its by priary car sta. Th SAMHSA-HRSA Ctr or Itrat Hath Soutios has a oi rsourcs avaiab or provirs to ucat thsvs o ctiv stratis to cobat cutura chas (s I this past yar, th i prouc ay wbiars that at with cutura a couicativ barrirs ihrt withi historicay sparat hath iscipis. Fro th istict triooy us by ach iscipi to basic itrprsoa couicatio that occurs o a aiy basis, practitiors hav xprss xprici so pushbac ro thir sta i rspos to th w prso a w ros withi th PC a/or MH a BH oais. Fro bhaviora hath provirs, o coo cocr rari itratio is th trucatio o ti a accssibiity to th patit. O BH provir ots, I ca t just wa i o a patit; I i to spt or ti with patits I o t i itrruptios, this is t th way I was trai (s Appix 2A, Wbiar 4: Covrsy, so PC provirs viw BH srvics i a PC stti as or o a covoutio o hath car srvics rathr tha a strai or o car. As o PCP ots, I o t i othr pop si y patits; th BHP sows ow; I ray oo with psych stu a I o t hp (s Appix 2A, Wbiar 4: Provirs who hav xpric cutura pushbac hav avocat or arship to isti i thir sta th ia that chroic physica iss is ot coorbi with chroic ta hath probs, which ca act th iity o th tratt o both issus i thy ar ot trat i ta (s Appix 2A, Wbiar 32: Wh th issu o hath is ra i a hoistic ar a is cary stat by arship as th oraizatioa staar or srvic ivry, it is asir or sta to s thsvs as part o a ta whos uty is to itiat patits ra o isss rathr tha to cotiu to a i a sio o o car. Chaptr 2 45

50 Coitiaity: Issus arou 42 CFR I aitio to cutura ircs, PC a MH/BH ica iscipis hav aso oprat ur irt privacy a ioratio-shari critria bas upo th srvics thy ivr a th typ o prsoa hath ioratio (PHI) thy ha. Evry oraizatio that has so or o PHI is subjct to ra privacy uiis ur th Hath Isurac Portabiity a Accoutabiity Act o 1996 (HIPAA). HIPAA provis a oor or iiu privacy staar or iiviuas PHI that a covr titis ust copy with; howvr, 42 CFR Part 2 as strictr coitiaity rquirts wh patits bhaviora hath ioratio is icu, spciicay ioratio rati to acoho a ru tratt a aythi that itiis a patit (ircty or iircty) as havi a currt or past ru or acoho prob. 42 CFR Part 2 privacy rstrictios appy to oraizatios, uits, or iiviuas that ar ray assist a ho thsvs out as provii, a actuay provii, substac us isorr iaoss, tratt, or rrra to tratt. For a or copt ovrviw o th Co o Fra Ruatios, Tit 42, Sctio 2 (42 CFR), pas rr to th La Actio Ctr s wbsit or rvat wbiars a ocuts o 42 CFR at: Th ost cooy cit issu that provirs hav xprss rari 42 CFR is that it ihibits th shari o hath ioratio that is critica to itrat or cooriat car. Howvr, provirs ay rciv writt cost ro patits to shar SUD ioratio (s Appix 2A, Wbiar 26: t=a&= ) a ay us Quaii Srvic Oraizatio Arts (QSOA) to aow or ioratio shari across oraizatios or so purposs. ( Hath IT: EHR Iptatio a Privacy A rct atioa survy o priary car provirs a spciaty car provirs utiizatio o ctroic hath rcor (EHR) systs ou that basic aoptio o EHR systs ha ris to 34% by March 2012 (DsRochs, Aut, Paitr, t a., 2013). O o th rivi actors bhi th icras usa o EHRs i PC sttis is th iacia ictiv put ito pac throuh th Hath Ioratio Tchooy or Ecooic a Ciica Hath (HITECH) Act, which provis ra subsiis or ictiv payts to support th aiu us o hath ioratio tchooy (HIT). Howvr, o o th ajor issus hiri EHR aoptio is that th HITECH Act i ot quaiy bhaviora hath oraizatios to rciv aciity ictiv payts that wou hav aow BH oraizatios to u EHR iptatio iitiativs (You, 2012). Micha Larir, th Natioa Couci s Vic Prsit o HIT a Stratic Dvopt, has stat that Without ths ra ictiv payts, bhaviora hath oraizatios ar uairy rstrict ro achivi th Trip Ai o iprovi th patit xpric o car, iprovi th hath o th popuatios, a ruci th pr capita cost o hathcar (You, 2012). Aothr ara o cocr cit by BH provirs as a barrir to itrat car is th shari o 42 CFR covr ctroic PHI ao irt typs o sta. Whi havi accss to a EHR syst ca strai a aciitat cooriat car, it is iportat to ow who is aow 46 Chaptr 2

51 accss to crtai ioratio a who is ot. SAMHSA piot projcts ar currty tsti th us o taata tai that propts ciicias to s patit cost bor iscosi spciic ata ts to aothr hathcar provir ("HHS, VA ostrat," 2012). SAMHSA a th VA hav rport say a scury trasitt a oc patit s substac abus tratt rcors ta with privacy taata ro o EHR to a irt EHR syst, but th u rsuts ro th piot projct hav yt to b ras. Whi this tchooy ay vtuay aow or uac privacy cotros or iiviua pics o patit ata, i th ati provirs ca ipt bat ata-shari soutios usi 42 CFR copiat cost ors (s prior sctio). Wororc iitatios Shortas o sta that ar aquaty trai to ha SUDs i a itrat stti prsist. This is a wors by th act that th oy BH sta FQHCs ca bi Mi-Ca or ar psychiatrists, psychooists, a LCSWs, a thy rport a shorta o worrs i ths prossios. Aowi othr typs o provirs to bi i ths sttis, icui LMFTs, wou aviat this situatio. S Sctio B a Chaptr 3 or or o wororc issus. Fiaci, bii, ruatios or itrat srvics, icui poicy chas I 2014, SUD covra throuh isurac pas, hac Mi-Ca bits or SUD srvics, a th Mi-Ca xpasio wi cobi to crat uprct w opportuitis to xpa SUD srvics i th stat. A ubr o chas a barrirs rai, howvr, icui: Th Mi-Ca carv-out: Priary Car aciitis typicay o ot hav Dru Mi-Ca crtiicatio, which is obtai throuh a irt procss (a uti rcty, a irt partt). Priary car s iabiity to bi or SUD srvics itrrs with orts to itrat such srvics withi priary car aciitis. Mi-Ca sa-ay srvic bii rstrictios: I Caioria, priary car provirs caot bi Mi-Ca or or tha o srvic o th sa ay. Thror, v i Mi-Ca bii cos or scri, bri itrvtio, a rrra to tratt (SBIRT) wr to b activat, priary car provirs si a patit or a ica visit wou ot b ab to aso bi or SBIRT or othr bhaviora hath srvics. Furthror, priary car provirs wi iy b ructat to provi SBIRT without havi aquat bhaviora hath sta avaiab to ha patits itii as i bhaviora hath srvics (wororc issus ar iscuss i Chaptrs 2 a 3). Crtiicatio o Dru Mi-Ca SUD tratt proras: Giv rsourc rstraits, it ay b chai or DHCS to wy crtiy ouh Dru Mi-Ca proras i ti or Th coutis hav xprss itrst i wori with DHCS to assu this uctio. Giv rait, thy hav a itrst i trii which proras rciv crtiicatio a cotracts i thir coutis. Chaptr 2 47

52 Istitutios or Mta Disas (IMD) xcusio: Rsitia aciitis with or tha 16 bs caot b riburs throuh Mi-Ca. Th purpos o th poicy is, i part, to avoi warhousi patits i ar stat hospitas (NAMI, 2013). Howvr, th rstrictio wi isquaiy a ubr o SUD rsitia provirs, which i tur wi hav a ativ ipact o syst capacity. Acotay, so proras circuvt ths rus by icsi utip sa uits sparaty, v i thy ar ocat o a shar capus, but this uoubty crats a ratr bur o both th stat a proras uri th crtiicatio procss. A soutio that aows crtiicatio o rasoaby siz xisti proras without rsuti i warhousi is. Loss o Micai covra u to icarcratio: Micai bits ar ot triat or icarcrat ors, which ca caus probs wh th iat is ras. Suspi rathr tha triati Micai bits or ors a aii Micai outrach a rot orts at iats ar rco soutios (Cuar & Cha, 2012). At this writi, AB 720 (Sir), which wou rquir asurs ao ths is, ha pass th Assby a has b rrr to th Sat Appropriatios Coitt. S Chaptr 1 or or o this topic. Iabiity to pac physicias i rsitia tratt proras: Havi physicias o sta at rsitia proras wou aciitat itratio a cooriatio with priary car, but this is currty ot aow. As o this writi, AB 395 (Fox) wou aow rsitia SUD tratt proras ics by DHCS to icu physicias o sta as part o a utiiscipiary ta. Lssos Lar I th past yar, th i has a prorss i ii aua a vopi rsourcs to support itratio. Currt stratis or achivi itratio icu EBPs, oraizatioa os, a tchooy, a proisi os tsti w practics cotiu to r. Howvr, urthr rsarch is to tri whthr ths approachs ca iprov quaity a outcos whi ctivy ruci costs. Siiicat barrirs to itratio cotiu to prsist withi th i. Ovr th ast yar, iscussios hav cotiu arou th vopt a chas rat to hath car ror iptatio a cutura issus across th hath car i, coitiaity, hath ioratio tchooy, wororc vopt, iaci itrat srvics, a ruatio rquirts a poicy barrirs withi th currt syst. Ths issus rquir ooi iscussio a stat-v arship to assist a aciitat coutis a provirs to aviat throuh th copxitis o ivri itrat car. This is a pri ti or rviw a vauatio o currt poicy arou substac us a bhaviora hath srvic ivry. 48 Chaptr 2

53 B. What is happi i Caioria Caioria Couty Itratio Survy 2012 As a oow-up to th 2010 SUD/PC itratio survy rport i UCLA s ECAL rport, this 2012 survy o couty acoho a othr rus (AOD) aiistrators assss th status o itratio orts i Caioria coutis ao couty-oprat or cotract SUD, ta hath, a priary car provirs i orr to tri prorss a tchica assistac s to prpar or hath car ror. Rsuts sust that ro 2010 to 2012, thr has b a icras i th ubr o coutis wori o or pai iitiativs to itrat SUD scri, itrvtio, a rrra to tratt withi ta hath or PC sttis. May coutis hav rport prorss i thir itratio iitiativs, spit th ay xisti barrirs sti itact ro 2010 (i.., iaci itrat srvics i various sttis a arssi ruatios a crtiicatios to aciitat itrati srvics). Tchica assistac cotius to b to assist coutis i ovrcoi barrirs to itrat car. Mor wor is aso to aiiariz priary car provirs with SUD spciaty car srvics a to ostr partrships btw th two. Purpos Th purpos o this survy was to oow-up a 2010 xaiatio o th scop o SUD a hath car itratio iitiativs i Caioria coutis. Th 2012 survy o couty acoho a othr rus (AOD) aiistrators, couct by UCLA, assss th status o itratio orts i Caioria coutis ao couty-oprat or cotract SUD, ta hath (MH), a priary car (PC) provirs i orr to tri prorss as w as th xtt o tchica assistac to aciitat chas i srvic ivry rsuti ro hath car ror. With bac ro ADP a th Caioria Istitut or Mta Hath (CiMH), th oriia 2010 survy was rvis to icorporat a icras oritatio towar itratio orts ao bhaviora hath provirs. This survy was part o a cotiui ort to provi vauatio srvics, tchica assistac, a traii activitis to urthr th itratio o SUD, MH, a PC srvics i Caioria (S Appix 2B or u survy). Not: withi th survy its, th trs AOD a SUD wr us wh appropriat to aow or acoho a ru prvtio, tratt, a rcovry srvics to b icu i th rsposs. Mthos To couct th survy, UCLA rsarch sta, with iput ro ADP a svra couty aiistrators, costruct a bri ctroic survy (usi Survy Moy) to t a sapshot o SUD/PC itratio activitis across th stat a to assss tchica assistac s. I Octobr 2012, AOD aiistrators ro vry couty (N=57) rciv a -ai with a i to th survy. Aiistrators wr iv six ws to copt th survy. Fity-thr Chaptr 2 49

54 aiistrators (93%) rspo to th 2012 survy, whi th 2010 survy saw a 77% rspos rat (=44). UCLA rsarch sta couct a scriptiv aaysis o th survy rsuts. A iscussio o th rsuts, hihihti y iis a suary statts, was couct uri th Itratio Lari Coaborativ ti #19. A suary o this iscussio was post oi o th ILC wbsit ( a is aso tai i this chaptr i th sctio tit: CA Itratio Lari Coaborativ, Topic suaris. Suary o Fiis: Gra Ratis o Itratio Fro 2010 to 2012, thr was a icras i th ubr o coutis wori o or pai iitiativs to itrat SUD srvics withi MH or PC sttis. Forty-six coutis (90%) rport that SUD/PC itratio orts wr urway, up ro 57% o coutis survy i 2010 (s Fiur 2.1). O th 7 coutis (10%) ot currty a i itratio wor, 43% rport pai SUD/PC itratio withi th coi yar. This iur rprsts a icras copar to th 2010 survy rsuts, i which oy 32% o thos coutis ot currty a i itratio activitis ha SUD/PC itratio pas i th utur. Fiur 2.1: Itratio orts urway (2010 vs. 2012) 100% 80% 60% 40% 20% 57% 90% 0% 2010 (=44) 2012 (=51) COUNTIES REPORTING 'YES' Mos o Itratio Itratio o AOD/SUD srvics ito PC (45%) was rport or rquty tha itratio o PC srvics ito SUD proras (31%) by 2012 survy rspots. Ovra, ratis o AOD/PC itratio activity icras i 2012 copar to 2010 rsuts. 50 Chaptr 2

55 AOD/SUD srvics i PC sttis Couty aiistrators wr as whthr AOD/SUD srvics, icui SBIRT, priary prvtio, a rcovry support srvics, wr bi provi i priary car sttis. Th prcta o rspots ari icras ro 23% i 2010 to 45% i 2012 (s Fiur 2.2). O thos who or AOD/SUD srvics i PC sttis i thir coutis, 31% rport that SUD tratt was provi, whi 18% rport that priary prvtio was or a 14% or rcovry support srvics (s Fiur 2.3). Th prcta o coutis rporti o itratio o AOD srvics i priary car sttis was owr i 2012 tha i 2010, a a hihr prcta o coutis rport that AOD srvics wr provi i or tha 25% o priary car sttis i thir coutis (s Fiur 2.4). Fiur 2.2: Rspots ari that AOD/SUD srvics ar provi i o or or PC ciics 50% 40% 30% 20% 45% 10% 23% 0% 2010 (=44) 2012 (=51) YES Fiur 2.3: Braow o AOD/SUD srvics provi i PC sttis (=51) YES - Tratt Srvics i Priary Car YES - Priary Prvtio Activitis i Priary Car YES - Rcovry Support Srvics i Priary Car 2012 NO 18% 14% 31% 49% 0% 10% 20% 30% 40% 50% 60% Chaptr 2 51

56 Fiur 2.4: Prcta o PC sttis provii AOD/SUD srvics (2010 vs. 2012) No (0%) 78% 61% So, but ss tha 25% Btw 25% a 50% Btw 50% a 75% 13% 12% 8% 10% 75% or or 2% 2010 (=45) 2012 (=51) 0% 20% 40% 60% 80% 100% PC srvics i SUD proras I 2012, 31% o rspots ot that PC srvics wr bi itrat ito AOD spciaty tratt proras, copris o SUD tratt provirs othr tha arcotic tratt proras ics to hav a osit ica prossioa provii priary car srvics such as physica xas to patits. Ths rsuts ostrat a sa but otworthy icras ovr thos o th 2010 survy, i which oy 25% o rspots ot that PC was bi itrat ito SUD proras. FQHCs a couity hath car sttis Nity-o prct o rspots ot that thir couty s FQHCs provi AOD srvics, a 30% ot that thir FQHC oo-ais provi AOD srvics (s Fiur 2.5). So o- FQHC couity hath ctrs wr rport as provii AOD srvics (22%) a a sa prcta o privat physicia oics (9%) a privat ciics (4%) wr rport as ori AOD srvics. Fiur 2.5: Typs o priary car sttis with AOD srvics (=23) FQHC 91% FQHC oo-ai Othr No-FQHC CHC Privat physicia oics 30% 22% 22% 9% 2012 Privat ciics 4% 0% 20% 40% 60% 80% 100% 52 Chaptr 2

57 AOD Srvics Th ost coo AOD srvics provi i th priary car ciics wr routi scris a bri itrvtios or rus a acoho, a cas aat (s Fiur 2.6). Fiur 2.6: Typs o AOD srvics or i PC (=23) Routi scrii or rus Routi scrii or acoho Cas aat/cooriatio o srvics Bri itrvatio or acoho Scri o prat wo or AOD/SUD Bri itrvatio or rus Eucatio a ioratio issiatio Psychosocia tratt or acoho Psychosocia tratt or rus Routi scri or icoti Rcovry support srvics Bri itrvtio or icoti Psychosocia tratt or icoti 9% 17% 70% 70% 65% 65% 65% 61% 57% 52% 48% 43% 39% % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Fui Mta Hath Srvic Act (Propositio 63) us wr th ost cooy rport sourc o ui or itrat AOD srvics i PC sttis, whras Mi-Ca a s-pay wr th ost coo sourcs o ui or priary car srvics i SUD tratt. I 2012, ha o survy rspots rport that 25% or ss (or o) o thir couty s SUD tratt provirs wr currty bii privat isurac or AOD srvics. Srvic Divry Mos Whr SUD srvics wr prst i PC sttis, thy t to b bttr-itrat tha wh ica srvics wr provi i SUD tratt sttis. Mica srvics provi i SUD tratt sttis t to oow a co-ocat o rathr tha u itratio. Aiistrativy, th ajority o coutis i 2012 ha bhaviora hath srvics (MH a SUD) ur o partt/acy a hath srvics i a sparat partt/acy (siiar to Chaptr 2 53

58 2010). I rouhy o-quartr o coutis rspoi, a thr srvics wr srv by a si partt/acy. Barrirs to Itratio Factors itii as barrirs i 2010 prsist i Aost a aiistrators (92%) biv that iaci was a critica barrir to itrat car (s Fiur 2.7). May aso ist ocutatio o itrat car (i.., shari ioratio about patits across provirs; 63%) a vopi partrships with priary car provirs (63%) as aitioa barrirs. Athouh iaci is sti cosir th priary barrir to itratio, th prct o aiistrators who prciv it as such (74%) has cras sic Docutatio a crtiicatio or icsi issus ar urstoo to b ratr barrirs tha thy wr i Sixty-iht prct o rspots ou ocutatio to b a barrir, up ro 63%, a 42% ou icsi to b a obstac, up ro 29% i Fiur 2.7: Prciv barrirs to itrat car (2010 vs. 2012) Fiaci barrirs Docutatio barrirs Partri with priary car provirs Crtiicatio or icsi issus Othr barrirs 92% 74% 63% 68% 63% 54% 29% 42% 33% 26% 2010 (=24) 2012 (=50) La barrirs 13% 10% 0% 20% 40% 60% 80% 100% Traii Rspots wr spciicay vry itrst i traiis o th topic o itratio with hath car Rspots wr spciicay itrst i: itratio stratis, chroic isass associat with SUD or MH, a wori i th hath car syst. Th survy rsposs wi b us to hp ui th Paciic Southwst Aictio Tchooy Trasr Ctr (PSATTC) i 54 Chaptr 2

59 vopi th traii curricua. A ajority o rspots wr itrst i participati i urthr iscussios throuh th othy ADP/UCLA ari coaborativ (ILC), which urthr vaiats th or this ooi oru. May rspots voutr to prst thir ow xprics i utur ILCs. Survy Liitatios A w actors iit th scop o ths cocusios. Th survy as aiistrators to provi thir bst usss rari itratio activitis occurri i thir coutis. Howvr, structurs or srvics vary by couty a ca rstrict th aout o ow or couicatio a aiistrator ay hav with thir provirs. Aitioay, at th ti o th survy, itt cosistcy xist i us o th trs rati to itratio. UCLA us or icusiv aua i orr to captur th u spctru o itratio activitis, but utur survys ai us o staariz catoris ay provi usu ioratio o couty itratio activitis. Suary/Lssos Lar Whi a w coutis hav ot yt bu th procss o itrati AOD srvics with ta hath a priary car, ay othrs hav rport prorss. Dspit ay barrirs raii itact btw 2010 a 2012, itratio iitiativs hav xpa ao Caioria coutis. Athouh a icras ubr o priary car sttis wr provii AOD srvics i 2012, or wor is. Thr rais rat ivrsity i os a ui sourcs or priary car srvics provi i SUD sttis, a th srvics provi xt byo icatio aat a a o-ti physica xa. SUD srvics t to b bttr itrat ito PC sttis tha ica srvics wr ito SUD sttis. Tchica assistac wi cotiu to b i orr to assist coutis i urstai barrirs to itrat car a to tri how to wor throuh th. Chaptr 2 55

60 Caioria Itratio Lari Coaborativ (ILC) Goas a Objctivs Th Caioria Itratio Lari Coaborativ (ILC) is a itractiv oru i which couty aiistrators, SUD provir oraizatio rprstativs, a othr y stahors ca coaborat o ii a vopi sustaiab approachs to th itratio o SUD srvics withi th broar hath car stti. Th ILC provis a ooi iscussio a tchica assistac oru whr participats rciv tchica assistac a support ro sct xprts i th i o iprovi spciic ciica a opratioa aras. Th objctivs or th ILC ar to ab couty participats to: Ea i activ couicatio a shar xprics, ias, soutios, a ssos ar to aciitat itratio. Gai tchica a socia support to iprov spciic ciica a opratioa aras. To this, activitis hav icu: Mothy tis or cas. Topics hav icu: Couty Itratio Iitiativs, Data Privacy, Hath Hos, Bii/Fui, Wororc Cosiratios, HCR i othr Lar Stats, Bri Tratt, Micatio-Assist Tratt (MAT), a th Prscriptio Dru Abus Prob (piiooica upat), Itratio Survy Rsuts, Couty Exprics with th LIHP, a Bhaviora Hath scri istruts. Dtai ti suaris a atrias ar avaiab o th wbsit: A istsrv was crat; to subscrib to th aii ist visit: I orr to a th ILC avaiab to a 58 coutis i Caioria, th ILC is couct via tcorc or wbiar. Wh possib, th ILC aso tas th or o i-prso prstatios a iscussios at th Couty Acoho a Dru Prora Aiistrators' Associatio o Caioria (CADPAAC) quartry tis. Ivitatios to participat ar st to couty AOD prora aiistrators a othr y stahors, icui th Associatio o Acoho a Dru Prora Excutivs (CAADPE), Caioria Opioi Maitac Provirs (COMP), Caioria Thraputic Couitis (CTC), Mta Hath Systs (MHSINC), Caioria Associatio o Aictio Rcovry Rsourcs (CAARR), Caioria Istitut o Mta Hath (CiMH), a Acoho a Dru Poicy Istitut (ADPI). Th ILC tis ar h o a othy basis, with topics tri coaborativy by UCLA, ADP, a th participati brs. Mtis coc i Apri 2011 a ar ooi. 56 Chaptr 2

61 ILC Mthos a Activitis Fro Auust 2012 to Ju 2013, th ILC h iv tcorc sssios a iv i-prso iscussios. O avra, tcorc attac was approxiaty 26 participats, whras th i-prso ti attac was as hih as 100. A ti atrias a suaris ar post o th Itratio Lari Coaborativ wbsit. Ooi couicatio a support ar provi via -ai. May o th topics scrib bow wr tri by rawi o ioratio athr ro th Caioria Itratio Survy. Th survy rqust topics o itrst a itii couty rprstativs who wr wii to rport o os a outcos ro thir ow itratio piot activitis. UCLA a ADP ca to a cossus o a topics i avac o ach ILC sssio. Topic Suaris Topic: Latst Fiis: Itratio o Substac Us Disorr (SUD) Srvics with Priary Car (Sptbr 26, 2012) Prstr: Darr Uraa, PhD This prstatio covr thr ai topic aras: th ipact o SUD o hath a hath car costs, th ipact o itratio o hath a hath car costs, a how w ca us toos a ata to strth th cas or provii itrat car. SUDs cotribut to ovr 70 coitios that rquir ica car (NCASA, 2012). SUDs icras th ris or chroic isass icui cariovascuar, puoary, a ivr isass (Sti, 1999), ta hath isorrs (CSAT, 2007), couicab isass such as HIV a hpatitis (Car, 2010), a srious ijuris (Viso, 2003). Pop with SUDs icur ovr oub th tota ica costs o pop without SUDs (Parthasarathy, 2003; Thoas, 2005). SUDs rouhy oub th cost o car or Micai ros who hav co-occurri ica coitios (Boy, 2010). It is aticipat that 147, ,000 w Mi-Ca ros i 2014 a byo wi SUD srvics (TAC & HSRI, 2012). Cost stuis hav ostrat th bits o provii SUD tratt. Bri physicia avic o SUDs as to $4.30 i savis or vry oar ivst (Fi t a., 2002). SBIRT i rcy partts ay rsut i $3.81 i hath car cost savis or vry oar spt (Gtio t a., 2005). Copar to ru-r tratt or opioi pc, buprorphi rucs costs by 30% (Basr t a., 2011). Copar to ora atrxo, Vivitro rucs th cost o ipatit srvics by 31 38% (Basr t a., 2011, 2011b). Ths stuis o ot ta ito accout othr o-ica savis, such as tratt i iu o icarcratio. For xap, or vry tratt coptr, Prop. 36 sav Caioria $4 or vry $1 spt. Masuri Itratio: Th Dua Diaosis Capabiity i Hath Car Sttis (DDCHCS) too ca b us to scor how itrat a priary car oraizatio is. Othr pottia asurs o itratio ay icu patit pipis, a survys to asur sta prcptios a attitus. Chaptr 2 57

62 A tai ti suary a atrias ar avaiab o th ILC wbsit: Topic: Op Tab Discussio: Hot Topics ro a AOD/SUD Itratio Survy (Novbr 28, 2012) As a rsut o th Itratio Survy istribut by UCLA ISAP i Octobr 2012, this ILC iscuss hot topics itii ro th survy (ioratio coct uri this ILC is aso scrib i th prci sctio Coo Barrirs a Chas). Th iscussio ba with a covrsatio rari ori partrships with priary car provirs a oraizatios as w as th chas rat to wori i a priary car stti. Fori ctiv partrships btw SUD a PCPs ca b vry chai. ILC participats shar how thy achiv such partrships a provi tips o ai priary car physicias a how to wor with th irt cutur o priary car a bhaviora hath. Th roup aso iscuss th chas associat with ipti scri protocos a th or th i to vop a staar or that ca b us i th priary car stti. Docutatio aso cotius to b a barrir to itratio, with ay coutis rporti that thy ar havi troub wori with coitiaity ruatios arou SUD a MH patit rcors (spciay ao car cooriatio cits). Discussio su rari th chas surroui ioratio xcha a 42 CFR (icui obtaii appropriat cost ro patits). Aothr barrir tio cocrs ii a EHR a a patit ristry that wors w a aquaty ts th s o th i. Th iscussio with a bri rar that th ost cooy cit barrir to SUD/PC itratio i Caioria cotius to b iaquat ui. A tai ti suary a atrias ar avaiab o th ILC wbsit: Topic: ADP-UCLA 2012 Itratio Survy Rsuts (Jauary 23, 2013) Prstr: Darr Uraa, PhD This ILC Mti covr th rsuts ro UCLA/ADP s 2012 Itratio Survy, as a oowup to th 2010 Itratio Survy (pas s Sctio B or a tai scriptio o th survy thos a rsuts). Cocusio: Whi a w coutis hav ot yt bu th procss o itrati AOD srvics with ta hath a priary car, siiicat prorss has b a i couty itratio iitiatio a iptatio ro 2010 to Th stat was ot ray or 2014 yt, but was ovi i th riht irctio. DHCS a UCLA pa to cotiu ori traii a tchica assistac to ai coutis vry stp ao th way. 58 Chaptr 2

63 A tai ti suary a atrias ar avaiab o th ILC wbsit: Topic: Chas or th SUD Wororc: 2013 a Byo (March 27, 2013) Prstrs: Richar Rawso, PhD, a Thoas Frs, PhD (UCLA ISAP) This ILC prstatio ocus o how to prpar th currt AOD wororc or th typs o stti a practic chas i SUD tratt ivry, rcovry, a prvtio brouht orth by hath car ror (s Chaptr 3 or a tai iscussio). Ovr th xt 10 yars, thr wi b a ar ort to vop poicis, irastructur, ucatioa curricuu at schoos, a traii ctrs to prpar th wororc to t th s o provii srvics i th broar hath car syst, which wi rquir Caioria crtiicatio/icsi ror as w. Whi thr wi cotiu to b a or SUD cousors i th spciaty car syst, thr wi b a ar bir or bhaviora hath ciicias i th broar hath car syst. I th ati, short-tr pas ar rquir to prpar or Propos ias icu: (1) Itiy traii s so that SUD/MH srvics ca bco a ctiv part o priary car, (2) Itiy spciaty car s vrsus MH/SUD raist sis, a (3) Itiy SUD prso who wat to ar w sis to wor i priary car a provi th with traii. Wororc vopt wi cotiu to b a hot topic as ACA iptatio raws cosr. UCLA a DHCS wi cov a ti o stat a atioa xprts i Sptbr 2013 to iscuss xt stps. A tai ti suary a atrias ar avaiab o th ILC wbsit: Topic: Low Ico Hath Prora (LIHP) i Los As a Sa Mato (Apri 24, 2013) Prstrs: Joh Virs (Los As) a Cara Boy (Sa Mato) Joh Virs scrib Los As Couty s orts i stabishi a LIHP prora with SUD srvics. Utiaty, th couty ci ot to pursu th LIHP prora i orr to ocus o Mi-Ca xpasio. Cara Boy scrib Sa Mato s currt Micai Covra Expasio or SUD Srvics. Th covr SUD srvics icu: Asssst, Bhaviora Hath Itratio, Cas Maat, Coatra Srvics, Day Car Rhabiitatio, Dtoxiicatio, Group Cousi, Iiviua Cousi, Micatio Assist Tratt, Narcotic Rpact Thrapy (Mthao), Outpatit Tratt, Rsitia Acut Stabiizatio, Rsitia Priata Tratt, Rsitia Tratt Icui Dtoxiicatio, a Scri a Itrvtio. Th chas that thy hav ac icu: th trasitory atur o th popuatio, pictur itiicatio rquirts, aiur to iscos a ico (upoyt), iiviuas with bits i ihbori coutis, ay otiicatio o covra to provirs, th chai ac o partrs a rrra sourcs (ro criia justic to priary car), a crtiai o sta Chaptr 2 59

64 (Stat ADP rquirts vs. hath isurac rquirts/icsi a th abiity to iaos). A ot o ti was spt ucati th provirs o ocutatio o ica cssity a srvics, ow o bii cos a stabishi ratioships with privat isurrs a priary car provirs. Sa Mato pas to cotiu to ar how to aviat th priary car syst a vop ratioships. Thy aso pa to urthr stabish rrra a couicatios protocos (bi-irctioa), provi outrach atrias to priary car provirs, a xpa icatio-assist tratt. Th utiat oa is to iprov th physica a ta hath o SUD patits throuh ratr cooriatio o car. A tai ti suary a atrias ar avaiab o th ILC wbsit: Topic: Itratio Upats ro th Fi (May 29, 2013) Prstr: Darr Uraa, PhD As w approach Jauary 1, 2014, th i is chai o a aiy basis. This prstatio souht to provi upats coct ro various rct corcs that hihiht atioa a itratioa trs. Issus with iaci a th wororc cotiu to b wiy iscuss. So biv that obiab bhaviora hath (BH) sta ur a accoutab car oraizatios (ACO) o ar a ovi towar bcoi biab as o as thy ar crtia. Th rus ar sti i prorss a wi vary ro stat to stat. Fori partrships btw a ray quaii hath ctr (FQHC) a BH wi bco icrasiy iportat, a iovativ xaps wr iv. FQHCs t pai bas o patit coutrs, with a atioa avra rat o $143 pr coutr. I o istac, a BH ctr that was si a ot o icatio-oy patits a tti pai vry itt u to thir ti-bas bii ov ths patits to a partr FQHC ctr, which cou bri i uch or oy u to thir coutr rat. This aow th FQHC to th pay th BH ctr or othr bhaviora hath srvics. Th s to priary car is that th octor ray wats to ha o th cryi patit to th BH ctr. This aows th octor to ov o to th xt patit a icras rvu whi sti provii th patits with quaity car. It is xcusiv to Caioria that cousors caot t pai i FQHCs. I othr stats such as Nbrasa, a ics ta hath practitiors (.., socia worrs, MFTs, a cousors) ca bi at FQHCs. Chroic pai a prscriptio ru abus cotius to b a rowi prob. I ai with ths patits, aiy uctioi a happiss ar th priary oas. Copt pai ri is uraistic. It is iportat ot to us th tr aictio i ai with chroic pai tratt. Doi so wi ot ip th practitior s abiity to rach patits who prsuaby bcaus o ia wi ot wat to b rrr to a spciaty ciic. This phasizs th or itrat car so that patits strui with aictio ca rciv quaity car without havi to cop with th ativ stia surroui th isas. 60 Chaptr 2

65 Ea s Natioa Tratt Acy ( has a ocus o patit-ctr car a prorac asurt. A Natioa Hath Srvics i Britai us a prorac asurt ca th t prootr scor (NPS). Th NPS is cacuat by asi ach patit, How iy ar you to rco th srvics that you rciv toay to a ri or aiy br, ro 0 to 10? I scors o ow, a ruator wi co i. I scors ar oo, th th oraizatio is t ao. Busisss with a hih t prootr scor (arou 7.5) ar iy to row vry ast, a thos that o poory ot o out o busiss. Th tr Hot Spotti was aso iscuss. Jry Brr, M.D., itii hih-cost usrs a app whr thy iv ovr th cours o iv yars. Thr ar hathcar cost hotspots which ar vry coctrat ubrs o hih cost usrs i sa oraphic aras. I w cou icorporat ths ata ito our approach, it cou hp with prvtio a tratt outrach. For or o hot-spotti, s Chaptr 1. A tai ti suary a atrias ar avaiab o th ILC wbsit: Topic: Bhaviora Hath Scri Istruts (Ju 26, 2013) Bhaviora Hath scri istruts, icui AOD scrs, MH scrs, two-sta scrs, a cobo scrs wr a topic rqust by th ILC brs. Scri is wh a hathcar prossioa asssss a patit or risy substac us bhaviors usi staariz scri toos. Scri ca occur i ay hath car stti. Accori to o 2010 survy o FQHCs, approxiaty 53% o FQHCs routiy scr a o thir patits or prssio (Larir, Jos & Prz, 2011). Wh th sa survy was couct or substac abus, that ubr ropp to approxiaty 39%, iicati that wr FQHCs scr or substac abus tha prssio. Th survy ha a ow rspos rat, a th actua prctas ay b owr. Th ost cooy us scri too us or substac abus was th CAGE (44.5%), oow by othr toos (36.1%) a th AUDIT (12%). Participats shar thir xprics with istruts, icui th UNCOPE (Aaa, Kr), ASI-MV (Sa Fracisco), CRAFFT (Sacrato), a bri cobiatio scrs (Ora). Two-Sta Approach As couity-bas scri or hath ris bhaviors, icui substac us, ar bi ipt, utiizi a two-sta approach to scri is bi coura by acis such as th PSATTC. This approach ivovs usi th utra-bri scrs i th irst sta a icus: a si qustio or acoho, si qustio ru us, th GAD-2, a th PHQ-2. Utra-bri scrrs hp itiy th pottia or a prob but o ot iv ouh ioratio to i vs o ris that ca ui itrvtio stratis. This is tru or th AUDIT-C+, th 2 o-it scrrs a th PHQ-2 a GAD-2. I th short scrr is positiv, th a sco, or istrut is us or thos patits (.., u AUDIT, DAST, GAD-7, PHQ-9). Chaptr 2 61

66 May oraizatios hav crat thir ow cobiatio scrr to it th s o thir patits. Cobi scri istruts ar icriby iportat u to th hih rqucy o coorbiity ao patits with SUD. Traci Patits Iprovt Ovr Ti Th chas o traci patit iprovt ovr ti was aso iscuss. Th UNCOPE a th Tratt Ectivss Asssst (TEA) wr iscuss as possib soutios. A tai ti suary a atrias ar avaiab o th ILC wbsit: Couty Cas-Stuy Suaris I aitio to th ILC tis, which ocus o crtai topics associat with itrati SUD srvics, othr ILC tis ocus o th itratio iitiativs urway i crtai coutis. Coutis voutr to prst uri th tis, which hps vryo a i itratio orts. Dtai ti suaris a atrias ar avaiab o th ILC wbsit: Bow is a ist o iiviua coutis* that prst thir itratio wor withi th ILC: Rivrsi Mrc Lass Ipria Triity * Los As a Kr coutis aso prst thir itratio wor withi a ILC, but thir suaris ar icu i th Piot vauatios sctio withi this chaptr. Each couty s wor has b oraiz to arss: Bacrou (Who was ivov? Whr wr th sits?) - Couty (a, siz, urba/rura popuatio) - Prora/sit - Itratio sttis (FQHC or othr) - Sta o itratio (ary/at) Objctivs a thos (What was th pa?) - Projct oas/scriptio - Mos us - Typs o itratio (MH a SUD tothr, MH a SUD ito PC) - Itratio partrs (i ow/appropriat) Iptatio outcos (Di it wor? What actuay happ?) 62 Chaptr 2

67 - Ky iis - Faciitators a barrirs Lssos ar Chaptr 2 63

68 RIVERSIDE COUNTY Bacrou Rivrsi Couty has a popuatio o 2.24 iio a covrs 7,208 squar is i Southr Caioria. Th upoyt rat i Rivrsi Couty is 10.5% (as o March 2013). Thr itratio proras i Rivrsi Couty wr iscuss uri th Itratio Lari Coaborativ o Auust 22, 2012: 1) Th Rubioux Pubic Hath Ciic (which is a FQHC-Loo Ai), 2) Th Bai Strt Mta Hath Ciic, a 3) Th Suboxo Tratt Prora with a Priary Car Physicia. Rubioux Pubic Hath Ciic This ciic is a FQHC-Loo Ai with ta hath srvics itrat withi a pubic hath ciic. Th ciic ba si patits i Auust 2012 a is a rat-u projct throuh th Rivrsi Hath Fouatio. Objctivs/Mthos Th prora was crat to arss th s o thir patits co-occurri isorrs (COD) patits ar yi at a avra a o 48 yars. Th prora oa is to itiy a i ta hath patits to physica hath car, a to i physica hath patits to ta hath car. Th ta hath ciic itii thos ta hath patits i th pubic hath catcht ara who ha two or or physica hath probs, who wr ot a with a priary car provir, a who itrat aat o hath probs. Th prora sta icus two biiua MFTs a a psychiatrist thr ays/w (20 hours tota). Most o th patits srv withi th Mta Hath Ciic ar iib or Mi-Ca. Th MH ciicia ss patits i a xa roo withi th pubic hath ciic. Mta hath ciicias wr trai i aiistri th CRAFFT, which is us to scr patits or substac us. Patits rcivi a crtai scor ar rrr to substac abus tratt srvics. Nurss ro othr octors bri patits to th MH ciicia i th octor is prscribi a psychotropic ru. I thr is a acut crisis, th ciicia a/or psychiatrist wi s soo iiaty (i thy r avaiab). Th prora is traci a srvics provi uri th rat prio so thy ca iur out how to bi ur avaiab ui i th utur. Th rat ro Rivrsi Hath Fouatio covrs: psychiatrist ti, urs practitior ti at Bai St. Ciic, a iit aout o physica hath st-up costs. Th charts ar uy itrat at this sit. Iptatio Outcos Prora barrirs icu ii th appropriat sta, patit cocrs, a ri irt wor cuturs. Lics sta wr or th prora, but thy cou ot i LCSWs to i th positio. It was car uri th pai procss that th octors i ot ursta what ta hath (MH) provirs o. Th ica o at th Pubic Hath ciic is vry irt ro th ta hath o. Thy hav two irt wor stys a auas. This has rquir patic, torac, a opss i orr to r th two cuturs. Dysuctio xist i ach syst. W ow w hav it w just o t ta about it. W 64 Chaptr 2

69 o t ow a th hi rus i th othr th syst, sai o prora aiistrator. So ta hath patits i ot wat to ov to a Pubic Hath Ciic or srvics. Bai Strt Mta Hath Ciic This ciic is a itrat aut outpatit ciic. Th prora srvs auts as who hav a srious ta iss. Th prora provis iitia assssts icui crisis a urt car srvics. A utiiscipiary ta provis ta hath tratt, cas aat, a ia to couity srvics. Tratt ras ro psychiatric srvics a short-tr thrapy to ooi support, housi, a bits assistac. Th prora aso provis vocatioa srvics to auts currty rcivi srvics throuh th Dpartt o Mta Hath. Objctivs/Mthos Th rat ro th Rivrsi Hath Fouatio aow or th pact o a urs practitior (NP) who was biiua a xpric i pubic hath to wor i th ta hath ciic. Th prora ocus was o basic physica hath car prvtio a ucatio srvics icui birth cotro, STD ucatio a tsti, a wo s rprouctiv hath car (or wo a 40 a or). Th prora was iitiat bcaus th ta hath patits hav hih rats o obsity, cacr, hih boo prssur, a iabts. Th patits osit ica srvics. To aciitat ths srvics thy st up a priary hath car xa roo, which cost $35K or quipt a suppis (which was or tha xpct). Th ciic aso to hav a ab roo or suppis a spci coctio. This rquir spciaiz quipt icui a phbotoy chair, or rrirators, uri tst cart, icroscops, sis, ar scops, tc. Th ciic is pi th charts sparat (o or ta hath a o or physica hath), but th two ar pt tothr so thy ca both b pu wh th ciicia or octor ss th patit. Both charts ar us at th sa ti. Iptatio Outcos I th irst two ws o th a phasis o physica hath car, thr wr two ica criss itii that th poys ha ot b awar o that rquir rrra to th rcy roo. Hiri th riht prso or th job was aso vry iportat. Th NP has a oo way o tai to th patits; sh provis ucatio a avocacy, which is cssary to provi cooriat car. Th NP ha to t to ow th MH patits a thy to t to ow hr. It was critica to stabish that ratioship. Iitiay MH sta t to scr out too ay patits. Th NP aso to t th MH urss or coortab with physica hath issus. Th NP s irst approach was to tach th MH urss about phbotoy a how to approach patits to icras thir coort v. Th patits i ot wat to switch to th w srvic iitiay. Ciicias ou itrouci th patit to th NP i th ha vry hpu. Oc th patit t th NP, thy wr vry iy to p th xt appoitt. Chaptr 2 65

70 Suboxo Tratt with Priary Car Physicia This prora oow th ru auacturr s protoco, which rquirs thr oths o Suboxo, o a stp-ow basis, pus 3 oths o siutaous substac abus cousi, oow by o oth o Natrxo, i. Th couty rquirs a 4-oth outpatit substac abus tratt prora. Th protoco that was put ito pac ivovs th octor, pharacist, a tratt ctr a wori tothr. Th octor itiis Dru Mi-Ca iib patits i his privat practic, a writs a prscriptio that th patit tas to a spciic pharacy. Th pharacist cas th octor prior to ii th prscriptio or vriicatio ro th octor that th patit is obtaii SUD tratt. Th octor s urs chcs with th SUD ciic wy to s i th patit is pi appoitts. Sotis, i thr ar probs, th urs visits patits at th tratt sit. Th pharacist cas th octor to approv ris o prscriptios or ach aitioa 30 ays. Iptatio Outcos As o Sptbr 2011, th prora has trat 8 patits a 3 hav copt th prora. Thr wr o ropouts. Th rport rus o choic ao th trat patits wr Oxycoti a Norcos. O rauat copt thir Priata prora a is ow a Pr Support Spciaist. Sh has car a past a issus a pas to bco a voutr or our partt. Lssos Lar Lssos ar uri iptatio o itrat srvics i Rivrsi Couty icu th oowi: Doctors ucatio rari th ros a rsposibiitis o th MH sta. Patic, torac, a opss wr rquir ro both physica a ta hath car provirs i orr to r th two cuturs. Fii th NP ro with a prso who ha a stro abiity to stabish ratioships with patits was crucia. War haos btw physica a ta hath provirs i th ciic ha wr critica i stabishi patit-provir ratioships. 66 Chaptr 2

71 MERCED COUNTY Bacrou Mrc Couty is ocat i th hart o th Ctra Vay o Caioria. As o th 2010 U.S. Csus, th popuatio was 255,793 a th tota ara o th couty is approxiat 1,980 squar is ( Th couty srvs about 256,000 patits. Itratio proras i Mrc Couty wr iscuss uri th ILC o Auust 22, Th couty is bii to co-ocat srvics withi priary car sttis (two FQHCs). Mrc Couty has sta co-ocat o sit at th priary car aciity to wor with physicias, urss, a thir patits to couct scri a rrra or SUD srvics. Objctivs/Mthos Atr rcivi support ro thir psychiatrists a or buy-i, thy ba with a SUD cousor at th ciic or 20 hours pr w. Th prora is usi a Bhaviora Hath Scri Too, a thy hav trai th physicias o how to us it. A cosirab aout o ti has b spt traii th physicias o th sis/syptos o SUDs a how to us th scri too. Th procss is as oows: rot s sta iv out th scri too to a patits s i priary car; th physicia rviws it; patits that oow-up ar a; th SUD cousor is pa a th physicia provis a war hao. Sotis th patit spas with th SUD cousor i th xa roo or thy ar ta ito th cousor s oic. Patits provi cost to ras ioratio. Th oa is to provi sa roups at th ciic (roup thrapy a psych-ucatio roups) i th utur. Th Couity Outrach Prora Eat a Eucatio (COPE) prora ss to rach th ursrv a isparat racia popuatios throuhout Mrc Couty. COPE has urthr hac srvics by coaboratio with acy partrs, aw orct, a othr partts. COPE ciicias partr with priary hath ciics. Th couty aso has probatio co-ocat with th chir a aut SUD juicia ta. This provis a o-stop shop or cits to s thir probatio oicrs bor or atr thir tratt appoitts. MH a SUD sta ar co-ocat at juvi ha to provi SUD a MH srvics a aciitat a war hao wh cits ar ras to th couity. Iptatio Outcos It has b a o procss to t th sta o boar i Mrc. Th ciic sta wr us to rrri-out or SUD srvics. A cosirab aout o ti has b spt traii th physicias o th sis/syptos o substac us a how to us th scri too. O o th bits o co-ocati sta is that it aciitats war haos. Lssos Lar Lssos ar uri iptatio o itrat srvics i Mrc Couty icu th oowi: It was iportat to t th sta o boar with itratio orts ary. This was achiv succssuy throuh ucatio a traii orts. Co-ocati srvics was ou to aciitat war haos btw MH a SUD srvic provirs, thus provii sip o-stop shoppi or patits. Chaptr 2 67

72 LASSEN COUNTY Bacrou Lass Couty is ocat i rura Northastr Caioria a is th 8th arst (by ara) couty i Caioria. Lass has about 34,000 couty rsits. Lass is rat as o o th thr worst coutis i Caioria or cooic w-bi. Th upoyt rat hos stay at arou 17.1%. Out o a poy worrs, 60% ar poy by so typ o ovrt acy. About 41.4% o rsits iv bow th 200% ra povrty iit. Itratio orts i Lass wr scrib uri th ILC o Fbruary 27, Th Acoho a Othr Dru (AOD) a Mta Hath (MH) partts ba ri o Juy 1, 2012, to bco th Dpartt o Bhaviora Hath (BH). At th ti o th prstatio, MH a AOD srvics wr rport to b co-ocat but ot uy itrat, with sparat itas or MH or AOD, a srvics that wr ot w-cooriat. Th scri procss ivov assssi or ithr AOD or MH by oi a bri asssst; i a issu was tct, patits wr th rrr to th othr si or a sparat ita. Th BH partt is tryi to bco or hoistic a patit-ctr, a procss that wi iy ta svra yars. Objctivs a Mthos Th couty is bii to us a ta-bas approach to provi itrat car. A o th systs ar oraiz arou tas. I ach ta, thr ar cas aars, psychothrapists, psychiatrists, a urss a wori tothr. Lass pas to ipt th SAMHSA-HRSA Bhaviora Hath Ho o i its 5 BH ocatios i orr to provi bttr cooriatio o MH, AOD, a priary car srvics. Thy aso pa to a priary car srvics, such as brii i urss to ta patit historis, a stti up ruar osit scris to chc or pottia hath probs. Most patits hav SUD, MH issus, a physica coitios that ar sotis co-occurri. Iptatio Outcos So o th barrirs a chas to ipti th itrat o i Lass icu: o Buraucracy. Wori withi a arr buraucracy (with uios, prso, avisory boars) ca sow ow th procss o cha, athouh Lass BH has b wori o cobii both thir avisory boars a crati w byaws. o Liit or ustab oca rsourcs. As i ay rura aras, Lass has iit rsourcs with iit stabiity. o Oraizatioa istabiity/ucrtaity. Bcaus thir FQHC has rcty ischar th CEO, thr is istabiity a ucrtaity about what th utur o itrati with priary car wi oo i. o Dirt sts o rus, ruatios. AOD a MH hav irt sts o rus a ruatios, a irt ways o oi this. Th couty is waiti or or uiac ro th stat to s how it wi b possib to cobi to bco o uit, with o way o thii a oi this. o Cutura a iuistic ircs (vopi a coo aua). AOD a MH spa irt auas a to i th i rou a ar ach othr s aua. 68 Chaptr 2

73 o Sta turovr. May sta brs hav rtir. Th iux o w prso at irt stas o th ari curv has crat uasiss or xisti sta, who ar aso ai with w xpctatios a a w o thy ust ar to wor with. o Sta coptcis. So sta, spciay or sta, hav ot ta tsts i a o ti a ay b ucoortab or rsistat to w prorac rquirts a traiis. o Buii sta ora. Prior to itrati with AOD, MH sta ha tas that i t wor as w tothr. Mori co hours wr h to iv MH sta a opportuity to voic thir thouhts a cocrs a bo tothr. o Baaci copti as. Thr is a to baac a ocus o itratio with othr cocrs. Th AOD a MH systs i Lass aray ac chas bor itrati, a bii th procss without a stro ouatio a car structur a wor or iicut. Lssos Lar Th oowi ssos wr ar, as rport by Lass Couty: Dvopi ow a trust ao sta vop tawor a couicatio. Crati sta coptcis raty icras th quaity o patit car. It was iportat to ho sta accoutab, but aso provi assistac i rachi xpct vs o itratio. Chaptr 2 69

74 IMPERIAL COUNTY Bacrou Ipria is a rura couty ocat i Southr Caioria. Th Couty popuatio is about 180,000 rsits. Bcaus o its pc o aricutur, Ipria Couty rsbs th Ctra Vay or tha it os othr Southr Caioria coutis. Itratio orts i Ipria wr scrib uri th ILC o Fbruary 27, Ipria s systs ar oraiz arou tas. I ach ta, thr ar cas aars, psychothrapists, psychiatrists, a urss wori tothr. SUD is ow bi co-ocat ito th MH ciics a or to aoscts a auts. Evryo is assss or both SUD a MH a th rrr as appropriat. Ipria has partr with o FQHC a co-ocat BH sta thr. BH sta couct itas a ar vtuay oi to b at a th irt ocatios. Ipria BH is oraiz arou 3 ai parts o th popuatio: chir, you auts, a auts. For ach roup, Ipria has ipt EBPs or thir uiqu issus. Objctivs/Mthos Th chir s syst (as 0 14 yars) coctrats o srvics to schoos a th ostr car syst. A ot o ti a ort has b pac ito traua-ocus coitiv bhaviora thrapy (CBT), utiisioa tratt or ostr car, vopi a o or ADHD procsss, a urturi parti. For youth a you auts (14 25), thy hav ipt uctioa aiy thrapy, traua-ocus CBT, SMART rcovry, urturi parti, a CBT. Th aut syst (25 a or) is oraiz arou th ia o havi rcovry ctrs at irt ciics. W ipt EBPs or, a trai sta to a with, spciic isorrs (or xap, axity isorrs, schizophria, bipoar isorr, tc.). Th rcovry ctr provis proras i icatio ucatio, aiy ucatio, SMART rcovry (or SUD, AOD, a soi cssatio), physica itss, CBT, occupatioa srvics a acaic srvics. Th ctrs ar si to hp pop ar th sis to aa thir iss. Oc thy ai sis to aa thir iss a physica hath, thy aso t hp ari a tra or oi to co. Iptatio Outcos Ipria BH is oraiz arou 3 ai parts o th popuatio: chir, you auts, a auts. For ach roup, Ipria has ipt EBPs or thir uiqu issus. Ipria has o FQHC with co-ocat BH sta. BH sta hav b thr or a coup o yars. Thy o itas a ar vtuay oi to b at a th irt ocatios: 3 ai ciics a 5 satit ciics. Hopuy, this wi a to bttr hathcar or MH patits, a hp physica hath patits t accss to MH hathcar. Lssos Lar Lssos ar, as rport by Ipria Couty, icu th oowi: Arssi th s o spciic patit popuatios is y to provii srvics that trat th who patit. 70 Chaptr 2

75 It is critica to ostr a shar visio a oas across a ciics throuh ruar sta tis a stro couicatio ao oraizatio arship. Chaptr 2 71

76 TRINITY COUNTY Bacrou Triity Couty is ocat i Northwst Caioria, a is borr by Hubot, Shasta, Sisiyou, Mocio, a Thaa coutis. Th couty siz is about 3,000 squar is a th popuatio cosists o about 13,000 rsits. A stiat 17% iv bow th povrty i. Th rura poor ar th ai roup that BH wors to srv. Th Triity BH Dpartt is sa a srvs patits with both MH a AOD cocrs. Thr ar a stiat 57 AOD patits. Itratio orts i Lass wr scrib uri th ILC o Fbruary 27, Objctivs/Mthos Thr ar sparat assssts a tratt pas or MH a AOD, athouh th iaosis or is shar. Patits ca b scr a rrr ro o partt to th othr. Rasi ioratio is a cha, so a MH a AOD patits si a ras to us thir ioratio i th shar Kisviw EHR, which has b i us or 4 yars, a thy ar coortab with it. MH patits with AOD issus ar ot put i th ua iaosis roup at irst i th issus ar ot svr. Th roup ocuss or o har ructio a asssss i rrra to AOD is appropriat. Th AOD prora its is abstic bas. Thr ar sparat ta tis or ach prora, but MH a AOD aso t joity ach w to iscuss patits o cocr a ai with criss. MH a AOD hav joit avisory boars as w. With rar to priary car, Triity has participat i th Sa Couty Car Itratio (SCCI) ari coaborativ throuh CiMH. Triity is pai to o th sa or AOD patits i th utur. Ur th SCCI projct, Triity BH has aso o a soi cssatio prora that is oi w. BH is wori o buii ratioships with th hospitas a hospita sta. Iptatio Outcos Triity is tryi to bco or patit-ctr. Thy hav MH rop-i ctrs i both Wavrvi a Hayor that ar op to pop with both MH a AOD issus. AOD a MH ar wori tothr with thir MHSA prora. Both th AOD irctor a th MH irctor ar ivov at th stat v to prpar or hath car ror. Lssos Lar Lssos ar, as rport by Triity Couty, icu th oowi: Eucati a traii sta about itratio hp to coura provir buy-i. Dvopi ow a trust ao sta support tawor. Eiiati sios a hirarchica thii by courai op couicatio a bac ao sta a arship was critica to succssu iptatio. It was iportat to acow that cha is iicut. 72 Chaptr 2

77 Piot Evauatios UCLA is wori with a sa roup o coutis to aciitat itratio, icui coutis that ar i th ary itratio stas as w as coutis that ar or avac. UCLA sct svra coutis (scrib bow) to ocus ths piot vauatio orts. A pa was crat or ach couty a was approv by ADP. Th Los As Tpsychiatry a Vivitro piot projcts a parts o th Kr wor wr u by ths rspctiv coutis, but th rsuts rvat to itratio ar iorativ or stat orts a ar thror prst hr. LOS ANGELES COUNTY Los As (LA) Couty is ocat i Southr Caioria a has th arst popuatio o ay couty i th atio. Approxiaty 27% o Caioria's rsits (10.4 iio rsits) iv i LA Couty. Athouh ach o th 88 citis i th couty has its ow city couci, thy a cotract with th couty to provi uicipa srvics (.., pubic hath protctio, pubic socia srvics, proprty asssst, a vita rcors). It is such a ivrs couty with or tha 140 cuturs a as ay as 224 auas that sotis provii srvics to its rsits ca b chai. Nvrthss, LA Couty has ay proras to protct, aitai, a iprov th hath a ta hath o its rsits. Ths icu provii ow-cost a o-cost car at pubic a privat aciitis, cooriati th rcy ica srvics syst, wori to prvt isas, a protcti aaist basic thrats to pubic hath (acouty.io). Svra piot projcts hav b ipt i Los As Couty, icui th Tpsychiatry Prora at th Atop Vay Rhabiitatio Ctr (iscuss uri th ILC), th Vivitro Piot Projcts (iscuss uri th ILC), a th Dua Diaosis Capabiity i Hath Car Sttis vauatio o a ray quaii hath ctr. Each scriptio bow hihihts th itratio orts tai pac withi thos proras. Tpsychiatry at th Atop Vay Rhabiitatio Ctr (AVRC) i Acto, CA Bacrou Sic Apri 2011, UCLA ISAP has partr with th Couty o Los As Dpartt o Pubic Hath, Substac Abus Prvtio a Cotro (SAPC) oic to provi tpsychiatry srvics or ipatit substac us isorr patits aitt to th couty-oprat Atop Vay Rhabiitatio Ctr (AVRC) i Acto, CA. Tici is i as th practic o hath car ivry, iaosis, cosutatio, tratt a trasr o ica ata a itractiv toos usi auio, vio a/or ata couicatio with a patit at a ocatio rot ro th provir a has b i us or ovr 20 yars. As tchooica avacs rapiy vop, so too has th vopt a xpasio o tici, which copasss a ubr o ica iscipis, icui Tpsychiatry. Objctivs/Mthos Th AVRC is ocat i th hih srt o Los As Couty, whr accss to psychiatric srvics is iit u to th rotss o th aciity. Rsarch susts that 33% 50% o patits i substac us isorr (SUD) rhabiitatio proras ot hav co-orbi psychiatric probs (Dra t a., 2007), yt vry w rhabiitatio proras (a v wr Chaptr 2 73

78 rura proras) hav osit psychiatrists (Hity, 2007). Throuh this projct, UCLA ISAP psychiatrists provi srvics rat to SUD a othr ta hath issus to AVRC patits o ay a w usi a scur Wb-bas, obi tici cart a accopayi sotwar. This syst aows th psychiatrist a patit to cary s a har ach othr. Oc th psychiatrist ts with th patit, thy a ots that ar stor with thir UCLA patit rcor a copis ar st via a scur i to th ica prso at th Acto aciity or pact i th patit s AVRC i. Prscriptios ar writt by th UCLA psychiatrist a i at a oca Acto pharacy. UCLA/AVRC Tpsychiatry Protoco 1. Patits ar itii by th AVRC psychooist or LCSW, as appropriat, to rciv tpsychiatry srvics. 2. Patits copt tici ioratio sht, tici cost or, a uti-cosortiu cost or. AVRC sta axs via a scur i a ais har copis to UCLA Nuropsychiatric Hospita. 3. Patit ristratio is procss a UCLA ica rcor ubrs ar issu. 4. Ristratio ioratio is orwar via scur i to ISAP psychiatrist. 5. AVRC ais copis o patits ciica ioratio ircty to ISAP psychiatrist. 6. ISAP psychiatrist coucts th sssio a copts ictatios which ar stor with th patits UCLA patit rcor. 7. Copis ar st via a scur i to th ica prso at th Acto aciity or pact i th patit s AVRC i. 8. Prscriptios ar writt by th UCLA psychiatrist a i at a oca Acto pharacy. Iptatio Outcos As o Ju 3, 2013, 171 tpsychiatry patits hav b ischar. Most patits hav ha a ubr o oow-ups a pi o thir s, so ar s o a wy basis. Usi a ow-cost icatio oruary, psychiatrists prscrib psychotropic icatios or a ubr o issus icui prssio a axity. As a rsut o th ow-cost oruary a icras icatio aat, or patits ar ow ab to icorporat psychotropic icatios ito thir tratt. This projct has rsut i a ubr o positiv outcos icui a ruc barrir to psychiatric car or patits i rot aras a a icras i icicy or th AVRC a UCLA systs. Thr was a 25.3% icras i iaoss o ta iss. Thr was a 126.1% icras i th prscribi o icatios or ta hath issus (Dri, L.L, Crvcour- MacPhai, D.A t a. 2013). Th icrass i iaoss a prscrib icatios or o- Srious a Prsistt Mta Iss (SPMI) patits ar aso ot as a bit o th cotiuous car. Othr bits icu opportuitis or hac cutura coptcy (i.., icras itractio with traitioay ursrv thic roups) a itr-a itra-acy coaboratio. A satisactio survy was couct that ostrat that this projct has b w-rciv by participats, a bac ro UCLA sta a AVRC sta has aso b positiv. 74 Chaptr 2

79 Lssos Lar Th Tpsychiatry projct icras accss to ta hath srvics a icatios or patits i a ursrv ara. Patits a sta hav rport positiv bac o th us o tpsychiatry. This iovativ projct ostrats a succssu coaboratio btw two Los As Couty acis (Pubic Hath a Hath Srvics) a UCLA ISAP. It is tstat to th bits o itrat car, which has bco icrasiy iportat as th i o substac us isorr tratt cotius to ov towar a chroic car o. Los As Couty Vivitro Piot Projcts Bacrou Vivitro is th ijctab or o atrxo, a opioi rcptor ataoist that acts by boci th u-opioi rcptors i th brai. Ths rcptors ar rsposib or th hih or buzz iiviuas wh acoho is cosu. Wh th rcptors ar boc, th hih or buzz is o or achivab a cravis or acoho ar ruc siiicaty. Th rsuts ro a piot projct i Los As Couty to aiistr Vivitro i thr ar, pubicy u tratt oraizatios i Los As Couty wi b iscuss as w as a oow-up stuy. Objctivs/Mthos I , th Los As Couty Dpartt o Pubic Hath, Substac Abus Prvtio a Cotro (SAPC), i coaboratio with UCLA, couct a outco vauatio o th iptatio o Vivitro i thr couty-u tratt ctrs (Vivitro Phas I). Th ais o th outco vauatio wr to tri chas i patit outcos a cousor attitus. To o so, thr acis wr sct to aiistr Vivitro. Data coct icu th Ur to Dri Sca, th Micatio Assist Tratt Survy, a survy vop by UCLA to asur cousor attitus, a th Los As Couty Participat Rporti Syst (LACPRS) aissio a ischar qustios. Iptatio Outcos Rsuts iicat that approxiaty 60% o patits wr iv a sco ijctio. Th outco vauatio tri that th patits urs to ri a rii bhaviors wr ruc, with iit si cts ro th icatio (Vivitro Fia Rport, 2011). Spciicay, urs to ri cras ro a avra scor o 19.3 to 6.6 (out o a tota o 30). Vivitro patits aso ostrat ruc us o thir priary substac, bttr tratt at, a hihr coptio rats copar to th avra couty patit. I aitio, rsuts iicat that isrvic traiis iprov sta attitus rari th us o icay assist tratts. Cocusios ro this iitia piot projct sust that cousor ucatio a support appar to b iportat i th ort to hp patits rai o Vivitro or sco a subsqut oss. Th crass i urs to ri ay aso hav a ipact o patit outcos, i that patits who rai o th icatio ar aso or iy to rai i tratt. Chaptr 2 75

80 Vivitro Phas II Giv th succss o th irst piot projct, SAPC, aai i coaboratio with UCLA, souht to xai how patits cssatio o Vivitro ipacts patit cravis a outcos. I at Fbruary 2012, LACES ba th Vivitro Phas II projct, a oow-up stuy o th oriia projct. Th Phas II oow-up prio or Vivitro patits was ro Fbruary 2012 to Fbruary This bri oow-up stuy xai whthr patits ca aitai thir sobrity oc thy ar o or rcivi Vivitro ijctios. Cosistt with Phas I, th projct coct ata o icay assist tratt (to ascrtai si cts, ays us, tc.) a th ur to ri/us (to ascrtai cravis). I aitio, patit outcos wr aso xai as that ata bca avaiab. Priiary rsuts sust that patits who hav ta at ast o os o Vivitro rport ciicay siiicat crass i th ur to ri acoho or us opiois. Rsuts appar to sust that patits ur to ri/us rai withi a ciicay sa ra (scori bow 10; rcti itt ar o raps) 30- a 60-ays atr thir ia ijctio o Vivitro. Th cras i ur to ri/us ay iicat a cotiu ructio i ur to ri/us, or at ast a siiicat ay i a rtur o urs atr th icatio is o or aiistr. Aitioay, priiary aaysis susts that Vivitro ay cras th ubr o ays usi acoho a/or opiois. Patits aso s to hav ruc thir ays o us to itoxicatio, which is ciicay siiicat. It aso appars that th patits ar ab to aitai th ructio i ays us or itoxicat atr th icatio is o or aiistr. Futur aaysis wi xai i ths iis ar statisticay siiicat. About a thir o a patits xpric si cts (.., haach, ausa, atiu) atr rcivi a ijctio. A ovra tr appars to sust that si cts ss atr th iitia ijctio. It ust b ot that this stuy is a vauatio stuy a ot a ciica tria. Rao assit was ot us to tri whthr a patit wou rciv th Vivitro icatio or a pacbo. Thus, o o th shortcois o th currt piot is that o causa cocusios ca b a a it ust b cosir that th rsuts cou hav occurr without th icatio. Futur aayss wi xpor tratt outcos ao thos rcivi Vivitro copar to siiar patits who ar ot rcivi Vivitro. Lssos Lar Th Vivitro Piot Projcts (Phas I a Phas II) hav ostrat th bits o icatioassist tratt (MAT). Micatio-assist tratt, athouh a rcoiz vicbas practic, is sti w to ay SUD tratt provirs. May hav iit ow o th w icatios avaiab that ay b us to hp patits bttr ha withrawa a cravis, a hp to ruc th iihoo o raps. Cousors shou b iv opportuitis to ai th ucatio a sis thy to arss thir cocrs as w as th cocrs o thir patits. This, i aitio to othr barrirs to MAT, such as cost a avaiabiity o prscribi ica sta, ust b arss iv th iprovts to hath car with HCR a parity. 76 Chaptr 2

81 Dua Diaosis Capabiity i Hath Car Sttis (DDCHCS) Bacrou As part o a two-ay traii couct by Mar McGovr, Ph.D., or UCLA sta o th Dua Diaosis Capabiity i Hath Car Sttis (DDCHCS) too, a sit visit was couct at a ray quaii hath ctr ocat i a urba ara i Los As Couty. A bri scriptio o th DDCHCS a suary o th iis ar prst bow. Objctivs a Mthos Th DDCHCS too was si to assss th xtt to which priary car, ta hath, a SUD srvics ar itrat withi hath car sttis a to hp itiy aras i which itratio ca b iprov. Aiistratio o th DDCHCS ivovs a i-prso sit visit, obsrvatio o th ciic iiu a physica stti, itrviws with y sta brs a patits, a ocut rviw (.., ica rcors, prora auas). Th hath ctr rcivs ratis o sv isios: prora structur; prora iiu; ciica procss asssst; ciica procss - tratt; cotiuity o car; sta; a traii. Each isio is assss iiviuay a iv a scor btw 1 (Hathcar Oy Srvics) a 5 (Dua Diaosis Ehac); a ovra scor is aso cacuat. Th hihr th scor, th or itrat th priary car, ta hath, a substac us isorr srvics. Iptatio Outcos Th hath ctr s ovra DDCHCS scor was 2.82, which iicats that it is ary Dua Diaosis Capab. Th hath ctr s prora structur a prora iiu wr both rat 4.0, iway btw Dua Diaosis Capab a Dua Diaosis Ehac, whras th ra o scors or th othr iv isios (ciica procss asssst, ciica procss tratt, cotiuity o car, stai, a traii) was btw 2.0 a 2.8, which iicats a owr v o itratio btw Hathcar Oy Srvics a Dua Diaosis Capab. Lsso Lar Ovra, whi so ts rquir or itratio ar prst at this hath ctr (.., prora ocus o both MH a SUD srvics), thy ar cssary but ot suicit. Ovrsiht a cooriatio o th MH a SUD srvics by a si suprvisor with a itrst a/or xpric i both iscipis wou hp iprov itratio orts. For or DDCHCS outcos, s th Kr piot bow. Pas or Yar 2 Activitis Patit prspctivs o th itratio o bhaviora hath a priary car i couity hath ctrs I Yar 2 o th ETTA projct, UCLA is pai to couct a piot vauatio to obtai aut patits prspctivs o th bhaviora hath car thy hav rciv i priary car sttis. UCLA wi couct o ocus roup (si-structur roup itrviw) with patit voutrs (=6) who hav rciv bhaviora hath srvics at a sct couity hath ctr sit i Los As Couty that has iitiat itratio orts. Patits rcoatios to iprov th itratio o bhaviora hath srvics wi aso b soicit. Chaptr 2 77

82 Objctiv: To obtai patit prspctivs o what is wori w, what is ot wori as w, a how bhaviora hath car cou b bttr itrat i priary car sttis. Siiicac: Patit-v ioratio ay ir substatiay ro th sta prcptios coct prviousy, a urstai such ioratio is critica or patit-ctr car. Data coctio is currty urway. 78 Chaptr 2

83 KERN COUNTY Bacrou Kr Couty is vry ar (approxiaty 8,500 squar is), which rquirs that th srvic ivry syst b oraiz to rach outyi aras. I Barsi, th priary iustris ar oi a aricutur, a th upoyt rat is 32% i o couity. Kr Couty s popuatio is aso vry ivrs (o couity is 80% 90% Hispaic whi othr couitis ar 60% 70% Whit rsits). Th ta hath syst o car cosists o crisis a rsitia srvics (iv ciics, 31 physicias, iht cotract provirs). Th SUD syst o car cosists o traitioa outpatit car i rioa aras, with ipatit car ha i Barsi (14 ciics, icui ipatit a thao). Thr ar 27 FQHCs i Kr Couty. Kr Couty Mta Hath (KCMH) is wori with FQHC partrs to ipt a SBIRTtyp o i priary car sttis (Projct Car). Usi MHSA us, Projct Car provis sct MH a SUD scri a tratt srvics withi th priary car aciitis. Projct Car s ui aciitats war haos (i.., th priary car provir ircty itroucs th patit to th MH/SUD provir) by aowi provirs to b riburs or provii two srvics i th sa ay (.., or a physica ait a a SUD), ui othr priary car sits i Caioria that ry o Mi-Ca (Micai) riburst. Objctivs/Mthos Projct Car ais to proot itratio throuh ruar tis o cas aars, us o ctroic ristris, us o vic-bas practics, a rquir aiistrativ tis, practitior twori, a traiis. Th oas o Projct Car ar to provi uivrsa scri o a aut patits coi to th ciics. Thr scri istruts ar us (PHQ9, GAD7, a Auit-C+). Bri itrvtios ar ivr osit a icu SUD asssst a MH soutio-ctr tratt (usi th Assist Mo a Motivatioa Itrviwi tchiqus) that ta pac ovr 6 10 visits. Itrat cas corci with th physicia, psychiatrist, a bhaviora hath sta ar aatory, a Projct Car uss ata to oitor prorss. Iptatio Outcos Kr Couty wors with UCLA to provi prora vauatio srvics o Projct Car. Th vauatio copot cosists o aiistrativ ata aaysis, asurs o th v o itratio at ach ciic usi th Dua Diaosis Capabiity i Hath Car Sttis (DDCHCS) too, sta satisactio survys, a patit itrviws. Aiistrativ Data UCLA has b wori with th thr priary car oraizatios to obtai aiistrativ ata (ata ow coct by ach o th participati oraizatios as a part o thir routi car) o th ubr o pop scr, thir scors, a th ubr assss, trat, a rrr. Wh uy ipt, this ata wi b rat by ach oraizatio usi i2i ristry sotwar. This i2i sotwar wi arat iiviua patit-v ata ro thir NxtG ctroic hath rcor (EHR) syst to ruary prouc autoat a custoiz arat rports that NxtG its os ot hav th capacity to crat. Howvr, a thr o th Chaptr 2 79

84 oraizatios ar i various stas o trasitio to th w EHR syst, which has ay istaatio o i2i. Wh i2i is uctioa, th oraizatios wi b ab to prouc thir ow rports o a ruar basis, but i th ati, UCLA is obtaii raw ata i sprasht orat a aayzi it usi SAS sotwar. Fiur 2.8 shows th icrasi ubr o scrs at ths ciics ovr th ast w yars Fiur 2.8 A Sits Scris by Yar 0 Yar 2011 Yar 2012 Yar 2013 so ar Fiur 2.9 provis a priiary xap o o sit s substac us isorr scors bor a atr tratt. Fiur 2.9. AUDIT-C+ Scors Ao Patits with at Last Two Scris First Auit-C+ 6.5 Sco Auit-C+ 80 Chaptr 2

85 Dua Diaosis Capabiity i Hath Car Sttis (DDCHCS) Th Dua Diaosis Capabiity i Hathcar Sttis (DDCHCS) too was si to asur th r o priary car, SUD, a ta hath itratio withi hath car sttis, a as such, was aopt as a y asur or th vauatio. DDCHCS aiistratio rquirs a iprso sit visit, ispctio o th sit a rcors, a itrviws with utip sta brs. UCLA couct DDCHCS visits with a Projct Car sits i 2011 a oow-up visits i Ratis o aspcts o itratio asur by th DDCHCS asssst (Fiur 2.10) hav icras o avra or th oraizatios assss. Th arst iprovt occurr with rar to traii, which icras by 1.04 poits. Avra scors o stai, ciica asssst a tratt a icras by at ast.65 poits. Fiur Dua Diaosis Capabiity i Hath Car Sttis (DDCHCS) Avra Ratis Traii Stai Cotiuity o Car Ciica Procss: Tratt Ciica Procss: Asssst Prora Miiu Prora Structur Sta Satisactio Survys Sta satisactio survys wr aiistr to ta hath/substac us isorr sta, support sta, a priary car provirs ro a thr oraizatios. Th survy us was aapt ro survys vop by th Itrat Bhaviora Hath Projct ( Survy rsuts sust that itratio a MH/SUD srvics wr hihy vau at th Projct Car sits that wr stui, a that sta wr uiory itrst i urthr MH/SUD traii. Howvr, thr wr siiicat ircs i th way sta Chaptr 2 81

86 prciv currt procsss, particuary couicatio. A sco rou o survys, which wr coct i Ju a Juy 2012, tri how sta prcptios hav cha ovr ti. Duri th 2011 survy, bhaviora hath sta wr ss coit i th abiitis o ica sta to ha bhaviora hath patits tha th priary car provirs (PCPs) a support sta (SS) wr. About o yar atr basi asssst, this ap ha b ary ras (s Fiur 2.11). Fiur Sta Prcptios: Satisactio with th abiity o th ica sta to arss th s o patits with bhaviora hath issus. Stroy Ar Ar Ucrtai 3.00 BHP PCPs SS Basi Foow-up Lssos Lar Duri a ILC prstatio o Octobr 24, 2012, th priary car provirs (PCPs) i Kr Couty iscuss th chas a succsss xpric thus ar. Top 10 y ssos icu: 1) Iitiay, PCPs biv BH scris wou a pop ucoortab a thr was aso a ar that itrat BH srvics wou a to usirab cha i th patit popuatio. Th soutio was to ucat PCPs o SUD a SBIRT. 2) Havi BH Practitiors avaiab wh by th PC sta was chai. Thy ar that rotati BHPs throuh utip ciics o siat ays (Mobi Bri Srvics) i t wor. It crat a hit-or-iss rrra syst. Th soutio was to tach SBIRT to sta, a thy itrouc iut bri itrvtios. 3) Th riht sta or th BH job ust b itii. Thrapists ust b chos wisy. Th prso ust b xib, proactiv, ab to ha abiuity, a ab to or stro ratioships. 4) Stahors ust b wii to oiy iitia pas as. Ev oo pas twai wh put ito practic. 82 Chaptr 2

87 5) Buy-i ust b obtai ro a vs o ciic sta, a bac ust b wco. Couicatio is y a cotiui sta ucatio is iportat, as it as th vau a a iportat part o th procss. 6) Scri ors ust b aa thorouhy. Scri ors wr ot aways iv to patits to copt, patits i ot i th out, or thy wr ispac. So soutios icu ruci th th to a si pa a ai coor to a th or or visib withi patit pacts. Thy aso crat a box or scrs to b posit ito wh th thrapist is t iiaty avaiab. 7) Chapio physicias who att a traiis a th shar th ssos with th rst o th PC sta ar vry iportat. 8) Thr ar ay chas surroui th iptatio o a w EHR syst, such as probs with itchs a ata trasrs. Th ata traci syst ust b pt sip at th outst. 9) Patits ar biti ro th itratio o srvics. Patits urstoo a support with i-prso war haos. This buis trust, which aows patits to thy ar put i oo has. 10) Havi bhaviora hath provirs ow th ha ro PCPs crats a op, accssib virot. Pas or Yar 2 Activitis Kr couty Low Ico Hath Prora Data Aaysis Kr couty is o o th w LIHP coutis that icu a SUD bit. Patits ar ro i th LIHP prora at th Kr Mica Ctr rcy roo. Rporty, iptatio occurr without ays o Juy 1, Howvr, oboy has oo at th couty s ata spciicay i ratio to SUD srvics. UCLA pas to wor with Kr to oo at srvics a ica costs bor a atr this LIHP iptatio at to try to aswr qustios such as: Di SUD srvics t or rqut? What is o srvics wr us? Wr SUD srvics associat with a ructio i costs ao thos tti th? W biv ssos ro this ata ay hp ior th stat o what rsuts iht b xpct wh SUD covra xpas i 2014 throuh th Mi-Ca xpasio a isurac xcha pas. W ar currty i th procss o acquiri rcors ro Kr Couty Mica Ctr s NxtG Rcors. This ata wi b xtract by Kr couty sta a st to UCLA. Data wi icu ubr o visits, hospitaizatios, ica visits, ica costs, a ICD9 cos. UCLA a Kr Couty ar currty rviwi busiss associat arts to aow th trasr o ata. Patit prspctivs o th itratio o bhaviora hath a priary car i couity hath ctrs I Yar 2 o th ETTA projct, UCLA is pai to couct a piot vauatio to obtai aut patits prspctivs o th bhaviora hath car thy hav rciv at sct hath ctr Chaptr 2 83

88 sits as w as ioratio o thir acoho a ru us. UCLA wi couct ocus roups (si-structur roup itrviws) with patit voutrs who hav rciv bhaviora hath srvics at iv couity hath ctr sits with orat to hih vs o itratio i Kr couty. I aitio, UCLA wi couct iiviua pho itrviws, icui a 30-ay oowup itrviw, with a sap o aut patits who hav rciv bhaviora hath car at o sct hath ctr sit i th couty. 84 Chaptr 2

89 ORANGE COUNTY Bacrou Ora Couty is th thir ost popuous couty i Caioria, with 3 iio rsits. Th couty is ocat i Southr Caioria a has thr ai citis: Sata Aa, Aahi, a Irvi. Th city o Sata Aa srvs as th ovrta ctr o th couty, Aahi as its ai tourist stiatio, a Irvi as its ajor busiss a iacia hub. Ora Couty has a thrivi busiss cooy a a w-ucat wororc. I aitio, it is a rioa srvic provir a pai acy whos cor busisss icu pubic saty, pubic hath, virota protctio, rioa pai, pubic assistac, socia srvics, a aviatio. As such, it ors urous itrvtio a prvtio srvics or ta hath isorrs a ay accssib bhaviora hath tratt aciitis ( Objctivs/Mthos Ora Couty is wori o a bi-irctioa car projct. Fu throuh MHSA, th prora is a uiqu pubic/privat partrship btw a couity ciic, substac abus tratt provir, a ta hath provir. Thy hav our sits: two FQHC a two FQHC ooais. Th Bhaviora Hath (BH) Ta cosists o two pr cousors, a psychiatrist, a a BH thrapist at ach sit. Th pr cousors provi ho visits, outrach, utritio ucatio, soi cssatio, a icatio copiac. Th BH ta a priary car ta t o ti pr w or cas cooriatio o srvics. Th itrat hath car o us i th prora ais to arss th ut s o patits by provii a cooriat ta o SUD, MH, a PC prossioas ur o roo. Iptatio Outcos Thy hav coutr ay chas, icui: (1) Ristry: th vopt o a patit ristry is costy. Thy o that suits thir s a aows or ioratio shari across acis, a (2) Coitiaity: 42CFR a HIPAA ruatios hav b a hur. Currty, ioratio ca b shar btw irt acis. Ora Couty is aso wori with UCLA to trai a "coach" at i FQHCs a/or ta hath acis u to provi uy itrat hath car a bhaviora hath. Svra otivatioa itrviwi (MI) a SBIRT traiis hav b couct or provirs wori o ths projcts. For physicias, traii is provi at thir othy rsit ucho. Ooi coachi srvics (o-sit 2 3 ays pr w) wi b provi to th bhaviora hath sta to sur thy ar ctivy crati itrat tas (o part-ti LCSW was hir as th coach). A scri too was stabish with i qustios arssi axity, prssio, acoho, ru, a ostic vioc (traiis wr provi o how to copt this too). Forty-two coachi sssios wr provi to sits uri th cotract prio o ti a ovr 100 sta wr trai. Th ia vauatio survys show that sta t coit i copti a bri itrvtio a i usi th Ora Couty Scri too. Th prora iptatio phas is currty urway. Patits ar bi scr usi th Ora Couty Scri too. Dpi o th scri rsuts, a bri itrvtio wou b o usi otivatioa itrviwi sis. Fiis ro this prora wi b avaiab i th ar utur a wi b iscuss i a utur Itratio Lari Coaborativ ti. Chaptr 2 85

90 Lssos Lar Th itrat hath car o us i th prora ais to arss th ut s o patits by provii a cooriat ta o SUD, MH, a PC prossioas ur o roo. Thouh chas hav b coutr, th bits o itrat car ar apprciat by sta. SBIRT a MI traiis wr w rciv. Th sta t or coit i copti a bri itrvtio a i usi th Ora Couty Scri too. Pas or Yar 2 Activitis Patit prspctivs o th itratio o bhaviora hath a priary car i couity hath ctrs I Yar 2 o th ETTA projct, UCLA is pai to couct a piot vauatio to obtai aut patits prspctivs o th bhaviora hath car thy hav rciv i priary car sttis. UCLA wi couct o ocus roup (si-structur roup itrviw) with patit voutrs who hav rciv bhaviora hath srvics at a sct couity hath ctr sit i Ora Couty that has iitiat itratio orts. Patits rcoatios to iprov th itratio o bhaviora hath srvics wi aso b soicit. 86 Chaptr 2

91 SAN FRANCISCO COUNTY Bacrou Th City a Couty o Sa Fracisco has a popuatio o 825,863 i a 46.9 squar-i a ara, ai it th ost sy popuat ara i th stat. Accori to csus stiats, Sa Fracisco s popuatio is 54% Whit, 34% Asia, 6% Arica Arica, a 4% ix. Ovrai o ths thic catoris, 15% rport bi o Hispaic thicity. ( Objctivs/Mthos W itii o FQHC i Sa Fracisco as oi itratio wor svra oths ao wh w couct our survy o FQHCs (s sctio Fray Quaii Hath Ctr Itratio Survy a Itrviws or or o this survy). W visit th sit a ou that thy wr itrat i thir HIV/AIDS ciic i particuar, whr thy ha brouht i a SUD cousor to wor with ica sta a patits. Thy rport that this has a a bi irc, but thy ha t ha ti to oo at thir ata to prov that. This FQHC is aso ab to i to th couty s ata to acquir ata o rcy roo visits, hospita utiizatio, tc., putti it i a oo positio to trac patit outcos. UCLA wi wor with this FQHC to xai whthr ai th SUD cousor i 2011 a ay oticab irc i cost a utiizatio. Th HIV/AIDS ciic is itrsti i that thy hav Rya Whit us, so thy ar ab to pay or SUD srvics. This FQHC ay thror b ab to provi ssos or othrs that ay acquir covra or SUD ur ACA provisios i This oraizatio is aso uusua i that ost FQHCs ar cosiri usi LCSWs a othr FQHC-biab sta that o t cssariy hav a rat a o SUD traii, whi this oraizatio is usi a CADAAC crtii Acoho a Othr Dru cousor. Data Aaysis D-itii ata was st to UCLA xtract ro thir oca ctroic hath rcor a ata traci ristry (NxtG/Liti Ciica Rcor usi i2i Tracs sotwar) covri iitia visit ats ro Octobr 1, 2010, throuh Octobr 1, Currt ata icus ica visits, CD4, vira oa, hospitaizatios, ica visits, ica costs, a ICD9 cos. Th patits ar osty a (90%), with a a a o 46 (ra o ro yars), a with a avra o sv substac abus cousi visits, our icay acut visits, a thr icay routi visits (avra o 15 visits tota). Ha o th ar Spaish spars a a thir hav a ustab ivi situatio. W ar i th procss o aayzi rcors ro Sa Fracisco to asur th ipact o thir SUD cousor o patit asurs. Chaptr 2 87

92 SAN LUIS OBISPO COUNTY Bacrou Sa Luis Obispo Couty is ocat ao th Ctra Coast o Caioria. Most o th couty s 3,326 squar is ar uicorporat. Th ajority o rsits iv ao th coast or th corrior o Hihway 101. Th astr rio is sparsy popuat, with vast aras o aricutura a ovrt as btw sa, uicorporat tows. Th Ctra Coast Bhaviora Hath Poicy a Eucatio Coitt (CCBHPEC), which rprsts privat, pubic, a o-proit prossioas, is wori coaborativy to icras accss to bhaviora hath srvics i Sa Luis Obispo (SLO) Couty i prparatio or ACA provisios ctiv as o Th Coitt was or subsqut to th Th Itratio o Bhaviora Hath ito Priary Car traii by Thoas Frs, Ph.D., that was h i Sa Luis Obispo Couty o May 15, Th CCBHPEC has rqust tchica assistac ro UCLA to hp it rach its oas: Di th ut s o SLO Couty rsits or aorab a accssib bhaviora hath car srvics; Crat a o or a couity-bas cotiuu o car or bhaviora hath s or E.R., FQHC, a priary car physicia rrras; a Eucat th physicias a couity about th rrra rsourcs. Th stti or th piot vauatio copriss couity provirs, icui North Couty Coctio, Couity Hath Ctrs o th Ctra Coast, Frch Hospita Mica Ctr, CCa Hath, Dpartt o Socia Srvics, Ipt Rsourc Ctr, a th Sa Luis Obispo Couty Dru a Acoho Srvics. Th provirs i th orth couty couity appar to b at th ary stas o itratio a i vopi a couity-bas syst o car or bhaviora hath i SLO Couty. Objctivs/Mthos Th oa o this projct is to provi ata a uiac to assist th SLO Couty CCBHPEC i vopi its couity-bas bhaviora hath cotiuu o car i prparatio or Th spciic projct objctivs vop i cojuctio with th CCBHPEC ar to: Couct aiistrativ ata (.., Uior Data Syst) aaysis to assist th Couty i its orts to: (1) itiy aps i ata coctio/traci, (2) stabish a basi to oitor prorss, (3) ostrat aras o or bhaviora hath srvics a obtai buy-i ro stahors or arssi such s, a (4) provi ata that ca b us i prpari rat proposas. Couct oow-up ata aayss, i rqust. Survy priary car a bhaviora hath srvic provirs (.., rcy roo physicias, bhaviora hath spciaists, couity hath ctr priary car provirs) to obtai a sapshot o bhaviora hath srvics itratio with priary car. 88 Chaptr 2

93 Masur th itratio o ta hath a substac us isorr srvics with priary car i thr couity hath ctrs to provi a basi to hp itiy aras i which itrat srvics ca b iprov. Aiistr oow-up asssst i rqust. Provi traiis o otivatioa itrviwi, SBIRT, a, pottiay, othr topics i. Itrouc icatio-assist tratt i priary car sttis, i possib a whr itrst xists. Aiistrativ ata aaysis UCLA pas to aayz aiistrativ ata that ar avaiab (.., Couity Hath Ctrs o th Ctra Coast, CCa, Tat, CaOMS-Tx, bii ata i avaiab). W wi iscuss with Coitt brs th possibiity o obtaii ata o ats a typ o bhaviora hath srvics rciv, bhaviora hath scri a asssst scors, iaoss, bii, a cost. W wi couct urthr aayss as aitioa rvat ata sts ar itii a rciv. Stahor survy I coaboratio with Coitt brs, UCLA wi vop a aiistr a wb-bas or papr survy qustioair to coct ata o priary car a bhaviora hath srvic provirs prspctivs o a xprics with th itratio o bhaviora hath srvics withi priary car sttis. This wi rquir -ai arsss o sta a buy-i ao Couity Hath Ctr a othr oraizatio ars. Dua Diaosis Capabiity i Hathcar Sttis (DDCHCS) UCLA wi utiiz th Dua Diaosis Capabiity i Hath Car Sttis (DDCHCS) too to coct ioratio o currt vs o priary car-bhaviora hath itratio a to provi rcoatios at 3 Couity Hath Ctrs o th Ctra Coast sits (Tpto, Lopoc, Nipoo). This wi rquir i-prso sit visits, obsrvatio o ciic opratios, rcors rviw, a itrviws with y sta brs ro a iscipis. Rports ro ths visits wi b prpar. Micatio-Assist Tratt (MAT) I thr is itrst a it is possib, UCLA wi provi physicias a rvat sta i priary car sttis (.., car cooriators, physicia assistats, bhaviora hath sta) with ioratio a uiac o MAT or aictio (.., buprorphi, Vivitro, atrxo), icui obtaii waivrs or physicias to prscrib buprorphi, a bii. Iptatio Outcos To at, svra UCLA-SLO Couty tis hav b h via corc ca to iscuss: ata variabs o itrst a pottia ata sourcs or th aiistrativ ata aayss; stahor survy purpos, vopt (.., qustios), a istributio ist; a visits to thr couity hath ctrs to aiistr th DDCHCS asssst. Chaptr 2 89

94 Futur pas ivov cotiui with our ruary schu biwy UCLA-SLO tis to sur prorss is a i ipti th activitis outi abov. Th piot vauatio projct i th orth couty couity is xpct to assss a ocut bhaviora hath srvics currty bi provi, th xtt o th itratio o such srvics i priary car sttis, ut s or bhaviora hath srvics, a rrras or couity-bas bhaviora hath srvics. UCLA hops to ar ro SLO Couty s vopt o a o or a couity-bas cotiuu o car that cou pottiay b ipt couty-wi a prhaps i othr coutis i th stat. Th o that is vop cou pottiay b us with othr coutis at th ary stas o itratio to ctivy a icity strai a accrat th procss. 90 Chaptr 2

95 Othr Statwi Evauatios Caioria Couty Mica Srvics Prora (CMSP)/ Path2Hath Survy 2012 Path2Hath, a 2-yar prora sposor by th Couty Mica Srvics Prora (CMSP) Govri Boar a authoriz ur Caioria s 1115 Micai Waivr, xpa ocost ica covra i 35 rura coutis to uisur, ow-ico auts. UCLA couct a bri 15-iut ctroic survy to coct ioratio o coutis xprics with th CMSP/Path2hath prora (rspos rat 76%). Our iis show that th xpa bit (particuary with th SUD covra) is proiaty urutiiz. Oy six rspots rport that thir couty ha attpt to procss cais or SUD srvics usi this bit, a ths rspots rport that (1) thr wr ay qustios at th bii, (2) payt was ot ouh to copsat or th sta ti rquir to procss cais, a rcivi payt was probatic, (3) thr wr ot ouh srvics authoriz uprot, a (4) th aout o srvics covr ur th bit i ot it th s o th typica SUD cit. Satisactio was ow ao ths rspots. Ths rspots rat thir satisactio as oy 1.8 o a 5-poit sca. Rspots who wr ot utiizi th xpa SUD bit (=20) rport rasos such as: (1) ot havi th irastructur i pac to bi to this bit or ay othr hath isurac (icui Dru Mi-Ca), (2) ot havi ouh CMSP-iib cits to bothr with th paprwor a rqut r-authorizatios rquirts, (3) bi that it i ot s to rat ouh oy to th couty to copsat or th ti to procss cais, a (4) u to ativ xprics a acota rports ro ow aiistrators o th isoraizatio, sow rspos ti, a icosistt ioratio at Ath Bu Cross, rspots i ot wat to a i th prora. Athouh thr wr a w positiv rars about th prora, ovra rsuts sust that th CMSP/Path2Hath xpa SUD bit wt ary urutiiz a thror ha iia ipact. Athouh so hav accss th covr srvics a rciv riburst, it cos with a hih aiistrativ cost that ay coutis ar ot ab to aor. Rsposs sust that cais procssi a payt s to b sipii a strai i SUD bits ar to b us ctivy wh thy bco or wiy avaiab i Provirs wi aso to hav th irastructur a aquaty trai sta to subit cais. Itrouctio Th Couty Mica Srvics Prora (CMSP) was stabish i Jauary 1983, wh Caioria aw trasrr rsposibiity or provii hath car srvics to iit auts ro th Stat o Caioria to Caioria coutis. This aw rcoiz that ay sar, rura coutis wr ot i th positio to assu this w rsposibiity. As a rsut, th aw aso provi coutis with a popuatio o 300,000 or wr with th optio o cotracti bac with th Caioria Dpartt o Hath Car Srvics (DHCS) to provi hath car srvics (ica, ta, visio a prscriptio bits) to iit auts. DHCS utiiz th Chaptr 2 91

96 aiistrativ irastructur o Mi-Ca's -or-srvic prora to stabish a aiistr th CMSP prora. Sic 1983, iaci o CMSP srvics has vari, but toay, CMSP is u xcusivy by Rait rvu (otor vhic ics s a sas tax) a couty ra rvu. Bii Octobr 1, 2005, Ath Bu Cross Li & Hath Isurac Copay assu aiistrativ rsposibiity or CMSP. CMSP ors hath covra or ow-ico auts who ar a 21 64, hav iit ico a assts, o ot quaiy or Mi-Ca, a iv i o o th aiy rura coutis that participat i th prora. Ath Bu Cross Li & Hath Isurac Copay (BC Li & Hath) aiistrs this prora or th CMSP Govri Boar. CMSP brs rciv hath car srvics ro participati octors, hospitas, a ciics i th BC Li & Hath/CMSP provir twor. Hathcar provirs cotract with Ath Bu Cross to participat i th Ath Bu Cross/CMSP Provir Ntwor. Oy provirs participati i th Ntwor ay rciv payt or o-rcy hath car srvics provi to CMSP brs. ( O Jauary 1, 2012, th Path2Hath prora was iitiat to or ary iptatio o covra, siiar to that xpct i 2014 ur th Aorab Car Act. Path2Hath is a Low Ico Hath Prora (LIHP) sposor by th Couty Mica Srvics Prora (CMSP) Govri Boar a authoriz ur Caioria s 1115 Micai Waivr. Path2Hath has ra ui or two yars ur a 1115 Micai Waivr th Stat o Caioria rciv. Th prora s Dcbr 31, Fra hath ror (Aorab Car Act) wi provi Mi-Ca covra to this popuatio bii Jauary 1, ( O a two-yar piot projct basis, Path2Hath is xpai o-cost ica covra i 35 rura coutis to uisur, ow-ico auts with icos up to 100% o th ra povrty v (about $10,890 or a si prso auay), a iibiity is xpa to thos btw th as o 19 a 64. Aitioay, with Path2Hath, ros wi ot hav to pay a shar o cost uss thy hav or tha $900 o ico pr oth. Fiay, i rspos to avorab rsuts ro a CMSP Bhaviora Hath Piot Projct couct ro 2008 to 2011, th bit paca withi Path2Hath was xpa to icu ta hath a substac abus cousi. Thirty-iv coutis participat i th CMSP/Path2Hath Prora. Ths coutis covr 92 Chaptr 2

97 ary 90,000 squar is o trritory a hav a ra popuatio o approxiaty 3 iio pop. O a othy basis, approxiaty 40,000 iit auts rsii i ths coutis ry upo CMSP bit covra. Eiibiity or CMSP/Path2Hath is tri by th couty socia srvics partts i th 35 participati CMSP coutis i accorac with iibiity rus st by th Govri Boar. A tratt authorizatio rqusts or ica, ta, visio, a bhaviora hath srvics ar procss by Ath Bu Cross or its ta a visio srvic subcotractors. Payt or ica, ta, visio, a bhaviora hath srvics is procss by Ath Bu Cross a its ta a visio srvics subcotractors i accorac with currt HIPAA staars. Both papr a ctroic biis ar procss. CMSP/Path2Hath provis payt or rcy hath car srvics provi to CMSP brs by Ntwor provirs a a othr provirs o rcy srvics i Caioria. Srvics covr icu: acut ipatit hospita car; aut ay hath car srvics; auiooy srvics; boo a boo rivativs; chroic hoiaysis srvics; ta srvics; urab ica quipt; rcy air a rou abuac srvics; hari ais; ho hath acy srvics; hospita outpatit srvics; aboratory a raiooy srvics; iit ta hath a substac abus cousi srvics; ica suppis; o-rcy ica trasportatio; occupatioa thrapy srvics; optotry srvics, icui y xaiatio a aowac o $80 or atrias (ss a ras); outpatit ciic srvics; outpatit hroi toxiicatio srvics; prscriptio ru srvics provi by twor pharacis; physica thrapy srvics; physicia srvics; poiatry srvics; prosthtic a orthotic appiacs; spch thrapy srvics; rcy a post-stabiizatio srvics i a 50 U.S. stats or a U.S. trritoris. Th iit substac abus cousi srvics icu: O asssst; Iiviua SUD cousi sssios (up to two) bas o ica cssity (authorizatio is rquir), SUD roup cousi sssios* (up to 20 roup sssios) Aow provir typs: ics psychooist, ics ciica socia worrs, ics arria/aiy thrapists, a ics prossioa ciica cousors, crtii substac abus cousors. *ciics (such as FQHCs, RHCs) wr ot iib to bi or substac abus roup cousi sssios. Purpos UCLA a ADP ar that athri ioratio o coutis xprics with th CMSP/Path2Hath bit Bhaviora Hath (BH) Tratt Srvics that wt ito ct o Jauary 1, 2012, wou b o bit to stahors. W ha two priary oas: (1) to ocut th utiizatio o a xprics with th CMSP/Path2Hath Bhaviora hath bit, with a phasis o substac us isorr (SUD) srvics (i.., what is wori w, what is ot wori w, rcoatios or iprovt); a Chaptr 2 93

98 (2) to athr ssos ar ro th utiizatio o this bit to hp ui othr coutis a th stat as thy prpar or Micai xpasio (icui SUD srvics) i Mthos UCLA couct a bri 15-iut ctroic survy usi Survy Moy to coct ioratio o coutis xprics with th CMSP/Path2hath prora bas o th objctivs ist abov. Tart qustioi ocus o th oowi aras: Eiibiity a Erot Authorizatio a Approva Bit Dsi Payt a Cais To assur aua carity, rvat qustioi, a bac o survy structur/si, UCLA cosut with y iorats such as CADPAAC s xcutiv irctor, To Rr, as w as o o th CMPS couty rprstativs, A Laorio, or iput a ia rviw. UCLA aso cosut with CMSP s Loca Hath Coctios Piot Projct aar o survy si a iquir about iptatio o th bit, but rciv iia bac. Th couty acoho a othr rus (AOD) aiistrators ro th 35 coutis who ar iib to participat i th CMSP bit wr st a -ai i Apri 2013 with a i to th survy (=34, sic Suttr a Yuba ar aiistrativy cobi). Aiistrators (or a at) wr iv iv ws to copt th 15-iut survy. Twty-six coutis rspo (76.5% rspos rat). Ovr ha o th rspots rport that thy wr ot participati i th xpa SUD bit. UCLA rsarch sta couct a scriptiv aaysis o th survy rsposs, which icu cots a xpaatios as to why so coutis opt out o th participati i th SUD bit or as part o th CMSP prora. Th survy is icu i Appix 2C. Fiis O th 26 couty rspots, oy six coutis rport attpti to procss cais, six rport so xpric/cotact with CMSP/Path2Hath, i coutis xpicity rport opti ot to us th bit, a iv coutis rport o ata, but rtur th survy. Rspots who wr ot utiizi th xpa SUD bit (=20) rport rasos such as: Not havi th irastructur i pac to bi to this bit or ay othr hath isurac (icui Dru Mi-Ca), Not havi ouh CMSP-iib cits to bothr with th paprwor a rqut rauthorizatios rquirts, A prcptio that it wou ot rat ouh oy to th couty to copsat or th ti to procss cais, a Nativ xprics or acota rports ro ow aiistrators o isoraizatio, sow rspos tis, a icosistt ioratio ro Ath Bu Cross. Rspots whos coutis i attpt to procss cais (=6) rat thir satisactio as oy 1.8 o a 5-poit sca rai ro 1 (ot at a satisi) to 5 (vry satisi). Fiv o th six 94 Chaptr 2

99 rspots copai about tiiss or o-payt o cais, a/or rco sipiicatio o th cai procss. Aitioa sct cots a rcoatios ro coutis that provi ata ar icu i th iis ist bow (=21), roup by ths. Eiibiity a Erot Gra cots Th or is tious to i out a ti cosui. Bcaus this or is to b i out at ita, qustios rari priary car physicia coopratio, tratt pa oas a prorss ar iappropriat. Thy shou b rov i th or is to b i out at this ti. Th rot.tti pop iib is asy a usu Rspot rcoatios or iprovt St up a oi stp-by-stp traii or irct i sta who support cousors i starti th iibiity/rot procss. A sparat brochur outii BH bits wou b hpu upo rot. Mor carity or ros as to wh thy to rappy. Icras couicatio a partrship btw roi acis a srvic provirs wou b hpu. Authorizatio a Approva Gra cots Our xpric has b oo; w hav start utiizi this procss with i sta Exct rspos to ax rqusts. Th procss oy aows or a vry iit ubr o srvics to b authoriz at o ti causi th procss to hav to b rvisit urous tis to accss th u bit or th cit. W o t hav a i-hous procss to attai authorizatios bcaus th procss is cubrso a ti cosui. Th srvics that wr approv wr st to th bactor rathr tha th srvic provir. Th bactor i ot ow what thy wr a i ot bri th to us. It was iicut to p trac o th ar ubr o pop a wh thir authorizatios wou ru out, to as or or. Pr-authorizatio procss is too cubrso to b iscay ctiv or BH bits as w as SUD. Rspot rcoatios or iprovt O or to authoriz th ita asssst a ooi tratt (i rco by sta). Most, i ot a, o our SUD cits utiiz th tota bit aout o 20 sssios. This wou wor uch bttr i a 20 wr authoriz up rot to prvt upicati paprwor a ti. Chaptr 2 95

100 W wou i to s or roups authoriz at oc bcaus our cits ay b schu 1 3 tis pr w Mor visibiity ro rioa rps ro Ath wou b hpu i that osit visits cou hp itiy procss iprovts i th iibiity a approva procss as w as covra aps bas o oca v. Authoriz or visits at o ti (at ast 10). Th provir shou approv th ubr o approv sssios. Bit Dsi Gra cots Covra such as this bits our cits a provis sothi or thos who ar i th i o various ico uiis. It s b a rat bit or thos that hav t ha accss to SUD srvics prviousy or at ast hps thos iaciay who hav ha to o it a out o poct. Th CMSP bit si is car a rsourcs wr provi; howvr, or priary sta who hav to aviat th syst/si it appars troubso. Ath aiistratio os hav oo oca v support. Th Ath Bu Cross rp (R. Moras) or CMSP/Path2Hath has b vry istruta. Havi irct cotact with hi hps our couty i tryi to i soutios to issus w ay hav. Rspot rcoatios or iprovt A bit that atchs currt staar or tratt,.., 3 sssios a w or 2 oths, 2 sssios a w or 2 oths, 2 sssios a w or 2 oths, a 1 sssio biwy or 2 oths. Cits typicay att 2 3 roups pr w or approxiaty 6 oths or SUD tratt. A 20-roup bit oy ts part o th tratt. Aow itrs to provi srvics. Coutis ar traii rous or itrs a rura coutis hav wr ics thrapists. Expa bit to icu cas aat or rhab srvics Outrach to th iib popuatio about th ovra CMSP bit, as w as th spciics o th SUD bit. Payt a Cais Gra cots Wh th urs is cotact, th procss is airy asy. Without a cotact, it s i th cais ar just ost a ot ajuicat. Our iitia xpric has b a ihtar. Lthy turarou tis (3 oths at a ti) with issus o payts a othr paprwor ost i th ai, tc. W hav oy rciv 2 payts W hav rciv o payts or SUD cosur. Cais ar i stati o authorizatio, wh pr-authorizatio was rciv. Substac us srvics hav b i as th srvics wr provi by sta othr tha thos ist o th authorizatio. Our aciity is a roup with ay o our crtii sta bi ab to provi srvics. W hav 55 ursov isputs Chaptr 2

101 Rquirs a ioriat aout o ti to procss a cai or itt to o riburst. Syst is ot th ast bit provir riy. Th Ath Bu Cross rp (R. Moras) or CMSP/Path2Hath has b vry hpu to procss payts. Rspot rcoatios or iprovt Bttr riburst rats Suary/Lssos Lar Gray, o th rspots whos coutis attpt to procss cais (=6), ost rport that (1) thr wr ay qustios at th bii, (2) payt was ot ouh to copsat or th sta ti rquir to procss cais, a rcivi payt was probatic, (3) thr wr ot ouh srvics authoriz uprot, a (4) th aout o srvics covr ur th bit i ot it th s o th typica SUD patit. Satisactio was ow ao ths rspots. Athouh thr wr a w positiv rars about th prora, ovra rsuts sust that th CMSP/Path2Hath xpa SUD bit wt ary urutiiz a thror ha iia ipact. I aitio, ata aaysis rport i Chaptr 1 rva that th CMSP coutis o ot appar to hav asuraby icras rrras ro hath car provirs to spciaty SUD provirs (s Chaptr 1, Fiur 1.2). Athouh so hav accss th covr srvics a rciv riburst, it cos with a hih aiistrativ cost that ay coutis ar ot ab to aor. Rsposs sust that cais procssi a payt s to b sipii a strai i SUD bits ar to b bttr us wh thy bco or wiy avaiab i Provirs wi aso to hav th irastructur a aquaty trai sta to subit cais. Chaptr 2 97

102 Low Ico Hath Prora (LIHP)/Micai Covra Expasio or Substac Us Disorr Srvics Survy Fiis ro a survy couct with aiistrators ro th iv Caioria coutis that icu SUD srvics as part o thir Low Ico Hath Prora (LIHP) hihiht so proisi practics a rcoatios that ay b hpu to othr coutis a th stat i prparatio or th Aorab Car Act provisios tai ct i Aiistrators rport usi a varity o stratis to aciitat rot o iib iiviuas ito LIHP (.., assrtiv outrach, traii sta at tratt proras a othr vus to hp iib cits appy or isurac covra, accooati wa-i rot at icay iit aut proras, a a strai appicatio procss). Oc iib iiviuas ar ro, thy to b pt a to utiiz th srvics or which thy ar iib. Iptatio o LIHP SUD srvics appars to b urway i th iv coutis ori such srvics (.., us o ctroic hath rcors or oitori SUD scri, cooriatio btw couty ta hath a physica hath systs, hospita-bas scri, a ctraiz icatio iitiatio uit). Th irastructur or bii Mi-Ca a Dru Mi-Ca a payts ay to b vop a provirs ay traii a tchica assistac (.., Micai rquirts) as thir xpric i ths aras appar to b iit. Itratio o SUD srvics i priary car sttis ivovs oraizatioa cutur cha; as such, iptatio rquirs aat ovrsiht a ti as w as sta accoutabiity or chas to occur. Itrouctio As part o Caioria s Bri to Ror Dostratio, a waivr rat by th ra ovrt to Sctio 1115 o th Socia Scurity Act, th stat ba xpai Mi-Ca covra to iib ow-ico auts throuh th Low Ico Hath Prora (LIHP) i prparatio or atioa hath car ror i Th prora cosists o two parts, Micai Covra Expasio (MCE) a th Hath Car Covra Iitiativ (HCCI), which wi both Dcbr 31, 2013, wh th ajority o ros ar xpct to bco Mi-Ca iib; th raii ros wi bco iib or th Caioria Hath Bit Excha. LIHP is a optioa oca prora that varis by couty i trs o whthr it ors both th MCE a th HCCI parts, th uppr-ico iit i ithr part, aitioa a-o srvics to th cor bits or ach part, a v o ro cost shar (rai ro zro to th axiu aowab). I aitio, iibiity, rot a othr iptatio procsss ay ir across coutis. Whi iht coutis ha pa to or a-o substac us isorr (SUD) srvics i thir LIHP (Maov, 2011), oy iv coutis participati i LIHP hav icu 98 Chaptr 2

103 approv SUD srvics i aitio to th cor MCE a HCCI bits as part o thir Dpartt o Hath Car Srvics cotracts: Kr, Sa Fracisco, Sa Mato, Sata Cara, a Sata Cruz. (Oy Sa Fracisco ors th SUD srvics covr or th MCE popuatio to its HCCI popuatio.) Th orts a xprics o th coutis participati i LIHP, particuary as thy rat to SUD srvics, ay hp ior othr coutis a th stat i prpari or a ipti provisios o th Aorab Car Act i (Aso s th suary o Cara Boy s prstatio o Sa Mato Couty s LIHP uri th ILC sssio h o Apri 24, 2013.) Th purpos o th piot projct was to coct ata o th status o th iptatio o a-o SUD srvics i th iv LIHP coutis ori such srvics, a scrib proisi practics a ssos ar that hav r i th rot a provisio o SUD srvics to patits ur LIHP. Mthos UCLA couct a bri ctroic survy usi Survy Moy to coct ioratio o coutis xprics with (1) xpai Mi-Ca covra to iib ow-ico auts throuh LIHP, a (2) ipti th covr SUD srvics. (A rat o th survy was rviw by Victor Kor, Excutiv Dirctor, Acoho a Poicy Istitut, a Chair o th LIHP Coutis ti h uri th CADPAAC/ADP quartry tis, a his iput was icorporat.) I Apri 2013, couty acoho a othr rus (AOD) aiistrators ro th iv coutis with LIHP a-o SUD srvics wr st a -ai that icu a i to th survy, a as to copt th survy withi two ws. (S Appix 2D or th survy.) Dscriptiv statistics wr cacuat ro th quatitativ ata. Quaitativ ata ro th op survy qustios wr copi a cott aayz. Th sap siz was sa, but a iv o th aiistrators rspo to th survy. Fiis Tart popuatios a sttis or LIHP SUD Srvics Th tart popuatios a sttis or LIHP SUD srvics vari ao th iv coutis. O couty rport that its tart popuatio icu priary car patits at our saty-t ica car ciics. Aothr couty tart a o its SUD patits, whi a irt couty ocus its LIHP SUD srvics o rsits btw 19 a 24 yars o a, ur 134% o th Fra Povrty Lv (FPL) who quaity or th Micai xpasio bit, with priary phasis o hoss auts, th criia-justic ivov (icui AB109), parts with chir, thos with co-occurri ta hath isorrs, a ay othrs or who tratt is iicat. Whi o couty s LIHP SUD srvics wr irct towar iiviuas bow 25% o th FPL u to th ar ubrs o Rya Whit patits who tr LIHP, aothr couty s LIHP SUD srvics wr ai at ica ipatits a psychiatric rcy ctr patits. LIHP SUD srvics wr or i rsitia, rsitia toxiicatio (with a without ica support), priata rsitia, outpatit, MAT, a thao aitac sttis by o couty a at ay provir sit withi th Couty AOD Tratt Provir twor ori a covr srvic by aothr couty. A thir couty rport that outpatit a rsitia srvics wr avaiab or a st o th LIHP popuatio (hospitaizatios or psychiatric Chaptr 2 99

104 rcis) a SUD srvics wr icu as part o scri a bri itrvtios i priary car sttis (ray quaii hath ctrs). LIHP SUD srvics iptatio status Ur thir LIHP cotracts, coutis ha th optio o ai 17 approv SUD srvics. Th avra ubr o LIHP SUD srvics ao th 5 coutis was 13, rai btw 6 a 16 srvics. A iv o th coutis survy or a ha ipt asssst, cas aat, roup cousi, iiviua cousi, a outpatit srvics. Four o th coutis or a ha ipt coatra srvics, toxiicatio, rsitia acut stabiizatio, rsitia priata tratt, rsitia tratt (icus toxiicatio), a tratt pact. Oy thr o th coutis or a ha ipt arcotic rpact thrapy (thao), scri a itrvtio, a bhaviora hath itratio srvics. O couty rport that it ha ot yt ipt scri a itrvtio or bhaviora hath itratio srvics (.., BH with priary or SUD itratio with MH) u to stai issus a pi triatio o ica cssity, rspctivy. Furthr, two coutis rport ori a havi ipt sobr ivi virot a icatioassist tratt (buprorphi) srvics, athouh o o th coutis iicat that it ha ot yt ipt icatio-assist tratt as it is tai ito cosiratio what is i th oruary a how to coura ica octors to provi it as part o outpatit tratt. Day car rhabiitatio was avaiab i oy o couty. Eiibiity a Erot Chas Th survy rspots scrib xprici a varity o chas rari LIHP iibiity a rot at th couty v. Two coutis rport r-rot iicutis atr ros iibiity prio ha xpir (.., six oths, o yar) a o aiistrator iicat that th photo itiicatio rquirt prov chai. Svra rspots ot th trasitory atur o hoss a SUD popuatios (.., rqut arss chas, iicuty cotacti th), a aothr aiistrator iicat that th couty s projct pharacy but was strtch u to th ra triatio that Rya Whit patits ust b covr ur LIHP a th couty s ar ubr o iib ow-ico HIV-positiv ros. Proisi Practics/Stratis Th survy rspots wr aso as to briy scrib iibiity a rot stratis that wr wori w i thir coutis. Exaps o proisi practics icu assrtiv outrach to ro iib patits (.., travi to rsitia a outpatit proras, ocati iibiity sta at a ctra bhaviora hath accss prora), wa-i rots at icay iit aut proras, a strai appicatio procss, a havi osit SUD provir sta trai to hp pottia ros copt appicatios to obtai bits or which thy ar iib. I aitio, o aiistrator iicat that th SUD scri is b ito th ctroic ica rcor at th hospita a osit scri is aiistr to ay hospitaiz patit to iitiat tratt optios. 100 Chaptr 2

105 Iptatio o LIHP SUD Srvics Chas A but o o th couty AOD aiistrators rport so chas i ipti LIHP SUD srvics, which vari by couty. Iptatio chas icu: tti priary car ciics (rot oic ica assistats a ica provirs) to ipt th ar-upo scri, bri itrvtio, a rrra to tratt (SBIRT) protocos, a iicutis rat to isurac bii a payts, so o which wr u to th ac o irastructur or a xpric with Mi-Ca bii a i ti Micai rquirts. I aitio, o couty aiistrator cot that sic LIHP ros ust o throuh th sa procss as ayo s si SUD srvics, th chas ar siiar to th tota syst i that so hih a srvics (rsitia, thao aitac) ay hav or accss waits. Proisi Practics/Stratis Rspots or xaps o stratis a practics that thy hav ou ctiv i ipti LIHP SUD srvics i thir coutis, icui: cos oitori o th iptatio o SUD scri usi th ciics' ctroic hath rcors, which has b usu i provii accoutabiity or iptatio o th scri protoco; cooriatio with ta a priary hath systs i th couty; havi a ctraiz icatio iitiatio uit or icatio-assist tratt (MAT), which aso srvs as a saty t or patits strui i priary car to b r-stabiiz; a hospita-bas scri. Maa Car Cocpts/Toos or Micai Expasio Eros Thr o th iv coutis that or SUD srvics ur LIHP ar usi tratt authorizatio, a th sa ubr ar usi utiizatio rviw (UR) cocpts/toos. Two coutis ar poyi both toos. O o th couty aiistrators cot, W ar oi this i a ss ora way tha w utiaty shou. As our toos or traci pact a outcos iprov, w wi hopuy b or icit i ths uctios. Aothr couty rport ot usi ithr o th toos, coti, Our irst priority is to t priary car to uy utiiz avaiab SUD asssst a tratt rsourcs. W ar ot yt cocr about aai SUD tratt costs, spciay sic th SUD bit is so iit (basicay, oy outpatit cousi). Furthr, a rspot ro a couty that is usi tratt authorizatio, but ot utiizatio rviw wrot, UR is sti bi vop. W o sit visits to rviw charts, but hav ot us it to y payt at this poit, whras a aiistrator ro a couty that is usi utiizatio rviw, but ot tratt authorizatio, cot, Atr 20 outpatit visits, rviw o ica cssity is iitiat. Rcoatios or Poicy Mars Couty AOD aiistrators wr as, Bas o your xprics, what shou poicy ars ow about ipti SUD srvics or th Micai Expasio Popuatio? Thir rsposs or isihts that ay b hpu i prparatio or th ACA provisios tai ct as o Eai ros to utiiz priary hath srvics is y. A u cotiuu o srvics is, icui roup/iiviua cousi, ay tratt, rsitia, arcotic rpact thrapy (NRT), cas aat, a rhabiitativ srvics. Chaptr 2 101

106 Avoi rpicatio o DMC prora, which has ay probs, icui "popuatio bas iitatios" (.., auts - priata oy or ay car rhabiitativ, rsitia) or iiviua sssio iitatios. Esur that AOD crtii cousors ca provi srvics (ur th ADP crtiicatio rquirts) with ovrsiht by a ics ciicia to t ica cssity. Dvop quivat oruaris a covr icatios across a pa typs so patits o ot hav to uro ciicay haru chas i thir pa chas. Whi a crisis provis a wiow o opportuity to a iiviuas, particuary thos who hav itt or o rcoitio that thy ar aict, thr is a to crat ribursab cas aat srvics to outrach to patits wh thy ischar. Hav th SUD bits ur LIHP avaiab to a broar st o th popuatio (.., iiviuas scr at hospitas). Iptatio o SUD/priary car itratio orts ivov oraizatioa cutur cha, a as such rquir aat ti a ovrsiht to aviat a otiat th chas. As o rspot put it, It is ot a cas o bui it a thy wi co. Cocusios Th iis ro this sa stuy or a ra o xaps a isihts ro iv coutis that hav ipt SUD srvics as part o thir LIHP. Thir xprics sh iht o what othr coutis a th stat ay coutr i 2014 wh provisios o th Aorab Car Act ta ct, a provi stratis that hav show proisi rsuts i th rspctiv coutis. So ta away ssas raw ro th iis icu: Iptatio o SUD srvics appars to b urway i th iv coutis that chos to or such srvics as part o thir LIHP proras, a has ivov us o ctroic hath rcors or oitori SUD scri, cooriatio btw couty ta hath a physica hath systs, hospita-bas scri, a a ctraiz icatio iitiatio uit. A varity o stratis hav b rport to aciitat rot o iib iiviuas i LIHP, icui assrtiv outrach, traii sta at tratt proras a othr vus to hp iib patits appy or isurac covra, accooati wa-i rot at icay iit aut proras, a a strai appicatio procss. Oc iib iiviuas ar ro, thy to b pt a to utiiz th srvics or which thy ar iib. Th irastructur or bii Mi-Ca a Dru Mi-Ca a payts ay to b vop a provirs ay traii a tchica assistac (.., Micai rquirts) as thir xpric i ths aras appars to b iit. Itratio o SUD srvics i priary car sttis ivovs oraizatioa cutur cha; as such, iptatio rquirs aat ovrsiht a ti, as w as sta accoutabiity, or chas to occur. 102 Chaptr 2

107 Fray Quaii Hath Ctr (FQHC) Itratio Survy a Itrviws Fiis ro th FQHC itratio survy a itrviws icu: So scri or SUD has occurr i FQHCs, but practics vary wiy. Most FQHCs rport avaiabiity o iiviua SUD cousi, but ss roup cousi. Thr is orat us o coo bhaviora-hath vic-bas tratt practics. SUD srvics ar ray ot as w itrat with priary car as MH srvics ar, ar rat as ss ctiv, a ar sparat ro priary car srvics physicay a tporay. Th irc i ctivss appars to b u to provir traii, ot i attitus towar SUD patits. SUD srvics wr or itrat with MH srvics tha with priary car srvics. Thr is rat itrst i SUD traii, a wor to b o o itratio o SUD ito ctroic hath rcors. Poicy rcoatios icu: xpai th SUD wororc that ca bi Mi-Ca (particuary arria a aiy thrapists) to ab FQHCs to rcruit sta; aowi sa-ay bii o two srvics; icui ici that has b show to b ctiv i trati opioi aictio (.., Suboxo, Vivitro) i th oruary; vopi th wororc to ctivy provi car to iiviuas who prst with SUDs i priary car sttis; a icras capacity i th couity or spciaiz SUD a support srvics, spciay rsitia tratt a toxiicatio. Purpos Rsarch susts that provii substac us isorr (SUD) srvics i hath car sttis is asib, ca rach ay or iiviuas tha riac o couity-bas spciaty SUD tratt ao, proiss bttr outcos or patits, a ca rsut i ruc ovra hath car utiizatio costs. Furthror, as a rsut o th Aorab Car Act, ta hath a SUD tratt ar xpct to bco or cosy itrat with ach othr a with priary car. Howvr, itt ata o th currt stat o itratio currty xists. UCLA couct a sa stuy uri 2012 tarti ray quaii hath ctrs (FQHCs) to assss SUD itratio with priary car, ta hath, a HIV/AIDS srvics i Caioria priary car sttis. Th stuy (Uraa, Pricipa Ivstiator) was support i part by th Caioria Prora o Accss to Car (CPAC) a th Caioria Dpartt o Acoho a Dru Proras (ADP). Mthos This stuy cosist o both quatitativ a quaitativ rsarch thos. I th irst phas o th two-phas stuy, FQHCs (=18) i iv Caioria coutis (Butt, Kr, Sa Fracisco, Sata Cara, Sooa) wr tart or a oi survy about spciic SUD-rat practics a itratio o ths practics with priary car, as w as with othr MH a HIV/AIDS srvics. (S th survy i Appix 2E.) Th quatitativ survy ata (78% rspos rat) wr aayz i cojuctio with aiistrativ ata o FQHC patit charactristics, stai pattrs a charactristics, srvics provi, a prora/srvics iaci usi ata ro th Hath Rsourcs a Srvics Aiistratio s (HRSA) Uior Data St (UDS) a ro Chaptr 2 103

108 Caioria s Oic o Statwi Hath Pai a Dvopt (OSHPD) Priary Car a Spciaty Ciics Aua Utiizatio Databas (Aua Survy o Ciics). I th sco phas o th stuy, quaitativ itrviws a ocus roups wr couct with 18 participats (.., aat, sta, patit rprstativs) ro thr FQHCs, o i ach o th sct coutis (Sa Fracisco, Sata Cara, Sooa) to ai a pr urstai o SUD-rat practics a barrirs to a aciitators o itrati SUD srvics i priary car sttis. Th quaitativ ata wr aayz usi Atas.ti, a quaitativ ata aaysis sotwar, a th costat coparativ tho (Gasr & Strauss, 1967). Suary o Fiis Th stuy iis ar ot at to b rprstativ o th stat s FQHCs sic thy rprst a sap o oraizatios that wr xpct to b or avac tha othr FQHCs i Caioria i itrati SUD srvics u to th itratio orts that wr urway i th coutis at th ti o th survy. Howvr, ths rsuts cou b itrprt as scribi a iy uppr iit with rar to itratio rsuts that wou b obtai i th stuy wr couct statwi. Survy Fiis So scri or SUD occurs, but practics vary wiy. Eiht o th 15 rspoi oraizatios (53%) rport scri a patits or SUD; thr (20%) rport scri a tart roup o patits; a our (27%) i ot scr or SUD. Thr is wor to b o o itratio o SUD ito ctroic hath rcors. Fiv o th 14 participats that rspo to this qustio (36%) rport that thy i ot yt hav a ctroic hath rcor syst that itrats both physica hath a bhaviora hath ioratio, whi i (64%) rport that thy o. Most FQHCs rport avaiabiity o iiviua SUD cousi, but ss roup cousi. Twv (86%) o 14 rspots rport havi iiviua SUD cousi avaiab osit, a our (27%) rport havi roup cousi osit. Morat us o coo vic-bas tratt practics was rport. Th ost coo bhaviora hath practics icu otivatioa itrviwi, coitiv bhaviora thrapy, a socia sis buii, a rport to b i routi us by sv o th 14 survy rspots (50%). SUD srvics wr ost cooy provi by a SUD cousor (35%), LCSW (57%), or psychooist (43%). Us o SUD icatio-assist tratt osit is irqut. Oy thr (21%) rport prscribi buprorphi (bra as: Subutx, Suboxo) sotis ; o o it routiy. Thr (21%) rport vr prscribi it, but bi itrst i ai it. Oy o (7%) rport prscribi itrauscuar atrxo (bra a: Vivitro). SUD srvics ar ray ot as w itrat with priary car as MH srvics ar, ar rat as ss ctiv, a ar sparat ro priary car srvics physicay a 104 Chaptr 2

109 tporay. Th irc i ctivss appars to b u to provir traii, ot i attitus towar SUD patits. Ev thouh w tart hih itratio coutis or th survys, sv (50%) o oraizatios scrib thir SUD srvics as havi iia or oy basic at a istac coaboratio with priary car, whi th othr sv (50%) scrib it as Cos Coaboratio, Party Itrat (i.., 4 o a 5-poit sca), but o scrib thir SUD srvics as uy itrat. By copariso, or ta hath a priary car itratio, 11 (79%) rport cos or u itratio. Statisticay, th irc i SUD a MH itratio vs was ariay siiicat (t(13)=-1.79, p<.10). Rspots aso rat thir oraizatio s ctivss i trati SUD probs o a 5-poit sca rai ro ot at a ctiv to xtry ctiv a ha siiicaty owr ratis or ctivss i trati SUD (a=2.9) tha MH isorrs (a=3.6) (t(13)= -2.35, p<.05). Th owr ctivss or SUD tratt i ot appar to b u to ircs i attitus towar trati ths probs, howvr. Participats wr as to rat thir art with th statts it is possib to trat substac us isorrs ctivy a it is possib to trat ta hath isorrs ctivy a provi sstiay th sa ratis or both (4.2 a 4.1 rspctivy, t(13)=.37, s). Ista th irc i SUD a MH tratt ctivss appar to rct sta traii. Participats iicat siiicaty owr ow o vic-bas SUD tratt practics tha MH tratt practics (3.3 vs 3.9, t(13)=-2.22, p<.05). A ariay siiicat corratio btw v o SUD itratio a prciv SUD tratt ctivss (r=.46, p<.10) was aso itii, with ratr ctivss ti to occur with ratr itratio. I oy two cass (13%) wr priary car a SUD srvics ocat i th sa buii. No FQHCs rport provii SUD srvics o th sa ay as a priary car rrra. Fiv (36%) sai it happ withi sv ays. Th othr 10 (64%) rport provii SUD srvics atr or tha sv ays. SUD srvics wr or itrat with MH srvics tha with priary car srvics. SUD srvics wr ray bttr itrat with ta hath, with six (43%) rspots rporti cos coaboratio btw th two, iy bcaus th sa bhaviora hath sta ray arss both MH a SUD probs. Sti, or tha ha (iht, 57%) rport that MH a SUD srvic itratio was oy iia or basic. Itratio btw SUD srvics a HIV/AIDS srvics is riv by ui. Across a oraizatios, SUD a HIV/AIDS srvics wr ou to b v ss w itrat tha SUD a othr priary car srvics. Fiv rspots rport cos coaboratio (36%), whi th othr iht (64%) rport oy iia or basic itratio. A o th oraizatios rporti cos coaboratio ithr bi SUD srvics as part o thir prospctiv payt syst (4 out o th 5) or throuh rats (2 out o 5), susti that itratio was stro oy whr th oraizatios ha ou a way to iac such srvics. Chaptr 2 105

110 Riburst or SUD srvics vari. Ni o th FQHCs (64%) icu SUDs i thir FQHC prospctiv payt syst rat. Othr rvu sourcs rport icu bii to othr couty hath sourcs (4, 29%), payi or srvics throuh rat ui (5, 36%), a srvics provi without ay bii (3, 21%). Six out o th sv oraizatios that rport cos coaboratio aso rport that thy ou ways (sotis iirct) to u thir SUD srvics throuh us o th prospctiv payt syst rat, susti th iportac o riburst or itratio orts. Thr is rat itrst i SUD traii. Twv o th 14 rspots (86%) ar that aitioa SUD-rat traii wou b hpu or thir ciic sta. Quaitativ Itrviw Fiis: Barrirs & Chas to Itratio Th ai ths that r ro th quaitativ ata o barrirs a chas to SUD srvic provisio a itratio ar prst bow. Quotatios ar provi to iustrat th ths. Wororc traii is a issu. Accori to svra participats at two o th sits, sotis it is chai to i bhaviora hath provirs who hav a itrst i a th si st (.., xibiity, biiua Spaish a Eish) to wor i couity hath car sttis. For xap, such spciaists ay b or coortab with a traitioa approach that is ocus o o-tr cousi a whr patits ar s by appoitt or a particuar prio o ti (50 iuts) rathr tha a crisis itrvtio or short-tr approach that arsss th iiat s o patits. A w provirs xpai: Th way thrapists ar trai is ot couciv to what s i a couity hath ctr. It os t wor. Th 50-iut hour is usss i a couity hath ctr, I thi, but that s [how] thrapists ar trai Th pop I s, thy o t stic to a schu. Thy o t waa ta or 50 iuts, a ot o th. Wh thy it, thy it ow. Th wh thy o t it, thy r ot oa co to a appoitt. To, thr s a w br o thrapists that w that I v oy t o or two that it that ro ovr th yars. W hav vry oo thrapists It s just so uch o what w s ar pop with ha ijuris or pop o bi vs o opiats a bzos. I a, isiht thrapy is ot ray oa b what hps th, but thy sur so ta hath i o hoi a cas aat a hpi. Most thrapists, that s ot ray what thy r prspctiv is. That s y ta o it. Usuay, [bhaviora hath] cousors o t i to a with pop with substac us issus. I you ca t a ta hath thrapist who spciaizs i substac abus thrapy a thy ca o th who pa, it cou wor. At ast i y obsrvatio, w'r tai 106 Chaptr 2

111 about vry irt s. I wou say th casoa or ta hath, prssio, prsoaity isorrs, so psychosis, but that's prtty iit, w usuay rr out or that, axity that's a prtty irt st o issus tha pop who ar abusi th or cocai or hroi. Dai with thos cits rquirs a vry irt si st. It was har to i soo quaii [or both SUD cousi a psychiatry]. O cours, w hav that xtra ayr o prrri to hav soo who is biiua a bicutura, bcaus that hps th to t a ot arthr with our cit popuatio. That was a xtra quaiicatio that was probaby a to th iicuty. Sti, it was har to i soo to i th positio. I aitio, so o participats itrviw sai that patits with chroic pai a/or SUD ca b chai or provirs to a with. Provirs vary wiy i thir coort a si vs i wori with ths patits, as th oowi cots xpiy. Th chroic pai stu a substac abus A ot o ocs co ito it with biass that ar ot particuary hpu. So o th ar t a that aab to cha. It s a har popuatio a thy push you to o this you o t coortab with a you hav to t coortab with stti iits a sayi oay to this a ot to that. It s a irt straty tha accooati vryboy a th way ao. W try to ta about that a thr s iri rs o itrst. Th ara whr provirs I thi o t rustrat is arou patits who hav a chroic pai coitio, whr arcotic si bhavior, or othr prscriptio ru abus is a bi part o thir substac us isorr that s vry rustrati a ot you i you'r i a positio whr you ca't trust your patit. Ot thr's aipuatio, whr thy try a us irt ta brs to sort o spit us, or co to th urs a say, Oh, I y ary ri, th octor to it was oay. I thi w a t a itt rustrat v owi it's part o a irt coitio that s tratt. It just ts tiri. Sa-ay SUD srvics ar ot biab. Provirs ar ot riburs throuh Mi-Ca or physica a ta hath srvics ivr o th sa ay. This poicy has a ativ ipact o both patits a provirs accori to ay o th provirs itrviw. Patits ust rtur o aothr ay or provirs ithr ar ot pai or srvics thy actuay provi or ust vop worarous to ivr th bhaviora hath srvics. As provirs i couity hath car sttis ar icrasiy utiizi utiiscipiary car tas, braci a patit-ctr approach to car, a tryi to icras accss to car, thy xpai that this poicy urcuts itratio orts: W ca t bi or a priary car a a ta hath visit o th sa ay It s crazy. That s a hu barrir or patits bcaus it as that I hav to vop a ths worarou this...thy hav to co bac So you hav to o o a irt ay, a it s vry copicat or us bcaus w hav so o our ta hath provirs i irt oics, a so w hav to a sur that thy o t a a appoitt to s Chaptr 2 107

112 a ta hath provir at a irt oic o th sa ay as thir priary car bcaus w wou t t pai or both visits. A hu issu that w v stru with ao with vryboy s is that you ca t bi or or tha o provir o a si ay. So hr w hav ths roup ica visits whr th psychiatrists, th priary car physicia, th psychooist a a ciica socia worr ar a si th patit o th sa ay. So basicay w v ha to at that cost ary. This is a wa-i ciic. Our os hav a har ti tti to pacs. Wh thy show up hr thy ot s thr or our provirs th sa ay, a w r a oi copty irt this with th patit. W ca t bi or it. That bi sai, w hav th hihst prouctivity rats i th couty a th hihst custor satisactio rats. I thi it s bcaus wh pop co hr thy i thy v ott a ray oo ba or th buc, a ray oo i us o thir ti. You ow thy hav to wait arou or hours to b s, but thy s thr or our pop, a thy t a ot out o it. Srvics provi by crtai provirs ar ot biab. Aothr bii issu rais across th sits visit is that SUD srvics provi or that cou b provi by arria a aiy thrapists (MFTs) a crtii SUD cousors currty caot b bi to Mi-Ca. That s th ubr o [barrir]. I a, w wou hav substac abus cousors o sta i you cou bi or it, but you ca t bi or it Th FQHCs, that s basicay how thy ru, is o biab srvics. Fro th FQHCs poit o viw, Mi-Ca is our priary ui sourc so i Mi- Ca pays or substac abus srvics, rat. W provi ti th cows co ho. I thy o t provi, ort it. Thy r ot oa t it. I w cou bi or a substac abus cousor, w hav soboy busy a th ti. So o th SUD icatios ar ot o th oruary. Th procss or obtaii prior approva or o-oruary icatio to trat opioi aictio (.., Suboxo, Vivitro) ca b copicat. Accori to svra participats at o o th proras with utip provirs ics to prscrib Suboxo, athouh a provir ca subit a tratt authorizatio rqust (TAR) a rciv approva or th icatio, th paprwor ca b copicat a thr ay b ays i rcivi such approva, which ay ativy ipact patits (.., osi, os ajustts) a provirs tryi to ivr car (.., ti a ort to subit a oow-up with paprwor). A ot o our patits at so poit up tti o ithr Mi-Ca or Micar This bco a ot or copicat at that poit, whr thr s this costat iht with th isurac copay rqusti approva or this o-oruary 108 Chaptr 2

113 ici, to th xtt that it puts th tratt o our patits at ris, caus thy ar ot ab to t th ici. It aso tis our has with osa chas, bcaus th TAR is sayi, Thy r oa b at 16 iiras or a oth. W, i i that oth w ci w to bup up thir os, w ca t. W hav to o a who w TAR, which tas a w or two to t approv, so w ca t hav a iiat ica cha to thir tratt. It tas ti or th procss, but it aso rquirs just a hu ry, just ro th sta o th ciic. Our urss ar ai with it. Our MAs ar ai with it. A o our provirs ar ai with it...w r a just costaty spi this xtra ti, which w o t hav, to iht with th isurac copais to t this approva. SUD rsourcs/srvics i th couity or patit rrras ar iit. Participats itrviw i a thr o th sct coutis cot that thr ar vry iit or o couity rsourcs/srvics or SUD, particuary rsitia tratt a toxiicatio. Th oowi quotatios ro provirs xpiy this th. Wh w waa t soboy ito ipatit rhab, it s aost ipossib i thy hav Mi-Ca or [th couty vrsio o Mi-Ca] I thy o throuh th criia syst, th thr s pty o bs. I thi waiti ists a th aout o papr wor that thy rqust ro us I was tryi to t a cit ito a rsitia, a thy wou't ait it uss h wou o to tox irst. I cou t t ito tox bcaus thy i't hav a spac. What o I o hr? Outpatit is sothi, but it s ray ot arssi th v o that y patits hav. It s i putti soo with a activ GI b i-i o t ow-a obsrvatio b or sothi. Ths ar ICU-v aicts, a w r ori th outpatit at bst. A ot o th tis, w o t v or that. Bcaus thy try to ca or ipatit or thr ws. Thy t owhr. Thy just up avi a ivi up. W bs. Soo is wii to o ito a tratt prora. It's vry har to t a spot i thy wat a rsitia prora Thy hav to o throuh th tox Th it just ss i thr is a vry iit suppy o that rsourc. Quaitativ Itrviw Fiis: Faciitators o Itratio Aitioa quaitativ ata wr coct o aciitators o SUD srvic provisio a itratio. Th ai ths that r ar prst bow. Easy accss to rsourcs osit or withi th oraizatio to arss SUD issus Participats i a thr oraizatios visit xprss that priary car provirs or coortab, wii, a ab to a with SUD issus wh thr ar bhaviora hath spciaists a othr provirs (.., a physicia ics to prscrib Suboxo, a cas Chaptr 2 109

114 aar), particuary o th car ta rsposib or th patit or withi th oraizatio, to provi SUD cosutatio a srvics. Accori to provirs itrviw, utiiscipiary tas ar ab to or ctivy arss patits ay a ivrs s, a ay aso cras th bur o ay o provir. Th oowi quotatios ro participats xpiy this th. As ar as th provirs bi ucoortab with substac abus, that's ot our xpric. Thy ray vau havi [th SUD cousor osit] thr. Thy [priary car provirs] ca ta about substac abus issus, but to hav soo to o th i o oow-up A ot o pop who ar ot o atirtroviras ar ot o th bcaus o substac us issus. Th octors ov to hav soo who ca spciicay arss that so that thy ca t th to a pac whr thy ca prscrib. Th othr thi is with th Suboxo it ca b ovrwhi or o provir to s pop, a th try to arss at ast so o thir s so that thy ca aitai thir sobrity I a th Suboxo hps. It s rat. It ca t ri o thir cravis. But th what? Thr s a this othr stu that cos ao with aictio that aso has to b trat or s thy r oa raps. Wh you hav ths ray copx, copicat, itrtwii issus a probs, th you ca t just cout o a crtai, o st o sis, a a prso who s a xprt i th physica issus to b ab to arss that So havi a psychiatrist o our sta, havi ta hath prossioas o our sta has b ray hpu. Provirs with th riht it or wori i couity hath car sttis Participats across th thr sits visit siiary cot about th iportac o havi th riht pop (.., sis, prsoaity, traii, xibiity, itrst i a coort v with aictio) i th appropriat ros wh tryi to itrat SUD srvics ito priary car. May o th patits i FQHCs car i utip aras, icui th haru us o acoho a rus. W hav a w provir [physicia].sh's riht thr. Sh tas pop coi i, Just t ' i. Just t ' i. I wat to s '. Sh has th ost hours Sh ray has th substac usrs Sh's o jut How ca w hp? You ray a sta who actuay ar oay wori with ru usrs. You ow, who o't thi that thy'r wa, ba pop, o't thi that thy shou't b wasti thir ti o th ayway. This ciic scts or pop who hav a itrst i aictio ici. Oraizatioa cutur a arship that supports iovatio Accori to participats itrviw, a oraizatioa cutur (.., patit-ctr, ta bas) a arship (.., Dirctor, chapio ) that coura a support w ias to icras patit accss to srvics, icui SUD srvics, ar iportat i th itratio o SUD srvics ito priary car. Th quotatios bow ro provirs iustrat this thatic ii. 110 Chaptr 2

115 I thi w hav a prorssiv aiistratio who s itrst i tryi to iur out how to t this stu i hr caus thy rcoiz th. [Th substac abus tratt prora is] a rat rsourc. Thy r a vry oo couity rsourc so it s ai ths coaboratios. W o t hav to rivt th wh. W just hav to iur out how to bri th pop that ow how to o this i o sit. Th pricips o patit-ctr ica ho I thi ar or i i with supporti th itratio o ths srvics, both bcaus thy s th or utiiscipiary car, but aso th typ o irastructur that's bi crat, it's or op accss schui. You'r ot schui visits our oths out or you wat to s a substac abus Th phasis is o you provi car wh th cit is ray to rciv car. I tai about how th ia or th uti-iscipiary ta visit or th Suboxo roups ca about, o o th participats cot, O o th rat this about hr, too you co up with a ia, w iur out how to a it wor. Aiistrativ Data Aayss No statisticay siiicat ratioships wr ou btw rport v o itratio a oraizatioa or patit charactristics ro UDS a OSHPD ata. Provir/Oraizatioa-v Proisi Practics Th oowi practics that aciitat itratio o SUD srvics wr raw ro th quaitativ itrviws with priary car sta. Us o utiiscipiary car tas (.., psychooist, psychiatrist, physicia, cas aar) hps to arss patits utip s a rucs th bur o ay o provir. Suboxo roups ar usu i provii patits with pr support a hpu to provirs i oitori patits who ar rcivi th icatio. Dvopt o ias/partrships/coaboratio with couity rsourcs aciitats patits accss to srvics (.., provi SUD cousi srvics osit or throuh rrras). Havi cas aat srvics avaiab is y or patits with utip s (.., ica, psychooica, ru us tratt, housi). Poicy-rat Rcoatios Participats who copt th oi survy a thos who participat i th quaitativ itrviws wr as or poicy rcoatios to aciitat itratio o SUD or MH srvics or rov barrirs to itratio. Th ai ths ar prst bow. Expa SUD wororc who ca bi Mi-Ca to ab FQHCs to rcruit sta. I particuar, FQHCs wat to a arria a aiy thrapists to th ist o sta that ar iib to bi Mi-Ca. Currty ics ciica socia worrs a psychooists ar th oy bhaviora hath provirs that ca o so. Chaptr 2 111

116 Aow sa-ay bii o two srvics. This is cosistt with bst practics rari war haos btw priary car a bhaviora hath. I a patit ust a a appoitt to rtur aothr ay to rciv ths srvics, thy wi ot bco o shows a a opportuity to arss thir probs wi b ost. Natioay, 28 stats currty aow sa-ay bii, but Caioria os ot. Icu ici that has b show to b ctiv i trati opioi aictio (.., Suboxo, Vivitro) i th oruary. Athouh provirs ay subit a tratt authorizatio rqust or Suboxo, provirs a support sta sotis i th procss to b ti cosui, abor itsiv, a rustrati, which ca ativy ipact provirs wiiss or abiity to provi icatios that ar ctiv i trati opioi aictio. Dvop th wororc to ctivy provi car to iiviuas who prst with SUDs i priary car sttis. SUD a rcovry shou b covr i th curricuu or ica a ursi stuts, socia worrs, psychooists, a othr irct-car provirs so thy ar coortab a ctiv i arssi SUD. Icras capacity i th couity or spciaiz SUD a support srvics, spciay rsitia tratt a toxiicatio. Patits who ar rrr ro priary car to spciaty SUD srvics i th couity i it xtry iicut to accss srvics u to ac o avaiabiity. Stuy Liitatios Thr ar svra iitatios that shou b cosir wh itrprti th stuy iis. Quaitativ iis wr raw ro a covic sap o FQHC sta a boar brs who wr wii to participat i th itrviws a who wr avaiab wh th sit visits wr couct. Thus, thir prspctivs ay ot rprst th prcptios a xprics o sta a Boar brs at th sct oraizatios who wr ot itrviw. Our sap siz o 18 participats is sa. Howvr, th itrviws wr couct with participats i ivrs iscipis a across thr irt oraizatios/proras to xpor a ra o prspctivs. Th prspctivs o sta who provi irct srvics to patits a patit rprstativs ar sstia i aii a or i-pth urstai o SUD srvics provi at th rou v i priary car sttis, whi th survy qustioair provis iportat brath o ioratio about itratio i ra-wor. Du to th arth o currt ioratio o SUD itratio a th rativy sa siz o this stuy, our ais wr priariy scriptiv. Th ac o siiicat ratioships btw so variabs (.., aiistrativ ata) is iy ary u to th sa siz o th stuy a accopayi ow statistica powr, a shou ot b itrprt as vic or th absc o such ratioships. 112 Chaptr 2

117 V. Chaptr Suary a Rcoatios Suary UCLA souht to arss th oowi objctivs i this oai: 1. Coct a issiat cutti ioratio o th itratio o SUD srvics with ta hath a priary car srvics 2. Cooriat a aciitat a itractiv oru (i.., Lari Coaborativ) with coutis a othr y stahors to iscuss SUD itratio barrirs a practica os 3. Couct cas stuy/piot vauatios As th i cotius to ov orwar i ipti SUD/MH a hath car itratio, tai rawors hav b vop a ri i rspos to th prousio o irt itratio os that xist. A ri itratio o th Staar Frawor or Lvs o Itrat Hathcar, was ras by SAMHSA-HRSA Ctr or Itrat Hath Soutios (CIHS, 2013). Th w rawor copasss six vs o bhaviora hath a hath car itratio, ur a cotiuu rai ro cooriat car to co-ocat car a iay itrat car. This rawor riorcs th act that iiviuas si priary car o ot hav isoat probs iit to oy SUD or oy ta iss, but ot hav issus that cooccur. Hc, th rawor copasss bhaviora hath a is at to icu both SUD a ta hath srvic itratio. Th ra tr itratio ot tas a wi varity o ors, a siiar rat trs ca a irt this pi o th cotxt a who is usi th tr. Bcaus itratio ivovs brii tothr cotributios ro irt is a prspctivs, cossus o basic triooy wou ai ths roups i wori with o aothr. Oc a coo cossus ca b rach about th iitios o ths trs, thy ca b us a bttr urstoo across iscipiary bouaris. As provirs cotiu wori o itrati bhaviora hath a priary car, vicbas practics (EBPs) ca pay a iportat ro i th procss by brii rsarch-support itrvtios ito ciica practic to hp iprov outcos. Cooy us EBPs us to aciitat itrat srvics icu: SBIRT, th us o otivatioa itrviwi (MI), a icatio assist thrapis (MAT). Howvr ach cotais barrirs to succssu iptatio such as wororc vopt rquirts, bii a riburst chas, as w as poicy obstacs. Ur hath car ror, w oraizatioa os ar ri a aii proic as ways to trasor car so that is bttr itrat, or coprhsiv, a or rsposiv to th s o patits. Exaps o ths os ar hath hos, patit-ctr ica hos (PCMHs), a accoutab car oraizatios (ACOs). Bcaus o thir phasis o itrati srvics, thy provi a pottia opportuity or bhaviora hath. A ar boy o vic supporti thir us has ot yt b vop, but ovr ti a st o bst practics ay r. Chaptr 2 113

118 Thr ar ay ways that tchooy ca b us to aciitat itratio (.: Thath a Hath Ioratio Tchooy a Ectroic Hath Rcors). Nw tchoois a th ass poyt o xisti tchoois xpas th abiity o provirs to ot oy shar ioratio with ach othr across iscipis, but aso to oitor a trac patits a couicat iportat vopts with patits rari thir hath. Howvr, iptatio is costy a is ib with barrirs arou coitiaity a ata/ioratio shari ruatios. Provirs across th coutry hav b piot-tsti proisi practics to itrat ta hath a SUD srvics with priary car. Dspit barrirs, so hav b ab to ctivy itrat irt srvics. This chaptr scribs a sctio o succssu itratio os hihiht across th stat ovr th past yar. Athouh ay hav ou positiv ipacts ro thir piot activitis, urthr rsarch is to tri whthr ths approachs ca sustaiaby iprov quaity a outcos whi ctivy ruci costs. Coo ys to succss icu rat or ouatio ui, stro couicativ twors, EMR iptatio, a rcoitio o th aout o tchica assistac a traii rquir or th provirs. Coo barrirs that cotiu to prsist icu: cutura ircs a pushbac ao th SUD, MH a PC iscipis, coo iscocptios about th atur a vau o bhaviora hath (particuary with SUD) asssst a tratt, coitiaity a issus arou 42 CFR, Hath IT a Ectroic Mica Rcor iptatio, wororc iitatios a traii s, a iaci/bii or itrat srvics, icui poicy ipicatios a chas buit withi currt ruatios. Withi Caioria, th UCLA Itratio Survy rva that whi a w coutis hav ot yt bu th procss o itrati AOD srvics with ta hath a priary car, ay othrs hav rport prorss. Dspit ay barrirs raii itact btw 2010 a 2012, itratio iitiativs hav xpa ao Caioria coutis. Th Caioria Itratio Lari Coaborativ cotius to uctio as a usu chais to shar ioratio a iscuss succsss a chas across couty aiistrators a xcutiv v provirs/aiistrators. It srvs as a othy chais or th stat to provi tchica assistac a traii opportuitis at th couty v thouh th aciitatio at UCLA. Throuh cas stuis a piot projcts, UCLA has b ab to itiy svra ssos ar ro th ay itratio activitis occurri across th stat. Dvopi partrships at th arship v across th hath car iscipis a sios was a iitia pac to bi itratio orts. Eucati a traii sta (at a vs) is critica to 1) cariy ros a rsposibiitis across th various coaborati iscipis, 2) to obtai buy-i at th provir a aiistrativ sta v, 3) to ostr a shar visio, 4) iprov utiizatio o vicbas practics, a 5) isti vau ao th wororc. 114 Chaptr 2

119 Itiyi a stro arship ta ui by a shar visio that ts ruary hps to crat succssu iptatio. Crati a op oru or sta bac to th arship v was crucia to aitai buy-i, isti accoutabiity, a aow or sta to b a part o th procss. Estabishi chapio physicias a icorporati th ito th arship ta was a succssu chais to ipt w srvics a practics. Scti th riht sta to couct itrat bhaviora hath i priary car sttis is critica. Ths sta ust b xib, proactiv, ab to ha abiuity, a ab to or stro ratioships. Stahors ust b wii to oiy iitia pas as. Couicatio is y a cotiui sta ucatio is iportat. Patic, torac, a opss wr rquir ro both th physica hath a bhaviora hath provirs i orr to r th two cuturs. It is iportat to acow that cha is iicut. Thr ar ay chas surroui th iptatio o a w EHR syst, such as probs with itchs a ata trasrs. Th ata traci syst ust b pt sip at th outst. Foow atst SAMHSA vopts to assur 42 CFR copiac wh shari ata; rviw cost a aissio or accoriy. Patits/cosurs ar biti ro th itratio o srvics. Acotay, patits urstoo a support with i-prso war haos. This buis trust, which aows patits to thy ar i oo has. Itrati srvics rquirs ui a/or a itii sta to aviat throuh th copx bii chaiss. Aitioa survys o sct FQHCs i Caioria rva that: SUD srvics ar ray ot as w itrat with priary car as MH srvics ar, ar rat as ss ctiv, a ar sparat ro priary car srvics physicay a tporay. Th irc i ctivss appars to b u to provir traii, ot i attitus towar SUD patits. SUD srvics wr or itrat with MH srvics tha with priary car srvics. Thr is rat itrst i SUD traii, a wor to b o o itratio o SUD ito ctroic hath rcors. Survyi SUD/BH aiistrators who participat i LIHP or CMSP proras rva that athouh so hav accss th covr srvics a rciv riburst, it cos with a hih aiistrativ cost that ay coutis ar ot ab to aor. Rsposs sust that cais procssi a payt s to b sipii a strai i SUD bits ar to b bttr us wh thy bco or wiy avaiab i Th irastructur or bii Mi-Ca a Dru Mi-Ca a payts ay to b vop a provirs ay traii a tchica assistac (.., Micai rquirts) as thir xpric i ths aras appar to b iit. Chaptr 2 115

120 Rcoatios Support rsarch to itiy bst practics o cooriat car a vauat o tr ipacts o quaity o car a patit outcos. Cotiu to ucat provirs a thir wororc o th iportac a ctivss o cooriat car a th vau o bhaviora hath or th ovra iprovt o quaity o patit car a outcos. Cotiu to avocat or th icusio o bhaviora hath oraizatios i aiuus subsiy proras. Cotiu orts to ostr partrships btw SUD a priary car provirs. Cotiu orts to support piot projcts at th couty a provir v as a chais to tst a vauat succssu iptatio stratis. Tchica assistac is to assist coutis i ovrcoi barrirs to itrat car, spciicay arou iaci itrat srvics a arssi ruatios that prst chas. 116 Chaptr 2

121 Rrcs Ar, R. (2008). Th ascap o txti 4 hath: tchooy, appicatios, poicy issus. Txti4Hath corc, prstatio Fbruary 29, Ar-Misti, J., Bats, D. W., & Jha, A. K. (2013). Opratioa Hath Ioratio Exchas Show Substatia Growth, But Lo-Tr Fui Rais A Cocr. Hath Aairs. Arica Socity o Aictio Mici (ASAM). (2013). Avaci Accss to Aictio Micatios: Ipicatios or Opioi Aictio Tratt: Avaiab at: A, L.C., Zhu, S., Nso, D., Ariia, N., Nut, S., Parti, M. & Josph, A. (2006). Bits o Tpho Car ovr Priary Car or Soi Cssatio. Archivs o Itra Mici, 166, Arw L. Chrry, Arw L. Uivrsity o Oahoa Schoo o Socia Wor. Rtriv ro: Basr, O., Cha, M., Fii, D.A. & Gastri, D.R. (2011). Cost a utiizatio outcos o opioi-pc tratts. Arica Joura o Maa Car,17(8), S235-S248. Basr, O., Cha, M., Rawso, R., & Gastri, D.R. (2011b). Acoho pc tratt: coprhsiv hathcar costs, utiizatio outcos, a pharacothrapy prsistc. Arica Joura o Maa Car, 17(8),S222-S234. Baur, S., Prcvic, R., Oo, E., Mra, R., & Kory, H. (2003). Us o Txt Mssai i th Atrcar o Patits with Buiia Nrvosa. Europa Eati Disorrs Rviw, 11, Brwic, D. M., Noa, T. W., & Whittito, J. (2008). Th trip ai: Car, hath, a cost. Hath Aairs, 27(3), Bout, Axar. (2003). Itrat priary car: Oraizi th vic. Faiis Systs a Hath, 21, Boy, C., L, B., Wiss, C., Wo, J., Habi, A., & Marti, L. (2010). Cariyi utiorbiity pattrs to iprov tarti a ivry o ciica srvics or Micai popuatios. Haito, NJ: Ctr or Hath Car Stratis (CHCS). Brry, H., & Krat, P. (2008). Happy Ei: a raoiz cotro tria o a iita uti-ia soi cssatio itrvtio. Aictio, 103(3), Brow & Rous, 1991 ( Bush K, Kivaha DR, McDo MB t a. Th Auit Acoho Cosuptio Qustios (AUDIT-C): A ctiv bri scri tst or prob rii. Arch Itra M (3): CDC. (2011). Vita Sis: Ovross o Prscriptio Opioi Pai Rivrs Uit Stats, MMWR, 60, 1-6. Ctr or Hath Car Stratis. Ctr or Substac Abus Tratt (CSAT) (2007). Th Epiiooy o Co-Occurri Substac Us a Mta Disorrs. Car, R.E. t a. (2010). Substac Abus a Hathcar Costs Kow Asst. Wb sit crat by th Robrt Woo Johso Fouatio s Substac Abus Poicy Rsarch Prora. Cois, C., Hwso, D. L., Mur, R., & Wa, T. (2010). Evovi os o bhaviora hath itratio i priary car. Nw Yor, NY: Miba Moria Fu. Chaptr 2 117

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125 Nova, S.; Hra-Stah, M.; Fary, B.; Zira, M. (2009). Physica pai, coo psychiatric a substac us isorrs, a th o-ica us o prscriptio aasics i th Uit Stats. Dru a Acoho Dpc, 100, Pa PA, Caro KE, Hoa RM, t a (2012). Prscriptio opioi abus, chroic pai, a priary car: a co-occurri isorrs ciic i th chroic isas o. J Subst Abus Trat, 43(4), Pars J, Foy T, Graha D. (2013, Ju 27). Micai Hath Ho Iptatio I Missouri: A Yar Latr [Wbiar]. Rtriv ro Parthasarathy SP, Mrts JMA, Moor C, Wisr CD (2003). Utiizatio a Cost Ipact o Itrati Substac Abus Tratt a Priary Car. Mica Car, 41(3): Pauozzi L, Xi Y. (2008). Rct chas i ru poisoi ortaity i th Uit Stats by urba rura status a by ru typ. Pharacopiiooy a Dru Saty, 17, P, CJ a Natioa Itratio Acay Couci. (2013). Lxico or Bhaviora Hath a Priary Car Itratio: Cocpts a Diitios Dvop by Exprt Cossus AHRQ Pubicatio (Vo. No.13-IP001-EF). Rocvi, MD: Acy or Hathcar Rsarch a Quaity. P, CJ, & Otah, G. (2010). A Cossus Opratioa Diitio o Patit-Ctr Mica Ho (PCMH), Aso ow as Hath Car Ho. Miapois, MN: Uivrsity o Misota a th Istitut or Ciica Systs Iprovt. Robrt Woo Johso Fouatio. Chroic Car: Mai th Cas or Ooi Car. Rors A., Corbtt, T., Bray, D., Rii, T., Wis, M., Li, R-B., & Jos, M.(2005). Do u so atr txt? Rsuts o a raois tria o soi cssatio usi obi pho txt ssai. Tobacco Cotro, 14(4): Roa, P. M., Abraha, A. J., & Kus, H. K. (2011). Usi icatio-assist tratt or substac us isorrs: Evic o barrirs a aciitators o iptatio. Aictiv Bhaviors, 36(6), SAMHSA-HRSA Ctr or Itrat Hath Soutios. (2013). Iovatios i aictios tratt: Aictio tratt provirs wori with itrat priary car srvics. Washito, D.C.: SAMHSA-HRSA Ctr or Itrat Hath Soutios. SAMSHA-HRSA, Ctr or Itrat Srvics. (..). Payi or priary car a bhaviora hath srvics provi i itrat car sttis: itri stat-bas bii a iacia worshts. Rtriv ro Satr, Dr D., Ducchi, Kvi, Lichtachr, Joatha, Stri, Stacy A., & Wisr, Costac. (2013). Motivatioa itrviwi to ruc hazarous rii a ru us ao prssio patits. Joura o Substac Abus Tratt, 44(3), Sith, P.C., Schit, S.M., Asworth-Davis, D., a Saitz, R. (2010). A Si-Qustio Scri Tst or Dru Us i Priary Car. Archivs o Itra Mici, 170(13), Sith, P.C., Schit, S.M., Asworth-Davis, D., a Saitz, R. (2009). Priary car vaiatio o a si-qustio acoho scri tst. Joura o Gra Itra Mici, 24(7): Chaptr 2 121

126 Söru, La Lih, Maso, Micha B., Ruba, Su, & Nis, Pr. (2011). A systatic rviw o otivatioa itrviwi traii or ra hath car practitiors. Patit Eucatio a Cousi, 84(1), Spitzr RL, Kro K, Wiias JBW, Low B. A bri asur or assssi raiz axity isorr. Arch Ir M. 2006; 166: Sti, M.D. (1999). Mica Cosqucs o Substac Abus. Psychiatric Ciics o North Arica. 22(2), Tai, B., Boy, M., Ghitza, U., Kapa, R. M., Car, H. W., & Grsi, K. (2012). Maiu us o ctroic bhaviora hath ata i priary hath car. Scic Trasatioa Mici, 4(119), 119r113. Tchica Assistac Coaborativ (TAC) & Hua Srvics Rsarch Istitut (HSRI) (2012). Caioria Mta Hath a Substac Us Syst Ns Asssst: Fia Rport. Subitt to Caioria Dpartt o Hathcar Srvics. Thoas, M.R., t a. (2005). Prvac o psychiatric isorrs a costs o car ao aut ros i a Micai HMO. Psychiatric Srvics, 56(11), U.S. Csus Burau: Viso, D.C., t a. (2003). A popuatio-bas cas-crossovr a th cas-cotro stuy o acoho a th ris o ijury. Joura o Stuis o Acoho a Drus, 64(3), Voi, C., Shis, A. E., L, T. A., Gibso, T. B., Marr, W. D., Wiss, K. B., & Butha, D. (2007). Mutip chroic coitios: Prvac, hath cosqucs, a ipicatios or quaity, car aat, a costs. Joura o Gra Itra Mici, 22 Supp 3, Vo Kor, M., Kato, W. J., Li, E. H., Cichaowsi, P., Ptrso, D., Lua, E. J.,... Ruttr, C. M. (2011). Fuctioa outcos o uti-coitio coaborativ car a succssu ai: Rsuts o raois tria. BMJ (Ciica Rsarch E.), 343, Wisr C, Parthasarathy S, Moor C, Mrts JR. (2010). Iiviuas rcivi aictio tratt: ar ica costs o thir aiy brs ruc? Aictio. 05(7): Wiss KB. (2007). Maai copxity i chroic car: a ovrviw o th VA Stat-o-th- Art (SOTA) Corc. Joura o Gra Itra Mici 22(Supp 3: Witz, J.A., Brhart, J.M., Usa, S., Mays, D., & Gaz, K. (2007). Usi Wirss Hah Coputrs a Taior Txt Mssai to Ruc Nativ Cosqucs o Drii Acoho, Joura o Stuis o Acoho a Drus, 68: Wir NL, Har PS, Art IO, t a (2007). Th Opioi Rwa Ciic: a priary car, aa approach to opioi thrapy i chroic pai patits at ris or substac abus. Pai M, 8(7), Ybarra, M. (2008). Usi Txt Mssai to Act T Hath, Itrt Soutios or Kis, Ic. You, C. (Ju, 2012). Bhaviora hath hapr i aopti hath it, survy is. Rtriv ro Zira, R.S., Noar, S.M., Fist-Pric, Soja, M., Dthar, O., Cupp, P.K., Ara, E., & Loc, S. (2007). Loituia tst o a utip oai o o aosct coo us. Joura o Sx Rsarch, 44(4): Chaptr 2

127 Chaptr 3: Stratic Pai or Wororc Dvopt: Prpari th AOD Wororc or 2014 a Byo Bray T. Osr, M.P.H., Richar A. Rawso, Ph.D., a Jssica Haa, B.S. As SUD a MH itratio orts ro out i Caioria, it is car that th wororc wi rquir a broa a ivrs st o sis. As SUD itratio ur hath car ror is sti vovi, th wororc cssary to ipt SUD srvics outsi o th spciaty syst rais ucar. Th oa is to prpar our currt AOD wororc or th typs o stti a practic chas i SUD tratt ivry, icui rcovry a prvtio, brouht orth by hath car ror. Rcoatios icu: A cocrt wororc pai ort shou b iitiat i which y stahors a wororc xprts wor i cocrt with th Dpartt o Labor Wororc Ivstt Boar (WIB). A sris o tis shou b cov to provi a oru or a rviw o th critica issus that wi tri th SUD wororc s as w as iscussios a pa vopt. A trasitio pa shou b crat to stabish a cousor crtiicatio irastructur i which thr is a si cousor crtiicatio/ics aiistr by th Stat o Caioria. Th SAMHSA carr ar or SUD cousi shou b ipt i Caioria. Th stat shou xpa xisti traii a tchica assistac srvics to sur that th SUD wororc vops capacity i aras that ar critica to provii coprhsiv a vic-bas SUD tratt. Ths activitis shou b si to prpar two istict wororcs o that wi cotiu to wor as SUD provirs i spciaty tratt sttis a aothr that wi vov ito Itrat Bhaviora Hath (IBH) provirs i ica sttis. I. Itrouctio As th SUD srvic ivry syst is shiti, stratic pas at th stat v rquir rvauatio. Ur irctio a with uiac ro ADP, UCLA has wor to itiy stratic pai pricips a rcoatios, with a phasis o wororc vopt, i a ort to assist ADP prpar or th chas aha a ui th utur vopt o a itrat ru-tratt ivry syst i Caioria ovr th xt 5 yars. A u ivstiativ rviw, icui itratur rviws, stahor cosutatios, a vauatios o Caioria a othr stats stratic pa vopts, has b couct a was subitt Dcbr 7, 2012 (Appix to ECAL Rport ). Sic that ti, ivstiativ wor has cotiu o this vovi topic a wi b suariz withi this chaptr. II. Objctivs This chaptr arsss th ADP/UCLA cotract Doai 2, tit Hath Car Ror a th Itratio o SUD Srvics with Mta Hath a Priary Car. Chaptr 3 123

128 1. Provi rcoatios or stratic pai pricips to ui th utur vopt o a itrat ru tratt ivry syst i Caioria ur hath car ror. III. Mthos Duri isca yar , UCLA cotiu to arss th objctiv to vop stratic pai pricips to ui th utur vopt o a itrat ru tratt ivry syst i Caioria ur hath car ror. As SUD itratio ur hath car ror is sti vovi, th wororc cssary to ipt SUD srvics outsi o th spciaty syst rais ucar. Th oa is to prpar our currt AOD wororc or th typs o stti a practic chas i SUD tratt ivry, icui rcovry a prvtio, brouht orth by hath car ror. I orr to t a pictur o th o-tr oas a short-tr pas or vopi our wororc o SUD cousors, UCLA urtoo svra tass. Spciicay, UCLA cosut with atioa xprts ro th Substac Abus a Mta Hath Srvics Aiistratio (SAMHSA), th Oic o Natioa Dru Cotro Poicy (ONDCP), Hath a Hua Srvics (HHS), Caioria s Wororc Ivstt Boar (WIB), Aapois Coaitio, a othr ars i th i o substac abus, ta hath, hath poicy, srvic bii/iaci, a wororc vopt. Discussios wr h with Sarah Wattbr (HHS/Oic o th Assistat Scrtary or Hath), Lia Kapa (SAMHSA), Doa Dooi (SAMHSA), May Cha (Tratt Rsarch Istitut), Patric Gauthir (AHP Hathcar Soutios), a rprstativs o NASADAD (Natioa Associatio o Stat Acoho a Dru Abus Dirctors) to athr uiac a isiht ro wororc vopt ars at th atioa v. I aitio, UCLA cosut rquty with ars at th Caioria Dpartt o Acoho a Dru Proras (Micha Cuiha, Dav Niso, Marcia Yaaoto) to urthr ursta currt prioritis a issus at th stat v. UCLA aso utiiz th ow ai across th cours o th ast 2 yars ( ) throuh th ECAL cotract, as w as ro th UCLA ISAP Traii Dpartt a th Paciic Southwst Aictio Tchooy Trasr Ctr (PSATTC), to copi rcoatios o couty- a provir-v wororc s. UCLA rviw ocuts prouc by th Aapois Coaitio, Joa Dioaro s rport, ocuts prouc by th Caioria WIB, a othr rports; ivstiat proras at cos a uivrsitis or wororc traii proras a os bi vop i th ara o SUD tratt i priary car; a ha covrsatios with stahors at th couty v a with FQHCs o th irctio that hath car ror wou ta th i. IV. Fiis Du to th various ivstiativ thos utiiz withi this chaptr, th iis ar oraiz arou th oowi activitis: 124 Chaptr 3

129 A. Bacrou B. Wororc Corc Ca with ADP a Stahors (Dcbr 17, 2012) C. CADPAAC Prstatio o March 27, 2013 (Rawso, Frs) D. Ivovt with othr Wororc Groups (WIB, HWDC, OSHPD) E. Ivstiativ Wor (Fiaci/Bii Micai Cos) A chaptr suary a st o rcoatios cocu th chaptr. A. Bacrou Rct chas i hath car poicy wi accrat th itratio o th SUD tratt i with th rst o th ica syst i Caioria whi rapiy xpai th popuatio that s SUD srvics a has accss to tratt. Ths trs wi cop SUD srvic provirs to hac thir prossioa coptcy i orr to oprat as brs o th ica wororc. Svra rct pics o isatio wi aciitat th icorporatio o SUD tratt srvics ito th rst o th ica syst. Th 2008 Micar Iprovts or Patits a Provirs Act (MIPPA), th 2008 Mta Hath Parity a Aictio Equity Act (MHPAEA), a th 2009 Chir s Hath Isurac Prora Rauthorizatio Act (CHIPRA) hav brouht isurac covra or substac us coitios i i with that or or othr chroic coitios by ruci co-payts a icrasi bits or SUD tratt. Th 2010 Aorab Car Act (ACA) wi xpa Micai covra to btw 149,000 a 195,000 prviousy uisur Caiorias who accss to SUD srvics withi hath car (icui SUD tratt), a provi th with SUD srvics as aat by th MIPPA, MHPAEA, a CHIPRA (Ns Asssst Rport, 2012). Thus, a siiicat ubr o Caiorias wi b aii accss to SUD srvics i th ar utur, a th tratt thy rciv wi b u by hath isurac rathr tha boc rats or othr sio SUD tratt us. Ovra, it is aticipat that ths shits wi rquir th SUD tratt wororc i Caioria to row by btw 2,100 a 2,828 FTEs by 2019 (Ns Asssst Rport, 2012). Th Aorab Car Act has phasiz th to iprov th quaity, avaiabiity, a aorabiity o hath car or a Aricas throuh itratio a coaborativ procsss. A ctra pricip i this syst cha is th to ov towar a coaborativ a patitctr approach to hath car throuh th itratio a cooriatio o hath srvics. Th substac us isorr (SUD) a ta hath (MH) is wi b part o th trasitio towar itrat car; it wi b sstia or SUD car a MH car to bco or cooriat a itrat with physica hath car (Istitut o Mici, 2006). Th currt substac abus tratt wororc is ot suicit i ubr a os ot hav a o th sis cssary to uctio i a itrat virot. Fwr cousor icsur/crtiicatio rquirts ar rquir or substac abus cousors i copariso to ta hath cousors. Rquirts or substac abus cousor crtiicatio varis substatiay across Caioria s i crtiyi oraizatios a os ot icu prparatio rat to physica hath coitios or wori i sttis othr tha thos provii substac abus spciaty tratt. Th ajority o brs o th cor iscipis (physicias, urss, Chaptr 3 125

130 socia worrs, psychooists, physicia s assistats, a othrs) ar aso iy to hav isuicit traii i aictio. Physicias rport barrirs to th us o icatio-assist tratt a scri a bri itrvtio, icui ot i coortab i aai a copots o ithr typ o itrvtio. It is sstia that th avaiabiity o pr support b aitai as tratt or substac us coitios is itrat ito priary a othr ica car sttis (Dioaro, 2011). Th chroic iss approach to substac us isorrs rquirs a cotiuu-o-srvics syst o that shits th phasis away ro acut sypto stabiizatio (pisoic tratt) towar a cotiuu icui prvtio, itrvtio, tratt, a o-tr rcovry support (Fahrty, 2006; Kipis & Kiar,..). This shit towar aai substac us probs as chroic hath probs a tai o a pubic hath approach is a atioa priority. Th cratio o a cotiuu o car that proots tratt o SUDs has substatia ruatory, iaci, a wororc ipicatios. Iptatio o th ACA wi rsut i substatia vopts i th wororc. Cosquty, ADP ba a iscussio with UCLA about sii a wororc vopt straty or th Stat o Caioria s SUD srvics. This coaboratio hops to prpar our currt AOD wororc or th typs o stti a practic chas i SUD tratt ivry, icui rcovry a prvtio, brouht orth by hath car ror. I orr to t a pictur o th o-tr oas a short-tr pas or vopi our wororc o SUD cousors, UCLA urtoo svra tass. UCLA ha covrsatios with stahors at th couty v a with FQHCs o th irctio that hath car ror wou ta th i. B. Wororc Corc Ca with ADP a Othr Stahors (Dcbr 17, 2012) UCLA oraiz a ti (i cojuctio with ADP) o Dc 17, Th purpos was to coct iput o wororc s i th ara o Dru a Acoho Cousors a to provi bac to th Caioria Wororc Ivstt Burau s (WIB) Hath Wororc Dvopt Couci (HWDC). A ti suary is provi bow. UCLA was as to assist ADP with th cratio o a stratic pa or wororc vopt i Caioria. Th pa shou icu both short-tr a o-tr actios to ta i th coi yars i orr to sur that our currt wororc has th cssary traii, ow, a crtias to t th as o both our currt popuatio a th wy xpa popuatio i Th Dioaro papr is a wori rawor/o that shou b us to ui poicis a qustios that to b arss, such as th short-tr a o-tr outco oas or our particuar syst o car; how to ctivy positio stat, couty, a oca provirs to b ray or HCR; a how to provi rsourcs/ictivs to achiv th sir outcos. At th currt stat o aairs, thr ar two irt obstacs to th abov stat oas: cousor crtiicatio a ACA rat wororc issus. Th currt Caioria cousor crtiicatio procss is ihrty cousi by havi i irt crtiyi bois, ach with thir ow staars a rquirts, which as uiority withi th iscipi xcptioay iicut. Th ACA, covrsy, brouht about with its uata chas to th 126 Chaptr 3

131 iustry its, wi rquir siiicat shits i th wororc, th ost ipactu bi th cras riac o spciaty car; ovi towar th itratio o ta hath (MH) a acoho a othr rus (AOD) srvics ito priary car; a icrasi th phasis o tabas car rathr tha iiviua provirs ivi cousi. So o th othr typs o worrs that ar bi cosir to coutract th aticipat shorta i th wororc icu couity hath worrs, rcovry support worrs, a xpa us o socia worrs. Ths w worrs ust ursta both MH a SUD i orr to ctivy wor i th PC/FQHC stti. Giv ths pottia stras o prso, howvr, prora aiistrators ar sti xtry cocr about bii iibiity or th wororc. Cit cocrs icu qustios about th srvics (icui SBIRT) ths worrs wou provi, th srvics thy wou b ab to bi or, a th at o th currt ~30,000 wororc a whthr or ot thy wi b t bhi (or out atothr). Th Caioria Wororc Ivstt Boar (WIB) has b itii as a pottia bri cocti poicy a wororc orts. Thr aras whr th WIB ca b utiiz to iprov th wororc situatio icu traii try-v worrs, PCP ucatio, a couity co ucatioa prora vopt. Th WIB cou b us ow to th spciaty syst with try-v worrs, which wou prpar it or th icoi stra o wy isur patits bi rrr ro th priary car syst. Aothr possib iiat actio th WIB cou ta wou b to ucat priary car provirs o th w wav o worrs that wi b a how to icorporat ths pop ito thir priary car practic. Lasty, th WIB ca wor with couity cos to vop a pipi or worrs with th si st or priary car-bas MH/AOD srvic ivry i th utur. Othr aspcts o traii wi to b urthr ivstiat to bttr ior bst practics os. Ths icu ascrtaii what si sts wi b or bhaviora hath a or priary car a th si how w ca us a vop our xisti wororc. Aso, iiviuas with broar xprtis i bhaviora hath, ot oy MH or AOD spciicay, wi b icrasiy iportat. W to hp th currt cousor wororc prpar or chas (sis, traii or th utur). For th o tr, w to vop a pathway or st o sis or pop wori to provi bhaviora hath srvics i priary car i th utur. Nxt Stps icu rachi out to ra acis or atioa uiac a a stahor ti. Mti Atts: Micha Cuiha (ADP) Marcia Yaaoto (ADP) av is (ADP) Marjori McKisso (CA DHCS) May Cha (TRI) Sarah Wattbr (HHS/OASH) Aicia Richo (HHS/OASH) To Rr (CADPAAC) Dis Koch (CADPAAC) Ji Sor (stai i or Abrt Sa - CADA & CAADPE) Victor Kor (ADPI) Chaptr 3 127

132 Stv Mauhart (COMP) Richar Rawso (UCLA) Thoas Frs (UCLA) Darr Uraa (UCLA) Traci Rica (UCLA) Eis Tra (UCLA) Vari Parc (UCLA) Bray Osr (UCLA) Bth Rutowsi (UCLA) C. Itratio Lari Coaborativ: Chas or th SUD Wororc: 2013 a Byo (March 27, 2013) Prstrs: Richar Rawso, PhD, a Thoas Frs, PhD (UCLA ISAP) Wororc iscussios cotiu uri th ILC prstatio o March 27, It is vit that ooi wororc vopt is iprativ wh w ta a oo at th currt substac abus tratt wororc. As th authors o a 2012 rport prpar or th Caioria Oic o Statwi Hath Pai a Dvopt s Wororc Ivstt Boar (OSHPD/WIB) cocu, th stat s SUD tratt wororc rais ui, acs car paratrs, a cuts across utip ics, crtii a ucassii prossios that hav ot b systaticay trac or aayz (Buc, 2012). ADP stiats that ss tha 35,000 prsos ar ristr or crtii as acohois a ru abus cousors (Day, 2011). O ths cousors, th a aua ico is $37,400, with a ra ro $23,784 to $51,512 (Burau o Labor Statistics, 2012). Ths ubrs ar ow copar to othr stats such as Michia, Aasa, Nw Jrsy, Cocticut, a Wiscosi, a o which s to prioritiz SUD cousors a thir wor. Ths rsuts warrat or rsarch o th wororc i orr to tri what particuary s ror. A PSATTC wororc survy couct i with ciica suprvisors i Caioria a Arizoa provi scriptiv ioratio about two sts o th substac abus tratt wororc: (1) i sta, th ciicias who itract ircty with substac abus tratt patits, a (2) ciica suprvisors, th iiviuas suprvisi a suri th ciica itrity o th tratt srvics that ar bi provi. Ciica suprvisors srv as th rspots to this survy to or a bttr urstai o th charactristics a wororc s o ths two critica uctios i th ivry o substac abus tratt. Bas o th stuy, rrri to th ciica suprvisors oy, th avra a is 52 yars, 80% ar Whit/No- Hispaic, 63% ar a, 36% wr i rcovry, 90% wor u ti, 61% ar ics or crtii i th i o SUD cousi, 41% hav ar a astr s r, a th avra ubr o yars spt i SUD tratt is 15. Th sa survy aso as ciica suprvisors to provi stiats or thir irct car sta. Bas o thir stiatios, 77% ar Whit/No- Hispaic, 67% ar a, 73% wor u ti, 39% wr i rcovry, 54% wr currty crtii/ics, 53% wr i-carr (a ra: yars), 39% ha ss tha a bachor s r, a 22% ha obtai a astr s r. 128 Chaptr 3

133 Th currt coptcis or spciaty car ray a ito thr catoris: urstai aictio, tratt ow, a appicatio to practic. To ursta aictio, prossioas ust b ab to ursta a rcoiz os a thoris o aictio/sud; th socia, cutura, cooic a poitica cotxts o aictio; th bhaviora, psychooica, physica hath, a socia cts o substacs o th prso usi a siiicat othrs; a th pottia o SUDs to iic or co-occur with othr ica a ta hath coitios. I, 37% o pop who ar pt upo or abus acoho a 53% o pop who ar pt upo or abus strt rus aso hav at ast o srious ta iss (NAMI, 2010). To b owab about tratt, prossioas ust b aiiar with EBPs or tratt; rcovry, raps prvtio, a cotiui car or aictio/sud; th iportac o aiy a couity i th tratt a rcovry procss; th iportac o rsarch a outco ata a thir appicatio i ciica practic; a th vau o a itriscipiary approach to aictio tratt. Wh appyi ths sis a isihts to practic, prossioas ust b ab to us stabish critria to iaos SUD a pac it withi th cotiuu o car; taior hpi stratis a tratt oaitis to a patit s sta o pc, cha, or rcovry; provi cuturay a iuisticay appropriat srvics; aapt practic to tratt sttis a oaitis; a b aiiar with pharacooica tratts or SUD (Ctr or Substac Abus Tratt, 2008). To prpar or xpct chas i th hath car wororc u to hath car ror, SAMHSA cov a ti o rprstativs ro hihr ucatio, th Natioa Associatio o Stat Acoho/Dru Abus Dirctors (NASADAD), th Stat Associatio o Aictio Srvics (SAAS), th Itratioa Crtiicatio a Rciprocity Cosortiu (IC&RC), th Natioa Associatio o Acohois a Dru Abus Cousors (NADAAC), a th Aictio Tchooy Trasr Ctr (ATTC) twor. Th purpos o this ti was to vop a Mo Scop o Practic a Carr Lar or substac abus tratt worrs (SAMHSA, 2011) that stats, jurisictios, a crtiai bois cou aopt a/or aapt as a as o vopi i carr paths, crtiai critria, a ucatioa opportuitis or prossioas tri or si to avac thir currt stai i th substac us isorr tratt i as it bcos or itrat ito priary car as a rsut o hath car ror. Bas o th SAMHSA-bas Ctr or Substac Abus Tratt s (CSAT s) Tchica Assistac Pubicatio 21 (TAP 21), tit Aictio Cousi Coptcis: Th Kow, Sis, a Attitus o Prossioa Practic, th Mo Scop o Practic a Carr Lar is th oowi activitis as ai withi th scop o substac abus isorr cousi: Ciica Evauatio; Tratt Pai; Rrra; Srvic Cooriatio; Cousi; Patit, Faiy, a Couity Eucatio; Docutatio; Prossioa a Ethica Rsposibiitis. Chaptr 3 129

134 Thr ar utip oraizatios i Caioria that crtiy cousors, a irt oraizatios hav varyi ucatioa rquirts a coptcy staars. Howvr, bas o th Carr Lar i by SAMHSA i Sptbr o 2011, a o ths cousors a ito our catoris o prossioa vopt: (1) Substac Us Disorr Tchicia (try v) or Associat Substac Us Disorr Cousor; (2) Substac Us Disorr Cousor; (3) Ciica Substac Us Disorr Cousor; (4) Ipt Ciica Substac Us Disorr Cousor/Suprvisor. Withi ach catory, ros a activitis ar i. Rarss o ACA iptatio, th SUD wororc rquirs siiicat ror to provi quaity car to prospctiv patits. Th poyt o EBPs (.., MAT, MI, SBI, bri tratts), th us o ata to oiy tratt, a a sass itratio with MH srvics wi a b critica i ths orts. It is aso sstia that th SUD wororc bco owab about th prscriptio ru abus piic, har ructio approachs, a chroic pai tratt. Aictio is a chroic isas a ust b viw as such to sur icit tratt, rcovry, a sustai stabiity. Thr ar yria ipicatios that th ACA has o SUD tratt. Prhaps th ost iportat coitio is that a pas ust icu substac us isorr tratt. Th SUD tratt i wi b h to th sa staars a rquirts as th priary hath i. Thror, th SUD tratt prossio s to b ray to ocut a coiy its srvics a srvic ivry systs. This ca b accopish throuh icras rcoitio o issus rat to o-couicab isass (icui co-occurri MH/SA isorrs), icras us o isas aat or chroic hath isorrs, a vopt o EBPs or SUD to b ipt i priary car. I priary car sttis, pop ivri bhaviora hath srvics (icui SUD) wi a vry ivrs st o ow a sis (Dioaro, 2011). Thus, SUD sta brs to prpar to hav wor riv by ata, to wor i itrat virots, to bui ta sis, a to hav a soi urstai o SUD, MH isorrs, coo hath coitios, a irt virota cuturs. Furthror, thy to stabish svra coptcis, icui: Urstai a appicatio o EBPs Arssi a bhavior cha issus, Acquiri a har ructio taity, Dvopi itrprsoa sis (.., couicatio, coict rsoutio, tawor) Dvopi quaity iprovt sis (.., us o ata to riv cha a tchooy coptc). Traii a cotiui ucatio is to ovrco barrirs to th aoptio o vicbas practics or th tratt o substac us coitios a or a sta to wor i a itrat virot. Th oowi ist icus th ow, practics/sis, a coptcis withi th i: Uivrsa Scri (Scri, Bri Itrvtio, a Rrra to Tratt [SBIRT]) Scri, bri itrvtio, a rrra to tratt (SBIRT) is ctiv i a varity o sttis. Its ctivss has b prov particuary i hospita rcy partts a 130 Chaptr 3

135 traua ctrs trati iiviuas with acoho-rat ijuris. SBIRT has aso b show to b ctiv i priary car sttis, whr it is icorporat ito othr routi ica assssts such as asuri boo prssur. Cor ciica copots icu: (1) bri itrvtio to rais awarss o ris a otivat cha; (2) bri tratt or patits si hp; a (3) rrra to tratt or patits with or srious probs rat to substac us. Bhaviora Thrapis Motivatioa itrviwi, a tratt approach vop by Wiia Mir a coaus, has b w stabish as a ctiv way to proot cha i iiviuas. This vica cossus-bas tchiqu has b show to icit cha i bhavior a attitus by hpi patits to xpor a rsov abivac. Traii worshops provi participats with a uata urstai o otivatioa itrviwi a spciic tchiqus or prooti bhavior cha. Coitiv bhaviora thrapy (CBT) is a typ o psychothraputic tratt that hps patits ursta th thouhts a is that iuc thir bhaviors. CBT is cooy us to trat a wi ra o isorrs, icui phobias, aictio, prssio, a axity. Coitiv bhaviora thrapy is ray short-tr a ocus o hpi patits a with a vry spciic prob. Duri th cours o tratt, pop ar how to itiy a cha structiv or isturbi thouht pattrs that hav ativ iucs o bhavior. Coticy aat (CM: aso ow as otivatioa ictivs ) is a bhaviora straty that has b show to b vry ctiv i prooti bhavior cha. CM is th appicatio o positiv riorct pricips to ruc bhaviors associat with ru us a icras bhaviors associat with abstic/rcovry. I SUD tratt, CM has b show to b xtry ctiv at icrasi tratt rttio a ruci stiuat us. Micatio-Assist Thrapis (MAT) Th U.S. Foo a Dru Aiistratio has approv six icatios iicat to trat substac us isorrs. Ora atrxo, isuura (Atabus), a thao aso hav o b avaiab or th tratt o acoho a opioi aictios. Ovr th past ca, th FDA approv thr aitioa icatios: buprorphi to trat opioi aictios i 2002, acaprosat to trat acoho aictio i 2004, a xt-ras atrxo (Vivitro) to trat opioi aictios i 2006 a acoho aictio i Two o th wr icatios buprorphi a Vivitro ar rrr to as oic-bas icatios bcaus thy ca b prscrib a aiistr i a physicia s oic rathr tha i a spciaty tratt or opiat tratt prora. Whi th tsti pipi cotais proisi pharacooica thrapis to trat thaphtai or cocai aictios, o icatios ar currty avaiab. Dspit thir prov ctivss, atioa ata shows iscouraiy ow MAT usa rats i couity tratt sttis. May rasos cotribut to ow rats o aoptio, icui ac o sta urstai o th icatios, oraizatioa phiosophy/sta bis about th us o icatios, cost o icatios, a ac o appropriat stai. Ori a u ra o ctiv tratt optios, icui icatios, to patits axiizs cosur choic a couras iprov outcos. Eucati th i o MAT wi b vry iportat. Chaptr 3 131

136 ACA iptatio wi aso rsut i w ros i itrat car. Thr ar thr typs o ros bi vop. Th irst is th Hath Eucator, whos rsposibiitis wi icu scri a bhaviora itrvtio a coaborati with prs a couity hath worrs. Th sco is th Bhaviora Hath Ciicia, who wi b rsposib or wori with a aspcts o BH cha (icui MH/SU). Th thir a ia w ro is th Expa Car Maar. I aitio to th thr ros scrib abov, a propos w ro is th Priary Car Bhaviorist (Fa & Fa, 2013). Th PCB wi b a priary car physicia with avac traii a crtiicatio i iaosis a tratt o ta a bhaviora probs. Th oa o xcuti this ro is to itrat xprtis i bhaviora isorrs i a si practitior. Svra proras hav aray b wori o itrati bhaviora hath srvics ito thir ica srvic provisio: Moutai Par Hath Ctr (Arizoa): Th Moutai Par Hath Ctr i Arizoa has a prora that poys bhaviora hath cosutats (BHC) who wor with patit s bhaviora hath issus. Patits ar rrr by thir physicia or urs practitior to a cosutat who th ust: (1) Itiy, tria, tart tratt, a aa priary car patits with ta or bhaviora hath issus that copicat ica probs, a (2) Coaborat with th ica sta to proot thir bhaviora hath sis. Ths two istict uctios ocus o rsovi probs withi th priary car srvic cotxt. BHC visits ar bri (15 to 30 iuts), iit i ubr (1 4, with a avra o btw 2 3 visits), ar provi i th priary car oic, a ar structur i a ar so that th patit viws ti with th bhaviora hath cosutat as a routi priary car srvic. Th BHC is trai i provii bhaviora hath itrvtios or ica iaoss. A patit with hyprtsio ay ar raxatio sis, iaphraatic brathi, a prob-sovi tchiqus. A patit with iabts ay ar s-aat, oa itiicatio a attait, oo hact a stabiity, a strss ructio. A patit with astha ay ar trir itiicatio, trir rova or aat, aiy oitori tchiqus, a actio pai. Ths xaps ar thr o ay ica coitios that BHCs ar spciaiz i trati. Uivrsity o Massachustts: Th Uivrsity o Massachustts has a crtiicat prora i PC/BH that trais MH a SUD prossioas to bco bhaviora hath prossioas i priary car. Hc, th prora is si to iv socia worrs, psychooists, cousors, urss, psychiatrists, or priary car physicias th riorous itrouctio thy to succ as priary car bhaviora hath ciicias (BHCs). Thr ar two prora optios, both o which cosist o 36 hours o iactic a itractiv traii a ivr i 6 u-ay worshops (o Friay pr oth or six oths). Th irst optio prpars prossioas to b raist Bhaviora Hath Ciicias a Car Maars i priary car sttis a th sco prpars prossioas to wor i priary car SPMI. Uivrsity o Michia: Th Uivrsity o Michia provis a wb-bas Crtiicat i Itrat Bhaviora Hath a Priary Car, si or wori prossioas 132 Chaptr 3

137 itrst i aii sis that ar critica or ctiv itratio o bhaviora hath a priary car. Each cours icus cutti- ioratio that ors th ouatio o ctiv practic. Participats ar throuh a ra o itractiv tachi thos icui cas stuis, ta sssios, a appi activitis. Ovra, th crtiicatio prora tachs up-to-at, vic-ior ow a sis that ar critica to ctiv itrat bhaviora hath a priary car practic sttis a hath ho srvic ivry os. Ovr th xt 10 yars thr wi b a ort to vop poicy, irastructur, ucatioa curricuu at schoos, crtiicatio/icsi, a traii ctrs. Whi thr wi b a or SUD cousors i th spciaty car syst, thr wi b a ar bir or bhaviora hath ciicias i th broar hath car syst. Fro th Aapois Coaitio Itratio Rport (2012), ths ar th cor coptcis or provii itrat car: Itrprsoa couicatio Coaboratio a tawor Scri a asssst Car pai a car cooriatio Itrvtio Cutura coptc a aaptatio Systs-orit practic Practic-bas ari a quaity iprovt, a Ioratics. Th oowi ar th cor coptcis or bhaviora hath ciicias (BHCs): Proicicy i th itiicatio a tratt o ivrs isorrs; Abiity to thi i trs o popuatio aat, with a ar cit i hihy icit ways; Kow o vic-bas bhaviora assssts a itrvtios rvat to ica coitios,.., isas aat, tratt ahrc, a isty cha; Abiity to a quic a accurat ciica assssts; Car-aat sis a ow o oca rsourcs or outsi rrras; Si i tart, bri psychothrapy a roups; Kow o basic physiooy, psychopharacooy, a ica triooy; Faiiarity with th stpp car o (patits ov ao irt vs o itrvtio pi o past rsposs); Abiity to ocut srvics i a way that is usu both to th priary car provir a to aat or quaity-iprovt srvics; Cosutatio iaiso sis; Rcoizs sstia iportac o har ructio. Bhaviora hath cousors ust b ab to uctio i th ast-pac priary car virot. To b ctiv, thy shou: b xib ouh to a with ois, rqut itrruptios, a costat chas i schui; b ab to or bri, tart itrvtios Chaptr 3 133

138 usuay asti ss tha 30 iuts; b coortab with short-tr cousi, ot asti ss tha 4 6 visits; uctio w i a ta-approach, accpti th act that thy ar ot i char o th patit s car; b bhavioray, rathr tha prsoaity, ocus; b ab to provi bhaviora itrvtios arssi chroic substac, ta hath, a ica isass; b ab to pror cosutatios a iv provir bac o th y ; b ab to ctivy couicat a itract with priary car provirs; a pror a otivatioa itrviwi approach to bhavior cha. Wh copari SUD cousors a BH ciicias, w ca a svra istictios: 1. Focus: SUD cousors ocus o or courss o itrvtios i spciaty sttis, whras BH ciicias ocus o copx probs a itrati ica, MH, a SUD itrvtios. 2. Tratt ti: SUD cousors hav ooi tratts that ar ivr ovr oths, whras BH ciicias copt itrvtios i our sssios or wr. 3. Srvic cooriatio: SUD cousors ocus o rcovry support, whras BH ciicias provi cooriatio across utiiscipiary srvics. 4. Srvic ivry: SUD cousors pa/schu srvic ivris, whras BH ciicias provi srvics o a, or uschu. 5. Ethics: SUD cousors oow th SUD syst (.., 42CFR, Part 2) i rar to bii a thics, whras BH ciicias vop a copx itrratioship across ivrs poicis a bii structurs. Wororc vopt wi cotiu to b a hot topic as ACA iptatio raws cosr. I th ati, short-tr pas ar rquir to prpar or So ar, propos ias icu: Itiy th traii to hp SUD/MH sta bco ctiv i priary car. Ma istictios btw spciaty car s a MH/SUD raist sis. Itiy SUD prso who wat to ar w sis to wor i priary car a provi th with traii. Dvop cott aras to bi to bui th Caioria Bhaviora Hath wororc. UCLA is currty vopi cott or a o th oowi traii curricuu: Provii Bhaviora Hath Car i a Priary Car Stti: Cutur, Ns a Itriscipiary Coaboratio; Scri Bri Itrvtio a Rrra or Substac Us, Mta Hath a Mica Disass; Urstai Chroic Mica Disass, Basic Physiooy, Triooy a Tratt Stratis; Urstai Coo Mta Hath Disorrs Itiicatio a Itrvtio; Mica Itrvtios or Substac Us, Physiooy o Drus o Abus a Micatio Assist Tratt; Car Maat o Patits i a Muti-Srvic Stti. 134 Chaptr 3

139 D. Othr Wororc Groups (WIB, HWDC, OSHPD) UCLA has stay appris o th orts o svra wororc roups i Caioria; this icus atti tis a participatio i avisory boars. Th Caioria Wororc Ivstt Boar was stabish by Excutiv Orr i rspos to th aat o th ra Wororc Ivstt Act (WIA) o 1998 (Pubic Law ). Th boar assists th ovror i stti a uii poicy i th ara o wororc vopt. Th Caioria Wororc Ivstt Boar (CWIB) is rsposib or assisti th Govror i prori th utis a rsposibiitis rquir by th ra Wororc Ivstt Act o A brs o th CWIB ar appoit by th ovror a rprst th ay acts o wororc vopt: busiss, abor, pubic ucatio, hihr ucatio, cooic vopt, youth activitis, poyt a traii, as w as th Lisatur. Th Boar ts o a ruar basis a th pubic is coura to att th tis. Dcisios ar rach throuh a coaborativ procss. Th CWIB Stratic Pa ircts its wor i provii uiac to th statwi wororc ivstt syst. Th Hath Wororc Dvopt Couci ais to hp aviat wororc shortas i Caioria s hath sctor. Th Caioria WIB stabish th Hath Wororc Dvopt Couci (HWDC) i Auust Th HWDC wi b a broa partrship cosisti o iustry rprstativs, ucatio, cooic vopt, ct oicias, th pubic wororc syst, phiathropic oraizatios, couity-bas oraizatios, hath prossioa a avocacy oraizatios a oraiz abor. Its issio is to hp xpa Caioria s hath wororc i orr to provi accss to quaity hathcar or a Caiorias. This icus th objctiv o xpai Caioria s u-ti priary car wororc by 10% to 25% ovr 10 yars. Th HWDC is tas with urstai th currt a utur hath wororc s o Caioria a with vopi a coprhsiv straty to t thos s. Hath wororc vopt issus wi b arss by th HWDC throuh stratic actios at th stat, rioa, a oca vs by urstai, assssi, a acti o th traii a ucatio, si vopt, a capacity a xpasio s o th Hath Sctor. Th HWDC uctios as a spcia coitt o th CWIB a sta support or th HWDC wi b provi by th CWIB a th Oic o Statwi Hath Pai a Dvopt (OSHPD). HWDC tis wi b op to th pubic ao with aas, prstatios, a othr atrias prst. E. Ivstiativ Wor (Fiaci/Bii - Micai Cos) Historicay, th ui or SUD srvics i Caioria has priariy co ro ra boc rats, with Mi-Ca (a spciaty bit rrr to as Dru Mi-Ca), CaWors, a couty us srvi as othr sourcs o ui. Pas or th iptatio o th Aorab Car Act icu a xpctatio that Mi-Ca wi pay a uch arr ro i th ui o SUD car i Caioria a that us o boc rat us wi to b rstructur to u oica srvics iiib or Mi-Ca riburst. This parai shit raiss ay issus that Chaptr 3 135

140 cosiratio: What wi th basic ra bit or SUD srvics ur Micai b? Wi Dru Mi-Ca cotiu to xist as a spciaty prora? How wi pas or aa car itrac with ths bits? Wi Caioria cosir a rhab optio or its SUD bit? How wi th ui o o-ica srvics usi boc rat us b o a how wi th itrac btw boc rat a Mi-Ca us b structur a oitor? May o ths qustios rai uaswr at this ti. UCLA ba to ivstiat how othr stats u itrat hathcar. Whi Micar bii procsss a procurs ar cosistt atiowi, Micai bits, coi, a payt rquirts vary across stats, trritoris, a th District o Coubia. To ctivy bi or Micai ribursab srvics, oraizatios ust subit a cai or that cotais spciic CPT (Currt Procura Triooy) cos that i to rvat biab iaostic cos a ar provi by appropriaty ics prossioas. CPT a iaostic cos ar cosistt across th coutry; howvr, stat Micai proras tri th typs o srvics, cos, a iiviuas crtia to provi srvics, rsuti i uiqu bii rus a ruatios i ach stat. CIHS has vop custoiz Itri Bii a Fiacia Worshts or ach stat that itiy xisti bii opportuitis or srvics provi i itrat sttis. UCLA copi a o th stat ata ito o sprasht (Appix 3A; upat Octobr 2012). Th srvics provi as part o biirctioa itratio ar ot or asiy biab i partrships btw Fray Quaii Hath Ctrs (FQHCs) a couity bhaviora hath oraizatios. Ths Bii a Fiacia Worshts itiy th cor st o CPT cos us to bi or spciic biirctioa hath a wss srvics provi by FQHCs a/or couity bhaviora hath oraizatios. Th Worshts i CPT cos with th stat-spciic iaostic cos a associat prossioa crtias to subit a succssu, payab cai. S Fiur 1 bow or th CPT cos i Caioria as w as th stti i which thy ar vai a who ay bi or th. FQHC FQHC HBAI Cos Crtia SUD Cos Crtia Y 01 MD, PA, NP, Ciica Psychooist, Ciica Socia Worr CMHC Y , 90807, 90809, 90811, 90813, MD, PA, NP oy. Excu CMHC MD, PA, NP, Ciica Psychooist, Ciica Socia Worr HBAI Cos Crtia SUD Cos Crtia N Y , 90807, 90809, 90811, 90813, Psychiatrist oy Psychiatrist, Psychooist 136 Chaptr 3

141 V. Chaptr Suary a Rcoatios As SUD a MH itratio orts ro out i Caioria, it is car that th wororc wi rquir a broa a ivrs st o sis, which vry w iiviuas i th currt SUD or MH wororcs possss. Priary car sttis ar vry busy virots that vau prso who hav a wi ra o xib sis to arss utip probs (Lizr, 2005, 2009). Priary car sttis ar ot couciv to prso who oy o o thi. I act, accori to xprts i bhaviora hath itratio, o o th ost coo cotributors to ai bhaviora hath itratio orts is th poyt o iiviuas who o ot hav a broa ra o MH a SUD sis (To, 2002). Thy phaticay cot that ovi th spciaty sios o SUD srvics a MH srvics ito priary car sttis is a sur orua or poor accptac o ths srvics by priary car sta a suboptia car or patits a thir aiis (Gra, 2003, 2004). For th utur succss o itrati SUD a MH srvics ito priary car, th traitioa sratio o ths srvics usi prso with a si st o spciaty sis (i.., SUD or MH) wi ipair itratio orts (Maru, 2008). Du to uai payt systs, it is sstia or th stat to ta arship i sorti throuh th copxitis o hath car iaci as ti to ribursts a poicy. By wori with xtra acis such as CMS (Ctrs or Micar & Micai Srvics), th stat ca bi to ai payt ictivs a ar th procsss ivov i rcivi riburst or SUD srvics i priary car. Th stat ca th provi th cssary tchica assistac rat to aquat subissio a rcipt o cais or SUD srvics. Payt chaiss to ictiviz a systs ivov i coaborativ car to otivat a sustai cha. Th stat s to bco irs i othr payt optios, pas, purchasi chaiss, a pubicy u aa car that wi b ti to payi or tratt o SUDs ur hath car ror. This wi ivov hih vs o ivovt with xtra acis a stratic pai to assur chas ar i pac to support bii a riburst. Th xpasio o Micai covra a ui or FQHCs throuh hath car ror th Arica Rcovry a Rivstt Act (ARRA) o 2009 a th Patit Protctio a Aorab Car Act (PPACA) o 2010 ar xpct to rsut i: (1) costructio o w FQHCs, (2) xpa bhaviora hath srvics (Hoay, 2004; LoSassa, 2010; Ws t a, 2010), (3) icras us o ctroic hath rcors that ay aciitat srvic itratio (CIMH IPI Rport), a (4) a raatic icras i th ubr o wy isur Micai patits who rciv srvics ro FQHCs (Ku t a., 2009). At th prst ti, it is ucar what th bst cours o actio is or Caioria to vop a rawor or a utur wororc. I orr to crat such a rawor, it is rco that: A cocrt wororc pai ort b iitiat i which y stahors a wororc xprts wor i cocrt with th Dpartt o Labor Wororc Ivstt Boar (WIB). A sris o tis shou b cov to provi a oru or a rviw o th critica issus that wi tri th SUD wororc s as w as iscussios a pa vopt. Chaptr 3 137

142 A trasitio pa shou b crat to stabish a cousor crtiicatio irastructur i which thr is a si cousor crtiicatio/ics aiistr by th Stat o Caioria. Th SAMHSA carr ar or SUD cousi shou b ipt i Caioria. Th stat shou xpa xisti traii a tchica assistac srvics to sur that th SUD wororc vops capacity i aras that ar critica to provii coprhsiv a vic-bas SUD tratt. Ths activitis shou b si to prpar two istict wororcs o that wi cotiu to wor as SUD provirs i spciaty tratt sttis a aothr that wi vov ito Itrat Bhaviora Hath (IBH) provirs i ica sttis. Futur Pas Th Sptbr 2013 SARC rsarch-to-poicy ti ocus o th th Chas a Opportuitis or th Substac Us Disorr Tratt Wororc 2013 a Byo. A ayo ti aa was assb that hihiht svra ajor ths or topics rat to th currt SUD wororc, a th chas a opportuitis prst to this wororc with u iptatio o th Aorab Car Act. A prstatios ivr at SARC ar rou i scic, a whvr possib, icu a iscussio o th poicy ipicatios o th atst pirica iis. W biv this ti brouht th i tothr to cotiu to or uii pas to arss th s o th SUD wororc. 138 Chaptr 3

143 Rrcs Buc, J. (2011). Th ooi xpasio a trasoratio o pubic substac abus tratt ur th aorab car act. Hath Aairs, 30(8), Burau o Labor Statistics. (1997). Substac Abus a Bhaviora Disorr Cousors. Avaiab at: Caioria Dpartt o Acoho a Dru Proras (ADP). (2010). Caioria Ns Asssst Rport. Sacrato, CA: ADP. Avaiab at Ctr or Substac Abus Tratt. (2008). Aictio Cousi Coptcis: Th Kow, Sis, a Attitus o Prossioa Practic. Tchica Assistac Pubicatio (TAP) Sris 21. DHHS Pubicatio No. (SMA) Rocvi, MD: Substac Abus a Mta Hath Srvics Aiistratio, 2006, rprit 2007 a Dioaro, J. (2011). Wororc issus rat to physica a bhaviora hathcar itratio spciicay substac us isorrs a priary car: A rawor. Wororc Issus: Itrati Substac Us Srvics ito Priary Car Corc. Auust 3, Fahrty, M. T. (2006, May). Rport: A Uii Visio or th Prvtio a Maat o Substac Us Disorrs: Buii Rsiicy, Wss a Rcovry; A Shit ro a Acut Car to a Sustai Car Rcovry Maat Mo. Istitut or Rsarch, Eucatio a Traii i Aictios (IRETA). Gra, C.E. (2003). Cotrasti th viws o substac isus a ta hath tratt provirs o trati th uay iaos. Substac Us a Misus, 38(10), Gra, C.E., Gi-Rivas, V., & Coopr, L. (2004). Prcptios o ta hath a substac abus prora aiistrators a sta o srvic ivry to prsos with co-occurri substac abus a ta isorrs. Joura o Bhaviora a Hath Srvics Rsarch, 31(1), Hoay, J.F., & Staiti, A.B. (2004). Fra ai strths hathcar saty t: Th stro t stror. Washito DC: Ctr or Stuyi Hath Syst Cha. Istitut o Mici. (2006). Iprovi th quaity o hath car or ta a substac-us coitios. Washito, DC: Natioa Acais Prss. Kipis, S., & Kiar, R. (2009). Maai aictio as a chroic isas [Wbiar]. Nw Yor Stat Oic o Acohois a Substac Abus Srvics (OASAS). Rtriv ro Ku, L., Jos, E., Fia, B., Shi, P., & Rosbau, S. (2009). How Is th Priary Car Saty Nt Fari i Massachustts? Couity Hath Ctrs i th Mist o Hath Ror. Washito DC: Kaisr Faiy Fouatio. Lizr, M., Bair Maw, L., Mut, M., t a. (2005, Fbruary). Oraizatioa Ciat, Strss, a Error i Priary Car: Th MEMO Stuy Fiis. Acy or Hathcar Rsarch a Quaity (AHRQ). Lizr, M., Maw, L.B., Wiias, E.S., t a. (2009). Wori coitios i priary car: Physicia ractios a car quaity. Aas o Itra Mici, 151(1), 28-36, W Chaptr 3 139

144 LoSasso, A., & Byc, G. (2010). Fui rowth rivs Couity Hath Ctr Srvics. Hath Aairs, 29, Maru, L., & Spc, R. (2008). Cousor a cit charactristics i ta hath vrsus substac abus tratt sttis provii srvics or co-occurri isorrs. Couity Mta Hath Joura, 44(3), Natioa Aiac o Mta Iss. (2010). Mta Iss a Substac Abus. Avaiab at: ubabus.p. Substac Abus a Mta Hath Srvics Aiistratio (SAMHSA). (2011). Scops o Practic & Carr Lar or Substac Us Disorr Cousi. Avaiab at: Tchica Assistac Coaborativ & Hua Srvics Rsarch Istitut, Caioria Mta Hath a Substac Us Syst Ns Asssst: Fia Rport. Rport prpar or Caioria Dpartt o Hath Car Srvics. Bosto: Th Authors, To, F.C., Sa, J.D., & Robrtso, P.J. (2002). Barrirs to optia car or patits with coxisti substac us a ta hath isorrs. Austraia a Nw Zaa Joura o Psychiatry, 36(6), Uivrsity o Massachustts Mica Schoo - Worcstr. (2007). Th Ctr or Itrat Priary Car: Priary Car Bhaviora Hath. [oi] Avaiab at: Uivrsity o Michia: Schoo o Socia Wor. (2013). Wb-Bas Crtiicat i Itrat Bhaviora Hath a Priary Car Uivrsity o Michia Schoo o Socia Wor. Avaiab at: Ws, R., Morrissy, J.P., L, I.H., & Raor, A. (2010). Trs i bhaviora hath car srvic provisio by couity hath ctrs, Psychiatric Srvics, 61(8), Chaptr 3

145 Chaptr 4: Traii a Tchica Assistac Activitis Bray Osr, M.P.H., Darr Uraa, Ph.D. Ovr th past yar, UCLA provi traiis a tchica assistac to aciitat itratio across th stat. This icu i-prso traiis, wbiars, tchica assistac to coutis, a tchica assistac or th Caioria Istitut or Mta Hath s Car Itratio Coaborativ. Traii a tchica assistac s rat to itratio prsist throuhout th stat. This chaptr arsss th ADP/UCLA cotract Doai 2, tit Hath Car Ror a th Itratio o SUD Srvics with Mta Hath a Priary Car, with th objctiv to provi traii at th couty v o stratis to prpar or hath car ror. Traiis a tchica assistac wr couct throuhout Caioria ro Juy 1, 2012, to Ju 30, 2013, o topics rvat to itratio. Bow ar scriptios a objctivs or ach topic oow by a ist o activitis couct. Evt atrias ca b ou o th wbsit provi i Appix 4A. Caioria Aictio Traii a Eucatio Sris (CATES) 2013: Th Chai Bhaviora Hath Car Lascap: Itratio, Iovatio, a Fiaci Mos or Succss Hath car ror has iitiat a trous cha i th bhaviora hath car sctor. With ay trasorativ ort, thr ar ay chas but aso a wath o opportuitis. For so, th chas ay s ovrwhi a th opportuitis out o rach. For othrs, chas ar but sp bups o th roa to opportuity a succss. This traii provi participats with ow a ioratio to ovrco th chas a capitaiz o th rowi art opportuitis that xist i th w hath car virot. Provirs vrywhr hav th opportuity to si thir utur i th spirit o iovatio a with a y towar car cooriatio, w ciica pathways, a th ri i o bhaviora ici. By vrai what w ow about Hath Nihborhoos, Hath Hos a Accoutab Car Oraizatios (ACOs), a iovativ iaci, bhaviora hath provirs ca ar to itiy ut s i thir couitis, couct or coprhsiv art rsarch tha vr bor, a vop w proras a srvics that ai th capabiitis o w partrs i utuay riorci busiss os. For so, th utur wi b about vrtica itratio, or a opportuity to xpa ito w arts. For othrs, th roa aha wi a to rrs a acquisitios. Sti or othrs, th utur wi b about aiiatio twors a cosortia. I ay vt, ths w busiss os rquir visio, pai, a xcutio. This traii provi participats with th bacrou, ow, a stratis to tur chas ito opportuitis. Itratio Stratis I March 2010, Prsit Obaa si ito aw historic hath car ror isatio that wi xt isurac to currty uisur a ur-isur Aricas. Th Patit Protctio Chaptr 4 141

146 a Aorab Car Act (ACA) supports prvious isatio rquiri that SUD a ta iss bits ar o par with thos or ica isss. Th w poicis outi i th ACA ar iy to raaticay cha how SUD tratt is u a th typs o srvics that ar ribursab. Th SUD tratt a rcovry wororc wi to ar aitioa sis to aviat a uch broar priary hath, SUD, a ta hath car syst. This traii xai y copots o th ACA a how SUD tratt practitiors ca atr thir practics to b ost rsposiv to patit s. Qustios a cocrs practitiors ay hav rari hath car ror wr arss, a svra spciic os a stratis or provii itrat bhaviora hath a priary srvics wr prst. Wori i th Hath Car Syst Faciitati cooriat car btw th priary hath a th substac us a ta hath isorrs tratt systs rquirs a urstai o th ost coo ica issus associat with isus o substacs. Ths traiis ocus o itiyi syptos o ica coitios associat with a th ica cosqucs o acoho a othr ru us. Th traii hp bhaviora hath provirs to vop stratis a aua or couicati a cooriati car with ica provirs to shit towars th provisio o itrat car. Ioratio was provi o priary car srvic ivry systs, icui aa car systs a Fray Quaii Hath Ctrs/couity hath ctrs. A siiar traii taior to physicias, urss, a othr ica provirs icu ioratio o how substac us isorrs ay b a aravati or uryi caus o coo ica probs, a how physicias iht thi about courai thir patits to arss thir substac us issus i thos cass. I aitio, th traii hp physicias, urss, a othr ica provirs to vop stratis a aua or ctivy couicati a cooriati car with bhaviora hath provirs to shit towars th provisio o itrat car. Th traii provi a ovrviw o stratis ica provirs ca us to coct at-ris patits with cssary bhaviora hath srvics. Scri, Bri Itrvtio a Rrra to Tratt (SBIRT) Scri, bri itrvtio, a rrra to tratt is ctiv i a varity o sttis. Its ctivss has b prov particuary i hospita rcy partts a traua ctrs trati iiviuas with acoho-rat ijuris. SBIRT has aso b show to b ctiv i priary car sttis, whr it is icorporat ito othr routi ica assssts such as asuri boo prssur. A ajor ocus o th ayo traii is o a tai rviw o y otivatioa itrviwi cocpts a pricips that ar ti to ctiv us o th FLO (Fbac; List a Ursta; Optios Expor) bri itrvtio. Cor ciica copots that ar covr icu: (1) bri itrvtio to rais awarss o ris a otivat cha; (2) bri tratt or patits si hp; a (3) rrra to tratt or patits with or srious substac-us rat probs. Micatio-Assist Tratt (MAT) Th purpos o this ha-ay traii is to provi participats with a tai ovrviw o icatios that hav b show to b ctiv as a copot o th tratt o acoho a opioi aictio. Topics wi icu: th cotxt or icatio-assist tratt (positiv a ativ prcptios), th piiooy o acoho a opioi pc, a ovrviw o ach 142 Chaptr 4

147 icatio, its iicatio, to who it is aiistr, a how it wors, a tratt sttis or icatio-assist tratt. Micatios iscuss wi icu: atrxo, acaprosat, isuira, thao, a buprorphi. Ti is provi or iscussio a qustios. Motivatioa Itrviwi (MI) Motivatioa itrviwi, a tratt approach vop by Wiia Mir, has b w stabish as a ctiv way to proot cha i iiviuas. Ths vic-a-cossusbas tchiqus hav b show to icit cha i bhavior a attitus by hpi patits to xpor a rsov abivac. This traii worshop provis participats with a uata urstai o otivatioa itrviwi a spciic tchiqus or prooti bhavior cha. Prscriptio Dru Abus Prob This traii provis a tai ovrviw o th piiooy o prscriptio ru abus a its ipact, icui th xtt o th prob a oraphics o thos act. Thr ajor catoris o prscriptio rus (.., opiois, stiuats, a sativs/traquiizrs) ar copar a cotrast to hp participats ursta why pop us ach cass o rus a how th cts o ths rus ir. Th sssio cocus with a coprhsiv rviw o various prvtio approachs a vic-bas tratts, icui bhaviora thrapis a icatio-assist tratt. Ethics a Coitiaity This traii itroucs participats to th coitiaity a thica issus associat with th provisio o tratt or substac us isorrs, as w as stratis that ca b us to bst a with patit criss a iicut patits. Chaptr 4 143

148 Traii List Juy 1, 2012 Ju 30, 2013 Na o Traii Locatio/Dat o Traii Itratio Stratis CALDAR Wstwoo, CA Sur Istitut (Los As, Hath Car CA) Ror a SUD Auust 13, 2012 Srvics i Caioria (Pary) CALDAR Sur Istitut Itrati Acoho a Dru Tratt with Priary Car: A Mica Ho Mo (Pary) Itratio o SUD srvics with Priary Car. Caioria Acoho a Dru Proras Nith Statwi Corc: Itrati Substac Us, Mta Hath, a Priary Car Srvics A Bri to Hath Ror Itrati Tratt or Co- Occurri Disorrs Micai Trasoratio Bhaviora Hath Wstwoo, CA (Los As, CA) Auust 13, 2012 Sacrato, CA Sptbr 26, 2012 Uivrsa City, CA (Los As Co) Novbr 7-8, 2012 Hoistr, CA (Sa Bito Co) Dcbr 13, 2012 Sacrato, CA, Fbruary 5, 2013 Trair(s) Richar A. Rawso, Ph.D. Costac Wisr, Dr. P.H., L.C.S.W. Darr Uraa, Ph.D. Nubr o Participats Bac-up Docuts 97 PPT sis 97 PPT sis 75 PPT sis Mutip 611 Aa/prora a PPT sis Shrry Laris, Ph.D. Darr Uraa, Ph.D. 34 (Couct or a spciic acy, ot a couty pt.) Aa a PPT sis 60 PPT sis 144 Chaptr 4

149 Itrati Tratt or Co- Occurri Disorrs Cocor, CA (Cotra Costa Co) Apri 3, 2013 Joy Chuzysi, Psy.D. 137 Fyr, aa, a PPT sis Los As Couty Aua Dru Court Corc Th Ipact o Hath Ror (Pary) Los As, CA (Los As Co) May 16, 2013 Way Suita, M.P.A. 200 Aa a PPT sis Caioria Aictio Traii a Eucatio Sris (CATES): Th Chai Bhaviora Hath Lascap Itratio, Iovatio, a Fiaci Mos or Succss Riato, CA (Sa Brario Co) May 17, 2013 Patric Gauthir, B.S. 58 Aa/prora a PPT sis CATES Foowup Wbiar: Itrati Srvics with Priary Car Wbiar Ju 19, 2013 Patric Gauthir, B.S. 3 PPT sis CATES Foowup Wbiar: Marti Stratis Wbiar Ju 26, 2013 Aa Havorso, M.P.A. 4 PPT sis Itratio o Substac Us Disorr Tratt with Priary Car i Prparatio or Hath Car Ror Sa Dio, CA Ju 17, 2013 Chry Truya, Ph.D. 150 PPT sis Chaptr 4 145

150 Wori i th Hath Car Syst Cutur o Wbiar Itrat March 7, 2013 Tratt Wbiar Thoas E. Frs, Ph.D. 32 PPT sis Chas or th SUD Wororc 2013 a Byo Cutur o Itrat Tratt Wbiar Cutur o Itrat Srvics Wbiar March 27, 2013 Wbiar Apri 2, 2013 Wbiar Ju 27, 2013 Richar Rawso, Ph.D. Thoas E. Frs, Ph.D. Thoas E. Frs, Ph.D. Scri, Bri Itrvtio, a Rrra to Tratt SBIRT a COD Traii Ahabra, CA (Los As Co) Aia Bo, L.C.S.W. SBIRT/ASSIST Traii SBIRT Traii SBIRT Traii SBIRT Avac Sis Traii (AM Sssio) SBIRT Avac Sis Traii (PM Sssio) SBIRT Avac Sis Traii Juy 17, 2012 Ahabra, CA (Los As Co) Juy 19, 2012 Sata Aa, CA (Ora Co) Auust 6, 2012 Sata Aa, CA (Ora Co) Auust 8, 2012 Cuvr City, CA (Los As Co) Auust 15, 2012 Cuvr City, CA (Los As Co) Auust 15, 2012 Los As, CA (Los As Co) Auust 30, 2012 Joy Chuzysi, Psy.D. Aia Bo, L.C.S.W. Aia Bo, L.C.S.W. Shrry Laris, Ph.D. Shrry Laris, Ph.D. Shrry Laris, Ph.D., a Aia Bo, L.C.S.W. 75 PPT sis 9 PPT sis 44 PPT sis 19 Aa a PPT sis 38 Aa a PPT sis 38 Aa a PPT sis 61 Aa a PPT sis 5 Fyr, aa, a PPT sis 15 Fyr, aa, a PPT sis 22 Fyr, aa, a PPT sis 146 Chaptr 4

151 SBIRT Avac Sis Traii SBIRT Traii SBIRT Traii (UNCOPE Pus) SBIRT Traii SBIRT Traii SBIRT Traii SBIRT Traii or Mica Provirs Wori with Aoscts (CRAFFT) SBIRT a MI Traii SBIRT a MI Traii SBIRT a MI Traii Lo Bach, CA (Los As Co) Sptbr 6, 2012 Sacrato, CA (Sacrato Co) Dcbr 7, 2012 Oaa, CA (Aaa Co) March 29, 2013 Ahabra, CA (Los As Co) Apri 25, 2013 Sa Luis Obispo, CA (SLO Co) Apri 26, 2013 Sata Aa, CA (Ora Co) May 29, 2013 Oaa, CA (Aaa Co) May 29, 2013 Grait Bay, CA (Pacr Co) May 30, 2013 Truc, CA (Pacr Co) May 31, 2013 Grass Vay, CA (Nvaa Co) Ju 1, 2013 Shrry Laris, Ph.D., a Joy Chuzysi, Psy.D. Bth Rutowsi, M.P.H. Thoas E. Frs, Ph.D. Joy Chuzysi, Psy.D. Thoas E. Frs, Ph.D. Aia Bo, L.C.S.W. Bth Rutowsi, M.P.H. Thoas E. Frs, Ph.D., a Bth Rutowsi, M.P.H. Thoas E. Frs, Ph.D., a Bth Rutowsi, M.P.H. Thoas E. Frs, Ph.D., a Bth Rutowsi, M.P.H. 14 Fyr, aa, a PPT sis 27 (Couct or a spciic acy, ot a couty pt.) Fyr, aa, a PPT sis 25 Aa a PPT sis 33 Fyr, aa, a PPT sis 38 Fyr, aa, a PPT sis 50 Aa a PPT sis 32 (Couct or a spciic acy, ot a couty pt.) Aa a PPT sis 55 Fyr, aa, a PPT sis 35 Fyr, aa, a PPT sis 29 Fyr, aa, a PPT sis Chaptr 4 147

152 Usi Bri Itrvtios to Proot Bhaviora Cha i Priary Car Sttis Scri Istruts Barsi, CA (Kr Co) Ju 25, 2013 Wbiar Ju 26, 2013 Micatio-Assist Tratt (MAT) Dtoxiicatio a Barsi, CA Pai Maat (Kr Co) Traii Juy 25, 2012 (Atroo Sssio) Opioi Dpc a Chroic Pai Traii (Evi MD Sssio) Nith Aua Traii a Eucatioa Syposiu (COMP) two o our pary prstatios ocus o MAT Acohois: Ovrviw o Disas Prorssio, Pharacooy, a Tratt Approachs (Atroo Sssio) Barsi, CA (Kr Co) Juy 25, 2012 Los As, CA (Los As Co) Sptbr 6, 2012 Barsi, CA (Kr Co) Jauary 29, 2013 Thoas E. Frs, Ph.D. Darr Uraa, Ph.D. Suztt Gasr- Ewars, Ph.D., a Larissa Mooy, M.D. Larissa Mooy, M.D., a Suztt Gasr- Ewars, Ph.D. Joh McCarthy, M.D., a Mar Staor, Ph.D. Thoas E. Frs, Ph.D., a Larissa Mooy, M.D. 34 Fyr, aa, a PPT sis 20 PPT sis 95 Fyr, aa, a PPT sis 49 Fyr, aa, a PPT sis 90 Aa a PPT sis 179 Fyr, aa, a PPT sis 148 Chaptr 4

153 Acohois: Ovrviw o Disas Prorssio, Pharacooy, a Tratt Approachs (Evi MD Sssio) NIDA CTN Paciic Rio No Rioa Dissiatio Corc (3 o th 8 prstatios ocus o MAT) Los As Couty Aua Dru Court Corc Micatio- Assist Tratt Stratis (Pary) Fouatios o Micatio- Assist Tratt or Substac Us Disorrs (Opi Wbiar) Fouatios o Micatio- Assist Tratt or Substac Us Disorrs (Cosi Wbiar) Motivatioa Itrviwi Motivatioa Itrviwi Acay Barsi, CA (Kr Co) Jauary 29, 2013 Los As, CA (Los As Co) Fbruary 28, 2013 Los As, CA (Los As Co) May 16, 2013 Wbiar May 20, 2013 Wbiar Ju 10, 2013 Los As, CA (Los As Co) Juy 11-12, 2012 Larissa Mooy, M.D., a Thoas E. Frs, Ph.D. Watr Li, M.D., Larissa Mooy, M.D., a Thoas E. Frs, Ph.D. Watr Li, M.D. Thoas E. Frs, Ph.D. Bth Rutowsi, M.P.H. Robrt Rhos, Ph.D. 41 Fyr, aa, a PPT sis 96 Fyr, aa/prora, a PPT sis 200 Aa a PPT sis 29 PPT sis 15 PPT sis 39 Fyr, aa, a PPT sis Chaptr 4 149

154 Ecti Cha throuh th Us o Motivatioa Itrviwi Ecti Cha throuh th Us o Motivatioa Itrviwi Motivatioa Itrviwi Basics Traii Motivatioa Itrviwi Acay Ecti Cha throuh th Us o Motivatioa Itrviwi Ecti Cha throuh th Us o Motivatioa Itrviwi Itrouctio to Motivatioa Itrviwi (AM Sssio) Avac Topics i Motivatioa Itrviwi (PM Sssio) Ecti Cha throuh th Us o Motivatioa Itrviwi Motivatioa Itrviwi Acay Ecti Cha throuh th Us o Motivatioa Itrviwi Sata Aa, CA (Ora Co) Juy 31, 2012 Sata Aa, CA (Ora Co) Auust 2, 2012 Sacrato, CA (Sacrato Co) Auust 8, 2012 Ecio, CA (Los As Co) Sptbr 18-19, 2012 Acto, CA (Los As Co) Jauary 24, 2013 E Mot, CA (Los As Co) Fbruary 7, 2013 Sa Luis Obispo, CA (SLO Co) Fbruary 20, 2013 Sa Luis Obispo, CA (SLO Co) Fbruary 20, 2013 E Mot, CA (Los As Co) Fbruary 25, 2013 Los As, CA (Los As Co) March 27-28, 2013 Gara, CA (Los As Co) Apri 29, 2013 Aia Bo, L.C.S.W. Aia Bo, L.C.S.W. Robrt Rhos, Ph.D. Robrt Rhos, Ph.D. Joy Chuzysi, Psy.D. Joy Chuzysi, Psy.D. Thoas E. Frs, Ph.D. Thoas E. Frs, Ph.D. Joy Chuzysi, Psy.D. Robrt Rhos, Ph.D. Aia Bo, L.C.S.W. 51 Aa a PPT sis 59 Aa a PPT sis 7 Fyr, aa, a PPT sis 31 Fyr, aa, a PPT sis 61 Aa a PPT sis 33 (Couct or a spciic acy, ot a couty pt.) Aa a PPT sis 71 Fyr, aa, a PPT sis 54 Fyr, aa, a PPT sis 19 Fyr, aa, a PPT sis 35 Fyr, aa, a PPT sis 9 Fyr, aa, a PPT sis 150 Chaptr 4

155 Avac Motivatioa Itrviwi Traii Ecti Cha throuh th Us o Motivatioa Itrviwi Motivatioa Itrviwi Acay Motivatioa Itrviwi Acay E Mot, CA (Los As Co) May 20, 2013 Sata Aa, CA (Ora Co) May 21, 2013 Los As, CA (Los As Co) May 22-23, 2013 Los As, CA (Los As Co) Ju 5-6, 2013 Prscriptio Dru Abus Prob Prscriptio Dru Abus Prscriptio Dru Abus Ethics a Coitiaity Ethica a Coitiaity Issus a Cit Criss i Substac Abus Tratt Ethica a Coitiaity Issus a Cit Criss i Substac Abus Tratt Laport, CA (La Co) Dcbr 5, 2012 Riato, CA (Sa Brario Co) May 23, 2013 Riato, CA (Sa Brario Co) Octobr 25, 2012 Frso, CA (Frso Co) Fbruary 13, 2013 Joy Chuzysi, Psy.D. Aia Bo, L.C.S.W. Robrt Rhos, Ph.D. Ari Bitsos, M.A., D.B.H. Bth Rutowsi, M.P.H. Joy Chuzysi, Psy.D. Shrry Laris, Ph.D. Joy Chuzysi, Psy.D. 25 Fyr, aa, a PPT sis 50 Aa a PPT sis 23 Fyr, aa, a PPT sis 29 Fyr, aa, a PPT sis 82 Aa a PPT sis 98 Aa a PPT sis 104 Fyr, aa, a PPT sis 202 Fyr, aa, a PPT sis **KEY Hihiht Coor Whit Yow Gr Bu Fui Sourc ETTA Cotract UCLA ISAP s art with ADPI (or a sparat TA cotract u by CA ADP) Sparat couty-bas traii cotract Sparat ui ro NIDA or SAMHSA- HRSA Ctr or Itrat Hath Soutios Chaptr 4 151

156 Tchica Assistac Th v o prparatio or hath car ror varis raaticay across th coutis. UCLA provis tchica assistac to coutis by rqust as rsourcs a xprtis aow. Duri th rporti prio, 26 ora tchica assistac rqusts wr a to UCLA o topics rat to itratio a prpari or hath car ror. Coutis rqust assistac o ay topics icui bii/iaci itratio, AOD crtiicatio procss, prpari provirs a cotractors or hath car ror, ctroic hath rcors, a os o coaboratio. Tchica assistac is provi via -ai or tpho. I aitio, UCLA oraiz a ubr o Itratio Lari Coaborativ cas that atur o-ucla spars (s Chaptr 2 or urthr ioratio). UCLA aso wor with th Caioria Istitut or Mta Hath (CiMH) to support thir ow coaborativ by provii SUD-spciic xprtis. CiMH Car Itratio Coaborativ Th CiMH Car Itratio Coaborativ (CIC) was oraiz to iprov th hath outcos o iiviuas with copx s throuh car cooriatio (CC) a rat practics. Th CIC was couct ovr a 12-oth prio (Fbruary 2012 Jauary 2013) with support ro DHCS. As part o our ETTA wor, UCLA was a activ participat i th CIC pai roup a provi SUD-orit tchica assistac to CiMH ovr th cours o th coaborativ. Th participats i th CIC wr iv couty tas with rprstativs ro ta hath, SUD, priary car, a oca hath pas. Ths tas participat i ac-to-ac a virtua coaborativ tis, ruar wb-corcs, a aitai cotact with ach othr a with CIC acuty via -ai a a scur wbsit. CiMH rport that itrati SUD srvics was prhaps th ost chai aspct o th CIC partrship approach. SUD oraizatios participat i ach CIC partrship, but th raatic ap btw a capacity o spciaty SUD srvics ipact a provirs abiity to bttr cooriat car a support or thir patits with substac us isorrs. I th, th tas a substatia prorss i itiyi iiviuas with SUD, obtaii cost to shar ioratio i copiac with 42 CFR part 2, poyi pop with MH/SUD iv xpric to support wss a s-aat, iprovi couicatio btw provirs, cooriati car or shar patits, a prori ruar iatio rcociiatios. For u tais about th CIC a ths rsuts, s Th Car Itratio Coaborativ Fia Rport (xpct to b o th CiMH wbsit atr this sur). Th ovra rcoatios ro this rport ar icu bow. Ky Rcoatios or Car Cooriatio a Itratio Ea a Ectiv Larship Coitt sior ar chapios ar sstia to iprovt spciay i copx cha procsss that ivov utip partrs. 152 Chaptr 4

157 Sior ars ust activy bui a sustai accoutabiity a th wi or iprovt withi thir oraizatio a across partri systs. Hath pas ar sstia partrs i sii a utiaty ictivizi CC procsss that wi rsut i bttr outcos a owr costs. Dvop Car a Accoutab Ros or Iiviua CC Provirs a Tas Mappi CC worows a procsss ro th patit (a provir) prspctiv is usu to cariy rsourcs, aps, a ros o participati spciaty MH/SUD a priary car oraizatios. CC across spciaty a priary car oraizatios rquirs car ai/purpos, oas a structur. Cary i th ro o car cooriator as w as rat ta ros a wor procsss. Ky Car Cooriatio a Car Itratio Procsss Provi support or vopt o ctiv provir couicatios, Shar Prob Lists/Car Pas a routi icatio rcociiatio as sstia CC uctios. Spciaty SUD tratt provirs ust b itra partrs i pai a crati w systs or car cooriatio. Activy ucat a a patits i CC a vop procsss to obtai patits cost (ROI) to shar ciica ioratio ao provirs ivov i thir car. Aopt a us a ciica ioratio shari too (prraby ctroic) to ctivy cooriat car ao partri oraizatios. Th Car Mo (CCM) Provis a Usu Systs Frawor or Car Cooriatio Th Car Mo (E War, MD, McCo Istitut) ors a rawor or systs chas rquir to cooriat a itrat car or prsos with SMI/SUD a cooccurri ica ris/coitios. Masurt o Patit Outcos a Syst s Procsss is vry Chai Across Mutip Provir Oraizatios Ea i a CC Partrship Oraizatios capacity to asur itra oraizatioa iprovt a to shar itrat CC rsuts across partri oraizatios, provirs a hath pas. I aitio, tais o th SUD-spciic rcoatios a cocusios icu th oowi: Substac Us Disorrs Must B Itii a Arss By A Provirs: CIC proot scri, rrra a tratt o substac us isorrs as sstia i CC/itrat car or prsos with copx coitios. Howvr, ot a tas icu SUD provirs a ac o accss to spciaty SUD tratt capacity was xpric as a siiicat barrir. CIC ta stratis icu co-ocati or suri cos proxiity o SUD sta to othr srvics, tsti ctiv scri a rrra procsss a provii MH/PC accss to SUD partrs icui ruar a a hoc cosutatio capacity. A traii sssio was provi by UCLA o Micatio Assist Tratt (MAT) as a ri vic-bas practic whr PC or MH physicias prscrib icatio to aa opiat or acoho withrawa whi SUD provirs provi ooi Chaptr 4 153

158 tratt a raps prvtio support. It was ot that vry w physicias ar trai or or MAT. I Caioria, th ap btw a avaiabiity o pubicy u SUD spciaty car sots or itsiv outpatit or rsitia tratt is w-ocut; howvr, parity rquirts a accss to a SUD isurac bit ur th ACA ay ostr xpa capacity withi th xt w yars. Futur CC iitiativs shou icras thir ocus o ivovi SUD provirs, prooti bst practics i SUD tratt a raps prvtio. PC a MH oraizatios shou b coura to trai thir bhaviora hath provirs to routiy or SUD scri a bri tratt wh spciaty SUD tratt is ot rquir. Spciaiz traii proras ar bcoi avaiab or PC bas SUD srvics icui so that ar or oi. Spciaty SUD tratt provirs ust b itra partrs i pai a crati w systs or car cooriatio. Giv th currt ac o aquat pubic sctor ui a capacity to provi spciaty SUD tratt, CC proras a partrships ust cotiu to phasiz SUD as th rsposibiity o a provirs. Eorts shou icu iprovi SUD scri, bri itrvtios, tratt, a rcovry support capacity. Whr accss to spciaty car is avaiab, iprovi rrra procsss to icu war haos is aso iportat. I aitio to th cocusios a rcoatios ist abov, th CIC ostrat th asibiity o th ari coaborativ o its. As a rsut, CiMH pas to auch a w Car Cooriatio Lari Coaborativ i th a o UCLA has b ivit to participat i this coaborativ a wi cotiu to provi SUD-rat tchica assistac. 154 Chaptr 4

159 Chaptr 5: Rport Cocusios a Rcoatios Darr Uraa, Ph.D., Vari Atoii, M.P.H. Doai 1. Data Aaysis: Urstai th Chai Fi o SUD Srvics Data aayss wr couct to arss th oowi objctivs: 1. Exai how ooi poicy chas ar acti who rcivs SUD tratt a how accss, srvics, costs, a quaity o car ar bi act. Ma rcoatios to iprov poicis, practics, a ata quaity. 2. Ri prora prorac a patit outco asurs. Ovra, icras covra o SUD srvics i a o its i ot appar to a to icras cooriatio btw hath car a spciaty car srvics. By xtsio, it ay b assu that th 2014 Mi-Ca xpasio a hac SUD bit ay ot, o thir ow, rsut i bttr cooriatio. Ista, partrships wi hav to b activy pursu. Currty, a rativy sa ubr o proras ar ruary rcivi rrras ro hath car sourcs u to cocrt orts by ths proras to vop ratioships with oca hath car provirs. Patits rrr ro hath car to spciaty SUD tratt t to b Whit, a, a tri toxiicatio or acoho us. This ay cha as or iiviuas ai covra throuh privat isurac or Mi-Ca i Furthr rsarch is to tri why a a Hispaic patits ar urrprst. A rviw o SBIRT iptatio i a six-stat SAMHSA-sposor stuy rva ata that cou iicat a ajor ipact to Caioria s currt SUD spciaty tratt syst i SBIRT is succssuy ipt i Caioria. I this vt th currt spciaty syst ay to uro a substatia xpasio. Thr ar, howvr, a ubr o Caioria-spciic barrirs that wi to b arss i orr to aciitat a succssu SBIRT iptatio. Data o AB 109 cits is spars a currty o qustioab accuracy, but sust that th ubr o AB 109 cits tri tratt ay b risi rapiy. Vry ow rot o AB 109 cits i Mi-Ca is o particuar cocr. Bits shou b susp uri icarcratio rathr tha triat, a Mi-Ca outrach a rot orts tart at soo-to-b ras iats ar. Data Iicator Rports or outpatit a thao aitac prorac asurt hav b poy, a vopt o asurs or rsitia tratt a toxiicatio ar xt. Iitia provir bac has rporty b positiv. Dru Mi-Ca ata a CaOMS-Tx ata ca pottiay b prouctivy us to asur prorac, itiy SUD hot spots, aayz costs, a tct rau, which ay b usu to poicyars. Chaptr 5 155

160 Rcoatios: 1. Moitor ioratio ro th Uior Data Syst to tri th ubr o patits trat or SUD i Caioria hath ctrs to t a bttr pictur o tratt as itratio occurs. Priary car provirs o ot rport to CaOMS-Tx. UCLA has rqust this ioratio ro th Hath Rsourcs a Srvics Aiistratio (HRSA). 2. Cotiu orts to trai a provi tchica assistac to iprov ata try procsss a ata quaity. 3. Cosir atrativ thos o obtaii or accurat AB109 ata. 4. Susp rathr tha triat Mi-Ca bits ro criia justic patits uri prios o icarcratio whr possib. 5. Ecoura th vopt o partrships btw SUD a priary car provirs. Currty, oy a rativy sa ubr o proras ar ruary rcivi rrras ro hath car sourcs. 6. Rvisit rstrictios o sa-ay bii a iib wororc i orr to aciitat th iptatio o SBIRT. 7. Cotiu to vop a poy prorac ashboars. 8. Rvisit currt Stat o Caioria poicis aati two usuccssu opioi toxiicatio attpts or aitac tratt iibiity. 9. Us Dru Mi-Ca a CaOMS-Tx ata tothr to iprov prorac, outco asurt, a rau tctio. Doai 2. Hath Car Ror a th Itratio o SUD Srvics with Mta Hath a Priary Car UCLA ha th oowi objctivs i this oai: Coct a issiat cutti ioratio o th itratio o SUD srvics with ta hath a priary car srvics Cooriat a aciitat a itractiv oru (i.., Lari Coaborativ) with coutis a othr y stahors to iscuss SUD itratio barrirs a practica os Couct cas stuy/piot vauatios Ky vopts i th i A ri itratio o th Staar Frawor or Lvs o Itrat Hathcar, was ras by SAMHSA-HRSA Ctr or Itrat Hath Soutios (CIHS, 2013). Th w 156 Chaptr 5

161 rawor copasss six vs o itratio ur a cotiuu rai ro cooriat car to itrat car. Cooy us vic bas practics us to aciitat itrat srvics icu SBIRT, otivatioa itrviwi, a icatio assist thrapis. Howvr ach cotais barrirs to succssu iptatio such as wororc vopt rquirts, bii a riburst chas, as w as poicy obstacs. Nw oraizatioa os ar ri to trasor car to b bttr itrat, or coprhsiv, a or rsposiv to th s o patits. Exaps icu hath hos, patit-ctr ica hos, a accoutab car oraizatios. Bcaus o thir phasis o itrati srvics, thy provi a pottia opportuity or bhaviora hath. Nw tchoois a th ass poyt o xisti tchoois (.: Thath a Hath Ioratio Tchooy a Ectroic Hath Rcors) xpas th abiity o provirs to ot oy shar ioratio with ach othr across iscipis, but aso to oitor a trac patits a couicat iportat vopts with patits rari thir hath. Howvr, iptatio is costy a is ib with barrirs arou coitiaity a ata/ioratio shari ruatios. Th Caioria Itratio Lari Coaborativ cotius to uctio as a usu chais to shar ioratio a iscuss succsss a chas across couty aiistrators a xcutiv v provirs/aiistrators. It srvs as a othy chais or th stat to provi tchica assistac a traii opportuitis at th couty v thouh th aciitatio at UCLA. Nw ata Withi Caioria, th UCLA Itratio Survy rva that whi a w coutis hav ot yt bu th procss o itrati AOD srvics with ta hath a priary car, ay othrs hav rport prorss. Dspit ay barrirs raii itact btw 2010 a 2012, itratio iitiativs hav xpa ao Caioria coutis. Throuh cas stuis a piot projcts, UCLA has b ab to itiy svra ssos ar ro th ay itratio activitis occurri across th stat. Eucati a traii sta (at a vs) is critica to 1) cariy ros a rsposibiitis across th various coaborati iscipis, 2) to obtai buy-i at th provir a aiistrativ sta v, 3) to ostr a shar visio, 4) iprov utiizatio o vicbas practics, a 5) isti vau ao th wororc. Itiyi a stro arship ta ui by a shar visio that ts ruary hps to crat succssu iptatio. Crati a op oru or sta bac to th arship v was crucia to aitai buy-i, isti accoutabiity, a aow or sta to b a part o th procss. Chaptr 5 157

162 Estabishi chapio physicias a icorporati th ito th arship ta was a succssu chais to ipt w srvics a practics. Scti th riht sta to couct itrat bhaviora hath i priary car sttis is critica. Ths sta ust b xib, proactiv, ab to ha abiuity, a ab to or stro ratioships. Stahors ust b wii to oiy iitia pas as. Couicatio is y a cotiui sta ucatio is iportat. Patic, torac, a opss wr rquir ro both th physica hath a bhaviora hath provirs i orr to r th two cuturs. It is iportat to acow that cha is iicut. Thr ar ay chas surroui th iptatio o a w EHR syst, such as probs with itchs a ata trasrs. Th ata traci syst ust b pt sip at th outst. Foow atst SAMHSA vopts to assur 42 CFR copiac wh shari ata; rviw cost a aissio or accoriy. Patits/cosurs ar biti ro th itratio o srvics. Acotay, patits urstoo a support with i-prso war haos. This buis trust, which aows patits to thy ar i oo has. Itrati srvics rquirs ui a/or a itii sta to aviat throuh th copx bii chaiss. Survys o sct FQHCs i Caioria rva that: SUD srvics ar ray ot as w itrat with priary car as MH srvics ar, ar rat as ss ctiv, a ar sparat ro priary car srvics physicay a tporay. Th irc i ctivss appars to b u to provir traii, ot i attitus towar SUD patits. SUD srvics wr or itrat with MH srvics tha with priary car srvics. Thr is rat itrst i SUD traii, a wor to b o o itratio o SUD ito ctroic hath rcors A survy o SUD/BH aiistrators who participat i LIHP or CMSP proras rva that: So hav accss th covr srvics a rciv riburst, but it cos with a hih aiistrativ cost that ay coutis ar ot ab to aor. Th CMSP procss o cais procssi a payt s to b sipii a strai i SUD bits ar to b bttr us wh thy bco or wiy avaiab i Th irastructur or bii Mi-Ca a Dru Mi-Ca a payts ay to b vop a provirs ay traii a tchica assistac (.., Micai rquirts) as thir xpric i ths aras appar to b iit. 158 Chaptr 5

163 Rcoatios 10. Expa SUD wororc who ca bi Mi-Ca to ab FQHCs to rcruit sta. I particuar, FQHCs wat to a arria a aiy thrapists to th ist o sta that ar iib to bi Mi-Ca. Currty ics ciica socia worrs a psychooists ar th oy bhaviora hath provirs that ca o so. 11. Aow sa-ay bii o two srvics. This is cosistt with bst practics rari war haos btw priary car a bhaviora hath. I a patit ust a a appoitt to rtur aothr ay to rciv ths srvics, thy wi ot bco o shows a a opportuity to arss thir probs wi b ost. Natioay, 28 stats currty aow sa-ay bii, but Caioria os ot. 12. Icu ici that has b show to b ctiv i trati opioi aictio (.., Suboxo, Vivitro) i th oruary. Athouh provirs ay subit a tratt authorizatio rqust or Suboxo, provirs a support sta sotis i th procss to b ti cosui, abor itsiv, a rustrati, which ca ativy ipact provirs wiiss or abiity to provi icatios that ar ctiv i trati opioi aictio. 13. Dvop th wororc to ctivy provi car to iiviuas who prst with SUDs i priary car sttis. SUD a rcovry shou b covr i th curricuu or ica a ursi stuts, socia worrs, psychooists, a othr irct-car provirs so thy ar coortab a ctiv i arssi SUD. 14. Icras capacity i th couity or spciaiz SUD a support srvics, spciay rsitia tratt a toxiicatio. Patits who ar rrr ro priary car to spciaty SUD srvics i th couity i it xtry iicut to accss srvics u to ac o avaiabiity. 15. Cotiu to ucat provirs a thir wororc o th iportac a ctivss o cooriat car a th vau o bhaviora hath or th ovra iprovt o quaity o patit car a outcos. 16. Cotiu to avocat or th icusio o bhaviora hath oraizatios i aiuus subsiy proras. 17. Cotiu orts to ostr partrships btw SUD a priary car provirs. 18. Cotiu orts to support piot projcts at th couty a provir v as a chais to tst a vauat succssu iptatio stratis. Stratic Pai or Wororc Dvopt: Prpari th AOD Wororc or 2014 a Byo Duri isca yar , UCLA cotiu to arss th objctiv to vop stratic pai pricips to ui th utur vopt o a itrat ru tratt ivry Chaptr 5 159

164 syst i Caioria ur hath car ror. As SUD itratio ur hath car ror is sti vovi, th wororc cssary to ipt SUD srvics outsi o th spciaty syst rais ucar. As itratio orts ro out i Caioria, it is car that th wororc wi rquir a broa a ivrs st o sis, which vry w iiviuas i th currt SUD or MH wororcs possss. Priary car sttis ar vry busy virots that vau prso who hav a wi ra o xib sis to arss utip probs (Lizr, 2005, 2009). Priary car sttis ar ot couciv to prso who oy o o thi. I act, accori to xprts i bhaviora hath itratio, o o th ost coo cotributors to ai bhaviora hath itratio orts is th poyt o iiviuas who o ot hav a broa ra o MH a SUD sis (To, 2002). Thy phaticay cot that ovi th spciaty sios o SUD srvics a MH srvics ito priary car sttis is a sur orua or poor accptac o ths srvics by priary car sta a suboptia car or patits a thir aiis (Gra, 2003, 2004). For th utur succss o itrati SUD a MH srvics ito priary car, th traitioa sratio o ths srvics usi prso with a si st o spciaty sis (i.., SUD or MH) wi ipair itratio orts (Maru, 2008). Du to uai payt systs, it is sstia or th stat to ta arship i sorti throuh th copxitis o hath car iaci as ti to ribursts a poicy. By wori with xtra acis such as CMS (Ctrs or Micar & Micai Srvics), th stat ca bi to ai payt ictivs a ar th procsss ivov i rcivi riburst or SUD srvics i priary car. Th stat ca th provi th cssary tchica assistac rat to aquat subissio a rcipt o cais or SUD srvics. Payt chaiss to ictiviz a systs ivov i coaborativ car to otivat a sustai cha. Th stat s to bco irs i othr payt optios, pas, purchasi chaiss, a pubicy u aa car that wi b ti to payi or tratt o SUDs ur hath car ror. This wi ivov hih vs o ivovt with xtra acis a stratic pai to assur chas ar i pac to support bii a riburst. Th xpasio o Micai covra a ui or FQHCs throuh hath car ror th Arica Rcovry a Rivstt Act (ARRA) o 2009 a th Patit Protctio a Aorab Car Act (PPACA) o 2010 ar xpct to rsut i: (1) costructio o w FQHCs, (2) xpa bhaviora hath srvics, (3) icras us o ctroic hath rcors that ay aciitat srvic itratio (CIMH IPI Rport), a (4) a raatic icras i th ubr o wy isur Micai patits who rciv srvics ro FQHCs. Giv that it is ot car what th bst cours o actio is or Caioria to vop a rawor or a rawor or a utur wororc, w hav ist th oowi rcoatios i orr to crat such a rawor. Rcoatios 19. A cocrt wororc pai ort b iitiat i which y stahors a wororc xprts wor i cocrt with th Dpartt o Labor Wororc Ivstt Boar (WIB). 160 Chaptr 5

165 20. A sris o tis shou b cov to provi a oru or a rviw o th critica issus that wi tri th SUD wororc s as w as iscussios a pa vopt. 21. A trasitio pa shou b crat to stabish a cousor crtiicatio irastructur i which thr is a si cousor crtiicatio/ics aiistr by th Stat o Caioria. 22. Th SAMHSA carr ar or SUD cousi shou b ipt i Caioria. 23. Th stat shou xpa xisti traii a tchica assistac srvics to sur that th SUD wororc vops capacity i aras that ar critica to provii coprhsiv a vic-bas SUD tratt. Ths activitis shou b si to prpar two istict wororcs o that wi cotiu to wor as SUD provirs i spciaty tratt sttis a aothr that wi vov ito Itrat Bhaviora Hath (IBH) provirs i ica sttis. Futur Pas Th Sptbr 2013 SARC rsarch-to-poicy ti ocus o th th Chas a Opportuitis or th Substac Us Disorr Tratt Wororc 2013 a Byo. A ayo ti aa was assb that hihiht svra ajor ths or topics rat to th currt SUD wororc, a th chas a opportuitis prst to this wororc with u iptatio o th Aorab Car Act. A prstatios ivr at SARC ar rou i scic, a whvr possib, icu a iscussio o th poicy ipicatios o th atst pirica iis. W biv this ti brouht th i tothr to cotiu to or uii pas to arss th s o th SUD wororc. Chaptr 5 161

166 162 Chaptr 5

167 Fia Rport Cocusios Th ssos ar throuhout this rport support a coo cocusio: O thir ow, th uch-aticipat hac SUD bits a xpa isur popuatio i 2014 wi ot sur aquat SUD tratt capacity or itratio. I a ubr o barrirs ar ot ovrco, th bit wi ot b us to its pottia. Both th CMSP/Path2Hath a LIHP xprics sust that ay tratt proras currty ac th irastructur a sta traii to bi Mi-Ca a isurac. Furthror, th CMSP/Path2Hath xpric ostrat that i th cais procss is prciv as too copicat or uriab, bits ay o uus. Particuary i sar coutis i thos srv by CMSP/Path2Hath, th costs o aitaii a bii irastructur ay outwih th payts that ca b obtai by srvi a rativy sa ubr o iiviuas. O soutio iscuss i UCLA s currt CATES traii sris is provir oratio o twors to shar th costs o bii irastructur, as w as pottiay othr xpss such as ctroic hath rcors, arti, a othr aiistrativ xpss. I priary car, such oraizatios, ow as Maat Srvics Oraizatios (MSOs) or Ipt Practic Associatios (IPAs), ar coo. Itratio aso hos th prois o ai SUD tratt accssib to or patits throuh priary car. Howvr, proras to activy pursu partrships with priary car. As scrib i Chaptr 1, a vry sa ubr o tratt proras currty rciv a outsiz proportio o rrras ro hath car provirs. Ths proras a thir priary car partrs ar ostrati that such partrships ca b succssu, but th ubr o proras that hav ta this stp has so ar b iit. Byo rrra arrats, SUD srvics ca aso b uy itrat ito priary car. A ubr o itratio iitiativs hav r arou th stat to attpt this (s Chaptr 2). Fro ths ivrs iitiativs, a w cosy rat a rcurri ssos hav r, icui th to ucat sta o th iportac o itratio a to cariy ros, th iportac o havi a chapio physicia to proot itratio, a th to obtai buy-i ao th participats. Ev i ucatio, a chapio, a buy-i ar prst at th rou v, howvr, thr ar ipits to itratio at th poicy v. Ths barrirs icu Mi-Ca rstrictios o sa-ay bii or two srvics (Chaptr 2), th ac o a aquaty trai wororc whos srvics ca b riburs i priary car sttis (Chaptrs 2 a 3). Without arssi ths probs, actios such as activati SBIRT bii cos ay ot hav th sir ct. To ovrco ths barrirs, traii a tchica assistac wi cotiu to pay a iportat ro i aciitati th i s prorss. To asur this prorss a iprov practics a poicyai, th coctio a us o vai a riab ata wi b critica. I cocusio, Caioria is cotiui to a prorss towar itratio, but urthr prparatios ar sti to prpar th stat or 2014 a byo. Chaptr 5 163

168 164 Chaptr 5

169 Appics 165

170 166

171 Appix 2A: ETTA Wbiars a Corcs ETTA Wbiars (FY ) Juy 2012 (1) Coparativ Ectivss Rviw o Scri, Bhaviora Cousi, a Rrra i Priary Car to Ruc Acoho Misus Juy 31, 2012 AHRQ Ectiv Hath Car Prora -ucatio/cer40/coparativ-ectivss- Rviw-o-Scri,-Bhaviora-Cousi,-a-Rrra-i-Priar y-car-to-ruc- Acoho-Misus Auust 2012 (2) Sa Da y Accss a Op Ms: A Rvoutio i Bhaviora Hath Auust 9, 2012 Natioa Couci or Couity Bhaviora Hathcar (3) Motivatioa Itrviwi Sris: Eai P op i Discussios about Hath-rat Chas Auust 15, :00-12:30 p Paciic SAMHSA-HRSA Ctr or Itrat Hath Soutios (4) Itrati Bhaviora Hath i Couit y a Mirat Hath Ctrs: Motivatio, Raiss, & Cutura Chas Auust 23, 2012 SAMHSA-HRSA Ctr or Itrat Hath Soutios Sptbr 2012 (5) Ehaci Stratis to Proot Iiviua Cha i Priar y Hathcar Sttis Sptbr 5, 2012 SAMHSA-HRSA Ctr or Itrat Hath Soutios (6) Th Powr o Poic y Wbiar 5 - Hath i A Poicis: Lssos Lar ro Caioria Sptbr 6, :00 a - 12:00 p Paciic Appix 2A 167

172 Arica Pubic Hath Associatio Poicy Capacity Buii Assistac (7) Maiu Us Sta 2: Th Nw Maat or Bhaviora Hath Sptbr 13, :00-3:30 p Eastr Natioa Couci or Couity Bhaviora Hathcar (8) Doi Busiss Dspit Disastr: HIT to th Rscu Sptbr 25, 2012 Natioa Couci or Couity Bhaviora Hathcar Octobr 2012 (9) How to o th Maa Car Dac What You N to Kow to Participat i Ntwors Octobr 16, :00-11:30 p Paciic SAMHSA-HRSA Ctr or Itrat Hath Soutios (10) How Cosurs Ca Driv Bttr Prsoaiz Outcos: Lari Fro Succssu Oraizatios Octobr 22, :00-2:30 p Paciic Natioa Couci or Couity Bhaviora Hathcar (11) MAT: A Psychiatric a Priar y Car Prspctiv Octobr 25, :00-11:00 a Paciic MAT Hath Ntwor Lari Coaborativ Novbr 2012 (12) Itrat Car withi th Patit Ctr Mica Ho: Th Hath Ctr Prspctiv Novbr 8, :00-10:30 a Paciic SAMHSA-HRSA Ctr or Itrat Hath Soutios (13) Micai Expasio Basics 168 Appix 2A

173 Novbr 13, :00-1:30 p Paciic Coaitio or Who Hath (14) Micai Expasio Avocac y Stratis Novbr 27, :00-1:30 p Paciic Coaitio or Who Hath (15) HIT Stratic Pai a Iptatio: Gui Tours, Part 1 o 3 Novbr 27, :00-12:30 p Paciic Natioa Couci or Couity Bhaviora Hathcar Dcbr 2012 (16) HIT Stratic Pai a Iptatio: Gui Tours, Part 2 o 3 Dcbr 11, :00 a - 12:30 p Paciic Natioa Couci or Couity Bhaviora Hathcar (17) Prscriptio Opioi Ovros a th Pubic Hath Rspos Dcbr 12, :00-11:00 a Paciic Arica Mica Associatio i=9902 Jauary 2013 (18) WHAM: Eiht Ws to Who Hath throuh Pr Support Groups Jauary 15, 2013 Natioa Couci or Couity Bhaviora Hathcar (19) A (Hath) Ho Ru: Opratioaizi Bhaviora Hath Hos Jauary 18, 2013 Natioa Couci or Couity Bhaviora Hathcar Appix 2A 169

174 (20) Eat o Sta i th Us o MAT Jauary 31, 2013 MAT Hath Ntwor y/wbiar- a t-sta-us-at Fbruary 2013 (21) HIT or Bhaviora Hath: What s i it or? Fbruar y 6, 2013 Grat Las ATTC (22) Erot a B yo: ACA Eorts a Ipicatios i Caioria Fbruar y 13, 2013 Aca yhath yhath.or/traii/rsourcdtai.c? ItNubr=10397 (23) Substac Us Disorr, Priar y Car a Erc y Roo Srvics: Estabishi Coaborativ Partrships throuh Chroic Disas Fbruar y 27, :00-11:30 a Paciic Los As Cout y Substac Abus Prvtio a Cotro a ADP I y.or/hcr/hcr.ht (24) Ehaci Bhaviora Hath Car Usi Hath IT Fbruar y 27, :00 a Paciic Ac y or Hathcar Rsarch a Quait y (AHRQ) (25) Us o MAT i Hath Ctrs Fbruar y 28, :00-11:00 a Paciic MAT Hath Ntwor (26) Patit Privacy a Coitiaity i th Chai Hath Car Evirot: HIPAA, 42CFR Part 2 a Hath Car Ror Fbruar y 28, :00-11:30 a Paciic SAMHSA/La Actio Ctr t=a&= Appix 2A

175 March 2013 (27) Itrati Tratt or Co-occurri Mta a Substac Us Disorrs March 12, :00 a-12:30 p Paciic Natioa Couci or Couity Bhaviora Hathcar (28) Riburst a Coi or Scri a Bri Itrvtios or Ciics/Hath S ysts/hospitas March 20, :00 a-1:00 p Paciic Natioa SBIRT ATTC y (29) Hath IT or Priary a Bhaviora Hathcar Itratio March 25, :00-12:30 p Paciic Natioa Couci or Couity Bhaviora Hathcar ars Apri 2013 (30) Maa Car How Ca I Do It? Succi i th Nw Wor o Maa Hath Car Srvics, Part Two Apri 18, :00-11:30 a Paciic Los As Cout y Substac Abus Prvtio a Cotro (SAPC) y. ov/sapc/hathcar/hathcarror.ht y.or/hcr/hcr.ht (31) Thath: It's Not About Tchooy, It's About Expai Accss a Ehaci Car Apri 18, :00-12:30 p Paciic Natioa Frotir & Rura ATTC May 2013 (32) Itrati Ps ychiatry ito Priar y Car May 8, :00a-12:30p Paciic Natioa Couci or Couity Bhaviora Hathcar Appix 2A 171

176 (33) A Cos Loo at Car Cooriatio Withi Patit-Ctr Mica Hos: Wst Viriia s Expric May 9, :00-11:00a Paciic Ac y or Hathcar Rsarch a Quait y (34) Th Aorab Car Act a Ipicatios or Rcovr y-orit Practic May 9, :00-1:30 p Paciic SAMHSA Rcovr y to Practic ytopractic/rtprsourcs.aspx (35) Ruci Hospita Raissios or Cits with Aictios May 22, :00a-12:30p Paciic Natioa Couci or Couity Bhaviora Hathcar Ju 2013 (36) Buii Hath Ioratio Exchas to Support Accoutab Car Oraizatios a Mica Hos: Dawar s Expric Ju 5, :00-11:00a Paciic Ac y or Hathcar Rsarch a Quait y (37) Brii Criia Justic S ysts a Couity Hathcar: Itratio s Ro i Rtr y Ju 18, :00a-12:30p Paciic SAMHSA-HRSA Ctr or Itrat Hath Soutios (38) Tratt Iovatios: Prspctivs ro Aictio Provirs Itrati Priar y Car Ju 24, :00-10:30a Paciic SAMHSA-HRSA Ctr or Itrat Hath Soutios (39) Aorab Car Act iptatio o yar post-cisio: Micai xpasio, 172 Appix 2A

177 prvtiv srvics a pubic hath ipicatios Ju 26, :00-11:00a Paciic Arica Pubic Hath Associatio (APHA) Powr o Poic y y/rports/wbiars/aut.ht (40) Micai Hath Ho Iptatio i Missouri: A Yar Latr Ju 27, :00a-12:30p Paciic SAMHSA-HRSA Ctr or Itrat Hath Soutios Appix 2A 173

178 ETTA Corcs (FY ) Juy 2012 No rport. Auust 2012 UCLA att th Ctr or Avaci Loituia Dru Abus Rsarch (CALDAR) Mti i Maria D Ry, Caioria o Auust 13, Dr. Rawso av a pary iscussio o: Hath Car Ror a Substac Us Disorr Srvics i Caioria. UCLA att th Caioria Dpartt o Acoho a Dru Proras (ADP) Corc o Auust 21-23, UCLA was ivov with svra worshops a wh ot prsti sta wr st to ta ots o othr worshops. Sptbr 2012 UCLA att th Acy or Hathcar Rsarch a Quaity (AHRQ) Aua Corc o Sptbr 9-10, 2012 i Bthsa, Marya. UCLA att th Caioria Istitut or Mta Hath (CIMH) Poicy Foru o Sptbr 12-14, 2012 i Sooa, Caioria. UCLA att th Couty Acoho a Dru Prora Aiistrators Associatio o Caioria (CADPAAC) Quartry Mti o Sptbr 26-27, 2012 i Sacrato, Caioria. Octobr 2012 UCLA att a prst at th Itr-stat Couity o Practic (CoP) tcorc o Octobr 23, 2012 (Topic: Prorac Maat). UCLA att th Aictio Hath Srvics Rsarch (AHSR) Corc o Octobr 17-19, 2012 i Nw Yor, Nw Yor. UCLA att th Isur th Uisur Projct (ITUP) Mta Hath Issus Worroup o Octobr 18, 2012 i Los As, Caioria. Novbr 2012 UCLA att th 9th Statwi Corc o Co-Occurri Disorrs (COD) o Novbr 7-8, 2012 i Uivrsa City, Caioria. UCLA att th Hath Foru at UCLA (Fii Schoo o Pubic Hath) o T h Ipact o th 2010 Ectio o Hath Car Ror o Novbr 28, 2012 Dcbr 2012 UCLA att ti o Crati a Stratic Pa or Wororc Dvopt i Caioria (t-corc) o Dcbr 17, Jauary 2013 UCLA att th UCLA Davi G Schoo o Mici 17th Aua UCLA Hath Car Syposiu: Briht Ias: Iovatios i Hath Car Divry h o Saturay, Jauary 12, 2013, 8:00AM to 12:30PM, at Cov Coos o th capus o UCLA. UCLA att ti o Stratic Pricips or th Itratio o SUD/MH Srvics i Caioria (Wororc Dvopt) (t-corc) with ADP o Jauary 17, UCLA att th CADPAAC Quartry Mti o Jauary 23-24, 2013 i Sacrato. UCLA att th Hath Foru at UCLA (Fii Schoo o Pubic Hath) o How Wi th 174 Appix 2A

179 Mta Hath Syst Cha Ur th Aorab Car Act? o J auary 30, Fbruary 2013 UCLA att th IT UP 17th Aua Corc: ACA: Th Fia Coutow Fb. 5, 2013 i Sacrato. DU participat as a paist a aso too ots. Goo corc! W shou p i touch with th IT UP roup. UCLA att th CiMH Mta Hath & Substac Us Poicy Foru Fb , 2013 i Sacrato. March 2013 UCLA att th CADPAAC Quartry Mti o March 27-28, 2013 i Sacrato. Dr. Rawso a Dr. Frs prst a rport o Wororc Dvopt. Apri 2013 UCLA att th Natioa Couci or Bhaviora Hath Corc o Apri 7-10, 2013 i Las Vas, NV. Darr Uraa prst o SUD itratio activitis at th Prcorc Istitut o Suay, Apri 7. UCLA att th CADA Pubic Poicy Corc o Apri 10, 2013 i Sacrato, CA. UCLA att th T hath Suit: Movi Caioria Forwar (CA Thath Rsourc Ctr) o Apri i Napa, Caioria. May 2013 UCLA att th Mta Hath Wororc Eucatio a T raii (WET) Fiv-Yar Pa Couity Foru o May 15 i Los As, CA. This vt was h by th Caioria Oic o Statwi Hath Pai a Dvopt (OSHPD). UCLA att th Caioria Aictios Traii a Eucatio Sris (CATES) traii vt h o May 17 i Riato, CA, i Sa Brario Couty: T h Chai Bhaviora Hath Car Lascap: Itratio, Iovatio a Fiaci Mos or Succss. Exprt spar Patric Gauthir prst a upat o hath car ror with a phasis o iaci a bii os or itrati SUD a ta hath (MH) srvics with priary car a othr ica srvics. UCLA att th CiMH Caioria Iovatios Suit: T h Trip Ai as a Frawor or Iprovi th Hath o Iiviuas with Copx Mta Hath, Substac Us, a Physica Hath Coitios o May 22-23, 2013 i Sacrato, CA. Corc atts icu ta hath a SUD provirs, aiistrators, a rsarchrs, as w as rprstativs o various Caioria hath pas. UCLA att th CADPAAC Quartry Mti o May 28-29, 2013, i Sacrato. Ju 2013 UCLA att th Co o Probs o Dru Dpc 75th Aua Scitiic Mti ro J u 15-20, 2013 i Sa Dio, CA. UCLA att th Joit Caioria Hath Wororc Aiac (CHWA) a Caioria Hath Prossios Cosortiu (CHPC) Quartry Mti o J u 24, 2013 i Uivrsa City, CA. Appix 2A 175

180 176

181 Caioria Couty Itratio Survy 2012 Itrouctio Purpos o Survy WwouiyourhpiassssithstatusoAOD/SUDsrvicitratioortsiCaioriacoutisato triwhattchicaassistac,iay,woubhputoyouiorrtoaciitatchasisrvicivry rsutirohathcarror. Thsurvyshoutaabout15iutstocopt.Pasaswrqustiostothbstoyourow thris otosurvyyourprovirs. Diitios AOD Acohoaothrrus. SUD Substacusisorr(s).RrstoprobswithAODusthathavbiaosarquirtratt. Priary Car Srvics Routihathcarocusiothprvtioaarytctioohathprobsthrouh ruarphysicas,booprssurtsts,aoras,asiiarprocurs.srvicsayoccuriaphysicia s oic,hathctr,orothrocatios.priarycaristhirst(priary)poitoicacosutatioorpatits,but Othr ayrsutirrrastospciatycar. Priary Prvtio ProrasaiatucatiacousiiiviuasoAODusaproviioractivitis toructhassociatriss.priaryprvtioicuswssactivitis,aosoticuaryitrvtio activitisorsrvicsirctatiiviuasarayiaoswithsud. Rcovry Support Srvics Nociicasrvicsthatassistiiviuasaaiisircovrirochroiciss. Hr,wrrspciicaytorcovryroSUD. Itratio AytyporoutiorstaarAOD/SUDscri,rrra,itrvtioortrattcouctia priarycarstti,aypriarycarsrvicscouctiaaod/sudstti,orbiirctioarrras.mayaso rrtothicusiooaod/sudpriaryprvtioorrcovrysupportsrvicsipriarycarsttis. Bhaviora Hath Provir Rrstoacouty opratorcotractprovirwithithcoutysystocar.may provitahathsrvics,a/oraod/sudpriaryprvtio,tratt,orrcovrysupportsrvics. FQHC Couity bashathctrsthatrcivratsupportthrouhthhathrsourcsasrvics Aiistratio(HRSA)acarcivhacMicairats. Othr FQHC Loo Ai Couity bashathctrsthattaothrquirtsoafqhcacarciv hacmicairatsbutootrcivratsupportthrouhhrsa. Couty *1. Couty: Appix 2B Pa 1 177

182 Caioria Couty Itratio Survy 2012 Currt Itratio Status *Rbrthat"provirs"throuhoutthissurvyrrstocouty opratorcotractprovirs,whoayb proviitahatha/oraod/sudpriaryprvtio,tratt,orrcovrysupportsrvics. *2. Ar bhaviora hath provirs* i your couty currty oi ay wor to itrat AOD/SUD scri, itrvtio, rrra or tratt with priary car or ta hath? j NO j YES withpriarycar j YES withmtahathipriarycarsttis j YES withpriarycarandmtahath j Do'tKow Iyoutocariyyouraswr,pasosohr. Pas or Futur Itratio *3. Ar bhaviora hath provirs i your couty pai to o ay AOD/SUD itratio wor i th xt yar? j NO j YES withpriarycar j YES withmtahathipriarycarsttis j YES withpriarycarandmtahath j Do'tKow Iyoutocariyyouraswr,pasosohr. Priary Car i SUD Tratt Sttis Pa Appix 2B

183 Caioria Couty Itratio Survy 2012 *4. Othr tha arcotic tratt proras (NTPs), ar ay SUD tratt provirs i your couty ics to hav a o sit ica prossioa who provis priary car srvics (.., physica xas) to patits? j NO j YES j Do tkow Iyoutocariyyouraswr,pasosohr. Priary Car i SUD Tratt Sttis 5. Othr tha NTPs, approxiaty what prcta o SUD tratt provirs i your couty hav a o sit ica prossioa who provis priary car srvics? (Pas iv your bst stiat thr is o to survy your provirs.) j 75%oror j Atast50%butsstha75% j Atast25%butsstha50% j So,butsstha25% j No(0%) j Do'tKow 6. Approxiaty how ay o th SUD tratt provirs that provi priary car srvics ar Fray Quaii Hath Ctrs (FQHCs) or FQHC oo ais? (Pas iv your bst stiat thr is o to survy your provirs.) j Do'tKow j ApproxiatNubr: Appix 2B Pa 3 179

184 Caioria Couty Itratio Survy Othr tha NTPs, how ar priary car srvics provi by SUD tratt provirs u? (Chc a that appy) c Mi Ca c DruMi Ca So c Micar c PrivatIsurac c FraBocGratFus c S Pay c Do tkow c Othr(passcrib) 8. How wou you bst scrib th srvic ivry o or SUD tratt provirs that provi priary car srvics i your couty? (Chc a that appy) c Co ocat thpriarycarprovirworsatthsudciicbutpssparatocutatio,bisorsrvicssparatyrosud srvics,aosotparticipatruaryitrattpaiorcaraat c Partyitrat thpriarycarprovirworsatthsudciic,pssparatocutatio,bisorsrvicssparatyrosud srvics,butcoaboratswithsudprovirsitrattpaiacaraat c Fuyitrat thpriarycarprovirworsithsudciicaocutatio,bii,trattpai,acar aataruyitrat c Do'tKow c Othr(passcrib) AOD/SUD Srvics i Priary Car Pa Appix 2B

185 Caioria Couty Itratio Survy 2012 *9. Ar thr ay priary car sttis that provi AOD/SUD priary prvtio, tratt, or rcovry support srvics? (Chc a that appy) c NO c YES PriaryPrvtioActivitisiPriaryCar c YES TrattSrvicsiPriaryCar c YES RcovrySupportSrvicsiPriaryCar c Do'tKow Iyoutocariyyouraswr,pasosohr. AOD/SUD Srvics i Priary Car 10. Approxiaty what prcta o couty oprat or couty cotract priary car ciics hav a bhaviora hath provir who provis AOD/SUD srvics to priary car ciic patits? (Pas iv your bst stiat thr is o to survy your provirs.) j 75%oror j Atast50%butsstha75% j Atast25%butsstha50% j So,butsstha25% j No(0%) j Do'tKow 11. Which typs o priary car stti(s), i ay, provi ay AOD/SUD srvics (by a bhaviora hath provir or ica prossioa)? (Chc a that appy) c FrayQuaiiHathCtr(FQHC) c FQHC oo ai c No FQHCcouityhathctr c Privatciics c Privatphysiciaoics c Do tkow c Othr(passcrib) Appix 2B Pa 5 181

186 Caioria Couty Itratio Survy Th bhaviora hath provir provis th oowi AOD/SUD srvics i priary car ciics: (Chc a that appy) c Eucatioaioratioissiatio c ScriopratwoorAOD/SUD(..,4P s) c Routiscrioricoti c Routiscrioracoho c Routiscriorrus c Briitrvtiooricoti c Briitrvtiooracoho c Briitrvtioorrus c Psychosociatrattoricoti c Psychosociatrattoracoho c Psychosociatrattorrus c Casaat/cooriatioosrvics c Rcovrysupportsrvics c Do'tKow 13. How ar AOD/SUD srvics provi by th bhaviora hath provir i th priary car stti u? (Chc a that appy) c DruMi Ca c EhacMi Ca(FQHCrat/PPS) c FraBocGratFus c OthrGrats c Mi Ca c Micar c MtaHathSrvicsAct(MHSA/Prop63) c PrivatIsurac c SPay c Do tkow c Othr(passcrib) Pa Appix 2B

187 Caioria Couty Itratio Survy How wou you bst scrib th srvic ivry o i priary car ciics that hav a bhaviora hath provir provii AOD/SUD srvics? (Chc a that appy) c Co ocat thbhaviorahathprovirworsatthpriarycarciicbutpssparatocutatio,bisorsrvics sparatyropriarycarsrvics,aosotparticipatruaryitrattpaiorcaraatwithpriarycarprovirs c Partyitrat thbhaviorahathprovirworsatthpriarycarciic,pssparatocutatio,bisorsrvics sparatyropriarycarsrvics,butcoaboratswithpriarycarprovirsitrattpaiacaraat c Fuyitrat thbhaviorahathprovirworsithpriarycarciicaocutatio,bii,trattpai,a caraataruyitratwithpriarycar c Do tkow c Othr(passcrib) 15. I you wou i to cariy ay o your aswrs about itratio o bhaviora hath provirs a AOD/SUD srvics ito priary car sttis, pas o so hr. 5 6 Barrirs to Itratio 16. What barrirs o you aticipat or hav you aray xpric i itrati AOD/SUD srvics a priary car? (Chc a that appy) c Fiacibarrirs c Docutatiobarrirs(i..,coitiaity,ctroichathrcor) c Partriwithpriarycarprovirs c Labarrirs c Provircrtiicatiooricsiissus c Faciitycrtiicatiooricsiissus c Othrbarrirs(passcrib) Appix 2B Pa 7 183

188 Caioria Couty Itratio Survy What barrirs o you aticipat or hav you aray xpric i itrati AOD/SUD srvics a ta hath srvics withi priary car sttis? (Chc a that appy) c Fiacibarrirs c Docutatiobarrirs(i..,coitiaity,ctroichathrcor) c Partriwithpriarycarprovirs c Labarrirs c Provircrtiicatiooricsiissus c Faciitycrtiicatiooricsiissus c Othrbarrirs(passcrib) Traii/TA Ns 18. W ar tryi to assss traii a tchica assistac s arou th stat. Pas rviw th ist o topics bow a sct th top thr that wou b ost hpu i your couty. Choic1 6 Choic2 6 Choic3 6 Iyousct"Othr",passpciy: Stas o Itratio *Rbr,AOD/SUD srvicsicupriaryprvtioactivitis,trattarcovrysupportsrvics. Pa Appix 2B

189 Caioria Couty Itratio Survy O a sca ro 0 to 4, rat your couty s v o AOD/SUD srvic* a priary car itratio: j (0)Notaiayactivityrattoitratio j (1)Lariaboutitratio j (2)Startitocouicatwithpriarycarprovirs j (3)Paiitratioiitiativswithpriarycarprovirs j (4)Eaiitratioiitiativs Iaiitratioiitiativs,pasiicathoway: 20. O a sca ro 0 to 4, rat your couty s v o AOD/SUD srvic a ta hath srvic itratio withi priary car sttis: j (0)Notaiayactivityrattoitratio j (1)Lariaboutitratio j (2)Startitocouicatwithpriarycarprovirs j (3)Paiitratioiitiativswithpriarycarprovirs j (4)Eaiitratioiitiativs Iaiitratioiitiativs,pasiicathoway: Bii 21. Approxiaty what prcta o SUD tratt provirs i your couty currty bi privat isurac (o Mi Ca) or AOD/SUD srvics? (Pas iv your bst stiat thr is o to survy your provirs.) j 75%oror j Atast50%butsstha75% j Atast25%butsstha50% j So,butsstha25% j No(0%) j Do tkow IyouwouitocariyayoyouraswrsaboutbiiprivatisuracorAOD/SUDsrvics,pasosohr. Appix 2B Pa 9 185

190 Caioria Couty Itratio Survy Is your couty currty wori with isurac provirs to provi AOD/SUD srvics to ow ico, iit popuatios i prparatio or 2014? (For xap, hav you b ivov i pai or oca iitiativs i LIHP, CMSP, Dua Eiibs cooriat car ostratio projct, tc.?) j NO j YES j Do'tKow Iys,passcribbriy: Structur o Srvics 23. Pas sct th optio that bst scribs th structur o bhaviora hath a hath srvics i your couty: j Mtahath,AOD/SUD,aphysicahathsrvicsaiistratioarprovibyasicoutyparttoracy j Mtahath,AOD/SUD,aphysicahathsrvicsaiistratioarprovibythrsparatcoutyparttsoracis j Bhaviorahathsrvics(tahathaAOD/SUD)arurocoutyparttoracy physicahathsrvicsarur asparatcoutyparttoracy j Soothrstructur(passcrib): 5 6 Lari Coaborativ Ivitatio ThADP/UCLA Caioria Itratio Lari Coaborativ (ILC)tsothy,typicayviatcorc,a ivovsiscussiooitratiooaod/sudsrvicsitotahathapriarycarsttis. *24. Wou you or soo ro your couty b itrst i participati (or cotiui to participat) i th ADP/UCLA Caioria Itratio Lari Coaborativ (ILC)? Ys No I itoparticipatorcotiuyparticipatioithilc. j j I bwiitoprstycouty sitratioworithilc. j j I itoiscusswithuclathpottiatopiotwitratioactivitiswithiycouty.(thisay j j ivovatacoctioa/ortchicaassistactaiortothcouty sorts.) Iyouaritrstipiotiwitratioactivitis,passcribyouriitiaias,iay: Pa Appix 2B

191 Caioria Couty Itratio Survy What topics wou b o itrst to you or iscussio withi th ADP/UCLA Caioria Itratio Lari Coaborativ? 5 6 Aitioa Thouhts 26. I you hav ay othr thouhts you wou i to shar about itrati AOD/SUD srvics with priary car that hav ot b covr by this survy, pas provi th bow. 5 6 Appix 2B Pa

192 188

193 CMSP Bhaviora Hath Bit Survy SURVEY OF AOD/BH COUNTY ADMINSTRATORS "COUNTY EXPERIENCES WITH THE PATH2HEALTH/COUNTY MEDICAL SERVICES PROGRAM (CMSP) WITH AN EMPHASIS ON THE ADDED OUTPATIENT BEHAVIORAL HEALTH BENEFIT" AspartoUCLA sevauatio,traiiatchicaassistacorsubstacusdisorrsrvicsitratio(etta) projcturcotractwithadp,warathriioratioocoutis xpricswiththpath2hath/cmsp bit,spciicaywithrartothrctyxpacovraorbhaviorahath(bh)trattsrvicsthat wtitoctojauary1,2012.athouhthbitcovrsbothoutpatittahathasubstacus isorrsrvics,ourocusorthissurvyisothutiizatiooaxpricwiththisxpabitwiththos sisubstacusisorrtratt. Objctiv 1:ToocutaurstathutiizatiooaxpricswiththCMSPBhaviorahathbit, withaphasisosubstacusisorr(sud)srvics(i..:whatisworiw,whatisotworiw, rcoatiosoriprovt). Objctiv 2:ToathrssosarrothutiizatioothisbittohpuiothrcoutisathStatas thyprparoratioahathcarror,asitprtaistomicaixpasio,hathcarcovra,athprovisio osudsrvics. Expct Ti:Thsurvyshoutaapproxiaty15iutstocopt. Rqust Rtur at:pascoptarturthsurvyoatrthamay3,ortusowiyouwoui orti. Not:Soqustiosayasyouorubrsa/orprctas.Iyouoothavthsiursatyourirtips, pasproviyourbststiat.thissurvyisotatoryoutootoouchiiiyourisorxact ubrs,butrathrassssyourprcptiosroyourxpric. 1. Na: 2. Tit: 3. Couty: Eiibiity a Erot Appix 2C Pa 1 189

194 CMSP Bhaviora Hath Bit Survy 4. Pas scrib your xpric* with patit iibiity a/or rot ito th xpa SUD bit. *Dtai acots ar coura. Pas cariy whthr your cot is ircty rat to Ath aiistrativ procsss or to th CMSP bit si Pas provi at ast ONE (1) rcoatio you biv cou iprov th iibiity/rot procss. 5 6 Utiizatio o th Bit Forqustios6,7,a8,pascoptthbas*orthoowiSUDsrvicscovrurbit. *Rbr,thissurvyisotatoryoutootoouchiiiyouris,soiyouo thavxactubrs, pasproviyourbststiatbasoyourxpric. PasproviyourstiatsorthtipriobtwJauary 1, 2012aDcbr 31, SUD asssst (co 90801/H0001) Nubroauthorizatio rqusts subitttoath: (Icurqustsapriiviua otubrosssiosrqust.) Nubr(or%)oauthorizatio rqusts approvbyath: (Dootcoutthosthatarcurrtyiprocss.) Nubr(or%)ocais procssorriburst: (Dootcoutthosthatarcurrtyiprocss.) 7. SUD iiviua cousi (co 90804, 90806, H0004 up to 2 sssios) Nubroauthorizatio rqusts subitttoath: (Icurqustsapriiviua otubrosssiosrqust.) Nubr(or%)oauthorizatio rqusts approvbyath: (Dootcoutthosthatarcurrtyiprocss.) Nubr(or%)ocais procssorriburst: (Dootcoutthosthatarcurrtyiprocss.) Pa Appix 2C

195 CMSP Bhaviora Hath Bit Survy 8. SUD roup cousi sssios (co 90853, 90857, H0005 up to 20 roup sssios) Nubroauthorizatio rqusts subitttoath: (Icurqustsapriiviua otubrosssiosrqust.) Nubr(or%)oauthorizatio rqusts approvbyath: (Dootcoutthosthatarcurrtyiprocss.) Nubr(or%)ocais procssorriburst: (Dootcoutthosthatarcurrtyiprocss.) Utiizatio o th Bit, ct. RbrtocariywhthryourcotisirctyrattoAthaiistrativprocsssortothCMSP bitsi. 9. Pas provi a bri statt o your xpric with th authorizatio/approva procss. Icu tais o what IS wori a what is NOT wori with this aspct o th bit Pas scrib how this xpa bit covra has ipact accss to SUD srvics i your couty Pas provi at ast ONE (1) rcoatio you biv ay icras utiizatio o th BH bit (particuarycovraorsudsrvics). 5 6 Bit Dsi RbrtocariywhthryourcotisirctyrattoAthaiistrativprocsssortothCMSP bitsi. Appix 2C Pa 3 191

196 CMSP Bhaviora Hath Bit Survy 12. Pas rat how satisi you ar with how th bit ts th s o th SUD tratt si popuatio i your couty. j 1 Notatasatisi j 2 Sihtysatisi j 3 Moratysatisi j 4 Vrysatisi j 5 Extrysatisi 13. Pas xpai your aswr. What wors? What os NOT wor? Dos this bit aow you to arss tratt srs with co occurri ta hath a substac us isorrs? Pas xpai. j Ys j No j Do'tow Expaatio: Pas provi at ast ONE (1) rcoatio you biv ay iprov th si o th BH bit. 5 6 Payt a Cais RbrtocariywhthryourcotisirctyrattoAthaiistrativprocsssortothCMSP bitsi. Pa Appix 2C

197 CMSP Bhaviora Hath Bit Survy 16. Pas scrib your xpric with th payt a cais procss or SUD covr srvics Pas provi at ast ONE (1) rcoatio you biv ay iprov th Payt/Cais procss ur th currt bit. 5 6 Appix 2C Pa 5 193

198 194

199 Couty LIHP SUD Srvics Survy Itrouctio LOW INCOME HEALTH PROGRAM / MEDICAID COVERAGE EXPANSION FOR SUBSTANCE USE DISORDER SERVICES SURVEY AspartoUCLA sevauatio,traiiatchicaassistacorsubstacusdisorrsrvicsitratio(etta) projcturcotractwithadp,warathriioratioocoutis xpricswith(1)xpaimi Ca covratoiibowicoautsthrouhthlowicohathprora(lihp)a(2)iptithcovr substacusisorr(sud)srvics. ThiportatioratioyouproviwihpuiothrcoutisathStatasthyprparoratioahathcar ror,particuaryasitprtaistomicaixpasio,hathcarcovra,athprovisioosudsrvicsorth xpasiopopuatios. Thsurvyshoutaabout15iutstocopt.Thayouiavacoryourti wapprciatavauyour iput! Pas copt this by May 3, or t us ow i you wou i or ti. Bacrou 1. Na: 2. Couty: 3. Briy scrib th tart popuatio(s) a stti(s) or LIHP SUD srvics i your couty (.., a SUD cits who ay b iib or LIHP a ica ipatits a psychiatric rcy ctr patits). 5 6 SUD Iptatio Status Appix 2D Pa 1 195

200 Couty LIHP SUD Srvics Survy 4. Pas iicat th iptatio status o your couty s covr LIHP SUD srvics or Micai Covra Expasio (MCE) ros. (You ay rr to your couty's LIHP cotract, Exhibit A, Attacht 15 Aitioa MCE Srvics a HCCI.) Notorur Ipt Notipt* thcouty'slihp cotract Asssst j j j BhavioraHathItratio j j j CasMaat j j j CoatraSrvics j j j DayCarRhabiitatio j j j Dtoxiicatio j j j GroupCousi j j j IiviuaCousi j j j MicatioAssistTratt(MAT)** j j j NarcoticRpactThrapy(thao) j j j Outpatit j j j RsitiaAcutStabiizatio j j j RsitiaPriataTratt j j j RsitiaTrattIcuiDtoxiicatio j j j ScriaItrvtio j j j SobrLiviEvirot j j j TrattPact j j j *I th SUD srvic is covr ur th couty s LIHP, but has ot yt b ipt, pas xpai: **Spciy which MAT srvics, i ay: Eiibiity a Erot Pa Appix 2D

201 Couty LIHP SUD Srvics Survy 6. Pas scrib th bist cha your couty has xpric with rar to LIHP iibiity/rot a how it has b or is bi arss Pas scrib at ast 1 proisi practic or straty that has wor spciay w i your couty with rar to LIHP iibiity/rot. (Icu ouh tais so othrs who iht b itrst cou ipt this practic/straty i thir coutis.) 5 6 Ipti SUD Srvics 8. Pas scrib th bist cha your couty has xpric i ipti LIHP SUD srvics a how it has b or is bi arss Pas scrib at ast 1 proisi practic or straty that has wor spciay w i your couty i ipti LIHP SUD srvics. (Icu ouh tais so othrs who iht b itrst cou ipt this practic/straty i thir coutis.) 5 6 Appix 2D Pa 3 197

202 Couty LIHP SUD Srvics Survy 10. Bas o your xprics, what shou poicy ars ow about ipti SUD srvics or th MCE popuatio? 5 6 Aitioa Qustios 11. Is your couty utiizi aa car cocpts/toos or MCE ros? Ys No TrattAuthorizatio j j UtiizatioRviw j j Cots, i ay: Pas iicat bow whthr you ca provi aitioa ioratio that wi hp UCLA ai a bttr urstai o your couty s LIHP. Dosyourcoutyhavcaisa/orcostatarattoLIHPSUD Ys No j j j j j j srvics? DosyourcoutyhavrportsthaticuLIHPSUDsrvics ioratio/atathatcoubsharwithucla? Maywcotactyouoroow upqustios,i? 13. Aitioa cots (optioa): 5 6 Pa Appix 2D

203 CPAC FQHC survy Cost to Participat i Rsarch INTEGRATION OF SUBSTANCE USE DISORDER TREATMENT WITH PRIMARY CARE IN PREPARATION FOR HEALTH CARE REFORM Survy Youarbiastotapartiarsarchstuyby,Ph.D.,rothItrat.Youwrsctasapossibparticipatithis stuybcausyouarthacotactoryouroraizatioithhathrsourcsasrvicsaiistratio suiordatasyst,a siothcotactprso,orwritiiasaappropriatparticipatbystahorsiyourara.yourparticipatioisvoutary,a youaywithrawatayti. PURPOSE OF THE STUDY Thpurposothisstuyistobttrurstathcurrtvoitratioosubstacusisorr(SUD)trattwithpriarycarath barrirsaaciitatorstosuchitratio.pasotthateven IF YOUR ORGANIZATION DOES NOT CURRENTLY PROVIDE SUBSTANCE USE Othr DISORDER SERVICES, YOUR PARTICIPATION IS VERY IMPORTANT. PAYMENT FOR PARTICIPATION Youwibproviwitha$100itcarorparticipatio.Iyoustartbutootcoptthsurvy,oriyousipayqustios,youwisti rcivth$100itcar. PROCEDURES Youarbiastoparticipatiawb bassurvyastiro8upto22iuts(piorsposs)tococtataotypsosud tratt,usovicbassudtrattpractics,itratiobtwsudapriarycar,tahath,ahiv/aidssrvics, oraizatioacharactristics,athrtowhichpoicis(..mi Cariburstrus)activryosrvics. POTENTIAL RISKS AND DISCOMFORTS Othr Youayotwishtoaswrsoqustios.Youayrustoaswrayqustiothatyouootwishtoaswr,orstopthsurvyatayti. POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY Thisstuywiotproviayirctbitstoparticipats.Howvr,thisstuywiivyouaopportuitytovoicyouropiiosasharyour xpricsrarisudsrvicitratio,ayouriputwibaiportatsourcoioratiothatwibissiattopoicyars itrstithistopic.thisaypottiayatoiprovtsipoicisapracticsthatactyouroraizatioaothrsiit. CONFIDENTIALITY Aoyourrsposswibcryptaaccssiboytothrsarchrs.Aothioratioyouproviwibitiibyaco ubrawibusorrsarchpurpossoy.aatacoctwibptiocisatthrsarchrs oic.noioratiothat itiisyouwibsharwithothrrsarchproras,orwithothracis,orbraswithoutyoursparatcost.aatarporti pubicatiosorrportswibiarator,aithatoiiviuawibitii.whthrsutsothisstuyarpubish,your awiotbus. PARTICIPATION AND WITHDRAWAL Yourparticipatioithissurvyisvoutary.Iyouocitoparticipat,youarrtowithrawyourcostastopthsurvyatayti. Youayasorustoaswrspciicqustiosyouootwattoaswrastiraipartothstuy. IDENTIFICATION OF INVESTIGATORS Iyouhavayqustiosorcocrsaboutthrsarchstuy,pasrtocotact,Ph.D.,thPricipaIvstiatorat.Hca Othr asobcaat orbywritito. Appix 2E Pa 1 199

204 CPAC FQHC survy RIGHTS OF RESEARCH SUBJECTS Youarotwaiviayacais,rihtsorrisbcausoyourparticipatioithisstuy.Iyouwishtoasqustiosaboutyourrihtsas arsarchparticipatoriyouwishtovoicayprobsorcocrsyouayhavaboutthstuytosooothrthathrsarchrs, pascathoicothhuarsarchprotctioproraat(310) orwrittoOicothHuaRsarchProtctioProra, UCLA,11000KirossAvu,Suit211,Box951694,LosAs,CA SIGNATURE OF STUDY PARTICIPANT Ihavra(orsoohasrato)thioratioproviabov.Ihavbivaopportuitytoasqustiosbycotactith rsarchrsaaoyqustios(iay)havbaswrtoysatisactio. *1. Cic o th butto bow i you ar. j IAGREE *2. Do you wish to rciv a $100 Visa it car or your participatio? Not oy th ivit participat or thir si is iib (o pr oraizatio). I a ivitatio to participat was orwar to you via ai a you ar ot sur o your iibiity, pas cotact. j Dci j Accpt(traaaiiarssbow) Which oraizatio/hath ctr o you wor or? 4. What is your positio withi your oraizatio/hath ctr? 5. I you wou b itrst i rcivi a rport that icus th arat rsposs o survy participats oraizatios at th cocusio o this stuy, pas iicat th ai arss th rport shou b st to bow. Whoptourstayouroraizatio'spracticsray,buturstathatiiviuasitscavaryratyipractics.IitisNOT possibtoraiz,pasaswraccoritopracticsattharstpriarycarsitiyouroraizatio(ostpatits/yar). Scri Scri rrstoabriasur(usuayoyoorasaubroqustios)toitiypatitsthatayhavacohoorothrsubstac usisorrs.thisaybaiistrithwaitirooaspartothpatit sitapaprwor,oraspartoasparatprocss.exapso cooscritoosicuthaudit,auditc/c+,assist,athcage.sositsayasousoororqustiosvopor thirowus. Pa Appix 2E

205 CPAC FQHC survy 6. Ar patits scr or substac us at your oraizatio? j Ys,apatitsarscrorsubstacus j No,patitsarotorayscrorsubstacus j Ys,asctortartroupopatitsisscrorsubstacus 7. What roups ar tart or scri (chc a that appy)? c Patitstratorbhaviorahath c Patitswithahistoryosubstacus c Patitswithcurrtsyptosorsis c Pratwo c PatitswithHIV/AIDS c Patitswithchroicpai c Patitswhoarhoss c Aoscts c Othr(passpciy) 5 6 Othr 8. What substac us scri toos ar us? (chc a that appy) c Ascritoocratbyyhathctr c AcohoUsDisorrsItiicatioTst(AUDIT/AUDITC/AUDITC+) c Acoho,Soi,aSubstacIvovtScriTst(ASSIST) c CAGE/CAGE AID c CRAFFT c DruAbusScriTst(DAST) c GobaAppraisaoIiviuaNsShortScrr(GAIN SS) c MichiaAcohoScriTst(MAST) Varis/Othr c MoiiSipScriIstrutorSubstacAbus(MSSI SA) c SubstacAbusSubtScriIvtory(SASSI) c Othr(passpciy) Appix 2E Pa 3 201

206 CPAC FQHC survy 9. Wh ar patits scr or substac us? (chc a that appy) c a.nwpatit siitiavisitoy c b.nwpatit siitiavisitpusaitioascrsasiicatbow c c.evryvisit c.evry3oths c.evry6oths c.auay c Othr/varisbypatit(passpciy) 10. Who typicay aiistrs th scri (who is out th ors)? j S aiistrbypatit(orxap,orscoptaspartopaprworuriita) j Frotssta j MicaAssistat j Nurs j Physicia sassistat j Physicia j BhavioraHathSpciaist(..icsciicasociaworr,cousor,psychooist,psychiatrist,tc.) j Othr(passpciy) 11. Who scors th scri istrut? j Notappicab,scrissipys/o. j Frotssta j MicaAssistat j Nurs j Physicia sassistat j Physicia j BhavioraHathSpciaist j Othr(passpciy) Pa Appix 2E

207 CPAC FQHC survy 12. I a scr is positiv, what happs xt? (chc a that appy) c Scriioratioisaavaiabtophysicia c Patitisivabriitrvtio*bythphysicia c Patitisivabriitrvtio*bysooothrthathphysicia c Patitisrrrorurthrasssst c Patitisproviwithioratioa/ucatioaatrias c Othr(passpciy) 5 6 *Briitrvtiosarshort,o o ocousisssiosrayaiatoratiaprso sacoho/ruus.briitrvtiosca biviaattroiutsaayicuapproachssuchasotivatioaitrviwithatarsitoprsuapopwhoar rsistattooratithiracoho/ruitaorwhoootbivthyarusithssubstacsiaharuorhazarousway. 13. You iicat that patits ar iv a bri itrvtio by soo othr tha th physicia. Who prors this tas? j Frotssta j MicaAssistat j Nurs j Physicia sassistat j Physicia j BhavioraHathSpciaist(..icsciicasociaworr,cousor,psychooist,psychiatrist) j Othr(passpciy) Asssst Asssstsarvauatiosopatitsubstacusisorrprobsthatarori pththascris.exapsocooasssst istrutsicuthaicatiosvrityix(asi)aaricasocityoaictiomicipatitpactcritria(asamppc). Whrasscriaistosipyitiypatitswithprobs,asssstistrutsstoquatiyprobsacbythspatitstoai ithvoptoatrattpa. 14. Ar patits iv assssts (as i abov) or substac us isorrs? j Ys j No Appix 2E Pa 5 203

208 CPAC FQHC survy 15. Which patits ar typicay tart or assssts? (chc a that appy) c Patitswhohaapositivscr c Patitsothrwisitiiasbiatris(withoutascriistrut)bysta c Patitsothrwisitiiasbiatrisbyaphysicia c Patitstratorbhaviorahath c Patitswithcurrtsyptosorsis c PatitswithHIV/AIDS c Patitswithchroicpai c Patitswhoarhoss c Aoscts c Patitswithahistoryosubstacus c Pratwo c Othr(passpciy) What istrut(s) ar us (chc a that appy)? c AictioSvrityIx(ASI,ASI it) c AricaSocityoAictioMiciPatitPactCritria(ASAMPPC) c StructurCiicaItrviw(SCID) c Othr(passpciy) 17. Who aiistrs th asssst (who is out th ors)? j S aiistrbypatit j Frotssta j MicaAssistat j Nurs j Physicia sassistat j Physicia j BhavioraHathSpciaist j Othr(passpciy) Pa Appix 2E

209 CPAC FQHC survy 18. Who scors th asssst? j Frotssta j MicaAssistat j Nurs j Physicia sassistat j Physicia j BhavioraHathSpciaist j Othr(passpciy) 19. I a asssst iicats that a patit s tratt, what happs xt? (chc a that appy) c Briitrvtio*ivriiaty c Trattosit c Rrrtoaoutsioraizatioortratt c Othr(passpciy) 5 6 *Briitrvtiosarshort,o o ocousisssiosrayaiatoratiaprso sacoho/ruus.briitrvtiosca biviaattroiutsaayicuapproachssuchasotivatioaitrviwithatarsitoprsuapopwhoar rsistattooratithiracoho/ruitaorwhoootbivthyarusithssubstacsiaharuorhazarousway. Itratio, Itrvtios, a Tratt 20. What is th status o ctroic ica rcor itratio i your oraizatio? j Ectroicicarcorsorphysicahathoy j Sparatctroicicarcorsystsorphysicahathatahath/substacusisorrs j Ectroicicarcorsystthatitratsbothphysicahathatahath/substacusisorrrcors j Noctroicicarcorsystipac j Othr(passpciy) 5 6 Appix 2E Pa 7 205

210 CPAC FQHC survy 21. Dos your oraizatio provi tratt or itrvtios or substac us isorrs, ithr osit or by rrra to a outsi oraizatio? j Ys j No 22. What substac us isorr srvics ar provi o sit or by ora rrra arrats? (chc a that appy) O sit O sit(rrra) Notavaiab Iiviuacousi c c c Groupcousi c c c Micatios(.. c c c c c c Buprorphi/Subutx/Suboxo, Natrxo/Vivitro,Mthao, Acaprosat/Capra,tc.) Othr IMicatios,passpciywhich.IOthr,passcrib. 5 6 Pa Appix 2E

211 CPAC FQHC survy 23. Which o th oowi spciic substac us isorr practics ar i us? Nvr Nvrbutitrsti ai Sotis Routi j j j j j j j j j j j j Motivatioaitrviwi j j j j Motivatioahact j j j j j j j j j j j j Coticyaat j j j j 12 stpaciitatio j j j j Sociasisbuii j j j j Tici j j j j CoputrizCoitiv j j j j Micatioassist tratt:buprorphi Micatioassist tratt: Vivitro/Natrxo Micatioassist tratt:othr thrapy Scri,Bri Itrvtio&Rrrato Tratt(SBIRT) Coitivbhaviora thrapy BhavioraThrapy Othr(passpciy) Who ivrs th substac us isorr srvics? (chc a that appy) c Nurs c Physicia sassistat c Physicia c SubstacUsDisorrsCousor c LicsCiicaSociaWorr c Psychooist c Psychiatrist c OthrBhavioraHathSpciaist c Othr(passpciy) Appix 2E Pa 9 207

212 CPAC FQHC survy 25. How ar substac us isorr srvics u? (chc a that appy) c Biasasrvic,icuithFQHCpr visitprospctivpaytsystrat c Notbitoaxtraur,oticuithpr visitpaytrat(costsarsubsiizbyothrsrvicsatthfqhc) c Coutyacohoaruui c MtaHathSrvicsAct(MHSA)ui c Gratui c Varis/Othr(passpciy) 5 6 Itratio Othr 26. Which o th oowi bst scribs th v o itratio btw your Substac Us Disorr (SUD) a PRIMARY CARE srvics? j MiiaCoaboratio:SUDprovirsapriarycarprovirsworisparataciitis,havsparatsysts,acouicat sporaicay j BasicataDistacCoaboratio:PriarycaraSUDprovirshavsparatsystsatsparatsits,butaiprioic couicatioaboutsharpatits j BasicO SitCoaboratio:SUDapriarycarprovirshavsparatsystsbutsharthsaaciity j CosCoaboratio,PartyItrat:SUDprovirsapriarycarprovirssharthsaaciityahavsosystsi coo,suchasschuiappoittsoricarcors.physicaproxiityaowsorruarac to accouicatioaosud apriarycarprovirs. j CosCoaboratio,FuyItrat:ThSUDprovirapriarycarprovirarpartothsata.Thpatitxprics thsudtrattaspartohisorhrruarpriarycar. 27. Which o th oowi bst scribs th v o itratio btw your Substac Us Disorr (SUD) a MENTAL HEALTH srvics? j MiiaCoaboratio:SUDprovirsaothrtahathprovirsworisparataciitis,havsparatsysts,a couicatsporaicay j BasicataDistacCoaboratio:MtaHathaSUDprovirshavsparatsystsatsparatsits,butaiprioic couicatioaboutsharpatits j BasicO SitCoaboratio:SUDaMtaHathprovirshavsparatsystsbutsharthsaaciity j CosCoaboratio,PartyItrat:SUDprovirsaMtaHathprovirssharthsaaciityahavsosystsi coo,suchasschuiappoittsoricarcors.physicaproxiityaowsorruarac to accouicatioaosud amtahathprovirs. j CosCoaboratio,FuyItrat:ThSUDproviraMtaHathprovirarpartothsata.Thpatitxprics thsudtrattaspartohisorhrruarmtahathcar. Pa Appix 2E

213 CPAC FQHC survy 28. Which o th oowi bst scribs th v o itratio btw your Substac Us Disorr (SUD) a HIV/AIDS srvics (.. prvtio, ucatio, tratt)? j MiiaCoaboratio:SUDprovirsastaproviiHIVsrvicsworisparataciitis,havsparatsysts,a couicatsporaicay j BasicataDistacCoaboratio:staproviiHIVsrvicsaSUDprovirshavsparatsystsatsparatsits,butai prioiccouicatioaboutsharpatits j BasicO SitCoaboratio:SUDastaproviiHIVsrvicshavsparatsystsbutsharthsaaciity j CosCoaboratio,PartyItrat:SUDprovirsastaproviiHIVsrvicssharthsaaciityahavsosystsi coo,suchasschuiappoittsoricarcors.physicaproxiityaowsorruarac to accouicatioaosud astaproviihivsrvics. j CosCoaboratio,FuyItrat:ThSUDprovirastaproviiHIVsrvicsarpartothsata.Thpatit xpricsthsudahivsrvicsaspartohisorhrruarcar. 29. (Not: This qustio is o Mta Hath). Which o th oowi bst scribs th v o itratio btw your MENTAL HEALTH (MH) a PRIMARY CARE srvics? j MiiaCoaboratio:MHprovirsapriarycarprovirsworisparataciitis,havsparatsysts,acouicat sporaicay j BasicataDistacCoaboratio:PriarycaraMHprovirshavsparatsystsatsparatsits,butaiprioic couicatioaboutsharpatits j BasicO SitCoaboratio:MHapriarycarprovirshavsparatsystsbutsharthsaaciity j CosCoaboratio,PartyItrat:MHprovirsapriarycarprovirssharthsaaciityahavsosystsi coo,suchasschuiappoittsoricarcors.physicaproxiityaowsorruarac to accouicatioaomh apriarycarprovirs. j CosCoaboratio,FuyItrat:ThMHprovirapriarycarprovirarpartothsata.Thpatitxpricsth MHtrattaspartohisorhrruarpriarycar. Appix 2E Pa

214 CPAC FQHC survy 30. Pas iicat which bst scribs th xtt to which th priary car (PC) sta a substac us isorr (SUD) tratt sta couicat i provii SUD car (icu ai or a shar ctroic ica rcor as a or o couicatio i us). j Vry Low PCa j Low PCaSUD j Morat PCa j Hih PCaSUD j Vry Hih PCa SUDciicastavry staaycouicat SUDciicasta ciicastaot thsudciicasta rarycouicat aboutapatit'ssud sotiscouicat couicatabouta aostaways byothiitiarrra iaosisooccasio, aboutapatit'ssud patit'ssudiaosis, couicatabouta aboutapatit'ssud oyirarsctcass. iaosis,athris athrisusuay patit'ssudiaosis, iaosis,orcouicat Proviibacor occasioa couicatioi athris iciiuposud shariioratioabout couicatioi ciiuposud couicatioi tratt.thrisitt SUDtrattprorssor ciiuposud tratt.thrisot ciiuposud bacorshario chasisoyo tratt,butotiost bacashario trattiostiota ioratioaboutsud irquty,with cass.thrisso ioratioaboutsud cass.thriscostat trattprorss, iscussioooutcos bacashario trattprorss, bacashario chasoroutcosatr iittosctcass. ioratioaboutsud chas,oroutcos.th ioratioaboutsud rrra,athris ThSUDsta trattprorss, SUDstacouicats trattprorss, aostocouicatio couicatswithpc chas,oroutcos. withthpcstaabout chas,oroutcos. aboutisssud staaboutisssud ThMH/SUDsta isssudappoitts ThSUDsta appoitts. appoittsbutoyi couicatswithth iostcass. couicatswithpc spciacircustacs. PCstaaboutiss staaboutisssud SUDappoittsi appoittsiaost aycass. acass. 31. Pas iicat which bst scribs th physica proxiity btw th priary car (PC) a th stti whr substac us isorr (SUD) srvics ar ivr. j Vry Low PCa j Low PCaSUD j Morat PCa j Hih PCaSUD j Vry Hih PC SUDsrvicsarsparat srvicsarocatwithi SUDsrvicsari srvicsarithsa srvicsarco ocat byaistacratrtha ourbocsbutotwithi irtbuiisbut buiibutiirt withsudsrvics,ith ourbocs. thsaica withithsacapus, practicaras. sapracticara. copxorcapus. oricacopx. 32. Pas iicat which bst scribs th sparatio i ti btw th rrra ro Priary Car (PC) a iitia schu Substac Us Disorr (SUD) visit. j Vry Low PC j Low PCrrraa j Morat PC j Hih PCrrra j Vry Hih PC rrraaiitiasud iitiasudvisit/srvics rrraaiitiasud aiitiasud rrraathiitiasud visit/srvicsar arproviatirt visit/srvicsarusuay visit/srvicsarach visit/srvicsarprovi schuatisticty tis,sparatbya proviwithia proviwithiashort urithsavisit,o irttis,sparat avrao15to21ays. avrao8to14ayso tiothothr,withi thsaay achothr. svays,butototh oavrabyortha 21ays. saay. Pa Appix 2E

215 CPAC FQHC survy 33. Pas iicat which bst scribs th array o Substac Us Disorr (SUD) srvics a xprtis avaiab withi th priary car (PC) stti. j Vry Low No j Low Vryiit j Morat So j Hih BasicSUD j Vry Hih Awi spciatysudxprtisis spciatysudxprtisis iitspciatysud xprtisisavaiabwith raospciatysud avaiabosit patits avaiabosit patits xprtisisavaiabo atraisudxprto xprtisisavaiabo withaythiortha withostycopx sit,withaxprt sitorcosutatioa/or sit aostabasictyps iorsudprobsar SUDprobsaraost avaiaborcosutatio tratt a osudsrvicsar awaysrrrtoo sit awaysrrrtoo sit bypho soshort tr pharacooicaa proviositbyuy spciatysudcar(i spciatysudcarorth cousiorrouti aycousisrvics quaiisudciicias avaiab)orthxprtis xprtisorsrvics SUDprobsar orsudprobsar patitswithaiso orsrvics.. proviosit patits avaiabosit oy SUDprobscab withoratycopx patitswithcopx trato sitwith probsarusuay probsortratt iiatous rrrtoo sit rsistacarusuay outsispciatysud spciatysudcarorth rrrtospciatysud xprtisorsrvics. xprtisorsrvics car Pas iicat which bst scribs th xtt to which priary car (PC) srvics a substac us isorr (SUD) srvics ar itrat with rspct to th iiatio o stia. j Vry Low ThSUD j Low ThSUD j Morat ThSUD j Hih Miia j Vry Hih No istictioisa,i istictioisa,i proraisowby oicorproraay oicorprorahasa aasia,ais havaaasia istictsparataa trsosia,ciic trsosia,ciic rrrtobythpcsta oyiirctyratto siabutitisot as,orithpcsta's as,orithpcsta's asasparatsiat SUDtratt irctyrattosud rrcs,btwth rrcs,btwth sttiorthosrquiri ( Bhaviorasrvics, tratt(.. Itrat PCsttiathSUD PCathSUDstti, SUDorothrMta HathCousi, EAP CarOic ).PCaSUD stti.pcasudsta apcasudsta Hath(MH)assistac Prora ),butpca staoaso araattptsto awaysavoirrritoit (i..th"psychta", SUDstaaitt attptstoavoirrri avoirrritoitor ortratiitasasparat "SUDCousor""MH attpttoavoirrri toitortratiitasa tratiitasasparat prora. Ciic").PCaSUDsta toitortratiitasa sparatprora. prora. tratitasasparat sparatprora. prora. 35. I ra, how ctiv is your oraizatio i arssi th s o patits with substac us isorrs? j Notatactiv j Sihtyctiv j Sowhatctiv j Prttyctiv j Extryctiv 36. Couicatio btw priary car a substac us isorr sta at y ciic is oo. j ArStroy j NotAppicab j Ar j Ucrtai j Disar j DisarStroy Appix 2E Pa

216 CPAC FQHC survy 37. Aitioa traii rari iaosi a tratt o substac us isorrs wou b hpu or y ciic's sta. j ArStroy j Ar j Ucrtai j Disar j DisarStroy 38. My ciic s sta is vry owab about th vic bas practics us to trat substac us isorrs. j ArStroy j Ar j Ucrtai j Disar j DisarStroy 39. It is possib to trat substac us isorrs ctivy. j ArStroy j Ar j Ucrtai j Disar j DisarStroy 40. I ra, how ctiv is your oraizatio i arssi th s o patits with ta hath isorrs? j Notatactiv j Sihtyctiv j Sowhatctiv j Prttyctiv j Extryctiv 41. Couicatio btw priary car a ta hath sta at y ciic is oo. j ArStroy j NotAppicab j Ar j Ucrtai j Disar j DisarStroy 42. Aitioa traii rari iaosi a tratt o ta hath isorrs wou b hpu or y ciic's sta. j ArStroy j Ar j Ucrtai j Disar j DisarStroy 43. My ciic s sta is vry owab about th vic bas practics us to trat ta hath isorrs. j ArStroy j Ar j Ucrtai j Disar j DisarStroy 44. It is possib to trat ta hath isorrs ctivy. j ArStroy j Ar j Ucrtai j Disar j DisarStroy Lisatio / Poicy / Ruatios Pa Appix 2E

217 CPAC FQHC survy 45. Has your ciic's ivry o substac us isorr srvics b act by rct poicy chas? (.. chas i th Low Ico Hath Prora, or covra by Couty Mica Srvics Prora ["Path2Hath"], i appicab i your couty) j Ys j No IYs,passcrib: I you ha a chac to t isators or othr poicyars what you wou i th to o to aciitat itratio o substac us or ta hath srvics or rov barrirs to itratio, what wou you t th? (your aoyous rsposs wi b pass o to poicyars) (optioa) So w ay t a bttr urstai o your oraizatio, w wou apprciat stiats o Fu Ti Equivats (FTEs) at your oraizatio or th oowi sta typs (approxiatios ar o) Physicias PhysiciaAssistats FaiyNursPractitiors Psychiatrists CiicaPsychooists LicsCiicaSocia Worrs Othrs Appix 2E Pa

218 CPAC FQHC survy 48. (optioa) Pas stiat th prcta o coutrs that ar pai or ro th oowi sourcs (approxiatios ar o) Micar Micar MaaCar Mi Ca Mi Ca MaaCar CoutyIit/CMSP/ MISP HathyFaiis PrivatIsurac S Pay/SiiF Fr 49. Tha you or your participatio. Wr thr ay qustios o this survy that wr iicut to aswr that you wou i to cot o, or o you hav ay aitioa cots? Wou it b o or th rsarchrs to cotact you i thy hav oow up qustios rari your rsposs o this survy? j Ys j No 51. Wh you i out this survy, which o th oowi i you oow? j Aswraccoritorapracticsiyoraizatioacrosssits. j Aswrwiththarstpriarycarsitii. j Othr(passpciy) Thayou! Pa Appix 2E

219 Stat FQHC Bii Cos (FQHCs) HBAI Cos Crtia SUD Cos Crtia AL Aabaa N N AK Aasa Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt Psychooist, Lics Ciica Socia Worr LCSW FQHC Y (90805, 90807, 90809, 90811, 90813, MD, PA, ANP oy) ,90853, MD, PA, ANP, Psychooist, Lics Ciica Socia Worr AZ Arizoa Y S Arizoa bii sht.? Y 90804, 90806, oy o tici; o tici AR Arasas N Y T1015. Psychooist & Socia Worr 90804, 90806, 90808, 90810, 90812, oy. MD, Psych, PA, ANP, D.O., LCSW (i Micar pai), Marria Faiy Thrapist, LPC MD, PA, ANP, Ciica Psychooist, Ciica Socia Worr CA Caioria Y 01 MD, PA, NP, Ciica Psychooist, Ciica Socia Worr Y , 90807, 90809, 90811, 90813, MD, PA, NP oy. Excu MD, PA, NP, Ciica Psychooist, Ciica Socia Worr CO Coorao N Y AOD Assss (99408, 99409) - SBIRT prora. CT Cocticut N Y (90805, 90807, 90809, 90811, 90813, MD, APRN oy) MD, PA, ANP, Ciica Psychooist, Ciica Socia Worr MD, APRN, Psychooist, IPBHP (icus LCSW, LMFT, LPC, a Lics Acoho a Dru Cousor LADC) DE Dawar Y 96150, 96151, 96152, 96153, 96154, T1015 Ciica Psychooist, Ciica Socia Worr Y , 90847, 90853, Ciica Psychooist, Ciica Socia Worr 90804, 90806, 90808, 90810, 90812, oy. MD, PA, NP, Ciica Psychooist, Ciica Socia Worr Appix 3A 215

220 Appix 3A 216 FL Foria N Y , 90847, 90853, 90857, H0004 MD, PA, APNP with Psychiatric Spciaty, Lics Ciica Psychooist, Lics Ciica Socia Worr GA Goria Y 90801, 90802, , 90846, Psychooist or LCSW N HI Hawaii Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, PA, APRN, Ciica Psychooist, Ciica Socia Worr Y (Excu 90808, 90809, & , 90807, 90809, MD oy.) MD, PA, APRN, Ciica Psychooist, Ciica Socia Worr ID Iaho Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, PA, NP, Ciica Psychooist, Ciica Socia Worr N IL Iiois N Y , 90847, 90853, MD, PA, NP, Lics Ciica Psychooist, Lics Ciica Socia Worr, Lics Ciica Prossioa Cousor (LCP, LCSW, LCPC) IN Iiaa Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, PA, NP, Ph.D., LCSW Y MD, PA, NP, Ph.D., LCSW , 90847, 90853, Ph.D & LCSW 90804, 90806, , 90812, oy. IA Iowa Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt KS Kasas Y Asssst MD, PA, ARNP, Ciica Psychooist, Ciica Socia Worr MD, PA, NP Y , 90847, Ciica Psychooist, Ciica Socia Worr 90804, 90806, 90808, 90810, 90812, oy N MD, PA, NP, Ciica Psychooist, Ciica Socia Worr

221 KY Ktucy Y Asssst, Rasssst, Iiviua It., Group It. MD, ARNP, Lics Ciica Psychooist, Lics Ciica Socia Worr N LA Louisiaa Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, PA, CNP, Psychooist, LCSW Y , 90847, 90853, MD, PA, CNP, Psychooist, LCSW ME Mai Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit MD, PA, APRN, Ciica Psychooist, Ciica Socia Worr, Lics Ciica Prossioa Cousor N MD Marya Y Asssst, Rasssst, Iiviua It. MD Y , 90847, 90853, 90857, AOD Group, IOP Srvics Crtii Aictios Cousor (CAC) MA Massachustts N Y 90804, 90806, 90847, & MI Michia N Y , 90847, 90853, 90857, AOD Assss, BH Scri, BH Cousi, AOD Group, IOP Srvics MN Misota Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit Physicia, APN, CNS-MH, LICSW, LLP, LPCC, LP MS Mississippi N N MO Missouri N Y , 90847, 90853, N Psychiatrist, Psychiatric Nurs, Cousor, Psychooist, LICSW, LCSW, LSWA, LMHC, Lics Acoho a Dru Abus Cousor LADAC I&II? Quaii Substac Abus Prossioa (QSAP). S Missouri bii sht or tais. Appix 3A 217

222 Appix 3A 218 MT Motaa Y Asssst MD, PA, NP Y AOD Assss (99408, 99409) MD, PA, NP, Lics Psychooist, Lics Ciica Socia Worr (LCSW), Lics Prossioa Cousor (LPC) NE Nbrasa N Y , 90847, 90853, 90857, AOD Assss [90804, 90805, 90807, 90808, 90809, 90847HF oy, H0001, H ] MD, PA/APRN, Psych, Prov. Psych, LIMHP, LMHP, PLMHLP, RN, LADC (Lics Acoho a Dru Cousor), PLADC (Provisioa Lics Acoho a Dru Cousor) NV Nvaa Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit MD, PA, ANP, Ciica Psychooist, Ciica Socia Worr Y , 90847, 90853, MD, PA, ANP, Ciica Psychooist, Ciica Socia Worr NH Nw Hapshir N N NJ Nw Jrsy Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt Physicia, Psychooist, LCSW N NM Nw Mxico Y Asssst, Rasssst NY Nw Yor Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt Lics Ciica Psychooist No-physicia ta hath practitiors Y , 90847, 90853, Y , 90847, 90853, Psychiatrist, Psychooist, Lics Psychiatric Nurs Psychiatrist, Psychooist, Lics Psychiatric Nurs, Lics Ipt Socia, Worr, Lics Prossioa Mta Hath Cousor, Lics Marria a Faiy Thrapist MD, APN, PA, LCSW

223 NC North Caroia Y Asssst, Rasssst MD, APN Y , 90847, 90853, MD, APN, APPCNS, Lics Psychooists, LCSW ND North Daota Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, PA, NP, Ciica Psychooist Y , 90847, 90853, MD, PA, NP, Ciica Psychooist OH Ohio N Y , 90847, 90853, OK Oahoa N Y , 90847, 90853, MD, PA, APN, ics Psych, ics CSW LPHP, CADC Crtii Acoho a Dru Cousor OR Oro Y Asssst, Rasssst, Iiviua It. MD,NP Y , 90847, 90853, Aso MD, ics provirs. S Oro bii sht or or io. PA Psyvaia N Y , 90847, 90853, RI Rho Isa N N MD, PA, CRNP, LCSW SC South Caroia Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit MD, PA, ANP, Ciica Psychooist, Ciica Socia Worr N SD South Daota Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit MD, PA, ANP, Ciica Psychooist, Ciica Socia Worr N TN* Tss* TX Txas N??? UT Utah N N Appix 3A 219

224 VT Vrot Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit Appix 3A 220 MD, PA, NP, Ciica Psychooist N VA Viriia Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, PA, NP, Ciica Psychooist, Ciica Socia Worr Y , 90847, 90853, 90857, AOD Assss MD, PA, NP, Ciica Psychooist, Ciica Socia Worr WA Washito N Y , 90847, 90853, MD, Psychooist, Ciica Socia Worr WV Wst Viriia Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt Lics Ciica Psychooist, Lics Ciica Socia Worr N WI Wiscosi Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt UA, UB HP, HO. S Wiscosi bii sht or or io. Y , 90847, 90853, UA, HP, HO. S Wiscosi bii sht or or io. WY Wyoi Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, PA, NP, Ciica Psychooist, Ciica Socia Worr Y , 90847, 90853, 90857, AOD Assss MD, PA, APNP, Ciica Psychooist, Ciica Socia Worr

225 Stat CMHC Bii Cos (CMHCs) CMHC HBAI Cos Crtia SUD Cos Crtia AL Aabaa N Y oy (A Substac Abus Cos ust us HF oiir.) 90847, (Excu 90857) Physicia MD or DO, Physicia Assistat PA, Lics Psychooist Ph.D., Lics Crtii Socia Worr LCSW, Lics Prossioa Cousor LPC, Lics Marria & Faiy Thrapist LMFT, Crtii Ristr Nurs Practitior CRNP, Psychiatric Ristr Nurs PRN, Mastr s Lv Thrapist MA, Crtii Substac Abus Prossioa CSAP AK Aasa N Y S Aasa bii sht. CMHC ust b sparaty approv by th Aasa Divisio o Bhaviora Hath to provi Substac Abus Rhabiitatio srvics. AZ Arizoa N Y , 90804, 90806, (90804, 90806, oy i Micar pai). AOD Assss, BH Scri, BH Cousi, AOD Group, IOP Srvics. Physicia, Psychooist, MHPC. Lics Substac Abus Cousor. MD, Psych, PA, ANP, DO, LCSW, LMFT, LPC (MH); Lics Ipt Substac Abus Cousor (LISAC-or so cos) Appix 3A 221

226 AR Arasas N Y H2019, H0005, T1006, H0001, H0047 CA Caioria N Y , 90807, 90809, 90811, 90813, Psychiatrist oy Crtii Divisio o Bhaviora Hath Srvics (DBHS) prossioa Substac Abus Tratt Srvics (SATS) provir, icui crtias: MD, DO, APN, PhD, PsyD, ED, LADAC (Lics Acohois a Dru Abus Cousor), ACADC (Avac Crtii Acohois a Dru Abus Cousor), CCDP- D (Crtii Co-Occurri Disorr Prossioa - Dipoat Lv), LCSW, LMSW, LPC, LMFT, LAC, LPE-I, LPE Psychiatrist, Psychooist CO Coorao N Y H0001, H0004, H0005 MD, NP, LAC, LCSW, LMFT, LPC, Lics Psychooist, Crtii Aictios Cousor (CAC I, CAC II, CAC III) CT Cocticut N Y , 90847,90853, 90857, IOP Srvics, H0020 (AOD Srvics) DE Dawar N Y 90806, 90847, 90853, FL Foria Y 96150, 96151, H0031 HO, H0031 TS Appix 3A 222 Mastr s Lv Practitior. S Foria bii sht or or ioratio. Y , 90847, 90853, 90857, AOD Assss, BH Scri, BH Cousi, AOD Group MD, APRN, Psychooist, IPBHP (icus LCSW, LMFT, LPC, a Lics Acoho a Dru Cousor LADC) MD, PA, NP, Mta Hath Ciicia, Cousor I, Cousor II. S Dawar bii sht or or ioratio. MD, A Quaii Practitiors (Mastr's/Bachor's). S Foria bii sht or or ioratio.

227 GA Goria Y 96150, 96151, 96152, 96153, 96154, HI Hawaii Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt Practitior Lvs 2, 3, 4 siat as U2, U3, U4. S Goria bii sht or or ioratio. Quaii Mta Hath Prossioa (QMHP), Mta Hath Prossioa (MHP). S Hawaii bii sht or or ioratio. Y 90853, AOD Assss, BH Scri, BH Cousi, AOD Group, IOP Srvics, AOD Srvics, Abuatory Dtox, Group BH Cousi a Thrapy, Faiy Sis Traii a Dvopt, Crisis Itrvtio Srvic, Psychooica Tsti, Srvic Pa Dvopt Y , 90807, 90809, 90811, 90813, MD oy , 90853, 90857, IOP Srvics. ID Iaho N Y , oy, AOD Assss, AOD Group Practitior Lvs 1-5. S Goria bii sht or or ioratio. Quaii Mta Hath Prossioa (QMHP), Mta Hath Prossioa (MHP). S Hawaii bii sht or or ioratio. Quaii Substac Abus Tratt Prossioa (QSATP). S Iaho bii sht or or ioratio. Icus Acoho a ru cousor crtii by th Iaho Boar o Acoho/Dru Cousor's Crtiicatio, Ic. (CADC or Avac CADC) IL Iiois N N IN Iiaa Y Asssst, Rasssst, Iiviua It., Group It. Physicias (MD), Avac Practic Psychiatric Nurs (APPN), Lics Psychooist (Ph.D.), Lics Ciica Socia Worr (LCSW), Lics Marria & Faiy Thrapist (LMFT), Lics Mta Hath Cousor (LMHC), MA v thrapist. Y , 90847, 90853, 90857, BH Scri, BH Cousi, AOD Group, IOP Srvics, , , , 90845, 90847, 90853, 90857, 90865, 96101, 90862, Crisis Srvics (iitatios appy) MD, APPN, Ph.D, LCSW, LMFT, LMHC, MA, LP (Lics Prossioa), QBHP (Quaii Bhaviora Hath Prossioa), OBHP (Othr Bhaviora Hath Prossioa). S Iiaa bii sht or or ioratio. IA Iowa N N Appix 3A 223

228 KS Kasas N Y AOD Assss, BH Cousi, AOD Group, IOP Srvics KY Ktucy N N Appix 3A 224 LMHP LA Louisiaa N Y , 90847, 90853, 90857, AOD Assss, BH Cousi, AOD Group ME Mai N Y , 90847, 90853, 90857, AOD Assss, IOP Srvics Rquirs ac to ac by Psychiatrist, Lics Mta Hath Prossioa (LMHP) ca o asssst; APRN, CNS, or NP ca o iitia asssst but ust obtai psychiatrist s siatur. MHP ur LMHP suprvisio. MD, APRN, LADC (Lics Acoho a Dru Cousor), CADC (Crtii Acoho a Dru Cousor), LCSW, LCPC, LMFT MD Marya Y Asssst, Rasssst, Iiviua It. MD N MA Massachustts N N MI Michia N Y , 90847, 90853, 90857? MN Misota Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt Physicia, APN, CNS-MH, LICSW, LLP, LPCC, LP N MS Mississippi N N

229 MO Missouri N Y , 90847, 90853, 90857, AOD Assss, AOD Group MT Motaa Y Asssst MD, PA, NP Y AOD Assss (99408, 99409) NE Nbrasa N Y 90804, 90806, 90808, 90847, 90853, AOD Assss, AOD Group, IOP Srvics (Faciity stti oy) Quaii Substac Abus Prossioa (QSAP). S Missouri bii sht or tais. MD, PA, NP, Lics Psychooist, LCSW, LPC MD, PA, APRN, Psych, Prov. Psych, LIMHP, LMHP, PLMHP, RN, LADC NV Nvaa Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit QMHP. S Nvaa bii sht or or ioratio. Y , 90847, 90853, 90857, BH Scri, BH Cousi, IOP Srvics QMHP, QMHA. S Nvaa bii sht or or ioratio. NH Nw Hapshir N N NJ Nw Jrsy Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt Physicias, Psychooists a stat ics Mastr s v ciicias Y , 90847, 90853, 90857, AOD Group Physicias, Psychooists a stat ics Mastr s v ciicias NM Nw Mxico N Y , 90847, 90853, Psychiatrist, Psychooist, Lics Ciica Nurs Spciaist, Lics Ipt Socia Worr, Lics Prossioa Mta Hath Cousor, Lics Marria a Faiy Thrapist. So cos ca aso b provi by Lics Mastr Lv Socia Worr, Lics Psychooist Associat, Lics Acoho a Dru Abus Cousor a othr Lics Mastr s Lv Cousor. Appix 3A 225

230 Appix 3A 226 NY Nw Yor N Y , 90847, 90853, 90857, AOD Assss, BH Cousi. Aso a Lics Crativ Arts Thrapist, Lics; MD/NPP, Psych, LMSW, LCSW, RN, LMFT, LMHC, LCAT, Lics Psychoaayst; Psychiatrist/NPP or PA with spciaiz traii approv by OMH NC North Caroia Y Asssst, Rasssst MD, APN Y , 90847, 90853, 90857, AOD Assss, BH Scri, BH Cousi, AOD Group MD, CNP, Lics Psych., LPA, LCSW, LPC, LMFC, CNP, CCNS, LCAS (Lics Ciica Aictios Spciaist), CCS (Crtii Ciica Suprvisor) ND North Daota Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt MD, Psychiatrist, Psychiatric Nurs, Ciica Psychooist Y , 90847, 90853, MD, Psychiatrist, Psychiatric Nurs, Ciica Psychooist, Lics Aictio Cousor, Lics Ciica Socia Worr OH Ohio N Y , AOD Assss, BH Cousi, AOD Group, IOP Srvics, Laboratory Uriaaysis, Mica/Soatic, Mthao Aiistratio, Abuatory Dtoxiicatio, Crisis Itrvtio Quaii practitior practici i ODADAS crtii Tratt Prora. S Ohio bii sht or or io. OK Oahoa N , 90847, 90853, 90857, AOD Assss, BH Scri, BH Cousi, AOD Group OR Oro N Y 90847, 90853, 90857, AOD Assss, BH Scri, BH Cousi, AOD Group LPHP, CADC Crtii Acoho a Dru Cousor Physicias, Lics Provirs (CADAC). S Oro bii sht or or io.

231 PA Psyvaia Y Rasssst???? RI Rho Isa N Y , 90847, 90853, 90857, AOD Assss, BH Cousi, AOD Group, IOP Srvics Physicia, Psychiatric RN, Lics Psychooist, Lics Ipt Socia Worr, Lics Marria & Faiy Thrapist, Lics Mta Hath Cousor, Lics Chica Dpcy Cousor, Crtii Co-Occurri Disorr Prossioa SC South Caroia N N SD South Daota N N TN Tss* * TX Txas N??? UT Utah N Y , 90847, 90853, 90857, AOD Assss, BH Cousi VT Vrot N N VA Viriia N Y , 90847, 90853, 90857, AOD Assss, IOP Srvics LMHT, Lics Substac Abus Cousor, Crtii Substac Abus Cousor, Crtii Substac Abus Cousor itr. Lics Socia Srvic Worr, Lics, Ristr Nurs, Lics Practica Nurs, Lics Substac Abus Cousor, Crtii Substac Abus Cousor, Crtii Substac Abus Cousor itr. LMHP, Quaii Substac Abus Prossioa (QSAP), Lics Substac Abus Tratt Practitior Appix 3A 227

232 Appix 3A 228 WA Washito N Y , 90847, 90853, 90857, AOD Assss WV Wst Viriia N Y , 90847, 90853, 90857, BH Scri, BH Cousi, AOD Group MD, PA, ARNP, CDP, MHC, MFT, MSW, Psychooist Prossioay Trai & Lics Sta PTLS), No- Prossioa Sta (NPS). S Wst Viriia bii sht or or io. WI Wiscosi Y Asssst, Rasssst, Iiviua It., Group It., Faiy+Patit, Faiy w/o Pt UA, UB HP, HO. S Wiscosi bii sht or or io. Y , 90847, 90853, 90857, AOD Group UA,HP,HO+HN. S Wiscosi bii sht or or io. WY Wyoi N Y , 90847, 90853, 90857, AOD Assss, AOD Group Psychiatrist, NP, Avac Practic Psychiatric Nurs (APPN) Psychooist, Lics Prossioa Cousor (LPC), Provisioa Prossioa Cousor (PPC), Crtii Aictios Practitior (CAP), Lics Aictios Thrapist (LAT), Provisioay Lics Aictios Thrapist (PLAT), Lics Ciica Socia Worr (LCSW), Crtii Socia Worr (CSW), Marria & Faiy Thrapist (MFT), Provisioay Lics Marria & Faiy Thrapist (PMFT) *Cotact th Stat Micai Oic (Tss)

233 Traii Matrias Pas visit this wbsit or traii atrias: Appix 4A 229