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Dual Diagnosis Capability in Healthcare Settings (DDCHCS)

NRI—September 6, 2011

MICHAEL LANE:

Good afternoon everyone. Welcome to the NASMHPD Research Institute’s Webinar Series. My name is Michael Lane. I’m the Events Manager here at NRI. We’re pleased that all of your could join us for the 60 minute Webinar. But we would also like thank SAMHSA for partially supporting today’s webinar and their continued guidance of our summer series. Before we get started I’d like to go over a few housekeeping issues. You should be looking at your screen and seeing the cover page of the Power Point presentation on the right hand side you’ll see a Q&A box in the middle of the screen. Down at the bottom right hand of the screen is a media viewer. That’s our closed captioning option. You can minimize that and close that if you’d like, or leave it open, whatever is your preference. During the presentation we will not be fielding any questions. However, if you would like you’re welcome to type in a question in the Q&A box again, on the right hand side of the screen. We will field the questions at the conclusion of today’s talk. And at this time I’d like to go ahead and get started. We’re pleased today, to have Dr. Steve Sullivan. He’s the Director for Center For Safety And Sustainability at the Cloudburst Group. And Dr. Noel Mazade, the Executive Director here at the NASMHPD Research Institute.

Dr. Sullivan oversees all research efforts for the Cloudburst clients. This includes conducting both quantitative and qualitative social science research to help shape strategies for reaching and serving their key audiences as well as performing program evaluations and impact assessments. Dr. Mazade is the Founding Executive Director of the NASMHPD Research Institute. He’s held managerial positions at the National Institute of Mental Health, North Carolina Mental Health Legislative Study Commission and the Oakland County, it’s in Michigan, Mental Health Services Board. He’s academic appointments in the departments of psychiatry, public health, social work and leadership at the University of North Carolina, Ducane, University of Maryland and Harvard among others. Today’s talk will highlight the Duel Diagnosis Capability in Healthcare Settings Assessment tool. This tool is intended to help primary care settings to integrate services for individuals, co-occurring mental and substance use disorders in their practice. This non-proprietary tool was developed and refined as part of the  joint federally funded Substance Abuse and Mental Health Services Administration, SAMHSA, and health resources and services administration HRSA pilot project that introduce and test the tool among federal qualified health centers.

At this time I’d like to pass over the phone, so to speak, to Dr. Sullivan to begin the presentation. Dr. Sullivan, the phone is all yours.

STEVEN T. SULLIVAN, Ph.D.:

Thank you Michael. Good afternoon everyone. I wanted to provide a brief quick overview of our session today. Talk first a little bit about the DDCHCS instruments, the index where it came from. Our application of that tool in the context of the jointly SAMHSA HRSA funded pilot study of FQHCs. And again, we’d like to thank our sponsor and agencies for underwriting the development to of this tool today. To talk about some other development activities and administration of the tool outside the pilot setting. We actually have cross-site data from a National Feasibility Study of the DDCHCS to present to you today. To talk a little bit about future applications. We think that the use of the tool, even its limited use today points to a fairly rich research program that many of the program evaluators, if you’re listening out there in the audience, will be interested to learn about. And then at the end we should have time for questions and answers. What is the DDCHCS?  Well, DDCHCS stands for Duel Diagnosis Capability in Healthcare Settings. And the DDCHCS is an index or a benchmarking tool, which is intended for healthcare settings that are beginning to or have undertaken action on integrating co-occurring capable behavioral healthcare into their primary care settings. So it’s for primary care settings where the intent is to add a co-occurring confident behavioral healthcare.

And it is suitable for FQHCs and other community health clinics. While it has not been tested in a broader range of clinical context, there is nothing FQHC specific in the tool. And we can talk about that a little bit closer to the end. The DDCHCS is a direct outgrowth of the Duel Diagnosis Capability And Addiction Treatment Index and the Duel Diagnosis Capability and Mental Health Treatment Index that were developed by Dr. Mark McGovern at the Institute For Psychiatric Research at Dartmouth University. The index is based on the five point scale for most of the scoring elements of the index is based on the American Society of Addiction Medicine, PPC-2R scale which was used originally in the DDCAT. For each of the 36 scoring elements the score is determined by figuring out which of the mutually exclusive states of the world best describes the clinical context of the program. And that determines the score for that item. Scores range from healthcare only services, which is the lowest score to DDC for Duel Diagnosis Capable, which is the middle score, a score of 3. Or Duel Diagnosis Enhance for DDE, a score of 5. And it’s to be noted here that everyone understands that not every organization that would undertake or undergo an assessment using the DDCHCS is interested in becoming a DDE, that is to say a Duel Diagnosis Enhanced organization.

Luckily, the fidelity scale nature of the tool and the detailed descriptions underlying each of the anchors allows the tool to measure relatively subtle policy or practice changes, such as the movement from clinician-driven practice which varies within a program to routine but unwritten practice to the emergence of written policies within a program. All of those changes are measurable across the 36 scoring elements of the DDCHCS. There are seven domains. And there are 36 total scoring elements of the tool. Program structure focuses on the mission of the organization, licensure and its model of integration, as well as barriers and incentives provided by the financing model for the organization. Program milieu focuses on the expectation of co-occurring prevalence among the patient population. And the provision of patient information regarding co-occurring substance use and mental health disorders and behavioral health to patients. The clinical process of assessment focuses on screening assessments, diagnosis and the tracking of the progress of co-occurring disorders in the patient record. The clinical process of treatment among other factors examines the extent to which there are integrated treatment plans that are aware of co-occurring issues.

Continuity of care focuses on the situation such as the referral offsite of patients for specialty outpatient treatment and their ability to return for care for the context within which the program is being measured. Staffing focuses on licensure certification or other expertise as well as the availability of staff with those license, certifications or expertise for consultation or case supervision. Training focuses on the provision of either basic training or co-occurring prevalence and screening, or specialty training for behavioral health or clinical staff. The current mode of administration of the tool is through external site visitors. It is not pay self assessment. It has not been validated for use in a self assessment context. Some of the other literature available on related tools within the DDCAT suite specifically the Duel Diagnosis Capability and Addiction Treatments tool has suggested that there is a self administration artifact of scoring and that self-administrations and external administrations cannot be directly compared. The mode of administration for the tool is typically two site visitors will pre-arrange for a site visit of approximately a half-day to a three-quarter day onsite at the clinic. During which time they will interview clinic leadership in primarily primary care.

But should also talk to behavioral health staff. We’ll do chart reviews. We’ll perform an ethnic graphic round while onsite and we’ll perform a number of standup interviews with both primary care, clinical staff and behavioral health staff while onsite. And the meeting typically concludes with a de-brief to the organizers of the visit and a brief written DDCHCS profile for the programs that have been assessed. The tool was initially administered in a pair of community health clinics in Vermont prior to the development of the specific scoring anchors. And it came to the attention of the evaluation team for the co-occurring contract at SAMHSA in June of 2010. We were casting about for various measures we might use in a pre-post context for the pilot work we were doing with SAMHSA and HRSA. And based upon the current state of development of the tool we selected it for use in our joint SAMHSA-HRSA pilot among FQHCs. We completed the work on the anchors in June of 2010. And we utilized it in our pilot, which made use of a pre-post design. This was or two FQHCs in downtown Baltimore, Maryland. We initially administered the tool in October of 2010. It was a retrospective administration where we visited in October of 2010 and asked about the state of the world in those FQHCs as of June 2010. We followed up in June 2011 and administered the tool again. And our pilot report was submitted to HRSA, excuse me, to SAMHSA in June of 2011.

Other development activities have included a work group funded by SAMHSA for the DDCHCS which paralleled the work of the Duel Diagnosis Capability in Addiction Treatment and Mental Health Treatment Groups. There were some revisions to the language of the measure in May 2011. And there were additional assessments that took place at one site in Vermont, two sites in Connecticut and four additional sites in Maryland that were not in the original pilot for a total of nine sites funded by SAMHSA. There were additional non-federally funded sites with assessors in Illinois, South Carolina and California who provided their data directly to Dr. McGovern and luckily we can report on some of that data from the National Cross Site Feasibility Study using data that we have from as recently as last week. The four non-pilot sites in Maryland were arranged through the National Association of Community Health Clinics and we thank Michael Lardiere of NACHC for his assistance and bringing those sites on board for our study. There is a draft tool kit available for the DDCHCS. And in addition to containing the index and the scoring manual for the DDCHCS which lists all 36 items and their anchors it provides a lit review and an annotated bibliography.

It provides some background on the psychometric testing and reliability and validity studies that have been done on the DDCAT and other tools in the Duel Diagnosis Capability Suite of tools. It provides some instructions and tips for the assessment team, including a detailed item scoring information, item by item for each of the 36 items. And a case vignette so that a person can read the case and sort of score it along with the manual. It provides extensive detail on improving scores element-by-element for each of the 36 scoring elements of the tool. And also it provides information on how to use the resulting information which is to say the completed detailed index and the report of the assessment team in a changed process or primary care programs who want to better integrate co-occurring capable behavioral healthcare into primary care. I want to talk just for a moment about some of the results that we have from our pilot assessments. As we noted we used the tool in a pre-post setting with two FQHCs, two thoroughly qualified health centers in downtown Maryland in 2010 and 2011. And the two slides that I’ll show, let me first give you an overview of these. The gray area at the bottom is essentially a line graph of the baseline scores for one of the two clinics across the seven domains of the index.

The green lines above that, the green area above that represents the item by item improvement as you move across the seven domains. So where there’s a large vertical distance between the old score and the new score is illustrated by the dark green area. That represents the improvement between baseline and one year follow-up. So I just wanted to show you first the two patterns of improvement. Two very different patterns of improvement for the two FQHCs over the course of the year. And I’ll speak really briefly, because I think it’s a very hopeful story about what the two FQHCs were able to accomplish over the span of a year. So I’m going to speak about these in turn. And the first of these refers to this first slide that we’re looking at, which we’ll refer to as Maryland 1. This site through the pilot which was to test a distance education technical assistance model to implement screening and brief intervention and referral to treatment in a primary care setting. Provided resources to the pilot sites in the form of face-to-face meetings, thee to five webinars, coaching calls and targeted technical assistance but none of the resources that were provided to the pilot sites took the form of any direct funding. So keep that in mind when we talk about what they were able to accomplish in a year.

So the first of these sites moved to increase integration of services for co-occurring disorders into their electronic medical record. They moved to create a routine staff exchange between primary care and behavioral health. With the training provided by the pilot they improved their ability to bill for either a medical or behavioral health services. They moved to the consistent use of screening tools with known psychometric properties for a mental health and substance use issues in patients. Which led to more routine diagnoses and in turn led to more consistent discussion of behavioral health issues and family education and family support sessions. They began including co-occurring notes in their treatment plans while they did not reach a fully integrated treatment plan for co-occurring, they began to introduce those notes into the medical record. They began training for their primary care staff  in stage of motivation assessment, although they did not yet reach the stage of developing stage wise appropriates treatments. They increased the number of clinical staff members who could provide mental health or substance use counseling services by making them physically present. They introduced the supervision of co-occurring cases including chart review and case conferences. And they introduced specific training dollars for screening brief intervention referral to treatment.

And for cross training primary care providers on co-occurring disorders. Again, in the span of less than a year. The second of the two sites moved to a clearer communication of expectations regarding the prevalence of co-occurring disorders and their patient population. They increased their ability to handle moderate to high acuity patients with co-occurring disorders. They improved their assessment process and made more consistent inclusion of behavioral health issues in the problem list in the patient record. They had a somewhat less sophisticated EMR than the first site. They moved to introduce stage of motivation assessment for patients. They improved patient education and family support around behavioral health issues for co-occurring. The Behavioral Health Director herself introduced supervision and a consultation for primary care staff for persons or their patient cases with co-occurring disorders including onsite treatment reviews. And as with the first site they introduced training dollars for the use of evidence base practices around co-occurring disorders in particular for screening brief intervention and referral treatment. Again, within the course of a year. We also learned a few things about the tool itself. And in fact this was part of a larger feasibility study. We learned the measure is very straight forward to administer.

And that a site visit team of two people working together can successfully administer the tool, even within a somewhat advanced clinical environment, in under one working day. We found that there were some minor adjustments in the language, particularly as regarding the discharge process. Some of the language that the tool inherited from the Duel Diagnosis Capability in Addiction Treatment Setting was not necessarily appropriate to a community health clinic context. And some of that language was adjusted. And we determined in particular that the measure works very, very well in a pre-post framework. So it can provided with a baseline administration and then a follow-up after an appropriate period of time. And while the reports don’t exactly write themselves, organizations can see what the next rung on the ladder is in terms of the scoring by reviewing the rating scale for each item. And assessors and TA providers who are using the tool can do exactly the same thing. Now I’d like to talk a little bit about some of our cross-site results from our feasibility study, which involves sites in Maryland, Vermont, Connecticut, Illinois, South Carolina and California. We had 13 sites in the cross-site, 12 of them got their data under the wire to be able to be included in this presentation.

What we found in those sites which many of which were motivated for their involvement in the site and in fact the National Association of Community Health Clinic sites, it was one of our selection criteria was that they all be interested in better integrating co-occurring confident behavioral healthcare into primary care. We found that half of all the sites that we assessed to date or either Duel Diagnosis Capable or between Duel Diagnosis Capable and Duel Diagnosis Enhanced. We have to note that we don’t think this is representative of the population of FQHCs as a whole. RN is small, it was not a random selection of sites. We don’t think that it’s statistically projectable and we would advise everyone looking at these numbers to consider this the output of the feasibility study for the DDCHCS. But we did want to talk about what some of the things that we saw. And what follows is some hopefully not too dry statistical output from our cross-site analysis. The following, it’s a series of boxed plots. Which are really intended to provide at a glance some distributional information about the scores across the 12 sites for each of the seven domain areas. And then we’ll be going domain by domain and talking about some of the scores for the individual scoring elements of the individual 36 scoring elements.

A boxed plot is a hopefully informationally efficient and merely confusing means of providing distributional information on scores. And what we’ve done here is to show the box itself, the rectangle is the inner cortile range of the score. The heavy line is the medium. The red sprite that’s printed in the middle of the box is the main. Okay. So what we see when we look across the seven domains is that four the 12 sites for which we have data here most are hanging about in the DDC neighborhood of an overall score of around 3 or slightly better, depending upon the particular domain. They tend to do best in the area of assessment. They tend to do least well in the areas of staffing and training. And we’ll talk a little bit about why later. And then we can go element by element. The domain 1 element on program structure. The first column under 1A, those are our scores per mission. Mission statements generally haven’t moved beyond statements about generic well being. Sites typically did better when it came to licensure or certification. We found lots of duel licensure in our small group of 12. Item 1C is for the model of integration. And 1D had to do with any financial barriers or incentives to integration of co-occurring competent behavioral healthcare into primary care.

Now one of the things that you see with 1D is a fairly significant amount of variation as given by the size of the inner cortile range for that score. And what we have going on in a lot of these situations is state level restrictions on the ability to be reimbursed for example for certain combinations of primary care and behavioral health treatment. In program milieu we find that in our group of 12 FQHCs are generally aware of the degree of co-occurring prevalence in their consumer populations, that’s the 2A item. While they have not moved all the way into the score of a 5, which would require a formal statement of expectation, item 2B focuses on the patient education materials that are typically available in the FQHCs. We found that most materials on display in the FQHCs still focus on hypertension, diabetes and healthy eating rather than behavioral health issues in particular behavioral health issues having to do with co-occurring mental health and substance use issues. Under the area of assessment we find the first column which focuses on screening. The second column which focuses on assessment. The third column which focuses on diagnosis. Finds half or more of sites engaged in screening assessment for diagnosis of co-occurring mental health and substance use issues. And the primary finding to come out of the remaining set of items is that the 3G item.

Which is that we don’t find a lot of assessment of stage and motivation within the FQHCs that we’ve worked with. In terms of treatment, we find that many of the sites that we reviewed are limited by the lack of an electronic medical record or are limited similarly by the policy of maintaining separate primary care and behavioral health files. We almost never observe integrated treatment plans. And we observe fairly consistently as across the other areas where it shows up here under 4D that stage wise specific treatments are not typically being used in the group of 12 FQHCs that we have used for the feasibility study. We find sites generally performing well in terms of providing continuity of care. Persons are typically not discharged from the care of an FQHC due to ongoing substance use or mental health or substance use issues or co-occurring issues with moderate to even high severity or acuity. The last two areas of staffing and training are the ones where the requirement that the tool places on the development of competencies in both mental health and substance abuse issues, this is where translates into relatively low scores on staffing. For example, the licensure and certification of staff. The requirement would be that they are licensed, certified, or possess expertise in both mental health and substance use disorders.

And under training again that they receive specific training on both mental health and substance use disorders. And one of the things that we have determined is that some of the low hanging fruit to be found here is in staffing and in particular training. What did we find overall as a result of the feasibility study?  First we found again hopefully that FQHCs can provide Duel Diagnosis Capable care. We’ve seen evidence of some really fantastic models of FQHCs who got started right out of the gate in some instances with an EMR that could handle the appropriate screening and development of integrated treatment plan. We learned that screening is very, very important. Screening seems to drive the development of high scores on a number of these different areas of the tool. That EMRs are also important in part because they drive the screening and assessment process. An EMR that will prompt the physician to run through a brief assessment, or a brief screening, a PHQ to an NI triple A single screen. There are a number of very brief screening tools that can be incorporated into EMR to ensure that in a rapid and non-obtrusive way that appropriate behavioral health screening can be provided for all patients. We also find that having the right EMR facilitates coordination and collaboration among the appropriate primary care and behavioral health clinicians.

And there are certain species of EMRs that allow the integration of co-occurring competent behavioral health treatment into an integrated treatment plan for patients with those complexities. As noted, we are very hopeful about future applications of the tool. We believe that the measure points to potential applications in healthcare reform and also a very rich research agenda. One of the questions that always comes up in evaluation research in terms of linking any patient outcomes that attended variable of patient outcomes to among other things a set of independent variables including an independent variable on primary care behavioral health integration is that you need the appropriate construction of that independent variable. You need a good measure of behavioral health primary care integration. You need one that has the appropriate construct validity. And we think that the DDCHCS provides a means of properly constructing a good independent variable. A good benchmark measure for the degree of integration of co-occurring confident behavioral healthcare into primary care. Another closely related question is to do pre-post analyses on FQHCs and other clinical context that are adopting evidence based practices supported by SAMHSA such as SBIRT.

And to determine which of those evidence based practices have the largest impact on assessment outcomes using the various scoring elements of the DDCHCS as the indicators. Finally, we can ask a similar question again in perhaps a pre-post context. As to which integration model such as accountable care organizations or patient centered medical home have the largest impact on assessment outcomes when they are adopted by organizations. So, it provides the opportunity for those organizations that are adopting or that are considering the move to a patient centered medical home format or an accountable care organization format to administer the DDCHCS as a baseline to go through their process of system change and then do a reassessment to determine what has changed. What do we still know about the measure?  Well, while we’ve collected a lot of information within the feasibility study, all of our sites were federally qualified health clinics, were federal qualified health centers. And so what we need to determine is whether the tool retained it’s reliability in a variety of clinical context including hospitals, group practices. We had some recent discussions with one state about trying to use them in context of measuring the degree and quality of integration of telepsychiatry into primary care.

And we’re finishing up just a slightly bit early. And so I think we could probably move onto questions.

MICHAEL LANE:

Thank you Dr. Sullivan. We appreciate your time in presenting this. And at this time just like he said, if anyone has any questions now would be the time to type it into the Q&A box should be in either the middle right hand side of your screen or down at the bottom of your screen. We have a question coming in actually right now from Barbara. She’s asking, how do we obtain this tool?

STEVEN T. SULLIVAN, Ph.D.:

I think the best thing to do is Michael if folks can get in touch with you as the organizer. I can provide them with a draft copy of the tool kit. It is nice to hear from you Barbara. We had a presentation of the draft tool kit to the sponsoring agencies last week. In a meeting, a learning community meeting for Duel Diagnosis Capability, where are of the users of all of the various tools in the DDCAT, DDMOT suites came together. And I have a version of that document. Again it’s a draft version of the tool kit, which I would be happy to provide via e-mail.

MICHAEL LANE:

Okay. So folks, so probably the easiest way to do it, is be able to get in touch via me, like you were saying Dr. Sullivan, and my contact information is on the NRI website. Which is nri-inc.org and you can go to About Us and find my contact information there and we have an events section on our website and you can also contact Noel, as well. Since he will be sending it over since NRI is the organizer of the event. So, alright we have another question from Jennifer. She said, she’s in Pennsylvania and asks:  Are there any thoughts of when this may be introduced in our state?

STEVEN T. SULLIVAN, Ph.D.:

That’s a good question. As noted, the mode of administration for the tool is for external site visitors. To come on site and run through the protocol of assessment which involves the interviewing and the chart reviews and the ethnic graphic round and standup interviews with as many clinical staff as we can pester in the halls without pestering them too much. The tool itself is available for you to review. As quickly as you can ask for it by e-mail through the process that we just outlined. In terms of training for site assessments, there isn’t currently a funding mechanism for assessments to take place as it took place for the pilot that we were just talking about. But Noel and I, I’m sure would be happy to talk to you about coming out and doing an assessment of your program. Feel free to just get in touch with us and we’ll try to see  how we can workout logistics. But as noted, all the work that’s been done up to this point was funded by SAMHSA or HRSA through a contract that will end at the end of this month.

MICHAEL LANE:

Thank you. We have a question from Darien. He asks how valid are the pilot results with such a small number of FQHCs in the pilot?

STEVEN T. SULLIVAN, Ph.D.:

I don’t believe that they are projectable to the overall population of FQHCs at all. I would not say that this, because one as noted the end is quite small for the population of FQHCs. I would also say that it was not a random sample of  FQHCs. There were FQHCs that were brought in because of their involvement in the initial writing of the DDCHCS tool. There were sites that were brought in through the membership association for FQHCs, NACHC. And our selection criteria were really appropriate to determining whether the process of administration of the tool and some of the language and specific scoring elements of the tool were appropriate to a primary care context. So I would not say that we’re entitled to infer much of anything about the overall population of FQHCs and their readiness. Mainly we’re talking about the ability of this tool to allow us to move forward with many, many hopefully many, many more FQHCs in the future.

MICHAEL LANE:

Okay, thanks. We have another question. Don. Did any of the pilot participants utilize the tool as a means to guide a new mental health FQHC partnership?

STEVEN T. SULLIVAN, Ph.D.:

They have not at present. What we have found in similar administrations of related tools such as the Duel Diagnosis Capability in Addiction Treatment tool. What is a common refrain when it comes to some of the after action reporting from the administration of the DDCAT is that it catalyzes a lot of process and practice change at the organization that have the assessment done. I think it would be very, very interesting and Noel feel free to chime in anywhere here about where we think some of those FQHCs might be in a year. Because all of them were on the cusp of doing something really spectacular, either with opening a new facility that would allow a co-location model of integration or in some cases really rapidly expanding their hiring of prescribers or other clinicians. But I don’t recall any of the FQHCs that we spoke to moving forward with that particular process or practice change in the immediate future.

NOEL MAZADE, Ph.D.:

This is Noel. Can you hear me?

STEVEN T. SULLIVAN, Ph.D.:

I can hear you.

NOEL MAZADE, Ph.D.:

I think one of the beauties of the instrument is its ability to in a comprehensive way have a FQHC and for that matter a mental health system assess the full range of what it takes to develop a partnership. As Steven was describing the various domains of this instrument. It’s really a holistic view as well as detail with any of the domains as to what it takes. So I think by the time that we left the sites both on the initial visit at the beginning of the year and again in June, July, these last several months going back, I think you see a certain pride in people being able to coherently think about how to develop a relationship using the DDCHCS as the framework for actual behaviors that need to be initiated with the mental health system.

STEVEN T. SULLIVAN, Ph.D.:

Thanks.

MICHAEL LANE:

Alright. Thank you Noel. Here we have another question from  Pat. This is a two-part question. Do you know if most states do not allow visit with a primary care doctor and a mental health professional on the same day, even if it’s in the same location?

STEVEN T. SULLIVAN, Ph.D.:

Noel, I would defer to you on that one. But we have encountered situations where financing of a mini visit by a behavioral health clinician within the context of a primary care appointment is challenging.

NOEL MAZADE, Ph.D.:

Yeah, I would concur with that. I don’t have the actual data about literally how many states in terms of Pat’s question. But it’s definitely an issue. And it was actually raised and with some intensity when this was administered the first time out. Because it instantly raises a significant policy issue around the Medicaid State plan and what’s reimbursable. So, in Maryland I know as Steve indicated we were in two FQHCs in Baltimore. This issue is now raised to the forefront in terms of arranging meetings with the higher policymakers in the State agency to look at the really wisdom of disallowing that kind of a duel visit on the same day. So, the issue definitely has surfaced through the DDCHCS. And yet also raises the issue of vision. That is, if there was no prohibition to that type of a reimbursement, just think how more robust the services could be. So, I think it’s an issue that people are aware of but it’s as yet unsolved.

STEVEN T. SULLIVAN, Ph.D.:

Right. Because having to make another appointment, having to go to another facility, having to make another phone call, those are all places where a lost follow-up can creep in. Which is why I think everybody would like to be able to roll things together and have a seamless set of handoffs as possible. And of course we found also, and I’m sure everyone listening knows that this is true, that you know, organizations respond fairly powerfully to these incentives. And you know, the mini visit wasn’t really the only place where we heard that financing and reimbursement effect the mix of services that are provided. We heard it in terms of group. I think there were a couple of different FQHCs who, you know, who might have had the ability to facilitate certain group therapies onsite who said, you know, we don’t get reimbursed for it, so we don’t do it.

NOEL MAZADE, Ph.D.:

And there’s also kind of a regretful phenomena of more or less of a lead lag phenomena of between the development of highly integrated electronic medical records which would instantly be able to capture a warm handoff literally in real time versus the policy that lags behind that to prevent that from happening. So the technology in essence is a bit of a policy on there the question.

MICHAEL LANE:

Okay. Well, I think you answered that, sort of the other part of Pat’s question as well. So let’s move onto, we have another question from Jeff. He just wanted to clarify again how to access the DDCHCS site review.

STEVEN T. SULLIVAN, Ph.D.:

Sure. Well, they can contact— you might ask for a clarification whether he means the data from the cross-site?

MICHAEL LANE:

Yeah, Jeff O’Neil. If you could clarify what Dr. Sullivan’s asking. So we could more effectively answer your question here. Go ahead.

STEVEN T. SULLIVAN, Ph.D.:

For the tool itself just contact Michael or contact Noel or contact me. And we’ll provide you with the tool kit that has everything in it. Keep in mind it’s in draft form. But that has everything in it. And again, please everybody keep in mind the caveat this hasn’t been validated for self-assessment. It’s not designed for self-assessment. Any results proceeding from self-assessment can’t be normed against what’s done an external assessment framework.

NOEL MAZADE, Ph.D.:

Jeff just answered on an actual onsite review is what Jeff just responded back to you.

STEVEN T. SULLIVAN, Ph.D.:

But I would just say again that there’s currently no funding mechanism, no federal funding mechanism for that work to be done. But as people who have conducted probably more of these by this point than anybody else around, I’m sure Noel and I would be happy to talk to you about how that sort of thing can be done for your organization.

MICHAEL LANE:

Thank you. Actually back to the earlier question. We had a response back from Karen. She says that South Carolina Medicaid will allow visits to a PCP and a mental health provider on the same day. That’s just a comment from Karen. We have another question here from Thomas. It makes sense for SAMHSA to promote integrated care. Are there any champions speaking out for integration on the primary care side?  And is that message being promoted to state public health and/or other audiences?

STEVEN T. SULLIVAN, Ph.D.:

Well, no, perhaps you could talk a little more about this. HRSA is also very, very interested in this as evidenced by their very substantive support for what we did during the pilot.

NOEL MAZADE, Ph.D.:

Just to pick up on Steve’s last comment on HRSA. We plan on going back to HRSA now that the funding has ended on the SAMHSA-HRSA side to look at how this might be continued over this next federal fiscal year. So hopefully something will be done about that. On the macro level with regard to state agencies, there’s a dialogue that’s really begun with some intensity here in Washington between and among the public health officials, the National Organization of State Mental Health Program Directors and the Association of State Health Departments to look at integration really from a policy standpoint down sort of the states. But in this particular project I don’t believe that we really uncovered any state level, that is state agency level integration. This particular initiative as you can see is highly microscopic. It’s down at a single facility level. And then, of course, additively across them. But in this effort we really didn’t pick that up. It’s obviously a tremendous question and a tremendous need, if this is to move further in the field over the next seven years.

MICHAEL LANE:

Thank you Noel and Steve. Let’s see, we have a question from Sean. He asks, is it possible for Dr. Sullivan and/or Dr. Mazade to conduct a training for to develop external reviewers?

STEVEN T. SULLIVAN, Ph.D.:

I would love to do something like that.

NOEL MAZADE, Ph.D.:

It makes total sense. There will be up to 12,000 FQHC sites within the next 12 months, assuming that federal funding moves forward as it’s planned. And clearly this is a tool to help leverage and also be a catalyst for this to really occur at a much faster pace than ordinarily would be the case. So this is, it’s a great idea to do that.

STEVEN T. SULLIVAN, Ph.D.:

And it sounds like we have some sites that are looking for external assessments to be done and also some folks who are looking for training in how to become an external assessor and the economist in me is always happy when he observes a mutual coincidence it wants.

MICHAEL LANE:

Alright. We have another question here from Adrian. What stages of change, clinical measures are recommended by the DDCHCS?  What stages of change, yeah, go ahead.

STEVEN T. SULLIVAN, Ph.D.:

Okay. That’s a good question. The tool itself is as agnostic as to any particular measure. Just that it just asks the question of whether it’s being in done in any way shape or form. And connected through whatever stage of motivation assessment is done to stage specific treatment.

NOEL MAZADE, Ph.D.:

I think what we found is that the instrument nicely identifies the ends versus the means in some cases of realizing a certain state of excellence. And we found some variability in how FQHCs were going about doing their clinical work or developing a record system, etc. In some cases there are, as you’ll see items on the DDCHCS that talk about specific yes or no types of things being present or not in the FQHC. But again, I think one of the strengths of the instrument is to simultaneously identify means and ends and it really gives the participant in the site visits. And recall that in all our site visits we attempt to meet with people in groups. And that in itself creates a certain synergy as the clinical staff of the management staff think about what is that the center is doing and where it could be moving on this continuum of excellence. So one of the important and powerful parts of the site visit has to do with the dialogue that goes on among the staff around answering some of the questions and to reach a consensus as to where they fall on this five point continuum on each of these items. It really is thought provoking in that sense.

STEVEN T. SULLIVAN, Ph.D.:

I hasten to clarify that while we have information from the feasibility study that would seem to suggest at least provisionally that there are certain evidence based practices such as SBIRT that are high octane interventions that move a number of the little indicator needles at once. This tool does not privilege by construction any particular evidence based practice.

MICHAEL LANE:

Okay. Let’s see, we have a couple more questions. And it’s winding down. We have about five  minutes. And you’ll notice, everyone should see a file transfer box, hopefully on your screen. And for attendees who wish to download the presentation, it downloads in a PDF directly to your computer if you just run your mouse over the file name and then you would highlight it and you’d click download and it would download directly to your computer. Okay, let me get to this question here. We have a question from Jim. Is there is a separate clinical chart review form and/or a mission interview form in the draft tool kit?  Also, were clients interviewed at the sites to assess or understanding of “integrated care?”  It’s kind of a several part question there.

STEVEN T. SULLIVAN, Ph.D.:

There is not a specific chart review protocol. What we were looking for primarily was evidence of the degree of collaboration or coordination by different clinicians in addressing the existence and the progress of any co-occurring mental health substance users. Let’s see, as for the second part of that question. I need a little bit of a refresher.

MICHAEL LANE:

Also, were clients were interviewed at sites to assess their understand of “integrated care?”

STEVEN T. SULLIVAN, Ph.D.:

While ideally we would interview clients. We were not able to identify clients or excuse me, interview clients in any of the FQHCs that we, where we piloted the tool.

MICHAEL LANE:

Let’s see, we have a couple minutes. Anymore questions at this time?  Or anymore comments from either Dr. Mazade or Dr. Sullivan in regards to the presentation you all delivered today?

NOEL MAZADE, Ph.D.:

Did we answer Jennifer Anderson’s question here on FQHC?

MICHAEL LANE:

Yes, we did. I responded back to federal qualified health centers is what FQHC stands for.

NOEL MAZADE, Ph.D.:

Right. Jennifer, you might go on the www.hrsa.gov website and I’ll think you’ll find quite a bit of information about HRSA’s funding of these primary care settings across the country.

STEVEN T. SULLIVAN, Ph.D.:

And as we noted we’re very, very interested in ensuring that the tool is applicable to a wide variety of clinical context including and not including FQHCs.

MICHAEL LANE:

Well, if we don’t have any more questions. I’d like to personally thank Dr. Sullivan and Dr. Mazade for sharing their presentation and stimulating a very lively discussion. I want to say I’ve gotten several e-mails from our attendees requesting information about the instrument and the tool. And we will respond to those as quickly as possible. But again, I want to thank SAMHSA and both Dr. Mazade and Dr. Sullivan for putting this together. This was a very interesting presentation. I think it stimulated a lot of thoughts and hopefully you all could come back in a year and present new results if we can get some more funding in there. That would be great. Any last thoughts from either one of you all?

STEVEN T. SULLIVAN, Ph.D.:

Thanks for listening everybody.

NOEL MAZADE, Ph.D.:

It’s been a pleasure, thank you.

MICHAEL LANE:

Thank you very much.