# Presentation: 722105

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

**Constance Weisner, DrPH, MSW****Stacy Sterling, MSW, MPH****Sujaya Parthasarathy, PhD****Jennifer Mertens, MA****Charlie Moore, MD, MBA**
**University of California at San Francisco and ****Division of Research, Northern California Kaiser Permanente**Conference on “Complexities of Co-Occurring Conditions: Harnessing Services Research to Improve Care for Mental Health, Substance Use, and Medical/Physical Disorders,” June 24, 2004, Washington, DC

- From studies funded by the National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, Center for Substance Abuse Treatment, and Robert Wood Johnson Foundation

## Broadening the research focus in improving access and utilization of  best practices

- Asking new research questions
- develop questions in collaboration with clinicians
- Studying the implementation process
- the variety of stakeholders that influence adoption of, and access to, best practices

## Sources of Research Questions

**Sources of Research Questions**
**Research literature**
**Policy issues**
**Clinical concerns**

**Program change implemented**** **

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

**Generates research intervention study**

**Intervention evaluated**

**Stakeholder concerns shape implementation**

- Sterling & Weisner, (2002) “Closing the Loop: A Model to Address the Transfer of Research to Practice”

**Notes:**
2-way process: Research to practice and practice to research

My talk motivated by working with forward-thinking clinicians, spending time in programs

BR report – working with BP group, trying to find ways of integrating tx

## OVERVIEW

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

## Research Supporting Integrated Services 

*Assessment:*  Many individuals entering CD and MH treatment have co-occurring problems. *(Rounds-Bryant et al., Grella et al. 2001; Rao, 2000; Greenbaum et al., 1996)*
*Screening:*  These co-occurring problems could be identified earlier before they are severe. *(Samet et al., 2001)*
*Integrating services:*  Providing services that address those problems is related to outcomes. *(McLellan et al., 1998, 1993; Willenbring & Olson, 1999) *

**Notes:**
Established, especially among adults

## Setting

** ****Oakland**

**  • ****Sacramento**

***Setting***

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

** ****Vallejo**

**Vacaville**

**Kaiser Permanente Medical Care Program****of Northern California**

**Notes:**
Going to illustrate this by using data from KP – looking at problems, outcomes, and building a business case for access

## Adolescent Chemical Dependency Treatment Sample

- 419 adolescents (143 girls, 276 boys) and parents
- 4 facilities
- Age ranged from 13 to 18 years
- Ethnicity:     9% Native American/Asian
- 			 16% African-American
-  			 20% Hispanic
- 			 49% White
- Treatment intake, 6-month, and 1-, 3-, & 5 years
- Response rate: 6-month 91.4%; 1-year 92.1%

## Psychiatric Conditions of Adolescents Entering CD Treatment (in %)

|  | Intakes

(419) | MatchedControls
(2007) | 

p-value |
| --- | --- | --- | --- |
| Depression | 24.0 | 0.3 | <.0001 |
| Conduct Disorder
  with ODD | 17.0 | 0.2 |  <.0001 |
| Conduct Disorder | 11.0 | 0.2 | <.0001 |
| ADHD | 10.0 | 0.7 | <.0001 |
| Anxiety | 6.4 | 0.3 | <.0001 |
| Eating Disorders | 1.2 | 0.1 | <.01 |
| 1+ Psychiatric Conditions | 37.0 | 2.0 | <.0001 |

## ARE PSYCHIATRIC SERVICES RELATED TO OUTCOME?

## 	Receiving mental health services while in chemical dependency services was related to better alcohol and drug outcomes at 6 months.

***Role of Dual Treatment:  Logistic Regression****** Predicting Abstinence at 6 Months***

## An Adult Example:   5-Year Abstinence  when Psychiatric Services Provided

- For those who still had psychiatric problems at 12 month follow-up:** **
**	**2 or more hours/year over the 5 years
- 				O.R. = 5.5*
**   **
-     *P<.05
-     Controlling for age, gender, type of dependence, abstinence goal, readmission, # of 12-step meetings, recovery-oriented social support, treatment intensity

**Notes:**
I need to check what the difference is for larger amounts.  Why did we divide at 2+?

## Are Medical Services Related to Outcome?

***Are Medical Services ******Related to Outcome?***

## An Adult Example:   CD Patients and Matched Health Plan Members:  Medical Conditions*

|  | CD Patients 
(N=747) | Matched Members
(N=3,690) |
| --- | --- | --- |
| 
Injury and Overdoses | 
25.6% | 
12.1% |
| Lower Back Pain | 11.2% | 5.8% |
| Headache | 9.2% | 3.8% |
| Hypertension | 7.2% | 3.4% |
| Asthma | 6.8% | 2.6% |
| Acid-related Disorders | 5.5% | 2.1% |
| Arthritis | 3.9% | 1.3% |

- *all p<.001

- Mertens, Lu, Parthasarathy, Moore, Weisner. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: Comparison to matched controls. *Archives of Internal Medicine.*

## Randomized Adult SAMC Group: Logistic Regression Predicting Abstinence at 6 Months: 

| Independent Variable | O.R. | 95% C.I. |
| --- | --- | --- |
| 
Integrated Care
(vs. Usual Care) | 
1.90 | 
(1.22, 2.96) |

- Controlling for baseline alcohol and drug severity

- Weisner C, Mertens J, Parthsarathy S, Moore C, Lu Y. (2001). Integrating primary medical care with addiction treatment: A randomized controlled trial. JAMA 286(14):1715-1723.

## Medical Costs 12 Months after Treatment for Randomized CD Patients with Psychiatric & Medical Conditions

***p<.05; **p<.01**

- Parthasarathy S, Mertens J, Moore C, Weisner C. (2003). The utilization and cost impact of integrating substance abuse treatment and primary care. *Medical Care.*

## Sources of Research Questions

**Sources of Research Questions**
**Research literature**
**Policy issues**
**Clinical concerns**

**Program change implemented**** **

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

**Generates research intervention study**

**Intervention evaluated**

**Stakeholder concerns shape implementation**

- Sterling & Weisner, (2002)“Closing the Loop: A Model to Address the Transfer of Research to Practice”

**Notes:**
2-way process: Research to practice and practice to research

My talk motivated by working with forward-thinking clinicians, spending time in programs

BR report – working with BP group, trying to find ways of integrating tx

##  Research            Practice Model

**	****  ****CD & MH Directors’/Chiefs’ Groups:**
**Business case:  outcomes & cost**
**Parity legislation**
**Identifying next generation of research questions**
**Survey of pediatricians**
**Clinicians**
**Development of assessment for MH and CD clinics**
**PC & ER physicians**
**Results to their professional organizations**
**Identifying next generation of research questions**
**Assessment in MH and CD clinics**
**Readiness to change AOD use in MH clinics**
**Dual Diagnosis Best Practice Committee**
**Concept & development of liaison model**
**Core competencies, care guidelines**
**Training**
**Identifying next generation of research questions**
**Dual diagnosis continuity of care, utilization & cost**
** **

## Conclusions

**A wide variety of stakeholders influence access**
**Demonstrating both outcome and cost is important in improving access**
**Integrating research and practice can lead to better understanding how to study and address access**

**Notes:**
SHOULD HAVE “Conclusions” written at the top

## COLLABORATORS

- Felicia Chi, MPH
- Steve Allen, PhD
- David Pating, MD
- Bill Brostoff, MD
- Christine Waters, MD
- Agatha Hinman, BA
- Georgina Berrios, BA
- Tom Ray, M.A.
- Wendy Lu, MPH
- Cynthia Campbell, PhD
- Derek Satre, PhD
- Carolynn Kohn, PhD
- Melanie Jackson, BA
- Cynthia Perry-Baker, BA
- Lynda Tish, BA
- Barbara Picchoto, BA

**Kaiser Permanente Clinics**
- Oakland
- Sacramento
-  San Francisco
- Stockton
-  Vacaville
-  Vallejo