Recovery and Recovery-OrientedSystemsofCare Integrating Treatment for Substance Use, Primary Care, and Psychiatric Y Mental Health Disorders

T he need for integrated treatment of substance use disorders (SUDs) and psychiatricYmental health disorders (PMHDs) is at an all-time high. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) 2014 National Survey on Drug Use and Health, an estimated 43.6 million (18.1%) Americans aged 18 years and up experienced some form of mental illness, 20.2 million adults (8.4%) had an SUD, and 7.9 million people (3%) have both a mental disorder and an SUD (SAMHSA, 2014). Couple these facts with an extremely reduced psychiatricYmental health workforce and it is notable that the ability of this population to access specialized care requires a sea change in the current healthcare delivery system. As of January 2015, the Health Resources and Services Administration (2015) had designated 4,071 mental health professional shortage areas, including one or more in each state, the District of Columbia, and each of the territories. (SAMHSA, 2014). Most patients with PMHDs and SUDs are receiving care in prisons (Torrey et al., 2014). In 2012, the number of mentally ill persons in prisons and jails was 10 times the number remaining in state hospital with the estimation of 356,268 inmates with severe mental illness in prisons and jails and approximately 35,000 patients in state psychiatric hospitals, indicating a ratio of 10:1 (Torrey et al., 2014, p. 6). The bulk of care in the outpatient setting is now being delivered in heavily overburdened primary care and emergency room settings with 70% of primary care visits related to psychosocial disorders, and police and first responders are serving as the primary community-based workforce (Olsen, 2014). Although the concept of integrated behavioral health and primary care has been written about since 1995 (Katon et al., 1995), it has been implemented only in a piecemeal manner across the country. States, however, are catching on, and legislatures are funding programs (Stanek & Gauthier, 2013). Some states are now legislating integration of PMHDs and SUDs (Washington State Healthcare Authority, 2015; WA State SB 6312, 2014), but these efforts are slowed by federal restraints on providers licensed to provide medication-assisted treatment, again pointing to access-to-care issues. The concept of recovery in alcoholism began with the formation of Alcoholics Anonymous in the mid-1930s but was not extended to drug addiction until the mid-1980s with the formation of the Secular Organization for Sobriety and Rational Recovery (www.sossobriety.org/). The concept of recovery in mental illness was not described in the literature until 1993 (Anthony, 1993). Bringing all three components together, the first National Summit on recovery was convened by the SAMHSA Center for Substance Abuse Treatment in 2005 for the purpose of developing criteria for a common understanding of the guiding principles of recovery and the elements of recovery-oriented systems of care (ROSC; Center for Substance Abuse Treatment, 2007). Also in 2007, the first statewide recovery-oriented system of mental health care was described (Davidson et al., 2007). In 2009, ROSC (see Figure 1) was defined as ‘‘a coordinated network of community-based services and supports that is person-centered and builds on the strengths and resiliencies of individuals, families, and communities to achieve abstinence and improved health, wellness, and quality of life for those with or at risk of alcohol and drug problems’’ (SAMSHA, 2010; Sheedy & Whitter, 2009). Although the focus of ROSC is coordinated treatment of alcohol and drug problems, the treatment of co-occurring PMHDs and a need for primary care are inherent. However, the concept and components of ROSC have also been slow to catch on as states are dealing with severe budget cuts and hampered by the political process in general. A few states, such as Washington, are developing programs based on a paradigm of triple integration: mental health, substance abuse, and primary care treatment all under one roof. An example is the Northwest Integrated Health in Tacoma, WA (www.nwih.org). Mary D. Moller, DNP, ARNP, PMHCNS-BC, CPRP, FAAN, PMHNP, DNP Program, Pacific Lutheran University School of Nursing, and Northwest Integrated Health, Tacoma, Washington. Katherine Fornili, MPH, RN, CARN, Department of Family & Community Health, University of Maryland School of Nursing, Baltimore. The authors report no conflicts of interest. The authors are responsible for the content and writing of the article. Correspondence related to content to: Mary D. Moller, DNP, ARNP, PMHCNS-BC, CPRP, FAAN, Northwest Integrated Health, 5929 Westgate Blvd., Tacoma, WA 98406. E-mail: mollermd@plu.edu DOI: 10.1097/JAN.0000000000000116