Center of Excellence for Integrated Care
Cathy M. Hudgins, Ph.D., LPC, LMFT
“Do I contradict myself. Very well, I
contradict myself. (I am large. I
contain multitudes).”
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Walt Whitman, 1855
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What common issues are related to your clients’
MH/SA?
What factors impede adherence and recovery?
What parts of your client’s whole-person health
are outside of your scope of practice?
What do you want and need to know about the
other parts of your client’s whole-person health to
fully address the whole person in front of you?
How you can help other providers understand the
whole-person needs of your client?
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Assumes that health is a shared community
responsibility and can be achieved through the
dissolution of barriers that result in silo-style service
provision (Mauer & Jarvis, 2010).
Mental health and medical care providers work
together to coordinate the detection, treatment, and
follow-up of both the physical and mental health
needs of their patients.
Strategic framework stressing team-based care that
supports individuals in their whole-person health
needs and goals.
Meets the Triple Aim.
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The majority of people have comorbid mental
health and medical problems but do not
receive care consistent with established
practice guidelines (Institute of Medicine,
2006).
Developing an interdisciplinary cadre of
health care providers that work with patients
and their loved ones can ensure that wholeperson, evidence-based care is the standard
of care (Kaslow et al., 2007).
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Physical Health
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Emotional/Behavioral Health
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Oral Health
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Spiritual
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Social/Community
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Others?
Policy/
Law/Statutes
Social Services
Practice
Patient/
Family
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Behavioral health issues affect quality of life
◦ SMI population die at younger ages
(25 years less than average life expectancy)
than people with non-major mental illness
diagnoses (Lutterman et al., 2003).
◦ SMI population less likely to be linked to a
primary care home (Collins et al., 2010).
ANNUAL MEDICAL COSTS FOR ADULTS
Without MH
• All adults
$1,913
• Heart Condition $4,697
• High BP
$3,481
• Asthma
$2,908
• Diabetes
$4,172
With MH
$3,545
$6919
$5492
$4,028
$5559
Robert Graham Center for Policy Studies in Family Medicine and Primary Care, March,
2008. Information from US DHHS 2002 and 2003 MEPS AHRQ
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Bidirectional Integrated Care involves placing
primary health care providers into specialty
mental health settings.
Levels of bidirectional integration are also on
a continuum.
Primary Care services do not replace the need
for more intensive, specialty care. The focus
is on targeted medical issues for the
population in the setting (Mauer & Jarvis,
2010).
Research shows benefits ranging from:
 Lowered long-term healthcare costs;
 Decreased outpatient costs;
 Dramatic reductions in Emergency Department visits;
 Reduced costs to treat high-cost, high-risk patients;
 Reduction in inpatient cost, reduction in ER cost, and
reduction in total medical cost for substance abuse
patients;
 Significantly higher abstinence rates for substance abuse
patients;
 Significantly increased rates and number of visits to
medical providers and reduced likelihood of ER use;
 Significantly improved quality of most routine preventive
services;
 Increased receipt of recommended preventive services, and
 Increased patient work productivity and reduction in work
absenteeism.
(Collins et al., 2010; Mauer & Jarvis,
2010)
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Completes the continuum of care.
Focuses on lifting the barriers to gaining access or
receiving primary care services, including the
impediments related to negotiating complex
health systems.
Bridges the division between physical and mental
health, patient-centered care, which calls for
“meeting people where they are.”
Traditional primary care settings may not be
perceived as a welcoming place to those with
mental and behavioral health diagnosis, resulting
in poor access and poor health outcomes.
Addresses ineffective referral methods that do
not work and that easily disrupt care.
(Collins et al., 2010; Mauer & Jarvis, 2010)
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Recognition and treatment of medical disorders
that exacerbate/interact with psychosocial
problems;
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Early detection of “at risk” clients, with the aim of
preventing further physical deterioration;
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Prevention of relapse or morbidity in conditions
that tend to recur over time;
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Prevention and management of addiction to pain
medicine or other medications prescribed to
address physical symptoms;
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Prevention and management of work and/or
functional disability related to whole-health
problems;
Efficient and effective treatment and
management of clients with chronic health
problems;
Efficiently moving clients into appropriate
medical or mental health specialty care
when indicated.
(Open Door, 2005)
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Gastrointestinal Disorders
Cardiovascular Disorders
Hematologic Disorders
Pulmonary Disorders (Other Than Infectious)
Neurologic System
Infectious Diseases
Other Conditions
(SAHMSA, 2006)
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The disease model reflects the progression of
the disorder.
◦ At a certain point, the addict loses control over the
use (compulsion)
◦ Not a moral choice/not a character flaw (Moral
model)
◦ The idea that one may never use again on any level
(relapse)
◦ Could be used as an excuse (one of the criticisms)
◦ Relevance of this model
 Helps the treatment provider determine the severity
and intervention
 Helps the addict’s family, friends, coworkers, etc.
better understand the progressive nature of the
disease and reduces blame and hurt
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DSM 5 diagnosis criteria reflects a progression of
use.
 Usefulness
 Challenges
 Flexibility
◦ DSM 5 no longer identifies abuse and dependence as
distinct disorders – they are identified on a continuum.
• Contemporary medical diagnosis criterion is unilateral
and should be combined with other factors, such as
those included in the DSM to determine the nature of the
use and the type of treatment required (Borges, et al.,
2010).
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The criteria for substance abuse and dependence
diagnosis should be individualized
 Tolerance
 Withdrawal
 Social/interpersonal consequences
 Culture, age, gender, and other contextual factors
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Identification requires a more comprehensive,
whole-person view (biopsychosocial model of
assessment).
 Biological
 Psychological
 Cognitive
 Social
 Interpersonal
 Developmental
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Unified whole-person care definition and vision
Policy change on all system levels
Need for cross-training and technical support
Collaborative data collection and analysis to
support change
Development of community collaboration and
partnerships to address issues outside of the
Integrated Care scope of practice
TEAMWORK!!!!
Think outside of your silo – reject the status quo!
Two Teams (may include
some or many of the
same members*):
 Program
Implementation Team
 Clinical Team
Possible Members*:
 PCPs
 BHPs
 Practice Manager
 Nursing Staff
 Care
Manager/coordinator
 Receptionist/support
staff
 Medical records staff
 Risk Management
Officer
 Others?
North Carolina’s health system is built to meet the
needs of the high moderate to severe needs
population.
 Result: Gap in care for those with emerging or
moderate to mild healthcare needs.
 Result: Patients with moderate to mild issues
divert needed resources away those with the
high-moderate to severe issues.
Many MH/SA have difficulty navigating and feeling
welcome in traditional healthcare settings.
 One solution: Integrated Care provides continuity
of care in a stigma-free environment for those
who need brief, focused treatment for mild to
moderate healthcare needs.
Finding referrals for SMI/Chronic SA
Populations for more intensive healthcare
 Ethical Issues
 Scope of the healthcare services
 Paradigm Shift
 Culture Shift
 Others?
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North Carolina Foundation for Advanced
Programs
◦ http://www.ncfahp.org/
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Center of Excellence for Integrated Care
◦ (ICARE) http://www.ncfahp.org/nc-center-ofexcellence.aspx
Staff:
Cathy M. Hudgins, Ph.D., LMFT, LPC -- Director
Christine Borst, Ph.D., LMFT -- Clinical Coordinator
Maria Dover, M.S., LMFT -- Pediatric Program Manager
Peter Rives, M.S. -- Consultant
Eric Christian, M.S., LPC -- Consultant
Who we are:
The Center is a multidisciplinary group of
experts assembled to promote, support,
develop, sustain, and improve local, regional
and statewide Integrated Care (IC) efforts.
What we do:
◦ Consult and provide technical assistance services
to support and advance IC services in all types of
healthcare and mental health settings.
◦ Present IC information related to best practices to
local, state, national stakeholders.
◦ Research and develop resources to facilitate
efficient and sustainable whole-person, IC
systems.
◦ Maintain an up-to-date clearinghouse of the IC
existing and evolving resources, literature and
research to support evolving systems.
Questions?
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Borges, G., Ye, Y., Bond, J., Cherpitel, C., Cremonte, M., Moskalewicz, J.,
Swiatkiewicz, G., & Rubio-Stipec, M. (2010). The dimensionality of alcohol use
disorders and alcohol consumption from a cross-national perspective. Addiction,
105, 240-254.
Collins, C., Hewson, D., Munger, R., & Wade, T. (2010). Evolving models of
behavioral health integration in primary care. Retrieved from
http://www.integratedprimarycare.com/Milbank%20Integrated%20Care%20Report.
pdf
Institute of Medicine. (2006). Improving the quality of health care for mental and
substance-use conditions. Washington, DC: National Academies Press.
Kaslow, N. J., Bollini, A. M., Druss, B., Glueckauf, R. L., Goldfrank, L. R., Kelleher, K.
J., ... & Zeltzer, L. (2007). Health care for the whole person: Research update.
Professional Psychology: Research and Practice, 38, 278.
Lutterman, T., Ganju, V., Schacht, L., Monihan, K., & Huddle, M. (2003). Sixteen
state study on mental health performance measures Rockville: Center for Mental
Health Services. Substance Abuse and Mental Health Services Administration.
Mauer, B., & Jarvis, D. (2010). The business case for bidirectional integrated care.
Retrieved from http://www.thenationalcouncil.org/galleries/policyfile/CiMH%20Business%20Case%20for%20Integration%206-30-2010%20Final.pdf
Open Door Community Health Center (2005). Open door community health
center’s behavioral health program. Retrieved on March 10, 2010 from
http://www.opendoorhealth.com/resourceguide.php.
Substance Abuse and Mental Health Services Administration (US). (2006). SAHMSA
Treatment Improvement Protocol (TIP) Series, No. 45. Rockville, MD: Center for
Substance Abuse Treatment.
Whitman, W. (1860). Leaves of grass. Boston, MA: George C. Rand & Avery.