Hartford Dispensary
Integrating Medical & Dental Services
into an Addiction Treatment Setting
Paul McLaughlin, M.A.
Hartford Dispensary
NIDA Steering Committee Presentation:
Bethesda, Maryland
September, 2010
1
Integrating Behavioral Health & Primary Care Services
Hartford Dispensary Background and Overview
 Hartford Dispensary is a private not-for-profit
organization establish in 1871 as an out-patient
medical and dental clinic.
 In the 1960’s, the agency Board of Directors
redesigned its health care services in response to the
heroin epidemic in the Hartford area.
 The agency presently operates nine (9) fully
licensed and accredited clinics in Connecticut that
currently serves over 3,800 MMTP patients on a
daily basis. In 2009, 5,735 unduplicated patients
were served
2
Integrating Behavioral Health & Primary Care Services
Mission & Recovery Philosophy
Mission Statement:
“Personal Health; Public Health; Public Safety “
Hartford Dispensary’s recovery philosophy is based on the
fundamental goals of medication assisted treatment:
 Improve the patients’ quality of life and productivity.
 Reduce untimely deaths associated with narcotic use.
 Reduce the risk of the transmission and spread of
infectious diseases.
 Reduce crime associated with narcotic addiction.
3
Integrating Behavioral Health & Primary Care Services
Clinic Development and Census Expansion
Year Established
Patient Census 8/2010
1971
Hartford - Doctors Clinic
669
1971
Hartford - Henderson-Johnson
736
1980
Norwich Clinic
390
1992 New London Clinic
362
1994
New Britain Clinic
408
1989
Willimantic Clinic
381
2003
Bristol Clinic
444
2008
Manchester Clinic
465
4
Integrating Behavioral Health & Primary Care Services
Presentation Summary
Hartford Dispensary developed and implemented a Primary Care &
Dental Services program in a Hartford based clinic in 2006 as a result of a
convergence of several factors:
 Since the mid 1980s, the agency had developed a comprehensive Infectious
Disease Program. This increased our interest in addressing the unmet infectious
disease related medical issues presented by patients.
 Patient surveys consistently indicated high interest in both on-site medical and
dental services. A number of patients explained they did not have access to
primary care or dental services in the community.
 By 2000, the agency began to experience budget surpluses which the Board of
Directors wanted to use to address unmet patient needs. Surpluses could be
returned to the state
 In 2004, the agency had medical staffing in our two Hartford area clinics,
sufficient to serve over 2,400 patients.
 The agency had over 5,000 sq feet of excess, unused space at the HendersonJohnson Clinic in Hartford, and,
 In 2005, at the time the agency was reviewing its strategic plan, the
Commissioner of DMHAS expressed support to our Board for development of
on-site, community based primary care & dental services.
5
Integrating Behavioral Health & Primary Care Services
Developing a Continuum of Behavioral Healthcare Services
Since 1971, in addition to opening six (6) new clinics, the
agency has developed a comprehensive behavioral health
care program that includes:
 Medication assisted treatment with physician and
nursing services – physicals, lab follow-ups, medication
management.
 Substance abuse counseling and referral services,
 Mental health & psychiatric services, to include a Cooccurring Disorder program,
 Comprehensive infectious disease services, with
hepatitis C screening, assessment and on-site treatment &
hepatitis A & B vaccinations.
 Women’s Services; and Acupuncture
6
Integrating Behavioral Health & Primary Care Services
Aging Population & Chronic Disease Management
Consistent with national population trends, the population served is
aging. Since 1997, the percentage of agency patients aged 51 and over
increased from 5.7 % to 21.7 %.
Hartford Dispensary
2010 Performance Improvement Report
Percentage (%) of Patients by Age: 51 and Older
40
The aging population
increases the
probability of more
patients with chronic
disease management
needs.
35
Percentage (%) of Population 51 or Older
30
25
21.4 21.7
19
20
15
10 10.6
10
5.7
6.3
14.2
12.3 13.2
15.9 16.9
7.5
5
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Percentage
5.7
6.3
7.5
10
10.6
12.3
13.2
14.2
15.9
16.9
19
21.4
21.7
7
Integrating Behavioral Health & Primary Care Services
Evolution of the HD Infectious Disease Component

From the mid -1980s the agency infectious disease focus
was on Hepatitis B, TB, & STDs.

During the 1980’s, the agency established and continually
enhanced a comprehensive HIV/AIDS services program,
following the review of the outcomes of an agency-wide
HIV/AIDS prevalence study.

During the 1990’s, Hepatitis C was identified as a growing
problem for intravenous drug users. In 2000, the agency
conducted a Hepatitis C prevalence study of 1,000 patients.
The study revealed that 50 -72% of patients had the
Hepatitis C antibody.

Data from the study was shared with state agencies, who
encouraged us to provide Hepatitis C training to staff and a
8
patient education program was established.
Integrating Behavioral Health & Primary Care Services
Addition of Hepatitis A & B Vaccination Program

In 2001, in order to guide the development of hepatitis C screening,
evaluation, and treatment services, the agency hired a
Gastroenterologist and an addictions psychiatrist. On-site hepatitis C
treatment for patients began December 2001.

In 2002, in collaboration with CT DPH, the agency established a
hepatitis A & B vaccination program in our two (2) Hartford-area
facilities using the Twinrix vaccine provided by CT DPH.

In 2003, the vaccination services were implemented at the agency's
Willimantic Clinic. In 2006, vaccination services were established in
agency clinics in New London, Norwich, New Britain and Bristol. And
in 2008, vaccination services began in the new Manchester Clinic.

As of April 2010, some 5,000 patients had began the Twinrix A & B
vaccination protocol. From 2002-2005 the completion rte was over
70%.
9
Integrating Behavioral Health & Primary Care Services
Development of Primary Care & Dental Services
 In 2002, the agency Board of Directors inquired as to the availability of
dental and medical services to patients and authorized the Executive
Director to explore dental options.
 In 2003, the agency conducted a patient survey to determine patient
interest in both medical and dental services. A majority of patients
indicated they would be interested in on-site services
 The dean of the University of Connecticut Dental School was contacted
and showed a high interest in our under-served population. The dean
recommended we establish a relationship with a FQHC as a referral
services provider.
 The agency formed a collaborative agreement for dental services with
Community Health Services – a local FQHC. The relationship worked
well for over a year. Due to transportation reliability issues; the
placement of our patients “last in line”; and budget reductions, the
agency considered an alternative model.
10
Integrating Behavioral Health & Primary Care Services
Development of Primary Care & Dental Services
 The dean of the University of Connecticut Dental
School was again contacted and proposed a contract for
dental services between the agency and the Dental
School. The Dental School would provide a dentist and
dental students.
 In March 2005, the Commissioner of the CT
Department of Mental Health and Addiction Services
spoke to the agency Board of Directors and
acknowledged his support for integrating primary care
serves and dental with behavioral health care
 The Executive Director and various agency staff then
toured the central medical unit at the APT foundation
in New Haven, CT. to study their 12 year old primary
care program model and their implementation process.
11
Integrating Behavioral Health & Primary Care Services
Development of Primary Care & Dental Services

In July 2005, the agency prepared a “Primary Care & Dental Services
Business Plan” which was approved by the agency Board of Directors.

Our approach to developing the unit was to consolidate and centralize
medical resources to a renovated unit in one Hartford clinic. This was
completed by the summer of 2006.

The initial project objectives included:

Provision high quality, relevant primary care and dental services to
an underserved population 8 am to 3:30 pm, five days a week

Enhancement of our Recovery Model of Care by improving patient
access to primary care & dental services.

Establishment of a national model for the process of introducing
Primary Care Services - to include dental services - into community
based medication assisted treatment programs.
12
Integrating Behavioral Health & Primary Care Services
Primary Care & Dental Program: Office Development

Hartford is ranked as one of the poorest communities in the
country and is designated as a medically underserved city.

The agency’s two Hartford area - Henderson-Johnson
Clinic (H-J) and Doctors Clinic- had a combined patient
population of over 2,400 patients in 2005, with medical
staff e.g. physicians, nurses, and support staff assigned to
each unit.

The H-J Clinic, the agency’s largest clinic, served as the
central intake unit for the two clinics.

As a result, the H-J Clinic was chosen as the location for the
new unit. The campus had two building. The second floor of
one was under-utilized and renovated to serve as the
Primary Care & Dental Unit.
13
Integrating Behavioral Health & Primary Care Services
Primary Care & Dental Program Licensure & Accreditation
In preparing for licensure and accreditation, the agency initially
developed Primary Care Unit policies and procedures based on the APT
foundation model and The Joint Commission, Ambulatory Care
accreditation standards.
The Primary Care & Dental Unit opened May 2006, initially providing
intake and annual physicals to the medication assisted treatment patient
populations of Henderson-Johnson & Doctors clinics.
 On 1/17/07 the unit received an Outpatient Clinic, Primary Care
Services license from the CT Department of Public Health (DPH).
 On 6/20/07 DPH revised the license to reflect the addition of Dental
Service, effective 6/7/07.
 On 2/29/09 the Primary Care Unit was accredited under newly
developed CARF Integrated Behavioral Health Primary Care
standards
14
Integrating Behavioral Health & Primary Care Services
Primary Care & Dental Program Offices
15
Integrating Behavioral Health & Primary Care Services
Primary Care & Dental Program Staffing

The agency initially provided physicians for the Primary Care Unit by
moving physician hours from the two Hartford medication assisted
treatment program to the new unit.

In addition to new primary care services, the medical staff continued to
provide initial and annual medical evaluations, testing, and medication
monitoring, for the medication assisted treatment patients served by the
two Hartford clinics.

A receptionist, and two (2) medical assistants were transferred to the
program and a Primary Care Coordinator was hired

Dental services for patients were provided through a contract with the
University of Connecticut, Dental School. A dentist plus dental students
provide patient services. The agency hired and funded two (2) part-time
dental assistants.
16
Integrating Behavioral Health & Primary Care Services
Primary Care Medical Services

Methadone Maintenance Services: Admission and annual physicals; lab
follow-ups; Hepatitis A& B vaccinations; infectious disease testing

Primary Care Medical Services:







Comprehensive History and Physical exams.
Disease management: diagnosis and management of major/minor
illnesses.
Prevention services: nutrition and weight management & smoking
cessation.
Infectious disease services to include on-site Hepatitis C treatment.
(Seven current patients July 2010)
Laboratory services.
Pregnancy testing and referral.
Medical referrals for specialty services
17
Integrating Behavioral Health & Primary Care Services
2009 Primary Care Program Volume
2009: PCU
PT Volume
Total # of
Patient
Visits
MMTP
Admission
Physicals
MMTP
Annual
Physicals
New PC
Patients
Total PC
Patient visits
per month
Patent Lab
Follow-ups
January
223
52
53
7
62
52
February
294
47
89
16
76
75
March
371
50
150
15
59
104
April
443
45
175
8
65
148
May
270
38
101
8
47
79
June
335
37
97
14
92
104
July
251
36
76
14
60
65
August
246
33
69
13
71
70
September
281
40
120
1
40
70
October
290
47
86
6
49
96
November
256
35
85
6
60
51
December
219
44
52
8
68
45
3177
504
1084
116
749
959
265
42
90
8.8
62.4
80
Total
Average Per
Month
18
Integrating Behavioral Health & Primary Care Services
2009 Dental Program Services: June 2010
170 patient visits were scheduled. 136 visits took place. 80 individual
patients received services. This was an average of 1.7 visits per patient
Hartford Dispensary
served.
Primary Care Dental Program
Services Provided June 2010
21
Fillings
17
Emergency Extraction
13
Extraction
11
Full Mouth X-Ray
10
Scaling and Root Planing
Number
7
Full Exam
5
Limited Emergency Evaluation
3
Cleaning
16
Other
33
Continuing Care
0
10
20
30
40
50
19
Integrating Behavioral Health & Primary Care Services
Primary Care & Dental Program Modifications
Since 2006, primary care & dental program modifications
have occurred based on patient volume, changes in
resources, and program outcomes
 The primary care unit changed from a “walk-in-clinic” to a
“continuous practice model” in 2007. New physicians with this focus
were hired
 A nutritionist was hired in 2007. (However the position was defunded by
the state in 2009).
 During 2009, based on a reduced patient census, the staffing model was
modified from two (2) full time primary care physicians to two (2)
part-time physician and one (1) full time Physician’s Assistant.
20
Integrating Behavioral Health & Primary Care Services
Primary Care & Dental Program Modifications
 In 2009, the agency's Chief of Medical Staff, an addictions
psychiatrist, was relocated to the Primary Care & Dental
Unit to further develop the “one-stop-shopping” model.
 In 2010, the Dental Services Unit was expanded under a
new contract with UCONN from two (2) days per week, to
three (3) days per week due to increasing demand for dental
services.
 35% of the agency population served are female. As 55% of
primary care patients are women, a part-time APRN is being
recruited to focus on expanding women's medical services.
21
Integrating Behavioral Health & Primary Care Services
Lessons Learned in Integrating BH & Primary Care Services
 “Build-it-and-they-will-come”. Over 1,400 individual
patients from two (2) agency clinics were seen at least once
during 2009.
 A 2010 survey of 2,288 patients in the agency’s other six
clinics revealed 1850, or 81% of patients would use dental
services if provided on site while 1,807 or 70% of the
population stated they would use medical services if
provided on site.
 The medication assisted treatment program requirement for
intake and annual physicals provides an opportunity to
market primary care and dental services.
22
Integrating Behavioral Health & Primary Care Services
Lessons Learned in Integrating BH & Primary Care Services
 Re-aligning current medical and support staff, and
co-locating then in a single location can be an
efficient and cost effective method to develop and
staff a primary care unit.
 Models need to be flexible enough to change based
on patient volume, changes in resources, changes in
patient demographics, etc.
For example, the age of persons served is increasing,
thus more chronic disease management medical
resources will be required.
23
Integrating Behavioral Health & Primary Care Services
Lessons Learned in Integrating BH & Primary Care Services
 Consolidating multiple services and co-location in a central location
creates synergy and can improve patient access to all services.
 Monitoring data on clinician productivity, billing and claims is
essential for use in managing and modifying services to properly meet
customer needs in a cost effective manner.
 Relationships with medical specialty referrals sources must be
developed to address complex patient medical needs.
 Partnering with medical & dental schools in collaborative
relationships can create benefits for all parties.
For example, nearly 25% of all 3rd year UCONN dental students now
rotate through the agency dental clinic, gaining exposure to
community based treatment and the needs of underserved populations
24