Thomas E. Freese, PhD
Sherry Larkins, PhD
UCLA Integrated Substance Abuse Programs
Pacific Southwest Addiction Technology Transfer Center
1
The County of Los Angeles Department of Mental Health
has collaborated with the Department of Health Services
(DHS) to implement the following programs in an effort
toward integration:
 The LACDMH/DHS Collaboration Program
 Healthy Way L.A. Community Partners
 Project 50
 MHSA Innovation Programs
 Center for Community Health of Downtown Los Angeles
 LACDMH & HealthCare Partners
Collaborative Care Program

The LACDMH/DHS Collaboration Program
DMH has co-located small teams comprised of social workers,
marriage and family counselors, and medical case workers, in DHS
Comprehensive Health Centers (CHC) and Multiservice Ambulatory Care
Clinics (MACC) on a full-time basis. The DMH teams deliver shortterm, early intervention, evidenced-based, specialty mental health
services using the Mental Health Integration Program (MHIP) model to
treat persons with mild to moderate mental health symptoms. MHIP
is a stepped collaborative care model shown effective in treating
persons with depression and anxiety seen in primary care settings.
Clinical consultation with a psychiatrist is available to both the
treatment teams and to the primary care providers.
3

Healthy Way L.A. Community Partners
DMH has partnered with numerous health care agencies under
contract with the DHS, known as Community Partners (CP), to provide
short-term, early intervention, evidence-based, specialty mental
health services on-site at the CP agencies. CPs, many of which are
also Federally Qualified Health Centers (FQHC), are providing services
using the MHIP model. DMH has and continues to provide training on
the MHIP model to clinical staff employed by the CPs who are
providing services to individuals with mild to moderate mental health
symptoms. Furthermore, partnerships have been established between
the CPs and existing DMH directly-operated and contracted specialty
mental health clinics to provide a well-coordinated referral process
between health and mental health when a consumer requires a level of
care beyond a short-term early intervention.
4

Project 50
Project 50 is a demonstration program to identify, engage, house and
provide integrated supportive services to the 50 most vulnerable,
long-term chronically homeless adults living on the streets of Skid
Row. The Los Angeles County Board of Supervisors passed the motion
to implement Project 50 in November 2007.
Project 50 involves three phases:
1. Registry Creation
2. Outreach Team
3. Integrated Supportive Services Team.
Currently, Project 50 is operating in the third phase. Four Project 50
Replication sites have been developed in Santa Monica, Van Nuys,
Venice and Hollywood. They are at various stages of implementation.
5

MHSA Innovation Programs
DMH community stakeholders have identified four (4) models of care
that integrate mental health, physical health and substance abuse
services. MHSA Innovation (INN) model programs seek to learn which
practices increase quality of services, improve consumer outcomes,
promote community collaboration and the most cost effective in order
to meet the spectrum of needs of individuals who are uninsured/
economically disadvantaged, homeless and members of
underrepresented ethnic populations. By implementation and
evaluation of new and innovative approaches, the time-limited MHSA
INN model programs will contribute to learning and inform future
practice. The four Innovation Models include:
◦ Integrated Clinic Model (ICM)
◦ Integrated Mobile Health Team Model (IMHT)
◦ Community-Designed Integrated Service Management Model (ISM)
◦ Integrated Peer Run Models-Peer Run Integrated Service
Management (PRISM) & Peer Run Respite Care Homes (PRRCH)
6

Center for Community Health of Downtown
Los Angeles
Led by the Los Angeles County Chief Executive Office (CEO), the Center
for Community Health of Downtown Los Angeles (CCHDLA) is a
private/public partnership that employs a one-stop shop of resources
approach for homeless and low-income people in the Skid Row area of
downtown Los Angeles. Opened in 2009, it has increased access to all
health-related services, including primary health care, specialty care,
mental health, substance abuse, optometry, dentistry, medication, xrays, HIV education and prevention, and STD and TB clinics. Known as
an “Integrated Care for the Homeless Model,” CCHDLA employs an
Integrated Services Team approach in which all partner agencies
involved in the consumer’s care confer and develop a comprehensive,
integrated treatment plan and service delivery.
7

LACDMH & HealthCare Partners Collaborative
Care Program
DMH has developed an integrated pilot program with HealthCare
Partners (HCP) and LA Care Health Plan to treat chronically and
persistently mentally ill (CPMI) patients through collaborative care.
Dually-eligible (Medicare/Medi-Cal) individuals who enroll in an LA
Care Medicare Advantage program will be primarily treated in HCP's
Collaborative Care Centers, though they could also receive their care
at home, in long-term care facilities and elsewhere depending on the
individual needs of the patient. The patient's treatment plan is comanaged by a medical doctor and a psychiatrist along with a team of
nurse practitioners, care managers, social workers, and psychologists.
The patient’s medical care is fully integrated with behavioral health
interventions that include pharmacologic and behavioral/social skills.
It is anticipated that diagnoses included in this treatment model will
predominately include: schizophrenia, bi-polar and obsessivecompulsive disorders, severe major depression with and without
psychotic features, severe chemical dependency and dementia.
8


These projects represent a dramatic shift toward a
whole health orientation. This means that we all
need to think about the work that we do as part of a
wholistic system, rather than a separate entity.
This new orientation leads to the need for mental
health staff to fulfill new roles in all DMH settings
that ensure that services are provide in an integrated
way. This will:
◦ Increase treatment efficacy
◦ Improve client outcomes
◦ Increase staff satisfaction and
decrease burnout
See Handout
for a full
description
of each
project





Primary care culture and effective
communication
Role definitions for Mental Health staff in
primary care settings
Medical issues that commonly co-occur with
mental health and substance use
Barriers to service access
A case example.
10
11
Average spending on health
per capita ($US PPP)
Total health expenditures as
percent of GDP
Notes: PPP = purchasing power parity; GDP = gross domestic product.
Source: Commonwealth Fund, based on OECD Health Data 2012.
Distribution of health expenditures for the U.S. population,
by magnitude of expenditure, 2009
Annual mean
expenditure
1%
5%
10%
22%
50%
50%
$90,061
$40,682
65%
$26,767
97%
$7,978
Source: Agency for Healthcare Research and Quality analysis of
2009 Medical Expenditure Panel Survey.
In the USA and Canada, mental health disorders
account for 25% of all years of life lost to disability
and premature mortality1
One in four American adults experience a mental
health disorder in a given year, and 1 in 17 have a
seriously debilitating mental illness2
Among those who die by suicide, more than 90%
have a diagnosable disorder4.
In 2008, suicide was the tenth leading cause of death
in the USA6.





1.
2.
3.
4.
World Health Organization. (2004). The world health report 2004: changing history. Annex Table 3.
A126-A127. Geneva: WHO.
Kessler RC, et al. (2005). Archives of General Psychiatry, 62: 617-627.
US Department of Health and Human Services. (1999). Mental health: a report of the Surgeon General.
Rockville, MD: US Department of Health and Human Services, 1999.
Minino AM, et al. (2011). Final Data for 2008. National Vital Statistics Reports 2011; 59(10): 01-127.
Available: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf.
13

Mental health and substance use services are
integral to health care services. The goals of
DMH initiatives are:
◦ Ensure positive experiences of care
◦ Enhance customer services

Ensure care is effective
◦ Develop bi-directional care/behavioral health homes
◦ Implement data outcomes system to enable
monitoring of client progress

Control/reduce costs
◦ Develop strategies to extend care
◦ Develop strategies to reduce readmission and
preventable hospitalizations
14
Primary Care
 The aims of primary care are to provide broad
spectrum of care
◦ both preventive and curative;
◦ over a period of time; and
◦ to coordinate all of the care the patient receives.

All family physicians and most pediatricians
and internists are in primary care.
◦ www.medicinenet.com
15
Primary Care
 Practitioner must possess a wide breadth of
knowledge in many areas.
 Patients consult the same primary care doctor
for routine check-ups, and initial consultation
about a new complaint.
 Common chronic illnesses, often treated in
primary care, include:
◦ Hypertension
◦ Asthma and COPD
◦ Arthritis and other pain
-- Diabetes
-- Depression and anxiety
16
1.
2.
3.
4.
5.
The person receiving services is called…
The building(s)/place(s) where the person
receives services is called…
The room where the person receives
services is called…
The person who has the ultimate
responsibility for the care of the person is
called…
The person who is responsible for care
coordination is called…
17
18

It is important to understand the system with
which you are working
19


It is important to understand the system with
which you are working
Learn about the medical conditions that bring
people to primary care
20



It is important to understand the system with
which you are working
Learn about the medical conditions that bring
people to primary care
Expand your vocabulary to facilitate
communication
21




It is important to understand the system with
which you are working
Learn about the medical conditions that bring
people to primary care
Expand your vocabulary to facilitate
communication
Stay within your scope of practice in your
interactions
22





It is important to understand the system with
which you are working
Learn about the medical conditions that bring
people to primary care
Expand your vocabulary to facilitate
communication
Stay within your scope of practice in your
interactions
Make yourself visible and useful
23






It is important to understand the system with
which you are working
Learn about the medical conditions that bring
people to primary care
Expand your vocabulary to facilitate
communication
Stay within your scope of practice in your
interactions
Make yourself visible and useful
Be accessible and available
Who does what in an
integrated care system?
25
In an integrated care system, what is the best
role of each of the following disciplines. What
should they take lead on? How should they
be involved in collaboration?
 Medical Provider
 Mental Health Provider
 Substance Use Disorder Provider
 Behavioral Health Specialist
 Peer Specialist
 Family
26

Differing practice styles

Differing practice cultures and language



Difficulty in matching provider skills with
patient needs
Heavy reliance on physician services
Tension between direct patient care services
(reimbursable) and integrative (nonreimbursable) services
27
27

Lack of recognition of provider limitations

Lack of MH knowledge in PC providers and lack of
health knowledge in BH providers

Lack of clinical competence in integrated service
models (MH/SU and BH/PC) and selection of
proper integration model based on practice
context

Differing confidentiality and information sharing
procedures

Differing coding and billing systems

Provider resistance
28
From Co-Location to Fully Integrated Care
Bill Rosenfeld
29






Behavioral Health Consultant (BHC) placed in
medical clinic
Considered a member of the primary care
team
Provides consultation (not therapy)
Goal of immediate access, minimal barriers
Emphasizes psychoeducation, population
mgmt
Focus on improving QOL, quality of health
care
30

Part-time IBH coverage

Allowing the BHC “Office Hermit” to go
on too long

Clinician’s housed outside of medical
providers service delivery area.

Approaching commercial insurance for
reimbursement…boomerang effect

Implementing a co-location model
31
Medical Diagnosis
Behavioral Health Intervention
HTN
Relaxation skills training, breathing,
problem solving
Diabetes
Promote goal identification and
attainment, enhance mood stability,
identify and restructure alarmist
thinking, stress reduction
Chronic Pain (multiple Promote the use of attention
presentations),
diversion techniques, relaxation
including fibromyalgia skills, stages of pain, values
syndrome
clarification
Obesity
Promote goal identification and
attainment, behavioral modification,
support healthy lifestyle attainment,
motivational change, diet/exercise,
motivation for change





Better blood sugar control
Diminished Missed School Days
Diminished rate of patients asked to
leave practice
Patient confidence in self-care enhanced
Ratio of SM goals set and education
attended enhanced
These goals are important to the
patient event if they do not have
a primary care provider
33

All PCPs reported:
 Satisfaction with the BHC service
 Access to BHC as “immediate” and “very helpful”
 Better able to address behavioral problems
 Recommend the service for other medical
providers

A majority (> 80%) said because of BHC:
 Have greater confidence in how BH issues are
treated within the collaborative framework
 Able to see more patients in 20 minutes
 Better recognize patient behavioral issues
34





90% said visit length “Very Good”, or
“Excellent”
88% rated quality of BHC care as “Very
Good” or “Excellent”
94% would recommend BHC to family or
friends
89% said it was helpful to meet w/ BHC
82% felt BHC involvement resulted in
improved health status
35



MPHC dismisses 75% fewer patients from our
practice since socially embedding a BHC in
Internal Medicine
Positive impact on recruitment of medical
providers
Broad range of staff training possibilities
36
Thanks for Bill Rosenfeld for providing this information
www.mountainparkhealth.org/
37
38
39


Type 1 diabetes is usually diagnosed in children
and young adults. The the body does not produce
insulin. Only 5% of people with diabetes have this
form of the disease.
Type 2 diabetes, the most common form of
diabetes, either the body does not produce enough
insulin or the cells ignore the insulin. Insulin takes
the sugar from the blood into the cells. If insulin is
not working, glucose builds up in the blood instead
of going into cells, it can lead to diabetes
complications. Type 2 diabetes is more common
in African Americans, Latinos, Native Americans,
Asian Americans, Native Hawaiians and other
Pacific Islanders, as well as the aged population.
40
Basic Overview:
◦ Metabolic disease.
◦ Hyperglycemia (too much
sugar) due to insulin
resistance and defects in
insulin secretion.
◦ Diabetes can lead to:
 blindness
 heart & blood vessel disease
 stroke
 kidney failure
 amputations
 nerve damage.
http://safediabetes.blogspot.com/2010/1
2/how-to-reduce-impact-type-2diabete.html
41


Often no symptoms at all.
Most common symptoms
include:
Blurred vision
Erectile dysfunction
Fatigue
Frequent or slow-healing
infections
◦ Increased appetite
◦ Increased thirst
◦ Increased urination
◦
◦
◦
◦
http://www.thetype2diabetesdiet.com/wpcontent/uploads/2009/03/symptoms-fortype-2-diabetes.gif
42
Gender*
Age*
*American Diabetes Association, 2011.
Ethnicity**
**US DHHS Office of Minority Health, 2010
43





The hemoglobin A1c test is used to
determine how diabetes is being controlled.
HbA1c provides an average of your blood
sugar control over a six to 12 week period.
When blood sugar is too high, sugar builds
up in your blood and combines with your
hemoglobin, becoming "glycated."
For people without diabetes, the normal
range for the HbA1c test is 4% - 6%. The goal
for people with diabetes is an hemoglobin
A1c less than 7%.
Retest should occur every three months to
determine level of control.
44




The Medical Provider
The Substance Use Disorders Provider
The Mental Health Provider
Peers and Family
45
Relationship with SUD
◦ Heavy alcohol consumption can increase risk
factors including: body-mass index, low HDL
(“good”) cholesterol and cigarette smoking
(Tsumura, 1999).
◦ A history of substance use is associated with
earlier age of onset of diabetes (Johnson, 2001).
◦ SUD is associated with increased mortality in
diabetics (Jackson, 2007).
Significance of Behavioral Health
◦ Diabetes patients also have increased depression.
Both diet control and depression respond to
behavioral activation strategies
◦ In 2006, it was the seventh leading cause of death,
and cost the US $174 billion in medical costs, loss
of productivity, disability costs
46



Medical services available on-site better link
clients in SUD treatment to medical services
compared to those with outside referrals
(Friedmann, 1999).
Social support for abstinence can increase
linkage to medical services. (Saitz, 2004).
Encourage activities that improve diabetes:
◦ Better diet.
◦ Reduce simple carbohydrate intake (i.e. potatoes,
white bread, corn, soda, candy, sweets).
◦ More exercise.
◦ Maintain regular appointments with doctor
overseeing diabetes treatment.
47
Common Medical Issues Associated with
Mental Health and Substance Use Disorders
48
90%
77%
80%
70%
67%
60%
50%
42%
41%
40%
31%
30%
30%
30%
28%
20%
10%
10%
Gender*
*Centers for Disease Control and Prevention, 2012.
Age*
Mexican
NH Black
NH White
75+
65-74
45-64
20-44
Female
Male
0%
Ethnicity*
49



Blood pressure (BP) is the
force against the walls of
one’s arteries while blood
is pumping.
Hypertension is when BP
is too high.
Example BP: 120/80
mmHg (“120 over 80”)
◦ Systolic (top number):
pressure while heart
contracts.
 Normal is <120. High is >180.
◦ Diastolic (bottom number)
pressure while heart relaxes
& enlarges.
 Normal is <80. High is >80.
50

Increased risk of:
◦ Stroke
◦ Blood vessel damage
(arteriosclerosis)
◦ Heart attack
◦ Tearing of heart’s inner
wall (aortic dissection)
◦ Vision loss
◦ Brian damage
(NIH, 2010)
51




Three or more drinks per day increases BP &
risk of hypertension in both women and
men (Sesso, 2008).
Decreasing alcohol consumption associated
with dose-dependent reduction in BP (Xin,
2001).
Stimulants like cocaine or amphetamines
can cause HTN and other acute and chronic
cardiovascular diseases. (McMahon, 2010).
HTN risk associated with quantity of
cigarettes smoked daily and the duration of
smoking (Orth, 2004).
◦ Former smokers have higher rates of
hypertension than those who never smoked
2004).
(Orth,
52

HTN can be well controlled in primary care
for most patients (Williams 2004).
◦ Some many need help finding transportation.
◦ Some may need help finding free or low-cost
clinics.



Ask about alcohol consumption. Encourage
limiting to 2 or less drinks per day.
If client smokes, give advice and support to
quit smoking (NICE, 2006).
Encourage weight loss and salt reduction.
◦ Losing 10kg (22 lbs) can reduce systolic BP by 10
points (Cappuccio, 2007).
53
Common Medical Issues Associated with
Mental Health and
Substance Use Disorders
54




In 2011, at least 100 million adult Americans have
common chronic pain conditions (excl. acute pain
and children)*.
Pain costs society at least $560-$635 billion
annually (an amount equal to about $2,000 for
everyone living in the U.S.)*.
Women are more likely to experience pain (in the
form of migraines, neck pain, lower back pain, or
face or jaw pain) than men**.
Adults age 45-64 years were most likely to report
pain lasting more than 24 hrs. (30%), followed by
young adults age 20-44 (25%0, and adults age 65
and over (21%)***.
*IOM, 2011; CDC, 2009; NCHS, 2006.
55
Condition
Number of Sufferers
Source
Institute of Medicine of
The National Academies
Chronic Pain
100 million Americans
Diabetes
25.8 million Americans
American Diabetes
(diagnosed and estimated Association
undiagnosed)
Coronary Heart Disease
(heart attack and chest
pain)
16.3 million Americans
Stroke
Cancer
American Heart
Association
7.0 million Americans
11.9 million Americans
American Cancer Society
http://www.rxreform.org/wp-content/uploads/2011/06/Toblin-2011-Kansas-Pain-corrected-proof.pdf
56


Any prescription drug can be “misused”
Misuse = “non-medical use” = Any use that is
outside of medically prescribed regimen:
◦
◦
◦
◦
◦
◦
◦
Non-compliance
Taking different dose
Sharing
Obtaining from non-medical source
Taking for psychoactive effects
Taking for effects not indicated
Use with alcohol or other substances
57
• Relieves pain
• Relieves suffering
• Relieves misery
• Makes you feel better
• Makes you feel good
• Makes you “high”
58






Broad availability of prescription drugs
◦ e.g., via the medicine cabinet, family,
friends, Internet, and physicians
Misperceptions about their safety
Focus on a pill for every ill (cultural trend,
media)
High rates of other substance use including
abuse cigarettes, drugs and alcohol
Childhood history of abuse, trauma and
neglect
High rates of depression and anxiety
59


Pain: An unpleasant sensory and emotional
experience arising from the actual or potential
tissue damage or described in terms of such
damage
It is always subjective. Each individual learns
the application of the word through
experiences related to injury in early life
(International Association for the Study Pain [IASP])
Early life – historical
Experience—learned
Subjective—private
Individual--unique
60
65% of patients with
depression experience pain


75% of primary care
patients with depression
present only with physical
complaints and do not
attribute their pain to
depression
0 or 1 physical symptom 2% were found to have
depression
≥ 9 physical symptoms –
60% were depressed
Bair MJ et al, ARCH INTERN MED, 2003
5% to 85% of patients with
pain have depression


Increasing pain severity,
frequent pain episodes,
diffuse pain, and
treatment resistant pain
are associated with more
severe depression
In patients with pain,
depression is associated
with more pain
complaints, greater
intensity, longer duration
of and greater likelihood
of nonrecovery
61
Trends in opioid prescribing (2000 and 2005)
with and without MH and SUDs
Insured
 34.9% with an MH or SUD
 27.8% without MH and SUD
Arkansas Medicaid
 55.4% with an MH or SUD
 39.8% without an MH or SUD
Insured
AR Medicaid
62


Chronic use of prescription opioids for NCPC is
much higher and growing faster in patients with
MH and SUDs than in those without these
diagnoses
Clinicians should monitor the use of prescription
opioids in these vulnerable groups to determine
whether opioids are substituting for or interfering
with appropriate MH and substance abuse
treatment
Edlund, Mark et al, Clinical Journal of Pain 2010
63



Kowalski & Bondmass
(2008) study of pain and
grief correlation in widows
Self-reported physical
symptoms included:
◦ Pain
◦ Gastro-intestinal
problems
◦ Medical/surgical
conditions
◦ Sleep disturbances
◦ Neurological/circulatory
issues
Psychological symptoms:
◦ Depression
◦ Anxiety
◦ Loneliness

Of the 173 women in the
sample, about two-thirds
the sample reported at
least one physical
complaint following
spousal loss
64
Kowalski & Bondmass, 2008
The Dilemma


Need to accurately diagnose disease and
provide effective analgesia
Some illnesses have no diagnostic test, but are
frequently cited as reasons for pain syndromes
needing medication treatment(s)







Headache
Low back pain
Pelvic pain
Arthritis
Fibromyalgia
Chronic Fatigue Syndrome
Has contributed to misuse of pain pills and
addiction
65

Predictive factors; as non-pain
patients
◦ Personal or family history of drug
abuse
◦ Current addiction to alcohol or
cigarettes
◦ History of problems with
prescriptions
◦ Co-morbid psychiatric disorders
66

No validated diagnostic criteria for
addiction in pain patients; only “at risk”
behaviors:
◦
◦
◦
◦

Control
Compulsive use
Continue use despite harm
Craving
Identifying “at risk” patients:
◦
◦
◦
◦
History
Screening instruments
Behavioral checklists
Therapeutic maneuver
67
Mark each box that applies:
1.
2.
Female
Male
Family history of substance abuse
Alcohol
1
3
Illegal drugs
2
3
Prescription drugs
4
4
Alcohol
3
3
Illegal drugs
4
4
Prescription drugs
5
5
Personal history of substance abuse
3.
Age (mark box if between 16-45 years)
1
1
4.
History of preadolescent sexual abuse
3
0
5.
Psychological disease
ADO, OCD, bipolar, schizophrenia
2
2
Depression
1
1
Administration
• On initial visit
• Prior to opioid therapy
Scoring
• 0-3: low risk (6%)
• 4-7: moderate risk (28%)
• > 8: high risk (> 90%)
Scoring totals:
Webster, et al. Pain Med. 2005;6:432.
68
Probably more predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing
another patient’s drugs
• Injecting oral formulation
• Obtaining prescription drugs
from non-medical sources
• Concurrent abuse of related
illicit drugs
• Multiple unsanctioned dose
⇧s
• Recurrent prescription
losses
Passik and Portenoy, 1998
69
Probably more predictive Probably less predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing
another patient’s drugs
• Injecting oral formulation
• Obtaining prescription drugs
from non-medical sources
• Concurrent abuse of related
illicit drugs
• Multiple unsanctioned dose
⇧s
• Recurrent prescription
losses
Passik and Portenoy, 1998
• Aggressive complaining
about need for higher dose
• Med hoarding when
symptoms are reduced
• Requesting specific meds
• Acquisition of similar meds
from other medical sources
• 1-2 unsanctioned dose ⇧
• Unapproved use of the
med for another symptom
• Reporting psychic effects
not intended by the
clinician
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“Luz”
A client from EXODUS ICM
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Cl is a 55year old Hispanic (Puerto Rican) female, divorced,
mother of 5 adult children, 4 sons and a daughter who
passed away 6 yrs ago. Currently estranged from all family
members except for one son. Currently renting a bedroom in
a home. Cl receives recently was awarded SSI and Medi-Cal
benefits. Enrolled in the ICM program September 2012.
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Presenting problems
Initially presented to clinic with sx of depression, anxiety,
crying spells, labile moods, angry outbursts, hopelessness
and restless sleep.
Reports she has been depressed most of her life but
depression exacerbated 6 yrs ago after the death of her
daughter in an MVA. She has extensive drug abuse hx. Drugs
of choice are crack and ETOH. Client recently graduated from
a residential treatment program and has been sober for 3 yrs.
In January 2013, client exhibited hypomania and delusions
that she is pregnant. Presented with elevated mood,
decreased need for sleep, racing thoughts, increase in goal
directed bx, auditory and visual hallucinations, heavy makeup and poor hygiene. Her diagnosis was noted as Bipolar
D/O.
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History
Client born in Puerto Rico. She has a 3rd grade education but
is illiterate. Speaks Spanish and English. Reports hx of severe
physical and sexual abuse at the hands of her father
beginning at age 8. Children have been removed form her
custody due to drugs and domestic violence with her
boyfriend. Family hx of addictions and depression.
Client has no work history other than “selling drugs” and
“prostitution”.
Psychiatric history
Client was referred by her rehab program to Exodus Urgent
Care Center and then to Exodus ICM . She has previously
received brief crisis based services.
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Medical history:
Client has Type 2 Diabetes, hypertension, COPD, and obesity.
At intake, her BP was 139/82, BMI 44.79, Hemoglobin A1C
8.2, smoking 1 pack of cigarettes a day.
Most recent values are as follows: BP 112/75, BMI 41.56,
Hemoglobin A1C 5.8, smoking 3-4 cigarettes a day.
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Laboratory Normal Values:
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BP:
◦ Normal systolic is <120. High is >180.
◦ Normal diastolic is <80. High is >80.
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HbA1c:
◦ Normal 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than
7%.
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BMI:
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Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater
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Diagnosis
Axis I 296.44 Bipolar D/O, Manic w/ Psychotic features.
304.80 Polysubstance Dependence in full sustained
remission.
Axis II No Diagnosis
Axis III Type 2 Diabetes, hypertension, hyperlipidemia, COPD,
and obesity
Axis IV Problems with primary support group, social
environment, educational, occupational, economic,
access to health care, legal, other
Axis V GAF 55
Medications
Lithium 600mg QHS (mood stablizer)
Celexa 20mg QAM (depression)
Abilify 2mg QAM (adjunctive tx for for bipolar disorder)
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1. Precontemplation
Definition:
Not yet considering change or
is unwilling or unable to change.
6. Recurrence
Definition:
Primary Task:
Raising Awareness—Connect
SU and MH Sxs
Experienced a recurrence
of the symptoms.
2. Contemplation
Definition:
Sees the possibility of change but
is ambivalent and uncertain.
Primary Task:
Primary Task:
Cope with consequences , relate to
MH functioning as precursor
and outcome
Resolving ambivalence/
Helping to choose change
Has achieved the goals and is
working to maintain change.
Committed to changing.
Still considering what to do.
Primary Task:
Primary Task:
Develop new skills to maintain
improvements in
MH and SU
Help identify appropriate
strategies to improve MH/
reduce SU
Stages of Change:
Primary Tasks in Linking
5. Maintenance
3. Determination
MH
and
SU
Definition:
Definition:
4. Action
Definition:
Taking steps toward change but
hasn’t stabilized in the process.
Primary Task:
Help implement change strategies
to decrease MH Sxs and SU
Stages of Change: Intervention Matching Guide to Link MH and SU
1. Precontemplation
2.
Contemplation
3.
Determination
• Offer factual information about MH-SU
connection
• Explore the person’s sense of selfefficacy to reduce MH symptoms
• Offer menu of options for addressing
MH Sxs and SU
• Explore the events that brought them
to treatment—Impact of SU/MH
• Explore expectations about change—
What is the role of SU on MH Sxs?
• Help identify pros and cons of various
change options
• Explore results of previous efforts to
improve MH. What was the role of SU?
• Summarize self-motivational
• Identify and lower barriers to change
• Explore pros and cons of improving
MH and decreasing SU
• Continue exploration of pros and cons
of improving MH and decreasing SU
4.
Action
5.
Maintenance
• Support a realistic view of change
through small steps
• Identify high-risk situations for SU
and impact of use on MH functioning
• Develop coping strategies
• Assist in finding new reinforcers of
positive change including feeling better
• Help access family/social/peer support
statements for change in MH and SU
• Help enlist social/peer support
• Encourage person to publicly
announce plans to change
6.
Recurrence
• Help identify and try supportive
behaviors and drug-free activities to
maintain goals.
• Frame recurrence as a learning
• Maintain supportive contact and
highlight progress in maintaining
improved functioning--What was the
role of SU?
• Explore possible psychological,
behavioral and social antecedents
• Set new short and long term goals for
MH and SU
opportunity—What was the impact
on MH?
• Help to develop alternative coping
strategies for strong emotions
• Encourage person to stay in the
process and maintain support
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Substance use
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Maintenance of abstinence
Supportive behaviors and drug-free activities
Maintain supportive contact
Set new short and long term goals for MH and SU
Diabetes
◦
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Blood sugar monitoring and control
Identify and support dietary changes.
Promote self mgt.
Enhance mood stability
Stress Reduction
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Obesity
◦ Monitoring food/diet
◦ Goal identification and attainment
◦ Exercise goal identification and tracking
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COPD
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Identifying Triggers
Smoking cessation (medical and behavioral)
Medication compliance
Daily Monitoring, Action Planning
Social support
◦ Identify drug free activities including 12-step,
church, and recreation
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Cl was initially identified primarily as depressed and
aggressive with people. Client only sought treatment at the
request of her rehab program. When she graduated from
rehab program, she became homeless. Program assisted her
with renting a room.
Client was encouraged to participate in Lunch & Learn,
Diabetes Support, Self Help and Seeking Safety groups.
She began making better food choices, reduced her smoking
and began walking daily. She lost 17 lbs and has been
abstinent from drugs for over 3 yrs.
Cl generally complies with meds and all medical and mental
health appointments. She engages in groups 3-4 days/wk,
goes to 12 step meetings, and participates in community
activities offered by the program. She arrives at the clinic
early, is good at seeking support, resources and referrals, and
always follows through.
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The Warm Hand-Off
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•
•
Approximately 5% of patients screened
will require referral to substance use
evaluation and treatment.
A patient may be appropriate for
referral when:
• Assessment of the patient’s responses to the
screening reveals serious medical, social, legal,
or interpersonal consequences associated with
their substance use.
These high risk patients will receive a
brief intervention followed by referral.
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•
•
•
Describe treatment options to patients based on
available services
Develop relationships between health centers,
who do screening, and local treatment centers
Facilitate hand-off by:
•
Calling to make appointment for patient/student
•
Providing directions and clinic hours to
patient/student
•
Coordinating transportation when needed
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Thomas E. Freese, PhD
tfreese@mednet.ucla.edu
Sherry Larkins, PhD
larkins@ucla.edu
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs
www.psattc.org
www.uclaisap.org
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