designing the road map: improving the continuum of care h. westley clark, m.d., j.d., m.p.h., cas,...

Designing the Road Map: Improving the Continuum of Care

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Department of Health and Human Services

President George W. President George W. BushBush

“In America's ideal of freedom, the exercise of rights is ennobled by service, and mercy, and a heart for the weak. Liberty for all does not mean independence from one another. Our nation relies on men and women who look after a neighbor and surround the lost with love. Americans, at our best, value the life we see in one another, and must always remember that even the unwanted have worth.”Inaugural Address – January 20,2005

Charles G. Curie, M.A., A.C.S.W.AdministratorSubstance Abuse and Mental Health Services Administration

“We have set key priorities for the Agency and for the field, which are identified in our matrix of program priorities and cross-cutting principles. By focusing on these priority areas, we can help provide people with the services they need to live, work, learn and participate fully in their communities.”

December, 2004

SAMHSAs’ Strategic PlanSAMHSAs’ Strategic Plan

EEFFECTIVENESFFECTIVENES

SS

VISIONVISIONA Life in the Community for EveryoneA Life in the Community for Everyone

Measure and reportMeasure and reportprogram performanceprogram performance

Increase serviceIncrease serviceavailabilityavailability

Improve serviceImprove servicequalityquality

AACCOUNTABILITYCCOUNTABILITY CCAPACITYAPACITY

MISSIONMISSIONBuilding Resilience and Facilitating

Recovery

Track national trendsEstablish measurements and reporting systemsDevelop and promote standards to monitor service systemsAchieve excellence in management practices

Assess resources and needsSupport service expansionImprove services organization and financingRecruit, educate, and retain workforceCreate interlocking systems of carePromote appropriate assessment and referral

Assess service delivery practices Identify and promote evidence-based approaches Implement and evaluate innovative services Provide workforce training and education

Substance Abuse and Mental Health Services Administration - Substance Abuse Funding

($ in thousands)

Budget LineFY 2004

ActualFY 2005

AppropriationFY 2006Request

Programs of Regional and National Significance:

Prevention Treatment Access to Recovery (non-add)

$198,458419,219(99,410)

$198,725422,365(99,200)

$184,349447,052

(150,000)

Sub-total, PRNS

Substance Abuse Block Grant

617,677

1,779,146

621,090

1,775,555

631,401

1,775,555

Total, Substance Abuse $2,396,823 $2,396,645 $2,406,956

Mental Health/Substance Abuse Treatment is 7.5 Percent of Total Health Care

Expenditures

SA = 1.3%

All Health = $1,372.5 B

MH = $ 85.4 billion

SA = $ 18.3 billion

All Health, 2001

MH = 6.2%

Cost of Substance Use

Estimated cost to provide treatment for substance use disorders and their related medical illnesses is $18.3 billion

Estimated cost to society for substance use exceeds $300 billion

There is no single road to Recovery. No absolute path. Each person must identify that which works. Some roads are paved, some are rough, and others are ill defined. No matter. Recovery works, but the burden rests on the individual, the family and the community.

3.8

10.9

19.2

23.3

18.3

13.4

8.8 8.4 8.16.8

3.92.0 1.1 0.6

0.0

5.0

10.0

15.0

20.0

25.0

Illicit Drug Use, by Age: 2003Illicit Drug Use, by Age: 2003

Age in Years

12-13 14-15 16-17 18-20 21-25 26-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

Percent Using in Past Month

Age 50+

DemographicsRacial/Ethnic Group Growth Rate, 1990-2000

– Asian Americans 63.24%

– Latinos/Hispanics 39.42%

– Blacks 15.26%

– American Indians 14.42%

– Whites 5.08%

Current Use of Illicit Drugs among Persons Aged 18 to 25, by Race: 2002 & 2003

22.9

18.2

29.5

8.9

14.2

29.3

22.5

18.2

31

11.8

15.6

29.2

0

5

10

15

20

25

30

35

White Black Amer.Indian/Alaska

Native

Asian Hispanic Two or MoreRaces

Perc

ent U

sing

in P

ast M

onth

National Survey on Drug Use and Health 2003

Current Use of Illicit Drugs among Persons Aged 26 or Older, by Race: 2002 & 2003

5.9

7.8

4.3

2.2

4.5

6.95.8

6.4 6.8

1.9

5.2

7.9

0123456789

10


Native


Perc

ent U

sing

in P

ast M

onth


Marijuana-The Most Common Marijuana-The Most Common Illicit DrugIllicit Drug

Marijuana is the most commonly used illicit drug. In 2003, it was used by 75 percent of current illicit drug users.

Approximately 55 percent of current illicit drug users used only marijuana,

Lifetime and Past Month Nonmedical Use Lifetime and Past Month Nonmedical Use of Stimulants among Persons Aged 12 or of Stimulants among Persons Aged 12 or

Older, by Race/Ethnicity: 2003Older, by Race/Ethnicity: 2003

Source: SAMHSA 2003 NSDUH.

10.7

2.7

5

10.2

8.3

2.8

0.2 0.41

0.20.6

0

2

4

6

8

10

12

White Black Hispanic AI/AN NH/PI Asian

Lifetime Use Past Month Use

Heavy Use of Alcohol among Persons Aged 12 to 20, by

Race: 2002 & 2003

7.9

23.1

1.8

4.3

8.2

1.1

4.1

2.94

8

1.6

0123456789

10


Native


Per

cent

Usi

ng in

Pas

t Mon

th


Number of Substance Abuse Treatment Facilities

10641 10860

1345515239

13428 13720

02000400060008000

1000012000140001600018000

1996 1997 1998 1999 2000 2002Years

Nu

mb

er

of

Fa

cili

tie

s

Source: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Uniform Facility Data 1996-1999; National Survey of Substance Abuse Treatment Services (N-SSATS), 2000.

Locations Where Past Year Substance Treatment Locations Where Past Year Substance Treatment was Received among Persons Aged 12 or Older: was Received among Persons Aged 12 or Older:

2002 and 20032002 and 2003

206

251

377

587

729

752

1,243

1,911

259

469

523

859

1,016

1,094

1,536

2,021

0 300 600 900 1,200 1,500 1,800 2,100 2,400

Prison or Jail

Emergency Room

Private Doctor's Office

Self-Help Group

20022003

Numbers (in Thousands) Receiving Treatment, = Significant change 2002 to 2003

Outpatient Rehabilitation

Inpatient Rehabilitation

Mental Health Center

Hospital Inpatient

Source: National Survey on Drug Use and Health 2003

Most People Who Needed Treatment for Illicit Drug Problems Did Not Feel A Need for Treatment

6%

81%

13% 6%

78%

16%

Female Male

Felt No Need for TX Felt Need for TXReceived TX

2003 NSDUH

2.2 million

3.5 million

Most People Who Needed Treatment for Alcohol Problems Did Not Feel A Need for Treatment

4%

89%

7% 3%

90%

7%

Female Male

Felt No Need for TX Felt Need for TXReceived TX

2003 NSDUH

5.4 million 11 million

64

6%

79%

15%4%

89%

7%

Illicit Drugs Alcohol

Felt Need for TX, but did not receive Treatment

2003 NSDUH

Felt No Need for TX

Received TX

21. 3 % (4.2 million people)

Mental Health Disorder

Substance Use Disorder

Co-O

ccurring

Disorders General Population

Survey (NSDUH)

Drug Use Disorder Treatment Seeking

Population (NESARC Study)

Mood Disorders

60%

19.4 million people

19. 6 million people

(6 million people need care for illicit drug use)

(16.7 million people )

Co-Occurring Disorders by SeverityIII

Less severe mentaldisorder/more severe

substance usedisorder

ILess severe mentaldisorder/less severe


IIMore severe mentaldisorder/less severe


Hig

h Se

verit

y

Low Severity High Severity

Alco

hol a

nd o

ther

dr u

g ab

use

Mental Illness

IVMore severe mental

disorder/more severesubstance use

disorder

Primary Locus of Care by SeverityH

igh

Seve

rity


A lco

hol a

nd o

ther

dru

g ab

use

Mental Illness

IIISubstance use

Treatment system

IPrimary healthcare settings

IIMental health

system

IVState hospitals,

jails/prisons,emergency rooms, etc.

Service Coordination by SeverityH

igh

Seve

rity


A lco

hol a

nd o

ther

dru

g ab

use

Mental Illness

IIISubstance use

system

IPrimary healthcare settings

IIMental health

system

Consultation

Collaboration

Integrated Services

IVState hospitals,jails/prisons,

emergency rooms,etc.

Continuum of Care Framework

Treatment is Effective

Significantly reduces substance use

Enhances public safety by reducing crime

Helps drug abusers to become more productive, responsible and stable members of society

Provides economic benefits to society

Aspects of Effective Treatment Programs

Continuity of care is essential for long-term success

Intensity and range of services influence success

Balanced incentives and disincentives have superior outcomes to programs too lax or too punitive

National Outcome Measures (NOMS)Abstinence from Drug / Alcohol UseEmployment / EducationCrime and Criminal JusticeFamily and Living ConditionsAccess / CapacityRetentionSocial ConnectednessPerception of CareCost EffectivenessUse of Evidence-Based Practices

Puerto Rico

Virgin Islands

WA

OR

CA

NV

AK

ID

MT

WY

UT

AZ

NM

CO

TX

ND

SD

NE

KS

OK

MN

IA

MO

AR

LA

MSAL

TN

KY

IL

WIMI

INOH

GA

FL

SC

NC

VAWV

PA

NY

MEVT

NH

MA

RICT

NJ

DEMD

D.C.

HI

T.O

T.O.

= ATR & SPF SIG (10 States)= ATR (4 States & 1 Tribal Org.)

= SPF SIG (9 States & Guam & Palau.)=

=

SBIRT (6 States & 1 T.O.)

COSIG (11 States)

ATR, SPF-SIG, SBIRT & COSIG Grants

Puerto Rico

Virgin Islands

WA

OR

CA

NV

AK

ID

MT

WY

UT

AZ

NM

CO

TX

ND

SD

NE

KS

OK

MN

IA

MO

AR

LA

MSAL

TN

KY

IL

WIMI

INOH

GA

FL

SC

NC

VAWV

PA

NY

MEVT

NH

MA

RICT

NJ

DEMD

D.C.

HI

= ATR

= RCSP

ATR and RCSP Grants

Access to Recovery (ATR)

In 2003, President Bush announced the Access to Recovery program

Congress approved $100 million for the ATR voucher program to fund non-traditional providers such as faith-based and peer-run recovery support service organizations

ATR designed to increase consumer choice, treatment outcomes, and treatment capacity

Access to Recovery

3-year $450 million investment in recoveryFY 2004: $99.4 million actualFY 2005: $99.2 million enactedFY 2006: $150 million request

Uses vouchers for the purchase of addiction treatment and support services

ATR Grantees

CaliforniaConnecticutFloridaIdahoIllinoisLouisianaMissouri

New JerseyNew MexicoTennesseeTexasWashingtonWisconsinWyoming

California Rural Indian Health BoardCalifornia Rural Indian Health Board

ATR Voucher ServicesGrantees may determine what services they cover

using vouchers – examples:

•Detoxification

•Brief intervention

•Group counseling

•Case management

•Family services

•Sober housing

•Employment coaching

•Traditional healing

•12-step groups

•Recovery coaching

•Other

Screening, Brief Intervention, Referral and Treatment (S-BIRT)

Cooperative agreements expand and enhance the State or Tribal Organization continuum of care by adding SBIRT services within general medical settings and by providing linkages with the specialty treatment system.

FY 04: $22.4M; FY 05 Enacted: $24.0M

S-BIRT

Increase screening and early identification of substance use disorders

Expand communities’ continuum of care– Increase access to clinically appropriate

treatment matched to the patient's stage of illness and problem severity

What Are S-BIRT Grants’ Capacity Expansion Goals?

To change the paradigm of primary general care to include SBIRT

We accomplish this by:increasing the number of people screened and receiving “early intervention” or “treatment” as necessary.

To increase the capacity of community generalist medical settings to identify, treat, and manage Substance Use Disorders

To increase access to clinically appropriate generalist services for nondependent persons and to specialized services for dependent persons

What Are S-BIRT Grants’ Capacity Expansion Goals?

Report Card

As of January 26, 2005:

Patients Served: 113,650 (98% of target)*

Brief Intervention 15%

Brief Treatment 2 %

Referral to Treatment 2.5%

These grants fund community-based recovery support services that help prevent relapse and promote long-term recovery

Peer recovery support services include emotional, informational, instrumental and affiliation support.

These grants respond to a need, consistently voiced by people in recovery and their families, for community-based recovery support services that help prevent relapse and promote long-term recovery. Peer recovery support services include emotional, informational, instrumental, and companionship support.

FY 04: $8.3M; FY 05 Enacted: $8.2M

New Publication: Know Your RightsNew Publication: Know Your Rights

“Know Your Rights” is a new booklet developed by CSAT to educate and inform members of the recovery community of their legal rights under the law.

A series of trainings on this subject will be conducted by the Legal Action Center in 2005.

(PFR)

PFR is a collaboration of communities and organizations mobilized to help individuals and families achieve and maintain recovery, and lead fulfilling lives by engaging in an array of activities including, but not limited to, workforce and leadership development, cross-cutting collaboration efforts, and anti-stigma/anti-discrimination efforts.

FY 04: $2.5M; FY 05 Enacted: $2.1M

Community-basedFaith-basedPrimary CareCriminal JusticePrevention and Early InterventionDiverse CulturesRural Populations

Engages More Partners

Changing the Nature of the Substance Abuse Field

Involvement of new providers, (e.g., faith community)

Emphasis on recovery and associated services

Use of treatment vouchers

Changing service milieu: primary care settings, drug courts, re-entry, co-occurring disorders, etc.

Changing the Nature of the Substance Abuse Field

Requirement to employ best/proven practices, “science-to-service”

New drug treatments

Emphasis on program performance and outcomes reporting

Telemedicine

Substance Abuse Workforce Challenges

Quantity – increase number of professionals

Quality – enhance professional training and credentials

Demographics – increase number of culturally competent providers

Service Disparities – geographic distribution of services (e.g., rural areas, reservations), cultural barriers

Workforce Certification

Approximately 50-55% of the direct care

treatment workforce is certified

Outpatient drug-free agencies have highest percentage of certified staff

Private facilities had higher percentage of certified counselors than publicly funded

Private facilities also had a lower ratio of certified counselors to clients.

Academic Training

Most academic education occurring at the community college level

Courses and programs are variable; accreditation standards are lacking

Most training didactic - effective science to service transfer requires ongoing skill building and clinical supervision

In-Service Training

Large number of clinical staff (90%) attend training annually but little is known about the quality of in-service education

Highest priority topics are clinical supervision;co-occurring disorders; pharmacology/pharmacotherapy and cultural competency

What is Needed? Accreditation process for substance abuse academic

programs

Standard guidelines for internships

Cross-training in mental health and substance abuse, statistical methodology, evaluation, etc.

Standards for in-service training

What is Needed

Conferences and training to promote evidence-based practices and technology transfer

Substance abuse curriculum added to all levels of medical training

Innovation and innovators!

Pacific Southwest Addiction Technology Transfer Center (ATTC)

One of 14 Nationwide resource centers for addiction related information funded by SAMHSA.

The Pacific Southwest ATTC serves California, Arizona, and New Mexico

www.psattc.org

Michael S. Shafer, PhD, Director 520-917-0841, x122

Many Pathways toMany Pathways to

SAMHSA Information

www.samhsa.gov

800-729-6686 for publication ordering or information on funding opportunities

800-487-4889 – TDD line

800-662-HELP – SAMHSA’s Helpline

designing the road map: improving the continuum of care h. westley clark, m.d., j.d., m.p.h., cas,...

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