Utilization and cost impact of integrating substance abuse treatment and primary care.
TL;DR: The findings for the full sample suggest that integrating substance abuse treatment with primary care, may not be necessary or appropriate for all patients, but it may be beneficial to refer patients with substance abuse related medical conditions to a provider also trained in addiction medicine.
Abstract: Objective. To examine the impact of integrating medical and substance abuse treatment on health care utilization and cost.Research Design. Randomized clinical trial assigning patients to one of two treatment modalities: an Integrated Care model where primary health care is provided along with substa
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01 Nov 2008
TL;DR: There is a reasonably strong body of evidence to encourage integrated care, at least for depression, and there is no discernible effect of integration level, processes of care, or combination on patient outcomes for mental health services in primary care settings.
Abstract: Objectives To describe models of integrated care used in the United States, assess how integration of mental health services into primary care settings or primary health care into specialty outpatient settings impacts patient outcomes and describe barriers to sustainable programs, use of health information technology (IT), and reimbursement structures of integrated care programs within the United States. Data sources MEDLINE, CINAHL, Cochrane databases, and PsychINFO databases, the internet, and expert consultants for relevant trials and other literature that does not traditionally appear in peer reviewed journals. Review methods Randomized controlled trials and high quality quasi-experimental design studies were reviewed for integrated care model design components. For trials of mental health services in primary care settings, levels of integration codes were constructed and assigned for provider integration, integrated processes of care, and their interaction. Forest plots of patient symptom severity, treatment response, and remission were constructed to examine associations between level of integration and outcomes. Results Integrated care programs have been tested for depression, anxiety, at-risk alcohol, and ADHD in primary care settings and for alcohol disorders and persons with severe mental illness in specialty care settings. Although most interventions in either setting are effective, there is no discernible effect of integration level, processes of care, or combination, on patient outcomes for mental health services in primary care settings. Organizational and financial barriers persist to successfully implement sustainable integrated care programs. Health IT remains a mostly undocumented but promising tool. No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care. Case studies will add to our understanding of their implementation and sustainability. Conclusions In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention to mental health problems from the effects of specific strategies, evidenced by the lack of correlation between measures of integration or a systematic approach to care processes and the various outcomes. Efforts to implement integrated care will have to address financial barriers. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can include removing obstacles, creating incentives, or mandating integrated care. Encouragement will likely differ between fee-for-service care and managed care. However, without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.
420 citations
Cites background from "Utilization and cost impact of inte..."
...Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial JAMA 2006 May 10; 295(18):2148-57....
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...Effect of Improving Depression Care on Pain and Functional Outcomes Among Older Adults With Arthritis: A Randomized Controlled Trial JAMA: Journal of the American Medical Association 2003 Nov; 290(18):2428-34....
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...Medical Journal of Australia 1976 May 1; 1(18):666-9....
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TL;DR: Significant progress has been made in adapting addiction treatment to respond more fully to the chronic nature of most patients’ problems, and the importance of adjusting treatment funding and organizational structures to better meet the needs of individuals with a chronic disease is addressed.
Abstract: This article reviews progress in adapting addiction treatment to respond more fully to the chronic nature of most patients' problems. After reviewing evidence that the natural history of addiction involves recurrent cycles of relapse and recovery, we discuss emerging approaches to recovery management, including techniques for improving the continuity of care, monitoring during periods of abstinence, and early reintervention; recent developments in the field related to self-management, mutual aid, and other recovery supports; and system-level interventions. We also address the importance of adjusting treatment funding and organizational structures to better meet the needs of individuals with a chronic disease.
327 citations
Cites background from "Utilization and cost impact of inte..."
...Godley and colleagues (2002, 2004, 2007) developed a protocol called assertive continuing care (ACC) and showed that it improved participation and recovery indicators....
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TL;DR: Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identify both the trends and the current distribution of treatment programs available for special population groups.
Abstract: s into the 14 special population groups shown in Table 14-1. Catalogued materials include research studies, books, newsletter articles, case studies, program descriptions, journal articles, monographs, communications, and so forth. Table 14-1 shows the frequency distribution of materials in each of the specified areas for three distinct time periods: 1973-1982, 1983-1985, and 1986-1987. The table also contains a summary for the total 15-year period, 1973-1987. THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 350 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. TABLE 14-1 Total Number of Resource Materials on Special Population Groups Included in the National Clearinghouse for Alcohol and Drug Abuse Information (NCADI) Data Base Special Population Group 1973-1982 1983-1985 1986-1987 Total 1973-1987 Youth 722 1,120 511 2,353 College/university students 8 119 134 261 Elderly 205 186 49 440 Alcoholic females 425 347 208 980 Homosexuals 16 14 22 52 Economically disadvantaged 39 66 47 152 Racial and ethnic groups (general) 301 338 165 804 Blacks 103 131 69 303 Hispanics 48 54 42 144 Asians and Pacific Islanders 54 60 30 144 American Indians 117 85 35 237 Religious groups 79 113 51 243 Public inebriates 2 33 46 81 Handicapped/disabled 0 22 23 45 SOURCE: Committee analysis of data from the National Clearinghouse for Alcohol and Drug Abuse Information data base. Over the 15 year period the emphasis in catalogued material has been predominantly on youth, women, and racial and ethnic groups. The increase in abstracted materials for all the special populations in the last five years deserves notice; youth and women are the categories for which the most materials are recorded. There is also a marked increase in attention paid to college students, whereas there seems to be a slight tapering off in attention paid to elderly, youth, and American Indians. It is possible to characterize the literature abstracted in the NCADI data base as containing only a very few controlled trials in which the effectiveness of generic treatment is compared with treatment specifically tailored to the characteristics of the special population under consideration. There is a paucity of adequate studies on treatment outcome for any of the groups identified (Gilbert and Cervantes, 1988; Vannicelli, 1988; Westermeyer, 1988). The comment on treatment outcome made by Braiker (1982) continues to have current general applicability to all special population groups: A review of the general literature on alcoholism treatment effectiveness reveals that most studies either fail to distinguish between outcome rates for men and women alcoholics or exclude the latter group from the study samples altogether. Among those studies that distinguish outcome rate by sex, varying and often conflicting results are reported. (p. 127) Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identify both the trends and the current distribution of treatment programs available for special population groups. These were surveys of alcoholism treatment services provided by all known public and private alcoholism and drug abuse facilities and units in the United States (NIAAA, 1983; Reed and Sanchez, 1986; NIDA/NIAAA 1989) (see Chapter 4 and Chapter 7). Table 14-2 presents data on the number of specialized programs offered by alcoholism treatment units by the year THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 351 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of the survey. Youth, women, the elderly, Hispanics, public inebriates, and blacks were the only special population groups included in all three of these surveys; American Indians/Alaskan natives were included in the last two surveys. TABLE 14-2 Specialized Programs Offered by Alcoholism Treatment Units by Survey Yeara Percentage of Total Units Reporting Specialized Program 1982b 1984c 1987d Youth 21 27 31 Elderly 9 9 8 Women 23 22 28 Hispanics 9 9 11 Blacks 8 7 6 American Indians/Alaskan natives —e 5 5 Public inebriates 13 9 7 Other 13 9 15 None 51 46 41 Total units reporting 4,233 6,963 5,791 a Includes both alcoholism-only units and combined alcoholism and drug abuse units. b Data from the 1982 National Drug and Alcoholism Treatment Utilization Survey (NIAAA, 1983). c Data from the 1984 National Alcoholism and Drug Abuse Program Inventory (Reed and Sanchez, 1986). d Data from the 1987 National Drug and Alcoholism Treatment Unit Survey (NIDA/NIAAA, 1989). e Not included in the 1982 survey. The inventory asked respondents to identify whether they offered one or more specialized programs to certain population groups. Judging on the basis of the treatment units reporting, it appears that an increasing percentage of units are offering one or more specialized programs. In 1987 the largest number of specialized programs offered in treatment units were for youth (31 percent), followed closely by those for women (28 percent), with a sharp drop to programs for Hispanics (11 percent) and the elderly (8 percent). Changes in the total number of units reporting and in the number of specialized programs must be interpreted cautiously because there was a more thorough outreach effort in 1984 to locate all units that were either not identified in 1982 or that did not respond; this effort may simply have uncovered existing units that had not responded earlier rather than identifying new units that had only recently been established (cf. Reed and Sanchez, 1986:2). An examination of these two sources—the NCADI database and the NIAAA surveys of treatment units— shows that women and youth are the special population groups that have received the most attention since the early 1970s. What they do not reveal are the most effective ways to meet the needs of individual problem drinkers or how to identify factors germane to a special population that might affect treatment. The overviews are also unable to provide guidance on when treatment should emphasize an individual's special population membership to facilitate a successful outcome. Indeed, if these overviews tell us anything, it is that women and youth appear to be the special population groups that people are most concerned about. Given the historical dilemmas, variations, and inconsistencies in defining which groups should be considered as special populations in the planning, funding and evaluation THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 352 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of alcohol problems treatment, Lex (1985:90) has suggested that a special population be defined as any subgroup that is “special in terms of their uniformity on some dimension and their differences from more typical societal patterns and problems.” The committee agrees with this definition. However, the definition does not fully capture the problems encountered in attempting to review existing knowledge on the value of special population programming. This review of the history of attention to special population groups suggests that their definition is often not only in terms of the unique biological and sociocultural characteristics that define a group with similar risk factors and drinking practices but also in terms of the momentary concern regarding access to appropriate services. Interest in each group has waxed and waned. There has been no systematic follow up to determine whether access has been improved or treatment outcome positively affected by these periods of attention. What is challenging, for both researchers and clinicians, is to determine where and how the emphasis on special population membership can best facilitate effective treatment for alcohol problems. Given this background, for the purposes of this report, a special population will be viewed as any subgroup that has been identified by the field as needing a specifically tailored “culturally sensitive” treatment program. The committee has chosen to look at developments and issues for only a few of the commonly identified special population groups and the evolution and effectiveness of treatment programs designed for them as portrayed in the research and clinical literature. It is important to note that these groups are by no means inclusive of all special population groups; rather, they have been selected as representatives of special populations as a whole. Chapter 15 considers these groups on the basis of structural characteristics (i.e., demographic characteristics); Chapter 16, adapts the perspectives of functional characteristics (i.e., circumstantial concerns) as a definitional framework. Chapter 17 presents the committee's conclusions and recommendations on the issue of treatment for alcohol problems among special populations.
272 citations
TL;DR: A small but growing body of research suggests that a range of models may hold potential for improving patients' health and health care, at a relatively modest cost.
195 citations
TL;DR: A review of the evidence shows that many forms of behavioral health services, particularly when delivered as part of primary medical care, can be central to such an improvement.
Abstract: The health care system in the United States, plagued by spiraling costs, unequal access, and uneven quality, can find its best chance of improving the health of the population through the improvement of behavioral health services. It is in this area that the largest potential payoff in reduction of morbidity and mortality and increased cost-effectiveness of care can be found. A review of the evidence shows that many forms of behavioral health services, particularly when delivered as part of primary medical care, can be central to such an improvement. The evidence supports many but not all behavioral health services when delivered in settings in which people will accept these services under particular administrative and fiscal structures.
169 citations
References
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01 Jan 1997
TL;DR: In this article, the authors present an objective analysis of the powerful multimillion-dollar accreditation industry and the key accrediting organizations and make recommendations that address consumer protections, quality improvements, structure and financing, roles of public and private participants, inclusion of special populations, and ethical issues.
Abstract: Managed care has produced dramatic changes in the treatment of mental health and substance abuse problems, known as behavioral health. Managing Managed Care offers an urgently needed assessment of managed care for behavioral health and a framework for purchasing, delivering, and ensuring the quality of behavioral health care. It presents the first objective analysis of the powerful multimillion-dollar accreditation industry and the key accrediting organizations. Managing Managed Care draws evidence-based conclusions about the effectiveness of behavioral health treatments and makes recommendations that address consumer protections, quality improvements, structure and financing, roles of public and private participants, inclusion of special populations, and ethical issues. The volume discusses trends in managed behavioral health care, highlighting the emerging role of the purchaser. The committee explores problems of overlap and fragmentation in the delivery of behavioral health care and discusses the issue of access, a special concern when private systems are restricted and public systems overburdened. Highly applicable to the larger health care system, this volume will be of particular interest to all stakeholders in behavioral health--federal and state policymakers, public and private purchasers, health care providers and administrators, consumers and consumer advocates, accrediting organizations, and health services researchers.
107 citations
TL;DR: The contention that the direct treatment of alcoholism can yield significant reductions in total health care costs and utilization not only for the alcoholic but his/her family members as well is supported.
Abstract: This is a six-year longitudinal study to determine if the treatment of alcoholism as a primary diagnosis results in a reduction of total health care cost and/or utilization for the alcoholic as well as other nonalcoholic family members. All health care costs and utilization were tracked for a group of 90 families, representing 245 individuals, enrolled with Blue Cross/Blue Shield through the Health Benefits Division, California Public Employees Retirement System. At least one member in each family received treatment under a specific diagnosis of alcoholism from July 1, 1974 to December 1, 1975. All health care utilization and costs were obtained for a 12-month period before initial treatment for alcoholism and up to July 1, 1979. In addition, a matched group of 83 comparison families with no alcoholic members and covering 291 persons was selected to reflect family composition, age, and sex. Total health care data were obtained over the same time period for these families. The results indicated that utilization and costs of all forms of inpatient care for both nonalcoholic family members as well as alcoholic family members dropped after alcoholism treatment began and ultimately reached a level similar to the matched comparison group. On the average, outpatient care also decreased in terms of frequency and costs for all members of the alcoholic's family; and in similar fashion converged in the fourth follow-up period to the matched comparison families. Total health care costs per family member decreased substantially over time following initiation of treatment of the alcoholic family member. The findings support the contention that the direct treatment of alcoholism can yield significant reductions in total health care costs and utilization not only for the alcoholic but his/her family members as well.
93 citations
"Utilization and cost impact of inte..." refers background in this paper
...Four cost measures were examined: (1) inpatient cost, (2) ER cost, (3) primary care cost, and (4) total medical cost (including inpatient, ER, and nonemergent outpatient visit cost)....
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TL;DR: By understanding the range and significance of possible medical problems in cocaine abusing patients, psychiatrists can ensure timely and appropriate evaluation, treatment, and referral to other specialists.
67 citations
TL;DR: Inpatient alcoholism treatment services were more frequently used than outpatient, with inpatient admissions averaging between 1.2 and 1.5 per person, and total alcoholism treatment costs averaged $4,665 per person (December 1985 dollars).
Abstract: This paper presents data on the utilization of alcoholism treatment services in three populations of insurance enrollees: enrollees covered by the insurance plan of a large midwestern manufacturing firm, 1981-1987 (N = 1.425); enrollees of the California Health Insurance Plan of the Public Employees Retirement System, 1974-1976 (N = 766); U.S. government civilian employees enrolled with the Aetna Insurance Company, 1980-1983 (N = 1,697). The average age of the treated alcoholics in these three groups ranged from 37 to 51. Between two-thirds and three-quarters were male. Inpatient alcoholism treatment services were more frequently used than outpatient, with inpatient admissions averaging between 1.2 and 1.5 per person. For enrollees of the midwestern manufacturing firm, total alcoholism treatment costs averaged $4,665 per person (December 1985 dollars). The influence of insurance plan coverage and other factors on utilization patterns is discussed.
52 citations