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2013 Toolkit


The 2014 Toolkit will be available in early summer.

Health Care Providers

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Introduction…

Every September, the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services (HHS), sponsors National Recovery Month (Recovery Month).  Now in its 24th year, this observance increases awareness and understanding of mental and substance use disorders.  It promotes the message that behavioral health is essential to health, prevention works, treatment is effective, and people recover.

The 2013 Recovery Month theme, “Join the Voices for Recovery:  Together on Pathways to Wellness,” represents the many ways that people can prevent behavioral health issues, seek treatment, and sustain recovery as part of a commitment to living a mentally, physically, emotionally, and spiritually healthy life.  While family, friends, and community members can support individuals throughout their unique recovery journeys, health care providers are vital to these processes.  They facilitate pathways to wellness by offering professional treatment, medical care, and group support.

Collaborating with health care providers is a key focus of SAMHSA’s Health Reform Strategic Initiative.  This initiative seeks to increase access to high-quality prevention, treatment, and recovery services.  It works to promote integration and coordination of care, especially for people with behavioral health and co-occurring conditions.1  Health care providers are also critical to executing SAMHSA’s Wellness Initiative, which promotes wellness for people with mental and/or substance use disorders.  This program motivates individuals, organizations, and communities to work toward improved quality of life and better mental and physical health.

This guide explains the vital roles that health care providers can play in supporting treatment and recovery from mental and substance use disorders.

Understand the Issue…

Behavioral health conditions are a leading public health concern in the United States. Mental disorders are as disabling as cancer or heart disease in terms of lost productivity and premature death, and people with a serious mental illness have a life expectancy that is 25 years shorter than people without a serious mental illness.2  Additionally, more than 23 million people in the United States are addicted to alcohol, prescription drugs, or illegal substances.3  These conditions are prevalent throughout every community, and for many, health care providers are a first line of support.

Prevention, treatment, and recovery services are not just the responsibility of behavioral health specialists.  All health care professionals, including primary care doctors, nurses, physician assistants, emergency care providers, pharmacists, peer support specialists, therapists, and counselors play an important role in helping those with a mental and/or substance use disorder.  Integrated, collaborative, and complementary care provides an individual with a mental and/or substance use disorder the best opportunity for support, treatment, and recovery.

Offering integrated care is critical to minimizing the effects of behavioral health conditions. This requires health care professionals to consider all of a person’s health conditions at the same time.  That way, it is easier to understand more about the whole person when making treatment decisions. Integrated health care consists of:4

  • Medical and behavioral health services located either in the same facility or in separate locations, as long as they communicate and coordinate adequately;
  • One treatment plan with both behavioral and medical elements;
  • Typically, a team working together to deliver care, using a prearranged protocol;
  • Teams composed of a physician and one or more of the following: physician’s assistant, nurse practitioner, nurse, case manager, family advocate, or behavioral health therapist; and
  • Use of a database to track the care of patients who are screened into behavioral health services.

Additionally, implementing an integrated care approach more effectively meets the needs of patients with a co-occurring mental and substance use disorder or a co-occurring physical and behavioral health condition.  To fully recover from a co-occurring disorder, research indicates that a patient must receive treatment for both conditions – treating only one will not ensure the other will improve.5  For patients with co-occurring mental and substance use disorders, integrated treatment entails receiving appropriate treatment for both their mental and substance use disorders in a coordinated fashion, resulting in more effective treatment.6

SAMHSA supports a “whole person” philosophy – which means caring for an individual’s health condition and delivering services in a recovery-oriented system by providing connections to long-term community care services and supports, social services, and family services.7  By providing complementary care, behavioral health specialists and primary care professionals address the physical health issues that often correspond with behavioral health conditions.  In addition to continually screening for behavioral health conditions and possible signs of relapse, practitioners should talk with patients about ways to improve their overall health, including making a commitment to a nutritional diet, daily exercise, social connections, and avoidance of nicotine, alcohol, and other substances.8

Recognize the Challenges…

To improve treatment and services provided to individuals with mental and/or substance use disorders, health care professionals can work to address the challenges often faced when providing behavioral health services, including:

  • Lack of training:  Many health care providers may not specialize in assessing mental and/or substance use disorders, or may not be trained on where to refer patients for treatment and recovery support services.9  Resources exist that can help providers point their patients in the right direction to get appropriate assistance.  For instance, providers can consult with organizations, such as the American Mental Health Counselors Association (AMHCA), American Society of Addiction Medicine (ASAM), or NAADAC, the Association for Addiction Professionals, which provide training to health care professionals.  Additional professional organizations can be found in the “Prevention, Treatment, and Recovery Resources” document in this toolkit.  For referral options, providers can refer their local network of providers, insurance companies, and other resources such as SAMHSA’s Treatment Locator to find referral options in their local area.
  • Patient uncertainty:  Some patients may feel uncomfortable disclosing their behavioral health condition to a health care professional due to confidentiality fears, or because of public misconceptions that may fuel feelings of embarrassment or isolation.  To help them feel more at ease, providers can use the following techniques to decrease a patient’s anxiety about discussing sensitive topics:10
    • Normalize:  Remind patients that many other people experience behavioral health conditions.
    • Use transparency:  Explain the reasons why you are asking him or her about a behavioral health condition.
    • Ask permission:  Give patients the option to discuss behavioral health conditions, as well as the option to not answer questions.
  • Time constraints:  Similar to other health care professionals, many primary care doctors lack the time to fully address the wide range of psychosocial issues that are presented by their patients.11  In fact, an average primary care physician visit lasts 10 minutes.12  Some screening tools for a behavioral health condition can take as little as two minutes.  SAMHSA and HRSA’s Center for Integrated Health Solutions includes brief three- question screeners for a variety of behavioral health conditions.  Also, provisions under the Affordable Care Act (ACA) designate funds for improving health information technology that will help paperwork to become standardized, leading to time savings and increased patient interaction that can be directed towards basic screenings.13
  • Reimbursement issues:  Both health care professionals and patients are often concerned that behavioral health services might not be fully covered, if at all. However, under the ACA, many preventive screenings – including screenings for depression, alcohol misuse, and behavioral problems for children of all ages – must be covered without patients having to pay a copayment or co-insurance or meeting a deductible.14  Behavioral health treatment services also are part of “essential health benefits,” which will require coverage by insurance offered in individual and small group markets as of January 1, 2014.15
  • Safe medication prescribing and management:  With rates of prescription drug abuse on the rise,16 health care providers may be concerned about safely managing a patient’s medication regimen.  Consider whether a patient has known risk factors of abuse or addiction, including:
    • Past cocaine use or history of alcohol or cannabis use;17
    • Lifetime history of a substance use disorder;18
    • Family history of substance abuse;19
    • Heavy tobacco use;20 and
    • History of severe depression or anxiety.21

If a patient is at higher risk of problematic prescription use, health care professionals can implement more extensive monitoring and assessment methods;22 it is imperative that practitioners continually manage their patients’ opioid use.  Effective management requires practitioners to regularly assess and document the benefits and harms of opioid use.  With diligent prescribing, management, and monitoring, health care providers can provide patients with prescription medicines safely and effectively.

By recognizing challenges to care and finding solutions, health care providers can help their patients live healthy, productive lives.

Help Patients With a Mental Illness…

As a health care provider, it is important to learn and recognize the signs and symptoms of mental illness and refer people to specialty treatment if necessary.  A patient’s mental health should be observed regularly to ensure that symptoms are detected early, helping lead to an intervention or the delay or prevention of a major mental illness.23

Screening and Diagnosis

Providers can initiate the screening process by asking patients if they have experienced any of the following symptoms:24

  • Little interest or pleasure in doing things;
  • Feeling depressed or hopeless;
  • Trouble falling or staying asleep, or sleeping too much;
  • Feeling tired or having little energy;
  • Poor appetite or overeating; and
  • Feeling down about themselves.

Some family doctors and pediatricians are qualified to diagnose common mental disorders such as depression, anxiety disorders, or attention deficit hyperactivity disorders.  Other conditions, such as schizophrenia and autism, must be evaluated and diagnosed by qualified professionals who have specialized knowledge of mental health – psychiatrists, psychologists, psychiatric nurses, social workers, or mental health counselors.25

Health care professionals can consult the Diagnostic and Statistical Manual of Mental Disorders (DSM) to aid in diagnosing a specific mental illness.  This manual classifies and describes more than 300 types of conditions, ranging from anorexia to schizophrenia.26  In addition to the DSM, free screeners such as The Patient Health Questionnaire (PHQ) are available online to help health care professionals recognize common mental illness such as depression or eating disorders.

Referral

If it is suspected that a patient has a mental disorder, health care providers should direct the person to a behavioral health specialist for diagnosis and treatment.  When referring a patient to medical treatment or therapy, emphasize that mental illness is common and treatment is effective. In a given year, less than one-third of adults diagnosed with a mental illness receive treatment,27 so it is important to follow up with patients to ensure that they receive treatment.

Health care professionals and family members can work together to develop an appropriate plan that is tailored to an individual’s needs.  Common treatment options include:

  • Psychotherapy;28
  • Medication therapy;29
  • Support groups;30 and
  • Peer specialists or other recovery support programs.31

Refer to the “Treatment and Recovery” section of this toolkit for further information about these treatment options.  Also visit SAMHSA’s Treatment Locator or the “Prevention, Treatment, and Recovery Resources” portion of this toolkit for more detailed information on local behavioral health treatment organizations.

Help Patients With a Substance Use Disorder….

Primary care providers, as well as professionals in emergency care, trauma care, and community health settings, can use SAMHSA’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) Model to support patients with a behavioral health condition.  SBIRT is an integrated public health approach to early screening and intervention for individuals with risky alcohol and drug use, and if needed, timely referral to more intensive substance abuse treatment.32  The approach includes the following steps:33

  1. Screening:  Determine whether patients are engaging in risky behavior that warrants intervention.  This screening process typically takes 5 to 10 minutes.  Commonly used screening tools, which are simple and easy to administer, are:
    • Alcohol Use Disorders Identification Test (AUDIT)
    • Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
    • Drug Abuse Screening Test (DAST)
    • Cut Down, Annoyed, Guilty, Eye-Opener Substance Abuse Screening Test (CAGE)
  2. Brief intervention:  Depending on a patient’s needs, providers should conduct a brief intervention that usually involves one to five sessions lasting about five minutes to one hour.  The goal of brief intervention is to educate patients, increase their motivation to reduce risky behavior, address long-standing problems with harmful drinking and/or drug misuse, and urge patients to obtain more long-term care.
  3. Referral to treatment:  Referral is recommended when patients meet the diagnostic criteria for substance dependence as defined by the DSM.  Only three to four percent of screened patients in a primary care setting typically need to be referred, and this action can be critical in helping patients get appropriate and timely care before their conditions worsen.34  In addition to becoming acclimated with the screening tools listed in step one, health care providers should be familiar with the signs and symptoms of substance use disorders, outlined in the “Overview” and “Young Adults” section of this toolkit.

With a commitment to screening, intervention, and referral, health care professionals can make a difference in their patients’ lives.

Make a Difference During Recovery Month and Throughout the Year…

Health care providers can help spread Recovery Month’s message every September and throughout the year.  Consider taking the following steps:

  • Seek volunteer and speaking opportunities:  Health care providers who are equipped with the clinical knowledge and tools to prevent, detect, and treat mental and/or substance use disorders are valuable assets to all communities.  Consider volunteering in underserved communities or speak at local schools and community groups about the importance of prevention and the positive effects of treatment and recovery on one’s overall health and well-being.
  • Attend trainings or continuing education courses:  As with any health condition, trends and research surrounding behavioral health disorders constantly evolve.  By staying current on these topics, health care providers can more effectively screen, assess, intervene, and refer individuals in need of treatment services.
  • Join in the celebration:  For patients in recovery, recognize their accomplishments and encourage them to continue to participate in support services, seek help whenever they may need it, and continue on their recovery journey one day at a time.

Additional Resources…

A variety of resources provide additional information on Recovery Month and mental and/or substance use disorders, as well as prevention, treatment, and recovery support services.  The toll-free numbers and websites below are available for people to share their experiences, learn from others, and seek help from professionals.  Through these resources, individuals can interact with others and find support on an as-needed, confidential basis.

Use the following resources to learn about the impact of health reform on access to prevention, treatment, and recovery support services:

  • BHBusiness:  Offers targeted training and support for behavioral health care executives, CEOs, and directors, including health care insurance enrollment training information.
  • Center for Financing Reform and Innovation:  Supports the need for information, analysis, products, and technical assistance to address significant changes in the organization and financing of behavioral health care, as well as the need to guide and support governments and people on how to most effectively and efficiently use available resources to meet the prevention, treatment, and recovery support needs of the public.
  • Healthcare.gov:  Contains information on finding health insurance options, help using insurance, information on the Affordable Care Act, help comparing providers, and information on prevention and wellness resources.
  • Kaiser Family Foundation:  Issued by a nonprofit health policy and communications group, this document provides a summary of the comprehensive health reform law.  It discusses the law and its provisions to expand coverage, control health care costs, and improve the health care delivery system. Visit the Kaiser Family Foundation’s Health Reform Source for more information.
  • SSI/SSDI Outreach, Access, and Recovery (SOAR):  Increases access to Supplemental Security Income and Social Security Disability Income for eligible adults who are homeless or at risk of homelessness and have a mental and/or substance use disorder.
  • The Parity Implementation Coalition’s Parity Toolkit:  Created by organizations including the Recovery Month Planning Partners, this toolkit aids individuals seeking help and individuals in recovery, as well as their families, providers, and advocates, in understanding their rights and benefits under the Mental Health Parity and Addiction Equity Act.

Inclusion of websites and resources in this document and on the Recovery Month website does not constitute official endorsement by the U.S. Department of Health and Human Services or the Substance Abuse and Mental Health Services Administration.


Sources:

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  2. Parks, J. et al. (2006). Morbidity and Mortality in People with Serious Mental Illnesses. National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council, Alexandria, VA.
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  4. Collins, C., Hewson, D., Munger, R., and Wade, T. (2010).  Evolving Models of Behavioral Health Integration in Primary Care.  Milbank Memorial Fund.  Retrieved September 19, 2012, from http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf, p. 12-13.
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  8. Substance Abuse and Mental Health Services Administration.  (2012).  SAMHSA’s Wellness Initiative – Information for General Health Care Providers.  Retrieved September 19, 2012, from http://store.samhsa.gov/shin/content//SMA12-4566/SMA12-4566.pdf.
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