The Rural Veterans Health Access Program presents - PowerPoint Presentation

Slide1

The Rural Veterans Health Access Program presents:Carolyn Lemsky, Ph.D., C.Psych.

Closing gaps in integrated care: Brain injury in the complex addictions and mental health clientSlide2

Rural Veterans Health Access Program The Rural Veterans Health Access Program (RVHAP) is part of the Health Planning and Systems Development Section, Division of Public Health,

Alaska Department of Health and Social ServicesThe RVHAP is funded by HRSA Office of Rural Health Policy: Grant number H3GRH26369Slide3

The Rural Veterans Health Access Program (RVHAP) deploys telehealth connectivity in selected remote SE rural communities with no or limited health care services to provide a Telehealth care network for behavioral health and primary care.

The Rural Veterans Health Access Program also provides training to behavioral and medical health professionals on the delivery of telehealth services using TH technology for Behavioral Health and Primary Care related to Traumatic Brain InjurySlide4

Traumatic Brain Injury is one of RVHAP’s priorities for the primary group served, Veterans and their caregivers as well as other rural community members with TBI and their families and caregivers

Provides Traumatic Brain Injury Assessment and Treatment training to RVHAP agencies and community health providers including the VA and other military health practitioners.Slide5

Tenakee Springs

One of the remote rural Southeast Alaska communities served by the

Rural Veterans Health Access Program

http://dhss.alaska.gov/dph/HealthPlanning/Pages/veterans/default.aspx

For more information on the RVHAP or this webinar contact the

Program

Director:

Susan Maley, MPH, Ph.D. susan.maley@alaska.gov, 907-269-2084Slide6

Closing gaps in integrated care: Brain injury in the complex addictions and mental health client

Carolyn Lemsky, Ph.D., C.Psych.Slide7

Acknowledgements

This research was supported by Ontario

Neurotrauma

Foundation

Data collection partnersSlide8

OutlineWhy should addiction and mental health providers be concerned about brain injury?

Prevalence of brain injury in clients served in your settings.Understand how brain injury is related to complex care needsAddressing system gaps Building awarenessScreening

Increasing AccessibilitySlide9

POLL 1What percentage of your clients do you think have a history of brain injury?Slide10

The Epidemiology of TBISlide11

Age DifferencesNon-fatal TBI Hospitalizations

in Alaska 2004-2008Slide12

Most Injuries Slide13

Causes of TBISlide14

Many Injuries are UncountedSlide15

ABI and Mental HealthAs many as 80

% of people living with TBI meet criteria for a primary psychiatric diagnosis within 7 years post-injuryPatients with TBI, compared to age- and sex-matched controls, have more psychiatric illness both before and after the

brain injuryCo-morbidity

is

common: 50

% of depressed individuals with TBI also had

Generalized Anxiety Disorder.Slide16

Mental Health in Alaska

http://dhss.alaska.gov/dph/HealthPlanning/Pages/scorecard

Alcohol Mortality 310% higher

Heavy Drinking 54% higher

Binge Drinking 26% Higher

Illicit drug use 35% Higher than U.S. rateSlide17
Slide18

Prevalence

Estimates: Alaska Mental Health Trust BeneficiariesPopulation

EstimatePopulation Rate

Adult Serious Mental Health

21,300

3.9%

Child Emotional

Disturbance

12,7259.0%

Traumatic

Brain Injury

(all ages)

11,900

1.6%

Child Alcohol Dependence

500.8%Adult Alcohol Dependence19,100

3.5%Slide19

Alcohol Association by Age Non-fatal TBI Hospitalizations in Alaska 2004-2008Slide20

Two sets of screening dataCentre for Addiction and Mental Health (CAMH)Reconnect Community Health ServicesSlide21

CAMH Screening Project

adaptation of the Ohio Valley Brain Injury Identification Method integrated into assessment protocol at main assessment siteSlide22

Screened ClientsSlide23

Lifetime substance use in years

No ABI

with LOC

N=2526

1 ABI

with

LOC

N=626

2 or more

ABI with LOC

N=163

Alcohol

19.11

22.42

22.60

Alcohol to intoxication13.07 14.90

17.94Cocaine4.977.077.16Cannabis8.79

11.2310.65Lifetime DTs.5421.342.70* Welch robust test of equality of means

Increase with greater brain injury loadSlide24

Mood Symptoms LifetimeSlide25

Other Symptoms LifetimeSlide26

# of previous episodes of inpatient treatment

Type of Treatment

No ABI

with LOC

N=2526

1 ABI

with

LOC

N=626

2 or more

ABI with LOC

N=163

Alcohol

.829

1.35

1.94Drug.8261.15

1.21 * Welch robust test of equality of means

Increase with greater brain injury loadSlide27

N=372

N=517

N=108

N=137

N=2177 Slide28

Screening in a Community Mental Health Setting

Total approachedYes TBI

No TBI Yes TraumaNo TBI No Trauma

Missing

(N/A or refused)

N= 254

145

11

94

4

Total with TBI

Improbable

Possible

Mild

Moderate

Severe

N= 14210

4862157N=

84 with some loss of consciousness

57%

59%

All current and new clients from an community-based mental health service provider (all programs)Slide29

US and Canadian StatisticsMental Health and Addictions Settings

Over 20% of people seeking services for addictions have had loss of consciousness (LOC)25 to 50% of all people who seek treatment for mental health issues have a history of brain injury (15% with moderate to severe injuries)High prevalence among marginalized populations: homeless, prisonSlide30

Brain Injury is a risk factor for Mental Illness

Danish nationwide population-based registerN=113,906 people who had suffered head injury.

Diagnosis

Increase in Risk

Schizophrenia

65%

Depression

59%

Bi-polar Disorder

28%

Organic Mental Disorders

339%

Orlovska

, Pedersen,

B

enros

, Mortensen,

Agerbo & Nordentoft (2014). American Journal of Psychiatry. 171(4) 463-469Slide31

Outcomes of Childhood Injury

Increase in general risk with brain injury

psychological

distress

52%

attempting suicide

239%

prescribed medication for anxiety, depression, or both 145%

Gabriella

Illie

(2015), St. Michael’s HospitalSlide32

25-87% of inmates report having experienced a brain injury or TBI as compared to

8.5% in a general population.Prisoners who have had head injuries are at increased risk for

depression

anxiety,

substance use disorders,

difficulty controlling anger, or

suicidal thoughts and/or attemptsSlide33

ABI and Homelessness

lifetime incidence of 53% of any injury12% moderate to severe injury70% injured before becoming homeless

seizures

mental health problems

drug problems

poorer physical health status

poorer mental health status

Hwang , Colantonio, Chiu,

Tolomiczenko

, Kiss, Cowan ,

Redelmeier

, Levinson (2008)Slide34

TBI history is prevalent among users of addictions and mental health services

Reflections on the data

Brain injury is a risk factor for the

development

of mental health and addictions as well as a

possible result

of these issues

People reporting TBI history also present with greater complex co-morbidity

History of brain injury may be associated with invisible disability that requires specialized careSlide35

In addition to cognitive problems…TBI seems to be associated with emotional

dysregulationA brain that has to work harder, tires quicker and is less resilientDamaged blood-brain barrierTBI may affect a persons ability to read emotions

TBI may reduce the capacity to respond to rewards and punishmentsTBI may interact with brain changes related to substance and/or medication useSlide36

The impact of brain injury

is often subtle…

Signs may include particular difficulties with…

A large gap between ‘say’ and ‘do’

Chaotic lifestyle and relationships

Rigid thinking

Remembering appointments

Paying attention /tolerating groups

Retaining information

Social skills (reading cues)Slide37

Were you surprised by the findings?Do you feel that you have the needed tools to effectively treat this complex group of clients?Slide38

The GapPeople with a history of brain injury often go unidentifiedOnce identified they may have difficulty accessing services

Limited models of integrated careVery limited resourcesThese clients seem to be the most complexSlide39

Barriers to CareServices not designed to manage complex co-occurring disorders

StigmaLack of knowledge/information

Wait times/complex admissions result in

lost to care

Limited Resources Slide40

Closing the GapIntegrating careIdentifying

those with a brain injury history.Systematically evaluating what happens in the current system/models of care.Developing appropriate interventionsDeveloping

system capacity to implement these structuresSlide41
Slide42

Mental Health and Addictions Providers

Brain- Injury SpecificServices Slide43

Screening for brain injury is an important step in motivating participation in Integrated CareSlide44

Elements of Capacity BuildingSlide45

What now?Screening can be done as part of intake/assessment

Track clients:Do they come back after assessment?Do they attend the program?

Do they complete?Do they need repeated treatment?Slide46

What is integrated care?

All of the client’s issues are managed together in a single, coherent plan.Cognitive and mental health, health and social features of the client’s presentation are considered together.The plan of action features the needs and most pressing concerns of the client and family and consideration is given to the

healthcarers perspectives.

Recommendations/plans are made in consideration of the client’s

actual

situation and the

current

resources available.Slide47

What are we integrating?

Care related to Diagnosis. Mental Health

Addiction

Neurocognitive Impact

Care across sectors

Healthcare

Inpatient Outpatient

Community

Social Services

Housing

Transportation JusticeSlide48

FundingAdministrativeOrganizationalService Delivery

Clinical

Dennis L.

Kodner

,

PhD, Adjunct Associate Professor of Health and Public Administration, Health Policy & Management,

Wagner Graduate School of Public Service, New York University

Cor

Spreeuwenberg

,

MD, PhD, Dean, Faculty of Health Sciences, Maastricht University,

The NetherlandsSlide49

FundingMental Health

Addictions TABI grantSlide50

Organizational:

Co-location of servicesDischarge and transfer agreementsInter-agency planning and/or

budgetingService affiliation or contracting

Jointly

managed programs or services

Strategic

alliances or care networks

Consolidation

, common ownership or mergerSlide51

Service delivery:

Joint trainingCentralized information, referral and intakeCase/care managementMultidisciplinary/interdisciplinary teamworkAround-the-clock (on-call) coverage

Integrated information systemsSlide52

Administrative

Consolidation/decentralisation of responsibilities/functions

Inter-sectoral planning

Needs assessment/allocation

chain

Joint

purchasing or commissioningSlide53

Clinical Integration

Standard diagnostic criteria (e.g. DSM V)Uniform, comprehensive assessment procedures

Joint care planning

Shared

clinical record(s)

Continuous

patient monitoring

Common

decision support tools (i.e. practiceguidelines and protocols)Regular patient/family contact and ongoing supportSlide54

Comprehensive, Continuous, Integrated System of Care (CCISC) Model

Substance Use Severity

ABI SeveritySlide55

Comprehensive, Continuous, Integrated System of Care (CCISC) Model

Co-occurring issues and conditions are an expectation, not an exception.

Care is client-centered and individualized. Treatment should be co-occurring.

The best practice intervention is integrated dual or multiple primary treatment, in which each condition or issue receives appropriately matched intervention at the same time.

Minkoff K & Cline C, Developing welcoming systems for individuals with co-occurring disorders: the role of the Comprehensive Continuous Integrated System of Care model. J Dual Diagnosis 2005, 1:63-89 Slide56

Continuum of servicesSlide57

POLL 3What are the challenges to implementing capacity building?Slide58

Factors that affect treatment recommendationsRelative severity of the brain injury and the substance use disorder

The client’s current readiness to participate in treatmentHow well aware the individual is of the disabilities associated with their brain injurySlide59

8 principles for integrated treatment (Corrigan, 2012)

Goals are interwoven- not sequential or parallelTreatment is holistic, addressing lifestyle not just substance useConsumer and clinician collaborate to develop a mutually agreed upon treatment plan

Clinicians help consumers to develop awareness and optimism so that their motivation for recovery can be internalizedSlide60

8 principles continuedDifferent services will be helpful at different points in recovery- staging, which must be incorporated into the overall treatment model

Treatment is longer-termKey staff are cross-trained to work with both TBI and substance use disordersStaff are more experienced and have smaller case loadsSlide61

Next StepsBuild the awareness

See the potential for cognitive impairment in your clients and the need for potential accommodations

Explore the need for neurobehavioural

accommodations

Do treatments need to be differentiated (this requires a research project)?Slide62

How to proceed

Adopt screening and tracking within existing procedures

Participate in cross training opportunitiesIn-person

Webinars

Distance learning

Start the discussion of how to create integrated care modelsSlide63

Community of Practice (COP)Cooperate for the benefit of research for developing best practices and for service development and advocacySlide64

SummaryIf you work in addictions and mental health ¼ of the people you see are affected by brain injury.If you work in concurrent disorders the number is much higher—half to 3/4.

Training is available to learn to :Screen for brain injuryRecognize and accommodate cognitive impairment and social and behavioural problemsPartnerships that enable Integrated care may increase efficacy and decrease costs