PHC has had intensive care management programs in many of our FQHCs since 2012.  These care management programs will be evolving into our health homes programs in 2017.  Health Homes is an evolution of the patient centered medical home with an increased focus on substance abuse, integration of mental and behavioral health with medical care and a more intense effort to work with homeless members.

One of the new components in patient assessments will be a look at how trauma has affected the lives of our patients.  How serious is this problem?  Here are a few statistics:

• Over half of women (55 to 99%) in substance abuse treatment report trauma
• Nearly all women in the public mental health system (85 to 95%) have had trauma
• Nearly all homeless veterans suffer PTSD
• Trauma exposed youth have arrest rates 8 times that of same age peers
• The economic costs of untreated trauma-related alcohol and drug abuse are estimated to have been $161 billion in 2000.

The Substance Abuse and Mental Health Services Administration (SAMHSA) concept of the trauma informed approach defines a trauma informed system of care:

• Realize the widespread impact of trauma and understand paths to recovery
• Recognize the signs and symptoms of trauma
• Respond by integrating policies and procedures in your practices
• Resist re-traumatizing patients

The goal is recognizing the effects of trauma on our patients is to provide an emotionally and physically safe environment for our patients.

How can you know if trauma is playing in a role in your patient’s behavior or choices?  You might start by asking about his or her childhood or how things are going at home.  Once you get a feel for whether trauma has affected your patient you may be able to be more direct in your questioning. The Life Events Checklist has 17 specific traumatic events, but you can consider a shorter list that we will be implementing into our PHC health risk assessments.

Have you been involved in or exposed to:

• A natural disaster such as a flood, fire or earthquake?
• Combat or a warzone?
• Physical or emotional abuse?
• Sexual abuse or assault?
• Sudden violent death or unexpected death in someone close to you?
• Any serious harm, injury or death caused by you?

Trauma is treatable. There are many evidence-based models and practices to help heal our patients and improve the behavioral manifestations of trauma.  A history of trauma is often hidden or denied and we don’t often ask about trauma in our patients with problematic behaviors.

How will this play out in your practices?  The next time someone acts out in your practice, consider asking “Can you tell me what happened to you?” instead of “What’s wrong with you?” You may be surprised at the answer.

While most people associate “magic mushrooms” and “X” with illicit drug use some recent research indicates these substances may have a role with some of the most difficult-to-treat psychiatric patients.

Two studies published in the December edition of the Journal of Psychopharmacology used psilocybin and similar study designs to treat cancer patient’s depression and anxiety. Previous studies have (unsurprisingly) shown high rates of both conditions in cancer patients with life-threatening diagnoses along with difficulty in adequately treating these same conditions leading to a variety of poor outcomes. (e.g. decreased survival rates, increase in suicides, decreased function, among others)

Utilizing a crossover study and high or moderate dose of psilocybin versus placebo or very low dose psilocybin both studies found not only a marked improvement in both depression and anxiety scores but also improving measureable factors such as spiritual wellbeing, general life satisfaction, and quality of life, life meaning, and optimism, while decreasing cancer-related demoralization and hopelessness, and death anxiety. Even more remarkable the effect on depression and anxiety (with reduction rates as high as 80%) persisted for 6-8 months with only a single dose of psilocybin!!  Both studies even used a Mystical Experience Questionnaire (MEQ30) which “is a self-report questionnaire that evaluates discrete mystical experiences induced by serotoninergic psychedelics and is sensitive to detecting psilocybin-induced mystical experiences.” As an additional benefit, no subjects in either study suffered from any serious side effects.

Along this same vein the FDA announced this week that based on the success of small drug trials it is allowing large-scale Phase 3 clinical trials to study the use of MDMA, or Ecstasy, for patients with severe PTSD. The Multidisciplinary Association for Psychedelic Studies (MAPS), a non-profit group that advocates for the medical use of banned drugs, sponsored six Phase 2 studies that led to the FDA’s decision.

In 2 of the trials they studied combat veterans, sexual assault victims, firefighters and police officers that suffered from PTSD and had not responded to previous treatments. The average duration of symptoms was 17 years! Subjects were given 3 doses of MDMA a few weeks apart under supervision of a psychiatrist along with psychotherapy. This was also a crossover study.

One study showed a 56% decline in severity and by the study conclusion 2/3 no longer met the criteria for PTSD. In addition improvements persisted for over a year. The researchers have applied for “breakthrough therapy status” with the FDA which could allow approval by 2021. Other researchers urge caution, using the opioid crisis as an example of how the drug could be abused.

As a historical aside, MDMA was first patented in 1914 but in 1978 it was resynthesized by chemist Dr. Alexander Shulgin. (Dr. Shulgin was my toxicology professor during my MPH studies at UC Berkeley – an interesting man to say the least!) He gave it to friends in the psychiatric field to use for augmenting psychotherapy but when it spread to more general recreational use the FDA classified it a Schedule 1 drug and initial research was halted.

The results so far are promising but likely a long way off for routine clinical use.

A previous blog on calcium supplementation raised concerns about reports that supplemental, non-dietary, calcium was linked to a greater incidence of cardiovascular, cerebral vascular and all-cause mortality. Continue reading →

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Recently, Collabria Care hosted an annual symposium on palliative care that drew over 80 physicians, nurses, social workers and others to American Canyon to consider the advances in palliative care. This annual event is jointly sponsored by Partnership HealthPlan of California.

Each speaker over the two day symposium offered challenges for daily practice in palliative and end of life care. None was more challenging, dare I say, ground-breaking than the last presentation of the symposium by BJ Miller titled “Not Whether, But How: Exploring the Potential of Palliative Care”. Dr. Miller is a palliative care specialist at UCSF, and an internationally-renown thinker and speaker (see his TED talk at https://www.youtube.com/watch?v=apbSsILLh28 ) who brings design thinking to the reformation of palliative care.

His hour-long talk was part philosophy, part design, and wholly focused on the care that we give our patients who have serious illness and are moving towards the end of life. His prime challenge to us was how to move from a disease centered to a human centered approach to care. He reproached current medical systems who are locked into the increasing complexity and technologies of diagnosis and therapy, and miss the opportunity to address what really matters to patients that he identified as:

• Not being a burden, esp financially to family and loved ones
• Spiritual peace
• Community and communion of loved ones
• Respect for culture and traditions

He challenged us to move beyond the dualities that our health system has set up, and which impede human centered care. These include:

• Acute vs chronic. Where is continuity and continuum of care in our system?

• Intervening vs. supporting. Our system is geared towards doing, often because we can rather than because it is best for the patient. How does our health system support the needs of patients which are different than the needs of the providers?

• Curing vs. healing. Does our health system truly understand what is meant by healing which is more than the elimination or control of disease?

• Quality of health vs. quality of life. The focus of health systems is to restore physical health rather than achieve the patient-desired quality of life.

• Less horrid vs. more wonderful. I love this paradigm where a health system moves beyond alleviating suffering (particularly physical) to a system that strives to bring delight and meaning to the people it serves. In other words, a system that brings wonder and creates an environment and state that is more wonderful. Contributing to the “horrid” mindset is our health systems proclivity to define illness, suffering, disability, aging, and dying as “abnormal” which need to be normalized.

• Self vs other. Our health systems are constructed on the model of we, the care providers, doing to they, the patients in need, who are often categorized and compartmentalized by their disease state (we have pediatric floors, medical floors, surgical floors etc). How could we envision a system where we the dying are caring for others who are also dying. I am reminded of Gayle Stephens (one of the fathers of family medicine) who advocated person centered care defined as care of a person by a person.

Dr. Miller emphasized two other design keys. First is “proportionality”. We have a health system that can’t help itself, is so taken by the awesomeness of its capabilities that it “bestows” on patients often more than is desired, more than is needed, leading to more suffering rather than less.  Related to the first is the tyranny of choice. Too often “what can be done (choices) takes precedent over what is best for the patient (as negotiated in communion with the patient)”.

As with many other sectors of society, healthcare is enamored of words which are latinzied and too often not understand by the user or recipient. Dr. Miller challenged us to think beyond words, to the realm of experience and how health systems can design and use experience to care for patients.

Finally, and perhaps most radically, Dr. Miller challenged us to move beyond the healthcare paradigm that is wrapped into a time continuum of past into future. Palliative care buys into this paradigm through disease and outcome prognostication. His final (or at least what he left us to ponder) challenge was how to create a system where patient-provider and all their individual and amalgamated meanings converge in the real time of the present.

I walked away exhilarated and inspired that these design principles not only apply to the domain of palliative care but all of health care. There is hope that in the redesign of palliative care will be a blueprint for the rest of healthcare.

Scott Endsley MD, Associate Medical Director for Quality

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The state of California will be implementing section 2703 of the Affordable Care Act in 2017.  Section 2703 defines the Health Homes Program (HHP) for Medicaid members in our state.  Most of us have heard the term, the Patient Centered Medical Home, and although Health Homes is new, the origins of the Health Homes Program goes back several decades.

The “Medical Home” was first defined by the American Academy of Pediatrics in 1967. The Standard of Child Health Care envisioned “one central source of a child’s pediatric records to resolve duplication and gaps in service that occur as a result of lack of communication and coordination.”  A few years later, the AAP issued a policy statement, “The Medical Home” (Pediatrics 1992;90:774), that proposed the pediatric practice as an Accessible, Continuous, Comprehensive, Family-centered, Coordinated and Compassionate place for the care of infants, children and adolescents to provide:

• Preventive care and immunizations
• Health screening and assessments of growth and development
• Patient and parental counseling about health and psychosocial issues
• Care over an extended period of time to enhance continuity
• Interaction with school and community agencies so that health needs are met
• Centralized records and enhanced communication

In 2002, the AAP added Culturally Effective to the definition and recommended that the care be “delivered or directed by well-trained physicians who provide primary care and help to manage and facilitate essentially all aspects of pediatric care.”

The key concepts of the medical home as envisioned by the AAP are preventive care, screening, counselling, continuity over time, interaction with the community and enhanced communication.  Two years later, the American Academy of Family Physicians, in the Future of Family Medicine project continued the evolution of the health home when they proposed the “Personal Medical Home” to provide continuous healing relationships, care customized to patient needs and values, the free flow of information, cooperation among clinicians and safe, timely, effective and equitable patient centered care.

The Patient Centered Medical Home (2006) was a joint statement by the AAP, AAFP, ACP and the AOA that added whole person orientation, coordinated care, quality and safety to the medical home. The Department of Health Services and the CMS Federal Work Group became involved and added coordination of medical and social services across the lifespan in 2008. Then, in 2009, in recognition that patients primarily receiving behavioral health care are often disconnected from medical care, SAMHSA added the integration of community based behavioral health care and medical care into the medical home definition.

All of these refinements came together with the Affordable Care Act in 2010.  Section 2703 of the ACA created the Medicaid Health Home program to coordinate the full range of physical and behavioral health services, community support services and long term supportive care with enhanced coordination of medical and behavioral health in a whole person philosophy of care.  The guiding principles and goals for the health homes program are to:

• Improve care coordination
• Strengthen community care linkages
• Offer team based care including community health workers
• Improve health outcomes for members with high risk chronic diseases
• Integrate physical and behavioral health issues
• Integrate palliative care into primary care delivery
• Recognize and respond to trauma informed care needs
• Improve medical care to homeless members
• Improve integration and treatment of patients with substance abuse disorder

PHC will be implementing the HHP program for our members in 2017.  PHC has been providing intensive care management in many of our FQHCs through an Intensive Out-Patient Care Management (IOPCM) program since 2012.  All of these IOPCM sites will transition to the health home concept next year.  Health Home sites will work to provide a multi-disciplinary approach for our members with increased use of health navigators and improved connections with community based resources to enhance the care of our most challenging health plan members

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Part 1 and 2 of this series on Managing the Monster have outlined the evidence that supports the extreme risk posed by co-prescribing benzodiazepines and opioids. This blog outlines the initiative that Partnership HealthPlan of California is undertaking to reduce this risk, starting with provider education.

Where are we going?

As Partnership dives in to our last phase of the Managing Pain Safely initiative, we are expanding its focus to include co-prescribing of benzodiazepines (BZD).  For the last two and a half years, Partnership has been actively working to reduce the number of members prescribed high dose opioids.  Since the start of the project in January 2014, we have seen a 74% reduction in the proportion of members on high dose opioids (>120 mg MED), PMPM, plan-wide.  This is only 1% away from our initial goal of 75% reduction!    As the project begins to accomplish the goals we initially set out to tackle, it is apparent that there is one crucial area that we have yet to focus on- co-prescribing BZD and opioids.

Why is it important?

As detailed in the last two blogs, the risks of severe complications, including overdose and death, are significantly higher when a patient uses a combination of opioids and benzodiazepines.  While the dangers of opioids alone are significant, they drastically increase when combined with BZD. It has been shown that as much as 80% of unintentional opioid overdoses deaths also involve BZD ¹.  In the past five years, the U.S. has seen a fivefold increase in the number of unintentional BZD associated deaths¹.  Studies have shown that the adjusted hazard ratio for risk from drug overdose for patients currently taking both opioids and BZD for is 3.86.³ This is especially concerning when keeping in mind that compared with opioid abusers, those taking both opioids and BZD are more likely to take the medications for longer periods of time and at higher doses.²

What are we doing?

Given the evidence of the dangers of co-prescribing, PHC leadership has designated this as a priority within this next year.  The MPS team has convened to determine a new goal for the initiative- to reduce the number of members with co-prescriptions of both opioids and benzodiazepines, PMPM.  While final plans and anticipated targets are still being defined, the top strategy of the health plan as of now is to provide education for our providers and our members.  The Plan intends on creating educational material for both providers and members, host a webinar to discuss how to manage patients taking both opioids and BZD, and share provider-site level data detailing who in the practice has prescriptions for both.  PHC is also promoting the CDC guidelines which recommend avoiding co-prescribing. PHC will also be working with community coalitions currently developing and implementing county-wide safe prescribing guidelines acknowledge the dangers of co-prescribing and recommend against the practice.

How will it impact you?

As mentioned, as of now the primary strategy to address co-prescribing will be to create educational materials for the provider and member, share best practices, share provider-site level data, and have 1:1 provider level academic detailing sessions with select provider sites.   PHC is dedicated to support our providers in continuing to grow a knowledge base and develop and utilize tools on safe prescribing.  Throughout the fall of 2016, expect to see more material and discussions on the use of BZD in conjunction of opioids.

Webinar on Co-Prescribing

Managing the Monster: Strategies in Managing Opioid and Benzodiazepine Co-Prescribing

Tuesday October 25, 2016

Noon-1pm

Registration: https://attendee.gotowebinar.com/register/8210921216123819778

References

• Gudin JA; Mogal S; Jones JD; Comer SD. “Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use”. Post Graduate Medicine, 2013, 125 (4) 0032-5481
• Jann M; Kennedy WK; Lopez G. “Benzodiazepines: A Major Component in Unintentional Prescription Drug Overdoses with Opioid Analgesics”. Journal of Pharmacy Practice, 2014, 27(1) 5-16
• Park TW; Saitz R; Ganoczy D; Ilgen MA; Bohnert ASB. “Benzodiazepine prescribing patters and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study”. BMJ Open Access, 2015, 350:h2698