The Staten Island Partnership for Community Wellness (SIPCW) is a non-profit organization established to promote wellness and to improve the health of the Staten Island community through collaboration and a multidisciplinary approach. For more than 20 years, SIPCW has addressed critical public health issues such as obesity, chronic disease prevention and behavioral health on Staten Island. SIPCW serves as project lead for the Staten Island Performing Provider System (SI PPS)’s Behavioral Health Infrastructure Project (BHIP). The PPS is responsible for the local implementation of the NYS Medicaid Delivery System Reform Incentive Payment Program (DSRIP). Under the auspices of BHIP, SIPCW and PPS staff are working closely with primary care and behavioral health providers to strengthen linkages, to encourage integration, and to build a supportive infrastructure for a patient centered care approach. Primary care physicians (PCPs) serve as gatekeepers for the health of the community. They are generally the first point of entry into the healthcare system and are uniquely poised to support patients in addressing whole-person care for those with complex health needs. However, PCPs on Staten Island have historically reported low comfort engaging with patients around substance use and mental health. Further, despite evidence demonstrating the effectiveness of SBIRT (Madras, Bertha K. et al; Drug and alcohol dependence, 2009), mental health screening tools, and Medication Assisted Treatment (MAT) in primary care settings (Volkow, N; National Institute Drug Abuse, 2014), many Staten Island physicians are reluctant to integrate behavioral health screening and treatment into their practice. This lack of engagement with behavioral health is coupled with the alarming rate of opioid related overdoses and avoidable behavioral health related emergency department visits and hospitalizations on Staten Island. To further complicate the issue, stigma has been reported as a major barrier to accessing behavioral health services in the community and many residents are not comfortable discussing prevention and treatment options with their primary care physician. In response, BHIP partnered with our local health department to conduct a two-pronged public health detailing campaign to increase the capacity of PCPs to address behavioral health in their practices on Staten Island. This strategy is based on the pharmaceutical detailing model of providing in-office education to clinical practices.
The first component of the outreach strategy targets primary care practices with high Medicaid populations that were not conducting the recommended behavioral health screenings for depression and substance use. The primary goals of this effort were to: 1) Have PCPs universally screen for mental health and substance use disorder 2) Link providers to behavioral health services 3) Have PCPs refer patients to care coordination services supported by the SI PPS. Preliminary conversations with physicians indicated that universal screenings and referrals to services required time and expertise that many PCPs did not feel that they had. To increase their capacity to address their patients’ holistic needs, outreach staff provided technical assistance to these practices to connect with a NYC Department of Health and Mental Hygiene program to provide city funded, co-located, behavioral health specialists (LMSW). Each practice was also provided with a behavioral health toolkit developed by the BHIP initiative that included evidence-based guidelines regarding depression and substance use disorders as well as a guide to local behavioral health services and care coordination. SIPCW provided support to 11 practices in submitting an application for city funded social workers. To date, four practices have been assigned co-located behavioral health specialists.
The second detailing component focuses on a subset of physicians waivered to prescribe buprenorphine to treat opioid use disorders (OUD). Despite being the gold standard of treatment (World Health Organization, 2013), MAT remains a controversial method of treatment among both primary care and substance use treatment providers. To assess the current state of buprenorphine prescribing on SI, BHIP outreach staff visited 41% of federally waivered physicians practicing on Staten Island to understand current buprenorphine prescribing practices, provide technical assistance to those interested in increasing their capacity to treat OUD (including the new order allowing Nurse Practitioners and Physician Assistants to prescribe), and provide them with toolkits on behavioral health resources and care coordination services on Staten Island. For those successfully managing their patient panel, BHIP provided an opportunity to serve in a mentoring capacity to newly waivered clinicians or practices seeking additional support. Another core resource, www.sidrugprevention.org developed by the PPS, offers authoritative information for professionals seeking information on a wide variety of these topics as well as for patients and families.
Despite a high burden of behavioral health issues among Staten Island residents and the influence of the stigma associated with substance use disorder, this strategy has been largely well received by the clinical community. Evidence of this is the success of the SI PPS project Development of Withdrawal Management Services which has accrued over 1,000 new patients into MAT since April 2015. Participating providers cited increased knowledge of behavioral health resources in the community and were interested in further engagement around additional topics and modalities. 65% of actively prescribing buprenorphine waivered physicians reported interest in increasing their capacity to treat additional patients with opioid use disorder. These positive preliminary findings indicate the need to continue to engage clinicians, using an in-person approach, in collaborative efforts to integrate primary care and behavioral health services.
This two-pronged detailing model serves as a point of entry for future outreach to educate health professionals on a variety of topics to institute behavioral health prevention in primary care. Future visits will be tailored to relevant topics by provider type/specialty in accordance with the NYS Prescription Monitoring Program (PMP) and additional data sources. Toolkits will include information specifically targeting opioid prescribing practices as opioid prescriptions and doses remain high in Staten Island and are strongly associated with mortality (Bohnert, A, et al; JAMA, 2011). Overall, the strategy intends to achieve long term changes in provider practices regarding screening for behavioral health conditions and competency with either addressing identified conditions on-site or connecting patients to appropriate resources in the community.
Credits: By the Staten Island Partnership for Community Wellness: Jazmin Rivera, MPH, Program Manager; Nadeen Mahklouf, MPH, PharmD, Senior Clinical Outreach Coordinator; and Adrienne Abbate, MPA, Executive Director. Staten Island Performing Provider System, Joseph Conte, PhD, Executive Director.
For more information on BHIP efforts, visit www.sipcw.org/bhip or www.statenislandpps.org/behavioral-health, or call 718-226-0258.