Screening is a two-way street

Stanley Street Treatment and Resources (SSTAR) in Fall River, Mass., has been ahead of the curve since its founding in 1977. As the first agency in the state to provide alcohol and drug treatment in the same place, integrating services was a core component of its mission, and continues to be today.

“In the 1980s, I was in Washington and heard Benny Primm [of SAMHSA] talking about holistic care,” says Nancy Paull, CEO of SSTAR. “It just resonated with me, and it's been my mission ever since.”

The 1980s brought integration of a different sort-specifically, the integration of addiction and mental health services-but it laid the foundation for SSTAR's future. With the integration of mental health and substance use care, SSTAR also found itself developing services to meet the influx of patients needing HIV/AIDS treatment, from counseling to testing. Without SSTAR's services, HIV/AIDS patients in the community would have to travel to Boston or Providence for treatment.

“Our medical director was saying people should be able to get this kind of care in their own community,” Paull says. “So we decided to open up a primary healthcare clinic.”

A bumpy road to one-stop healthcare

Development of the SSTAR primary care clinic-which started off as just two renovated exam rooms onsite at its treatment facility-began in 1990 and got off the ground in 1993. And although there were more than enough patients to justify its services, the clinic lost more than $250,000 in its first year.

“Right around that time, a recession hit and a lot of people started coming in,” Paull says. “Not just people who didn't have addictions, but a lot of people who had lost their healthcare.”

Even with just one nurse and one physician on staff, the primary care clinic drained SSTAR's capital reserves, putting Paull's vision of a one-stop shop for complete healthcare in danger of extinction.

But after SSTAR reached out to the Massachusetts League of Community Health Centers for guidance, the future of its integrated services became clear: It would have to achieve federally qualified health center (FQHC) status to stay afloat.

After it became a FQHC, increased Medicaid rates supported SSTAR's expanded services. The primary care clinic has since grown to successfully serve 6,000 patients per year.

New services, new challenges

Because every patient that accesses SSTAR's primary care services is screened for behavioral health disorders, the facility seeks physicians with certain qualities for their FQHC staff. Namely, these physicians must have some interest in behavioral health, but not necessarily experience.

“We get a lot of new physicians that we can help train,” Paull says. “We kind of like that.” SSTAR also looks for physicians who “are willing to grow and change” along with its evolving services.

To ensure that primary care physicians are equipped to screen and treat patients with behavioral health disorders, SSTAR requires that each becomes Suboxone waivered to treat opiate addiction and completes detox rounds as part of their on-call schedule.

The screening and cross-referral from one service line to the next should ensure comprehensive care for SSTAR's patients. But, Paull says, there are some big problems that still stand in the way.

“The biggest problem we have around behavioral healthcare is the lack of psychiatric time,” she says. “We probably have had more severe cases of mental illness than our primary care doctors can handle, and we certainly don't have enough psychiatric time to handle it.”

Counselors who want to refer behavioral healthcare patients to primary care services face similar barriers as well. Because Medicaid is part of Massachusetts managed care, patients who have traveled outside their home communities to SSTAR for detox or inpatient addiction treatment generally will not be authorized to receive primary care treatment in the clinic.

“We still screen them, and we'll make a referral [to a primary care doctor in their community] when they leave here,” says Pat Emsellem, COO of SSTAR. “But with this population, if they don't get it right away, you're apt to lose them.”

Instant access throughout the community

To meet patient needs for instant access to screening and integrated care, SSTAR partnered with other primary care providers in the Fall River community.

“The earlier we could get somebody into behavioral health treatment, the better off they will be, just like with any disease,” Paull says. “So we were interested in getting more primary care physicians to screen for substance abuse in their own practices.”

Likewise, SSTAR wanted to be able to offer those physicians screening for behavioral health instant access to a referral resource. “We wanted to work with physicians who were willing to screen, to assist them in helping patients break through denial and get them to treatment,” Paull adds.

A committee was formed to develop the community initiative, and two primary care practices got involved, including Dr. Madeline Colon-Usowicz's family medicine practice. As a recent graduate of UMASS Worcester's residency program, where integration of primary and behavioral healthcare had been heavily emphasized, Colon-Usowicz welcomed the approach.

“When the ability to integrate behavioral healthcare with SSTAR was offered, I jumped on board quickly,” she says. “I wanted to have that extra tool for my patients and that ability to offer them more services.”

To ensure screening consistency for the two primary care practices involved in the initiative, a standardized case questionnaire was adopted. Then, a release of information document was developed according to HIPAA and 42 CFR Part 2 standards to allow physicians to transfer referral patient information to SSTAR. This document also allowed SSTAR to report back to the referring physician on whether or not the patient showed up for treatment.

A hotline was then established specifically for physicians calling to receive screening and referral assistance. This line bypassed administrative staff and went straight to a case manager, who volunteered to carry an iPhone to field these calls throughout the day, even on days off, so physicians could access instant assistance.

“SSTAR has really served as this middle ground for all of us, and that's been very beneficial,” Colon-Usowicz says. “It's at our door, it's with us, and I think even physicians who weren't trained in this or haven't had the experience will find this is helpful and useful along the way.”

A pain clinic also recently joined the initiative, looking to refer patients abusing their pain medications to SSTAR for treatment.

“We're hoping it will continue to grow as time goes on,” Paull adds.

Behavioral Healthcare 2010 October;30(9):8-9