The Bermuda Triangle of Care Coordination: Medical, Psychiatric, and Substance Use Disorders

Many patients with substance use disorders (SUDs) have significant medical and psychiatric problems. SUDs can cause or worsen numerous health conditions related to the central nervous system (e.g., impaired memory or seizures), digestive system (e.g., cancers of the mouth or esophagus; or inflammation of the pancreas), hepatic system (e.g., inflammation or destruction of the liver tissue; fatty, diseased, or scarred liver), cardiovascular system (e.g., weakening of heart muscle; stroke; high blood pressure), musculoskeletal system (e.g., broken bones; swelling of the joints; polyneuropathy or damage to nerve tissue), or respiratory system (e.g., lung damage or disease). SUDs also contribute to HIV, hepatitis, and other infectious diseases. Individuals with long-term addiction have a reduced life span due to poor health habits, accidents, and medical diseases.  
SUDs are also associated with a significant increase in psychiatric comorbidity. Rates of SUDs are higher among patients with mood, anxiety, personality, eating, and attention deficit disorders. Severity levels of each condition may vary from mild to moderate to severe. In our care management program, we serve many patients who have SUDs and medical and psychiatric disorders. In addition, many of these patients have social problems that affect their physical and mental health such as poverty, housing instability, detachment from families, and nonsupportive social networks. These patients may have limited internal and external resources to help them cope with multiple problems that impact their overall functioning and quality of life. This article will discuss multidisciplinary care coordination and interventions that are helpful to patients with multiple, high-priority needs.
It is easy for patients with these multiple problems to get lost in treatment systems. This is especially true when people present to one system—such as a hospital emergency room—with a major complaint, but have other significant problems that affect their medical functioning and quality of life. For example, John, who has a long history of addiction and IV drug use, was admitted to a medical unit for endocarditis. In addition to the symptoms of this medical condition, John has been using heroin daily for the past several months and was recently kicked out of his apartment for failure to pay rent. In the past his medical team treated his medical condition, detoxified him from heroin, and suggested he continue addiction treatment upon discharge.
According to a SAMHSA report, 7.9 million adults in the United States had a co-occurring mental health and SUD (Ahrnsbrak, Bose, Hedden, Lipari, & Park-Lee, 2017). In 2015, the former NIMH director Thomas Insel explained that median reduction in life expectancy for those with mental illness was 10.1 years. He further clarified, “Most of the early mortality was attributed to natural causes such as acute and chronic co-morbid medical conditions (heart diseases, pulmonary diseases, infectious diseases)”  (Insel, 2015). This suggests that a coordinated approach to care is needed to address the multiple disorders and problems presented by patients seeking help for a medical, psychiatric, or SUD.

The Need for Coordinated Care
Providers across various medical, psychiatric, or addiction treatment systems may not work together to coordinate care for complicated patients such as John. As a result, patients may feel frustrated or even fail to comply with the recommended treatment plan because they feel their needs and problems are not being adequately addressed.  
The challenge we face is how to coordinate and provide integrated care and service coordination for patients with these multiple disorders to insure proper care for all problems. The challenge for providers is determining which problems or disorders to prioritize since each one seems to be a high priority for patients.
From the perspective of providers, patients with complicated, high-priority needs often take a significant amount of time. In addition, these patients have a high frequency of utilization of inpatient and emergency rooms, making their care difficult to track. Patients with complicated, high-priority conditions such as HIV, schizophrenia, and opioid addiction frequently seek care at hospitals; primary care physician practices; community agencies; and behavioral health and substance use treatment programs. Many of these patients receive multiple medications from different providers. Polypharmacy issues put some patients at risk for side effects that are not managed well, which may cause noncompliance issues. Patients being prescribed opioids and benzodiazepines by different prescribers are at greater risk for an unintentional overdose or to develop a SUD. Additionally, some patients who develop SUDs and cannot afford medications may transfer their addiction from drugs like prescribed opioids to cheaper, illicit street drugs like heroin or fentanyl.

Case Examples
In one case, a health insurance case manager gets a call from a patient asking for help with a referral to SUD treatment for alcohol and cocaine problems. The case manager searches for treatment services for the patient and completes conference calls to find out which provider will offer an evaluation appointment to the patient to determine what treatment may be needed. During this process, the case manager discovers there are transportation problems as well as untreated diabetes and depression. What seemed like a relatively simple call to connect to a patient to a SUD treatment program has involved many calls and connections to multiple medical, psychiatric, and SUD providers. It may take coordination among multiple providers to work together to assist a patient like this. In some cases of more severe medical conditions requiring close medical care in an addiction rehabilitation program, the case manager finds it difficult to locate a program that will consider treating the patient.
In another case, the case manager received a call from a hospital emergency department that a patient with multiple problems was taken there by first responders following a heroin overdose. The case manager discussed the discharge plan with the medical team and patient navigator, and agreed to contact the patient by phone on a daily basis until the patient engaged in treatment for opioid addiction. We have found that assertive outreach is needed by many of these patients to help facilitate their entry into care for problems such as an opioid addiction.  

Helping Patients with  Multiple Problems
So what works? For patients with chronic conditions, it is valuable to have a treatment perspective of wellness and recovery because their care is a journey, not a destination, since many of their multiple conditions are chronic. The key is a recovery approach to caring for these patients as well as having rapid outreach and intervention when patients are ready to receive help. Providers should understand that connection with complicated patients may be sporadic at times as a result of their noncompliance and dropping out of treatment systems. Creating a plan with these patients is important to see what priorities are important to them. Having knowledge of what interventions are available is also important for rapid response and intervention.
An example case is Shirley. She is a fifty-year-old with bipolar disorder and chronic obstructive pulmonary disease (COPD) from years of smoking addiction. Shirley has been to the emergency department sixteen times in the past six months since she has trouble breathing. Shirley has only been to her PCP once during this time. She has also been referred to home care, but refuses to let anyone in her home. Shirley’s behavioral health provider can see her decline, but is unaware of the medical emergency room visits that have occurred. Case managers from physical health and behavioral health have started to work together to help Shirley. With the input of Shirley’s health insurance case manager, information is provided to the behavioral health case manager and the emergency department. The goal is to link Shirley with transportation to the pulmonologist to create a plan with Shirley to improve her breathing. Shirley signed a release of information so her many treatment systems can work together to remove any barriers to care. Her behavioral health and physical health providers are communicating—with her permission—to ensure connections to care occur. Shirley also agreed to have a peer navigator come to her house and discuss how to get connected with community supports. As a result, Shirley now has her oxygen for night time and her medications delivered to her in blister packs so she knows what to take for each day, and she no longer goes the emergency room. Shirley also cut down significantly on her tobacco use through a tobacco education program and agreed only to smoke outside. Although the ideal is cessation of smoking, a harm reduction approach is needed for some patients who may not agree to stop all of their alcohol or drug use.

Conclusion
Future considerations to help members with complicated medical, psychiatric, and substance use issues include increased communication between providers in medical, psychiatric, and addiction systems of care. Shifting the view of care from a disease model to a person-centered wellness and recovery model is important to keep patients engaged in services and actively involved in their care. Hiring staff with clinical expertise in medical, psychiatric, and SUD treatment is also helpful in coordination of care. In summary, it takes a team approach among multiple providers willing to work together, with patients at the center, to improve care of patients with high priority medical, psychiatric, and substance use problems. c

About the Authors
Dennis C. Daley, PhD, served for  fourteen years as the chief of Addiction Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh School of Medicine. Dr. Daley has been with WPIC since 1986 and previously served as director of family studies and social work. He is currently involved in clinical care, teaching, and research.
Ann Giazzoni, LCSW, MBA,  is program manager of physical health/behavioral health integration at the University of Pittsburgh Medical Center Insurance Division.

References
Ahrnsbrak, R., Bose, J., Hedden, S. L., Lipari, R. N., & Park-Lee, E. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm
Insel, T. (2015). Blog post by former NIHM director Thomas Insel: Mortality and mental disorders. Retrieved from https://www.nimh.nih.gov/about/directors/thomas- insel/blog/2015/mortality-and-mental-disorders.shtml