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Constance Weisner Felicia Chi Sujaya Parthasarathy Jennifer Mertens

Integrating Alcohol and Drug Treatment with Primary Care: A Medical Home Model. Constance Weisner Felicia Chi Sujaya Parthasarathy Jennifer Mertens. Division of Research, Kaiser Permanente University of California, San Francisco CALDAR Summer Institute

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Constance Weisner Felicia Chi Sujaya Parthasarathy Jennifer Mertens

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  1. Integrating Alcohol and Drug Treatment with Primary Care: A Medical Home Model Constance WeisnerFelicia ChiSujayaParthasarathyJennifer Mertens Division of Research, Kaiser Permanente University of California, San Francisco CALDAR Summer Institute UCLA Integrated Substance Abuse Programs (ISAP) Promoting Substance Abuse Recovery within the Changing Health Services System August 13, 2012 Studies funded by NIDA and NIAAA

  2. OverviewIntegrating Substance Use services with health care • A conceptual model of integration using primary care • Development of approach • Screening, Brief Intervention, and Referral to SU Treatment • Integrating care during SU treatment • Continuing Care following SU treatment • Research Opportunities • Primary care as the anchor for ongoing medical care, monitoring of SU and mental health problems

  3. Disease Management/Chronic Care Approach Individuals with a serious chronic problem (e.g., diabetes) are treated in specialty care, and when stabilized return to primary care for management and monitoring Similarly, alcohol and drug dependence are chronic conditions requiring ongoing care or management delivered in more than one setting Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Institute of Medicine. Improving the quality of health care for mental and substance-use conditions: Quality Chasm series. Washington, DC: National Academies Press; 2005

  4. What might a continuing care modelfor alcohol and drug problems look like? Screen and treat in PC if moderate problem & continue monitoring Refer to SU treatment if needed Back to PC for monitoring & possible readmission Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Bodenheimer T, Wagner EH, Grumback K. Improving primary care for patients with chronic illness. JAMA 2002; 288:1775-9.

  5. Why Primary Care?

  6. Community Epidemiology Laboratory General Population Survey Agency Systems Alcohol Treatment (22) Drug Treatment (8) Mental Health (8) Welfare (7) Emergency Room (4) Primary Health Care (5) Criminal Justice (1) Weisner, Schmidt & Tam. Addiction, 1995.

  7. Prevalence of New Admissions of Problem Drinkers across General Population & Community Agency Caseloads (%) General Population (3069) Private Primary Care (358) Public Primary Care (394) Private ER (1102) Public ER (801) Welfare (621) Mental Health (406) Jail (1147) Drug Trtmt (304) Alcohol Trtmt (381) Data are weighted to adjust each sample for variation in agencies sampling fraction, rate, and fieldwork duration.

  8. Distribution of New Admissions1 of Alcohol Dependent2 Individuals in Community Agency Systems Alcohol and DrugTreatment 11.1% Welfare 6.6% Mental Health 3.0% Primary Care 55.7% Criminal Justice 23.5% 1 Data weighed for design effects, non-response, and to a common fieldwork duration so that each agency system sample is shown to its size. 2 Dependence rates over a base of those meeting DSM-III-R criteria across all agency systems.

  9. Distribution of New Admissions1 of Weekly Drug Users2 in Community Agency Systems Alcohol and Drug Treatment 6% Welfare 11% Primary Care 43% Mental Health 3% Criminal Justice 39% 1Data weighed for design effects, non-response, and to a common fieldwork duration so that each agency system sample is shown to its size. 2 Weekly drug use rates over a base of weekly drug users across all agency systems.

  10. Why primary care? • Screening • Ongoing care • Monitoring • Referral back to SU treatment when needed

  11. Staff-model integrated health care delivery system (medical, psychiatry, SU services) • Serves 3.4 million members (about 40% of insured population in the region) • 18 hospitals, 27 SU and MH outpatient clinics • Electronic medical record • Similarities wtih FQHC’s

  12. Screening and Intervention in Primary Care

  13. Hazardous Drinkers and Drug Users in Primary Care • Prevalence of 10% for either alcohol or drug problems • Hazardous drinkers and drug users had higher prevalence than other primary care patients of several common medical conditions, including: • Injury • Hypertension • Asthma, emphysema, COPD • Pneumonia • Depression, Anxiety, and Major Psychoses • Higher health care costs • Important for care of chronic conditions (including diabetes) Mertens JM, Weisner C, Ray GT, Fireman B, Walsh K. Hazardous drinkers and drug users in HMO primary care: prevalence, medical conditions, and costs. Alcohol Clin Exp Res. 2005;29:989-98. Ahmed A, Karter AJ, Warton M, Doan JU, Weisner C. The relationship between alcohol consumption and glycemic control among patients with diabetes differs by age and diabetes type: the Kaiser Permanente Northern California Diabetes Registry. J Gen Intern Med. 2008;23 (3):275-282.

  14. Medical Conditions: Example from a FQHC

  15. Screening, Intervention, and Referral to Treatment in Primary Care:Evidence Base and Research Need • SBIRT in primary care is effective, cost effective, and recommended by national guidelines but has not been widely adopted • Only a few rigorous implementation studies have been conducted in the U.S. Bertholet N, Daeppen JB, Wietlisbach V, et al. Arch Intern Med. 2005;165:986-995. Whitlock EP, Polen MR, Green CA, et al. Ann Intern Med. 2004;140:557-568. Solberg LI, Maciosek MV, Edwards NM. Am J Prev Med. 2008 Feb;34(2):143-152. Saitz R, Svikis D, D'Onofrio G, et al. Alcohol ClinExp Res. 2006;30:332-338.

  16. At-Risk Drinking In Primary Care Need Specialty Treatment Alcohol Dependent 7.5% At-Risk Drinkers Brief Intervention Low-Risk Drinkers Abstainers Institute of Medicine. 1990, and World Health Organization, 2001

  17. Helping Patients Who Drink Too Much: Kaiser’s SBIRT studyNIAAA: PI Jennifer MertensImplementation study of effective interventions

  18. Randomization 1/3 of PC modules randomized to control condition 56 Facilities 1/3 of PC modules randomized to PCP Arm 1/3 of PC modules randomized to ‘NPP’ arm • MAs are trained to Screen • BMS/Nurses/CHEs • Receive training (with • CME/CEUs) to conduct • BI and RT PCPs receive SBIRT training with CMEs Informational session on how to access and use Alcohol Screener

  19. Alcohol Screener in EMR

  20. Best Practice Alert

  21. Primary Outcomes (using the EMR) • Screening rates • Brief intervention rates • Referral to treatment rates • Cost and utilization

  22. Secondary Outcomes (Using the EMR) • Compare Effectiveness by Study Arm. • Effectiveness on patient outcomes of: • typical quantity consumed • days per week consumed alcohol • average weekly consumption • Related health outcomes: • blood pressure reductions for patients with hypertension diagnoses and, • antidepressant adherence (consistent with HEDIS standards) for patients with depression diagnoses who have antidepressant prescriptions.

  23. What might a continuing care modelfor alcohol and drug problems look like? Screen and treat in PC if moderate problem & continue monitoring Refer to SU treatment if needed Back to PC for monitoring & possible readmission Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Bodenheimer T, Wagner EH, Grumback K. Improving primary care for patients with chronic illness. JAMA 2002; 288:1775-9.

  24. Integration with Primary Care:During SU Treatment • In specialty care we have a more select population – with high rates of medical and psychiatric problems

  25. Controls Prevalence in Adult SU Treatment Patients Vs. Matched (%)(more than 20 conditions) Acid-Related Disorder Arthritis Asthma COPD Migraine Hypertension Lower Back Pain Injury Controls 0 5 10 15 20 25 30 SU patients Conditional Logistic Regression Results: p<0.01 for all conditions shown Mertens et al. (2003). Archives of Internal Medicine 163: 2511-2517.

  26. Prevalence in Adult SU Treatment Patients Vs. Matched Controls (%):ICD-9 Psychiatric Conditions* *all p<.001 Mertens JR, Lu Y, Parthasarathy S, Moore C, Weisner CM. Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: Comparison to matched controls. Arch Intern Med. Nov 10 2003;163:2511-2517.

  27. Integrating Primary Medical Care During SU Treatment: Evidence Base • Systematic reviews indicate that a small but growing literature suggests effectiveness of integrating primary medical care during SU treatment, but: • Few randomized trials • Lack cost-effectiveness analysis Butler M, Kane RL, et al. Integration of Mental Health/Substance Abuse and Primary Care. AHRQ Publication No 09-E003. October 2008. Druss BG and von Esenwein SA. General Hospital Psychiatry. 2006; 28(2): 145-53. Willenbring ML and Olson D. Arch Intern Med. 1999; 159 (16): 1946-52. Friedman P, Zhang Z, et al. J Gen Int Med. 2003; 18: 1-8.

  28. Outcomes of Integrating During SU Treatment Randomized those entering SU treatment to receiving their primary care in the SU clinic vs. receiving it as usual care in the clinics. Those with medical problems receiving integrated services were almost twice as likely to be abstinent at 6 months, and was cost-effective. There is still an effect at five years. Weisner C, Mertens J, Parthasarathy S, Moore C. Integrating primary medical care with addiction treatment: A randomized controlled trial. JAMA. Oct 2001;286(14):1715-1723. Mertens JR, Flisher AJ, Satre DD, Weisner C. (2008). The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug and Alcohol Dependence 98(1-2):45-53.

  29. What might a continuing care modelfor alcohol and drug problems look like? Screen and treat in PC if moderate problem & continue monitoring Refer to SU treatment if needed Back to PC for monitoring & possible readmission Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Bodenheimer T, Wagner EH, Grumback K. Improving primary care for patients with chronic illness. JAMA 2002; 288:1775-9.

  30. Case for Primary Care Continuityafter SU Treatment • SU treatment population has a high level of chronic or on-going medical and mental health conditions • It’s unrealistic to expect that chronic health problems will disappear with SU treatment • Health problems can cause relapse • A mechanism to continue to monitor SU problems

  31. Conceptual Approach: Disease Management/Chronic Care Approach • Individual with a serious chronic problem (e.g., diabetes) is treated in specialty care, and when stabilized returns to PC for management and monitoring • referred back to specialty care for services as needed in the course of their health care • Similarly, SU dependences is a chronic condition requiring ongoing care or management delivered in more than one setting • Not replacing aftercare – can be placed on top of all types of aftercare Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. Institute of Medicine. Improving the quality of health care for mental and substance-use conditions: Quality Chasm series. Washington, DC: National Academies Press; 2005

  32. A Model of Continuing Care FollowingSU TreatmentObservational study as a first step informing an intervention Three components: 1) Regular primary care as anchor 2) Readmission to SU treatment when needed 3) Psychiatric services when needed

  33. Patient characteristics and data sources of patients at 1 year, 5 year, 7 year and 9 year follow-ups) • KP Chemical Dependency Recovery Program (CDRP) in Sacramento, California • Study participants: 1,951 adult individuals (i.e. 18 years or older) entering treatment at the CDRP during April 1994 – April 1996 and April 1997 – December 1998 (93% of intakes) • Follow-up interviews at 1 year, 5 years, 7 years and 9 years, with response rates of 90%, 86%, 84%, and 78%

  34. A Model of Continuing Care Following SU Treatment • Need for specialty care: • having a non-zero Addiction Severity Index (ASI) score for the corresponding SU or MH problem domain at the prior interview time point • Membership and service utilization from the health plan’s administrative databases

  35. Nine-Year Primary Care-Based Continuing Care Outcomes(Observational Study) • Patients receiving continuing care were more than twice as likely to be remitted at each follow-up over 9 years (p<.0001).* • Results were consistent by gender, medical and psychiatric severity, and for all age groups except those older than 50 years. * mixed-effects logistic regression model controlling for time/follow-up wave, demographic characteristics, severity, and completion of index SU treatment Chi FW, Parthasarathy S, Mertens JR, Weisner C. (2011). Continuing care and long-term substance use outcomes in managed care: initial evidence for a primary care based model. Psychiatr Serv 62(10):1194–200..

  36. Receiving Continuing Care1 vs. Remission Over 9 Years, Stratified Analyses2 Note: 1 Receiving continuing care was defined as having regular PC and receiving both CD and psychiatric services when needed. 2 All models adjusted for the same set of covariates as in the model presented in the previous slide.

  37. Nine-Year Primary Care-Based Continuing Care Costs (Observational Study) • Those receiving continuing care in the prior interval were less likely to have ER visits and hospitalizations subsequently (p<.05).* *Linear mixed model controlling for age, gender, employment and marital status, whether completed treatment Parthasarathy S, Chi FW, Mertens JR, Weisner C. (2012). The role of continuing care on 9-year cost trajectories of patients with intakes into an outpatient alcohol and drug treatment program. Med Care 50(6): 540-6.

  38. Average Costs by Number of Continuing Care Components

  39. Summary of Continuing Care Outcomes and Cost Continuing care that includes regular primary care and specialty care predicted remission Those receiving all components of continuing care had lowest overall health care costs Costs reductions especially from hospitalizations Promoting a continuing care model that integrates different elements of the health care system appears to be cost-effective People used far less of the services to which they had access

  40. Realities • Difficult to get people to use health care appropriately – even when they have access • From SBIRT studies, training physicians doesn’t always work. • Health system realities: Patients may not see same physician over again.

  41. Interventions Linking Primary Care and SU Treatment Post-Treatment • Uninsured individuals in detox from alcohol, heroin, and cocaine • Medical and social work team in detox • Primary care appointment made and letter sent to primary care provider

  42. Continuing Care Linkage Study • Clinical Intervention to link SU patients with primary care for ongoing monitoring • Merges what we know from chronic care of other diseases with what we know about recovery • patient activation sessions • linkage phone call with primary care physician

  43. Continuing Care Linkage Study • Chronic Care/Disease Management Model merged with Recovery Model • Patient Activation/Empowerment • Wellness focus • Address stigma – relationship with physicians • Dealing with health care system

  44. Patient Activation Building the belief that the patient plays an important role in his or her health Supporting patients to develop the confidence and knowledge necessary to take action Increasing patient motivation to actually take action to maintain and improve health, and Developing strategies to “stay the course” even under stress

  45. Patient-centered Activation CurriculumFirst Part: group sessions • SESSION 1: Meand my health • SESSION 2: Lifestyle and Prevention • SESSION 3: Navigating the system • SESSION 4: Prepare, communicate and participate • SESSION 5: Collaborate and integrate • SESSION 6: Reduce your risk and maximize your health

  46. Some examples: Using Health IT Aids • Graphing blood pressure • Planning prevention tests • Preparing for doctor visit • Emailing doctor • Sleep/weight-loss programs • Changing doctors

  47. Learned from using the EMR

  48. Using the EMR, continued

  49. Linking with Primary CareSecond part: Linkage Phone Call Therapist, patient, and primary care physician (No training of physicians)

  50. Vignettes One participant related to the group that he never would have found the courage to tell his PCP about his addiction and/or recovery. He related how he felt that this call changed his life and recovery program, as it not only allowed him to include his PCP in his recovery support system, but it also prevented him from attempting to seek opiates from this provider in the future (as he had done in the past). He also shared how empowering it was for him to talk to his doctor about what is working and his successes.

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