VA CENTER FOR EXCELLENCE IN PRIMARY CARE EDUCATIONWEST HAVEN VA CONNECTICUT HEALTHCARE SYSTEM

Anthony Brinn, Psy.D.Kenneth Morford, M.D.

Sara Utzschneider, A.P.R.N.

An Interprofessional Approach to Substance Abuse in Primary Care

Asthma

Diabetes

Malignancy

Hypertension

Heart disease

Gastrointestinal disorders

Skin & soft tissue infections

Acute respiratory infections

Substance Abuse in Primary Care

THE PROBLEMIndependent of age, gender, race, or ethnicity, substance abuse significantly increases risk for comorbid:

(Dickey et al, 2002)

Integrated care refers to the systematic integration of general and behavioral healthcare (SAMHSA-HRSA, 2014).

An Integrated Primary Care Team

THE SOLUTION

Integrated primary care teams are associated with:

Increased provider satisfaction with clinical care

Increased patient access to mental health and addiction services (Vickers et al, 2013)

Among patients with Substance Abuse Related Medical Conditions (SAMC), integrated primary care contributes to:

Lower rates of hospitalization Decreased use of Emergency

Department Shorter inpatient duration Decreased monthly cost per

patient (Parthasarathy et al, 2003)

Who We Are

MD/APRN

Pharmacy

Addictions/Health

PsychologySocial Work

RN/HT

Patient

A post-graduate training program preparing health professionals to work in and lead patient-centered, interprofessional teams that provide coordinated longitudinal care. Educational Domains Shared Decision-Making Sustained Relationships Interprofessional

Collaboration Performance

Improvement

VA CENTER OF EXCELLENCE IN PRIMARY CARE EDUCATION (C.O.E.)

One of five C.O.E. sites across the country:

WEST HAVEN, CT

C.O.E. Team Structure

To offer comprehensive, efficient, and practical treatment of the individual patient in a way that thoroughly considers biological, social, behavioral, and psychological components of their presenting complaint.

To develop adequate and comprehensive treatment plans for patients typically referred to as “difficult” or “resistant”.

C.O.E

. Goals

U.S. Veterans Predominately

male Ages range

throughout the adult lifespan

Many with complex medical, psychological, and social histories

Who We Serve

45-year-old married, employed Veteran with a history of elevated liver function tests (LFTs) and fatty liver disease, who drinks a six-pack of beer most nights with his buddies and presents to primary care motivated to cut back to be a better father, but struggling.

23-year-old single, unemployed Veteran with a history of combat-related traumatic brain injury, chronic back pain, and knee pain who presents to primary care requesting renewal of his Percocet which was started after injury in Afghanistan.

68-year-old homeless, widowed Veteran with a history of combat-related PTSD, depression, and suicidality who presents to primary care with significant cardiovascular illness, daily tobacco and alcohol use, and intermittent cocaine use.

Some cases from our clinic

Develop awareness of personal value judgments regarding patients’ behaviors and minimize the impact these judgments have on quality of practice

Exhibit open-endedness in inquiry Elicits a greater wealth of valuable patient data with minimal impact of provider

suggestion through close-endedness

Endeavor to adopt the perspective of patients See the world as the patients do (NOT as we do)

Exhibit genuine curiosity for their experience

Perspective informs our course of treatment (i.e. barriers/facilitators)

Routinely reflect/summarize the patient’s experience to them Conveys that we heard/connected with their experience

Increases treatment compliance

Genuinely reinforce even the smallest improvements (may require adjusting our own perspective)

Approach to Substance Abuse

in the C.O.E.Through preceptor-trainee relationships, peer-to-peer teaching, and collaborative clinical practice, all C.O.E. providers learn to:

Direct Link to Specialized Care When concern for substance abuse arises, primary care providers

(i.e. MDs, APRNs) perform a warm handoff with specialists within the C.O.E.

A “warm handoff” is a novel approach to care transitions in which clinicians directly link patients with substance abuse problems with specialists, using face-to-face or phone transfer (Richter et al,

2012).

Specialists in the C.O.E. include:

Substance abuse specialist

Health psychologist

Social worker

Pharmacist

Approach to Substance Abuse

in the C.O.E.

Purpose:

To serve as a case-consultant for behavioral, emotional, psychological, and social issues pertinent to substance abuse/mental health, that may be complicating medical treatment.

To collaborate with providers in determining a holistic treatment plan that is both efficient and comprehensive.

To facilitate referral processes for patients interested in adjunctive mental health or substance abuse treatment.

To provide Screening, Brief Intervention (1-6 sessions), and Referral to Treatment (SBIRT) for patients ambivalent about their substance use or unwilling to attend treatment elsewhere.

Substance Abuse Specialist in the C.O.E.

Screening Brief Intervention Referral

What do you use? • Rather than, “Do you use

alcohol,” or, “You don’t use any illicit drugs, do you?”

When are you most/least likely to use? • Triggers/Perpetuating factors

How long have you used it?

Family history • As important as family medical

history

What is/has been the impact on functioning? • Pros/Cons; Refrain from

undermining patient’s reasons for using

Motivation to reduce use? • Scale of 1-10; Assessing relation

to personal values

Confidence in ability to reduce use? • Scale of 1-10; Determine

perceived self-efficacy

Motivation • Clarify values and

discrepancies between values and behavior

Confidence • “Sell” resources and provide

realistic feedback on the trajectory of change

Engagement • Link the patient’s primary

motivation to concrete behaviors

Monitor Behaviors • Build insight; Use behavioral

logs; Clarify antecedents and consequences

Collaborate to schedule and carry out concrete behavioral change

Assess the result and troubleshoot barriers to change

Warm handoff to Health/Addictions Psychology within the C.O.E.

Referral to appropriate specialty clinics by Health/Addictions Psychology or directly by MD/APRN if patient is motivated.

For patients declining referral, Health/Addictions Psychology can serve as a bridge to treatment and provide brief treatment within C.O.E.

SBIRT

in the C

.O.E.

The way we ask is paramount

Substance abuse presents an important and complex challenge for primary care providers

A team approach to substance abuse is critical for providing comprehensive and effective primary care

Take Home Message

Integrated teams optimize patient care, improve provider satisfaction, and allow various health professionals to learn from each other and build strong working relationships

The C.O.E. serves as a model for an integrated primary care team in an academic setting

Chan, Y. F., Huang, H., Sieu, N., & Unützer, J. (2013). Substance screening and referral for substance abuse treatment in an integrated mental health care program. Psychiatric Services, 64(1), 88-90.

Dickey, B., Normand, S. L. T., Weiss, R. D., Drake, R. E., & Azeni, H. (2002). Medical morbidity, mental illness, and substance use disorders. Psychiatric Services, 53(7), 861-867.

Parthasarathy, S., Mertens, J., Moore, C., & Weisner, C. (2003). Utilization and cost impact of integrating substance abuse treatment and primary care. Medical Care, 41(3), 357-367.

Richter, K., Faseru, B., Mussulman, L., Ellerbeck, E., Shireman, T., Hunt, B., Preacher, K., Ayars, C., and Cook, D. (2012). Using “warm handoffs” to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial. Trials, 13:127.

“What is Integrated Care?” SAMHSA-HRSA Center for Integrated Health Solutions. Retrieved April 10, 2014 from: http://www.integration.samhsa.gov/about-us/what-is-integrated-care.

Vickers, K. S., Ridgeway, J. L., Hathaway, J. C., Egginton, J. S., Kaderlik, A. B., & Katzelnick, D. J. (2013). Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access. General hospital psychiatry, 35(5), 461-467.

References