Connecting Concern to Care : Interdisciplinary Teamwork to Address Substance Use Disorders in Primary Care CAROLYN SWENSON, MSPH, MSN, RN & BRAD SJOSTROM, LCSW, MAC COLORADO STATE INNOVATION MODEL (SIM) – COLLABORATIVE LEARNING SESSION FRIDAY, OCTOBER 26 TH , 2018 – 10:45AM – 11:45AM BREAKOUT 1
Learning Objectives Review Screening, Brief Intervention and Referral to Treatment (SBIRT) Examine appropriate approaches and common challenges to accessing care Demonstrate how an inter-professional approach expands options for care
Screening, Brief Intervention and Referral to Treatment (SBIRT) Screening – Using validated questions Brief Intervention – Brief conversation to enhance motivation to change Referral to Treatment – Assessment and services for the person with a more severe alcohol or drug use problem
Focus of SBIRT Severe Alcohol Use Brief Intervention + 4% Disorder Referral to Treatment 25% Brief Intervention + Alcohol Misuse Monitoring and Support 71% Low Risk Use or Positive Reinforcement + Continued Screening Abstention Adapted from SAMHSA Alcohol use in the U.S. general population adults a ge ≥ 21 years
Brief Intervention Conversation with a Goal 1. Raise the subject 2. Provide feedback 3. Enhance motivation 4. Negotiate a plan and advise
Team Approach to SBIRT
Addressing Stigma & Barriers Fear of stigma is a common reason for not seeking treatment “ I should be strong enough to handle it alone .” “ I’m too embarrassed to discuss it with anyone.” “I hate answering personal questions .” “ I’m concerned that getting treatment might cause my neighbors or community to have a negative opinion of me .” “ I’m afraid of a possible negative effect on my job .” Only about 15% of people who meet criteria for a lifetime alcohol use disorder report receiving treatment
Interdisciplinary Teamwork Patient centered and driven Interactive, collaborative and involves empathy, knowledge and skill Supportive in establishing concrete follow-up and next steps Cultivates a relationship that adopts a shared language
Interdisciplinary Common Challenges Unclear expectations and clarifying language Lack of opportunities to meet either in person or via phone, no SUD ROI Lack of strong referral process and feedback pathways Limited access to data sharing and documentation Weak referral process, no formal forms Weak understanding of specialty strengths, resources
Patient Scenario – Bill 72 year old male – recently tripped and fell in the garage after driving home from a family gathering. Broken shoulder and hospitalized after surgery for a blood clot in his leg. Sent home with a month-long supply of opioids.
Bill’s SBIRT Screen Results Positive Screen: 3-5 drinks most evenings to try to improve sleep and mood On average, 15-20 beers in a week Symptoms checklist includes experiencing difficulty cutting down his drinking, feeling isolated and depressed, and having a strong urge to drink alcohol
Suggested Patient Questions What are your top priorities for our visit today? What things concern you the most about your health at this time? What are the next steps we agree on today?
Primary Care Visit Other health concerns: Long-time tobacco use Complains of chronic forgetfulness Hypertension GERD Insomnia Recently widowedPHQ-9 score = 10
Sample Referral Work Flow RN or identified referral specialist at the clinic fills out a referral form with the reason for the referral Referral Form INCLUDING what was given to Point Form is PCMP identifies a communicated to the patient and Person at PCMP faxed to BHP BHP need if medication management or to fax to Point at: FAX # consultation is being requested. Person at BHP *SUD ROI is obtained from patient for referral to BHP Documentation to be shared: - BHP Initial assessment and medical After summary from PCMP BHP Point Person sets appointment, up an appointment - Medication changes (goes both BHP Point BHP Point with the patient; ways), Consider possible medication Person will be Person will fax notifies PCMP that interactions. Pharmacy consult? given this form to PCMP the patient has an information to - 30 days (update) (Did patient appointment. *SUD fax to PCMP show up?) - 90 days, 120 days, etc. (update) ROI is obtained from Send fax to: patient through BHP. - Discharge summary FAX #
Ongoing Care & Monitoring Assessment of patient engagement Self-management status update Symptom monitoring Coordination among providers Referral and feedback pathways Anticipate and proactively address patient’s immediate safety needs Identify patient strengths Increase knowledge and access to support resources
Behavioral Health Provider Visit Seen at Community Mental Health Center Initial assessment for treatment Recommendations: Outpatient services – Individual psychotherapy and MAT to address depression and problem alcohol use
Interdisciplinary Shared Decision Making Discuss patient’s engagement level and patient’s desired goals for change Establish method for communication among providers Identify what is most important from the patient’s perspective When possible, both PCMP and BHP meet with the patient at the same time
Evidenced Based Treatment for SUD Cognitive Behavioral Therapy (CBT), Solution Focused Brief Therapy (SFBT), Motivational Enhancement Therapy (MET or MI) 12-Step Facilitation and Peer driven support (AA, NA, MA, CA, CMA, Life Ring, Smart Recovery) Family Behavior Therapy Contingency Management Community Reinforcement Approach Medication Assisted Treatment (MAT) – adult, adolescent
Spectrum of SUD Treatment Intensities Primary Care-Based Treatment Outpatient Treatment Intensive Outpatient Treatment Opioid Treatment Programs Residential/Inpatient Treatment Level I Residential/Inpatient Treatment Level II
SUD RT – Highest Levels Psychiatric Conditions: Depressive, psychotic or manic symptoms that impair a person’s ability to function, makes them a threat to other people or a threat to themselves, or renders the person unable to care for themselves. Treatment Types: Locked inpatient psychiatric units, Alternative Treatment Units (ATU) and Crisis Stabilization Units (CSU). Hospital based medical detoxification programs, withdrawal management centers and residential treatment facilities. Level of SUD: Grossly acute intoxication, severe withdrawal symptoms from alcohol or benzodiazepines, and in some instances opioids. Severe substance use disorders. Assessment venues: Emergency Department, Crisis Walk-in Clinic or Behavioral health facilities with on-site assessment capability Many of these conditions can be assessed at the treatment facility, but absent easy access to a treatment facility and or in the event of an emergency, Emergency Department is the first point of contact.
SUD RT – Intermediate Levels Psychiatric Conditions: Panic attacks, depressive symptoms without risk of harm, personality disorders, eating disorders and dissociative disorders. Treatment Types: Partial psychiatric hospitalization, intensive outpatient, medication management and long- term psychotherapy. Level of SUD: Mild to moderate substance use disorders with no major withdrawal symptoms and an ability to have some days without using. Assessment Venues: These services are typically offered at a behavioral health treatment facility.
SUD RT – Lower Levels Psychiatric Conditions: Adjustment Disorders, Phase of Life, Anxiety Disorders, Mild to Moderate Mood Disorders. Treatment Types: Individual and group therapy, mutual support groups, medication management and support groups. Level of SUD: harmful, hazardous and mild substance use disorders Assessment venues: These services are typically offered at a behavioral health treatment facility. Mutual support groups can be community based.
Integrated SUD Care – Medical Privacy Obtain consent upon intake including SUD Disclosure and Release of Information form as a standard of practice Federal Confidentially Laws – HIPAA, Substance Use Disorder (42 CFR Part 2) Colorado Specific Laws – Mental health, HIV/AIDS, Reproductive health CO is a “same as Part 2” state with patient consent and “stricter than Part 2” without patient consent
Colorado LADDERS • Referral resource for substance use, mental health and crisis services • Colorado.org /ladders
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