Intermountain Healthcare Substance Use Disorder Management Suicide Assessment/ Prevention 2015 Updates Carolyn Tometich PMHNP-BC, Operations Director
Why Focus On Substance Use Disorder? Addiction often starts in adolescence and becomes a lifelong problem. Drug abuse is a major problem in Utah. Patients are undertreated. SUD is costly. SUD has a high mortality rate.
Why Focus on SUD in Primary and Specialty Care Settings? PCPs aren’t talking to their patients about substance use SUD patients need medical and mental health treatment.
Summary—The Triple Aim A complex problem requiring an integrated solution Aligning philosophy and practice: Intermountain’s strategy for SUD care Improve the quality of health • Enhance the patient experience • Lower the cost of care •
SUD identified by the patient, family, physician, employer, etc.
SBIRT - S creening, B rief I ntervention, and R eferral to T reatment .
NIDA Quick Screen
Conversation basics: principles for effective intervention Remind patients that you screen everyone Affirm the patient’s privacy Present concerns in a direct way, avoiding judgment Use language that prompts conversation Show empathy Affirm the relationship
Engaging patients in the behavior change process Motivational Interviewing Readiness For Change
Motivational interviewing Asking open-ended questions to elicit the patient’s concerns and context (work, family, etc.). Listening actively and summarizing the patient’s concerns back to them. Empathizing and clarifying the patient’s experience without judging, criticizing, or imposing your own values. Enlisting the patient in suggesting options, setting goals, and planning details.
Readiness to change Assess the patient’s current stage of readiness by observing patient comments. Consider a brief intervention appropriate to that stage, as described in the table below. If the behavior change is critical and the patient is not ready, refer to a care manager or specialist for further motivational interactions with the patient.
Patient education materials to support SBIRT
Where to refer? Self-help community support programs (such as AA, Al- Anon programs) (see sidebar) MHI (for further assessment and treatment of moderate-risk patients) Primary Children’s Hospital Inpatient, Residential and Day Treatment Programs Specialty psychiatric clinics Emergency departments
Withdrawal management in primary care Alcohol withdrawal --Symptom Triggered Use Chlordiazepoxide (Librium) 25 mg, #20 tabs: Day 1-2: 1-2 tabs 3-4 times daily prn for tremulousness/withdrawal; Day 3-4: 1 tab 4 times daily until done. Patient should be seen within 1 week.
Opioids If the medication is prescribed for pain management, you can taper by no more than 10% per day, monitoring carefully (have your care manager check in regularly, if possible). Refer patients who fail the taper for SUD treatment. Opioid withdrawal management should be a transition to longer term treatment.
Medication Assisted Treatment (MAT) Alcohol dependence Opioids Acamprosate Narcan • • Natrexone Suboxone • • Antabuse Subutex • • Methadone •
Suicide in the United States
Suicidal behavior in children and adolescents: Epidemiology and risk factors
Utah Department of Human Services Division of Substance Abuse and Mental Health Taking a public health approach to Suicide Prevention Three areas of focus: Identification • Prevention • Postvention •
Suicide Death - Healthcare Contact 50% individuals have contact the month before a suicide death 22% a week before their death Only 45% had received a mental health diagnosis Most common visit is with PCP before death
I have the SKILLS I need to engage those with suicidal desire and/or intent .
What is in the CPM Description of the problem • Description of appropriate language • Which tool to use based on location • Description the process and tools • Standard screening tools – Adult 12 and up, Pediatric, 11 • and under Behavioral Health Providers use more in-depth forms • ( Lifetime/Recent or Since Last Visit ) Complete a Risk Assessment • Protective factors • Risk factors • Identification of appropriate level of care • For patients going home, develop Safety Plan •
Standard Processes Across the Organization ED Triage Nurse • ED Crisis Workers • Inpatient Behavioral Health Nurses • Inpatient Medical Nurses • Outpatient/Primary Care Clinics, Homecare • Behavioral Health Clinics • Other Specialty Services (e.g. sleep labs, arthritis • clinics)
What is not in the CPM but critical for patient care? Communication Skills and Clinical Judgment
Importance of Using Common Language Words to Use Don’t Use Attempted suicide Completed suicide Died by suicide Failed attempt Protective factors Parasuicide Risk factors Successful suicide Safety Plan Suicidality Nonfatal suicide Suicide gesture Manipulative Act Suicide threat
In the Clinic Setting When To Use the C-SSRS Screener Complete PHQ2 and if positive complete PHQ9 o If question 9 is positive, complete C-SSRS Screener o Classify patient as Low, Moderate, High Risk o Implement appropriate action based on patients risk (see page 4 of CPM)
Standard Questions in the C-SSRS (ALL ABOUT THOUGHTS AND BEHAVIOR) WISH TO BE DEAD THOUGHTS OF KILLING YOURSELF THINKING ABOUT HOW THOUGHTS WITH SOME INTENT STARTED TO/OR WORKED OUT PLAN DONE ANYTHING , STARTED TO DO SOMETHING, OR PREPARED TO DO ANYTHING
Recommended actions based on patient responses to screening tool Each location has a recommended set of actions depending on the patients response category: Low – Continue with usual care and communication Moderate – Likely needs additional assessment or plan High – Likely to need a higher level of care, more observation and intervention
Now What….. Based on screener AND CLINICAL JUDGEMENT Low risk – normal care • Moderate risk – referrals, further assessment and • intervention Risk factor assessment • Development of safety plan • High risk - immediate referral for next LOC (i.e. • inpatient care, meet with on-sight MHI provider)
Risk Assessment Identification of Risk Factors Modifiable Risk Factors Non Modifiable Factors Anxiety Gender • • Insomnia Age • • Intoxication Adverse events (i.e. • • family suicide, childhood abuse)
Modify Risk Factors Identify a risk factor and modify in some way: Insomnia – Treat • Anxiety – Treat • Intoxication – Wait • Guns in the home – Remove •
Safety Plan or Safety Contract Safety Plan Safety Contract Helps patient clearly identify Doesn’t legally protect steps/actions to be taken if clinician suicidal thoughts return Doesn't assist the patient in Who to call managing suicidal • ideation/plans What actions to take • Action to make home • safer, such as removing guns, stockpiled medications
Process Summary Usual clinic process of PHQ2 PHQ9 If yes to question 9 then screen using C-SSRS
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