Recognizing and Treating Alcohol Problems in Primary Care

1. Recognizing and Treating Alcohol Problems in Primary Care Katherine Watkins, M.D. Harold Alan Pincus, M.D. Terri Tanielian, M.A.

2. Alcohol Use Disorders Are a SignificantPublic Health Concern • Such disorders are common • 14 million people are addicted to alcohol or abuse it • 33 million engage in binge-drinking at least once a month • They have serious health-related and social consequences • They increase morbidity and mortality • Alcohol-related lost productivity, vehicle crashes, and health care come to $150 billion annually

3. Alcohol Use Disorders Can Be Treatedbut Often Are Not • There are effective treatments for the entire spectrum of alcohol-related problems • Most individuals needing treatment do not receive it • Primary care represents a missed opportunity • 70 percent of the population visits such a provider at least once every two years • One in five men and one in ten women visiting their PCP have alcohol problems • Fewer than 1 percent receive counseling

4. Why Are Alcohol Problems Not Widely Treated? • Alcohol disorders are rarely the main reason for a visit to a primary-care provider • Provider focuses on acute problem at hand, not bigger chronic-condition picture • Chronic conditions of any kind are generally not well treated

5. Outline • A model has been proposed for improving chronic care • We applied this model to alcohol use disorders

6. Outline • A model has been proposed for improving chronic care • We applied this model to alcohol use disorders

7. Usual Chronic Illness Care • 15-minute visit, poorly organized • Discussion and exam focus on symptoms and lab results, not preventive assessment • Patient’s attempts to discuss difficulties in living with the condition are discouraged • Focus is on physician’s treatment, not patient’s role in management • Treatment plan is limited to prescription refill and encouragement to make an appointment if not feeling well • Visit ends with physician rifling through drawers, looking for a pamphlet

8. What the New Model Hopes to Achieve Informed, Activated Patient Prepared Treatment Team Productive Interactions Better Functional and Clinical Outcomes

9. Why the New Model Is Important • Applies to the majority of illnesses • Would revolutionize the way the health system thinks about care • Is synthesized from demonstration projects and other evidence in the literature • Has been heartily embraced by many in the field

10. The New Chronic Care Model Guidelines Evidence-Based, Planned Care Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

11. The New Chronic Care Model Guidelines Evidence-Based, Planned Care Staffing: Who does what to whom? • Allocation of tasks • Roles • Appointments and follow-up • Incentives Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

12. The New Chronic Care Model Guidelines Evidence-Based, Planned Care Provider and patient • Identification of problems and treatment strategies • Self-management training and support activities • Patient role in follow-up Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

13. The New Chronic Care Model Guidelines Evidence-Based, Planned Care To optimally care for specific patients, PCP must have access to • Provider education • Decision support • Feedback • Consultation • Link to specialty care Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

14. The New Chronic Care Model Guidelines Evidence-Based, Planned Care Practices must develop a registry of all patients to track and monitor health • Key clinical data • Reminders • Outcomes Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

15. Outline • A model has been proposed for improving chronic care • We applied this model to alcohol use disorders

16. Why Is This Task Important Now? • We have a chance to put care for alcohol use disorders into the mainstream of medical care • We must catch this new wave of chronic care improvement as it goes by

17. Alcohol Use Disorders Are Like Other Chronic Conditions • A spectrum of severity must be accommodated • Condition is not obviously symptomatic at first • Course is unpredictable • Etiologies are complex • Include genetic component (for dependence) • Treatments are behaviorally oriented • There are significant problems in compliance, dropout, and relapse

18. Adapting the Chronic Care Model Guidelines Evidence-Based, Planned Care Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

19. Adapting the Chronic Care Model Guidelines • Screening • Assessmentand diagnosis • Treatment • Long-termmanagementsupport Evidence-Based, Planned Care Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

20. Adapting Chronic Care Components Guidelines Evidence-Based, Planned Care • How are patients screening positive tracked? • Who is responsible for assessing and discussing options with patients? • Who determines whether patients receive an intervention or a referral to specialty care? • Are there referral linkages to alcohol treatment? Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

21. Adapting Chronic Care Components Guidelines • Can patients choose how to completethe screening instrument? • Are patients encouraged to take charge of their conditions and given a chance to ask questions? • What self-management support programs are available to patients? • What links are established with support groups? Evidence-Based, Planned Care Screening Assessment and diagnosis Treatment Long-term management support Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

22. Adapting Chronic Care Components Guidelines • Is the screening instrument reliable and valid for the population? • How do PCPs obtain help from specialists when diagnoses are complicated? • Do the treatment guidelines cover simultaneous conditions? • How do additional providers gain access to the shared care plan? Evidence-Based, Planned Care Screening Assessment and diagnosis Treatment Long-term management support Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

23. Adapting Chronic Care Components Guidelines • Does the information system prompt for repeated screening? • Can the system track subgroups of patients based on severity? • Does it remind providers of when patients require follow-up? • How is confidentiality protected when information is shared between providers? Evidence-Based, Planned Care Practice/deliverysystem redesign Clinicalinformation systems Collaborativemanagement Decision supportfor providers

24. Identifying Next Steps • Prepare for feasibility study • Develop patient activation tools • Outline concrete research plan to pilot test model in 1 to 3 sites • Consider integrating model with care for other chronic conditions • Identify barriers to implementation and devise strategies to lower them • Be cognizant of cost and efficiency issues