Evidence Based Care Models for Recognizing and Treating Alcohol Problems in Primary Care Settings


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Addictions occur in eight to 11 percent of the general United States adult population, 6 but are found in 20 percent of patients in US primary care settings 7 and over 50 percent of patients in US hospital, emergency room and trauma centers. Addictions are merely the most severe of the substance use disorders SUDs. These are treatable medical conditions in their own right, but when unaddressed in the treatment of other medical illnesses they produce: Most severe, chronic cases of addiction will still be managed in specialty addiction treatment programs, but this care will soon be financed through the same health insurance plans as the rest of general healthcare.

In addition, the Mental Health Parity and Addiction Equity Act the Parity Act 16 requires that care for SUDs have generally the same type, duration, range of service options and patient financial burden as the care currently available to patients with comparable physical illnesses.

The implications are significant. For the first time, SUDs will be treated like other chronic illnesses see ref. Despite the clear clinical need and legislative mandate, actualizing this change will be complicated for two reasons. First, this has never been done, so there are few practical models to provide guidance. Key elements of the CCM are summarized in Table 1.

Improving primary care for patients with chronic illness: There is substantial evidence indicating that the CCM is more effective than traditional clinical care in the treatment of many chronic medical illnesses 19 , 20 including depression 21 ; is more appreciated by patients and physicians 22 ; and does not appear to cost more than traditional care. However, a recent systematic review of CCM studies in behavioral health conditions did not identify any randomized controlled trials comparing CCM to other models of care for the treatment of SUDs see ref. To prepare for integration of SUD treatment into mainstream healthcare and to set needed research priorities in this area, the National Institute on Drug Abuse convened a panel of experienced primary care providers and researchers to perform a two-stage, systematic examination of whether and how well the CCM could be applied in the treatment of SUDs.

Stage one focused on how the six core elements of the CCM Table 1 have been applied to the treatment of type 2 diabetes because it too is a prevalent, acquired, often complicated chronic illness, that is familiar to general medical audiences. Stage two examined whether and how each of the same six core elements of the CCM could be applied to the treatment of SUDs. The CCM reorients care from acute, reactive and procedure-oriented, to preventive, continuing and patient-oriented practices.

This type of proactive care requires organizations to redesign staffing models, develop new referral partners, and create, train and sustain inter-disciplinary teams of providers who interact and communicate effectively though an electronic health record EHR. A key goal of this re-design is prevention and early intervention for patients who are at risk or have early stage disease. Preventive diabetes care includes screening at-risk but asymptomatic adults e. Among patients already diagnosed with pre-diabetes or diabetes, proactive early intervention care includes counseling about nutrition, exercise and medication adherence.

For example, a triage nurse or medical assistant may review outstanding screenings and prompt the primary care provider, via the EHR, to order an HbA1c on an overweight patient. If a patient already being followed for diabetes has an elevated HbA1c, the physician adjusts the insulin dose and sends a note through the EHR to the diabetes care manager. Group visits conducted by nurses are arranged to assist patients with peer learning about diabetes self-management and to assure that all of the necessary services are accessible to the patient for maximum disease adherence.

The CCM appears to offer a good framework for achieving evidence-based care for SUDs using the same care team, deployed in essentially the same ways as for diabetes management. Again, disease progression and severity will determine clinical team actions. For example, a medical assistant can quickly screen a college student and identify at-risk drinking with three questions, occasioning a physician, nurse, or health behaviorist to deliver a single brief counseling intervention during the visit.

The patient can be added to a registry, and followed up longitudinally to monitor progress and to provide additional interventions as needed. Alcohol screening and brief counseling, are considered essential services within the PPACA legislation 17 ; carry a Grade B recommendation from the US Preventive Services Task Force; and are fully reimbursed elements of care without patient co-pay. Of all preventive services recommended by the Task Force, brief alcohol interventions yield the quickest and greatest reductions in healthcare costs.

A more severely addicted patient with alcoholic cirrhosis and ongoing alcohol dependence would be unlikely to respond to a brief intervention and would require more attention and a different service mix, including motivational enhancement therapy by the health behaviorist, and prescription of an anti-craving medication like naltrexone by the primary care physician.

Team-based care integrating medical and behavioral health produces favorable patient outcomes for patients with SUDs. Senior leadership must perceive the value of investing in proactive, team treatment, information systems and outcomes measurement through a strong business case justifying commitment of resources; as has been demonstrated in various evaluations of the CCM see ref.

Research indicates team treatment re-organization provides significantly better disease management and can also produce cost savings. There have not yet been cost-effectiveness evaluations of treating SUD in a CCM, but proactive, team-based treatment of opioid dependence with buprenorphine has produced significant cost reductions—for both inpatient and emergency department utilization—compared with untreated individuals. Expert-informed decision support to primary care teams can include provider education, facilitated expert consultation, standardized assessment tools, and evidence-based treatment algorithms.

These decision supports are used by primary care teams in cardiology, oncology and diabetes care. Specialty techniques to manage diabetes have been widely translated into routine primary care practice through EHR prompts to assess for microalbuminuria, links to expert guidelines, embedded expert protocols, and facilitated consultation with endocrinologists for patients with refractory disease.

Expert-informed decision support for providers may be even more important care for SUDs than for other medical conditions because of the relative lack of medical education and training in this area. There are now evidence-based decision supports in the form of: However, simply training primary care teams about screening tools or treatment guidelines may not be sufficient to improve practices regarding substance use care. For example, among family medicine residents, receipt of coaching and feedback from Motivational Interviewing experts was critical in skill adoption.

That record can prompt patient engagement through web-based or mobile applications that improve care management practices such as screening and care guidance to patients, their families and provider teams. A recent EHR initiative at Kaiser Permanente in Oakland California for managing diabetes included comprehensive order entry, diabetes-specific decision support for laboratory testing and treatment intensification, and secure messaging between providers and patients. The initiative led to improved rates of medication treatment adherence, follow-up monitoring, and glycemic and lipid control in patients.

As has been shown in diabetes management, 43 proactive engagement through electronic message, text or voice phone reminders and follow-up contacts, has produced improved patient retention, care participation and lower relapse rates among out-patients in substance abuse treatment. Initially, diabetes treatment regimens were chiefly biomedical in nature. Quality measures focused on the process of biomedical care, such as assessing for retinopathy and neuropathy; and usually only with patients having frank diabetes.

Increasingly, efforts are directed at improving self-management behaviors earlier in the disease course such as facilitating exercise, dietary control and medication adherence. In a recent study fewer than 15 percent of patients met goals for control of glucose, blood pressure, and low density lipoprotein. Recent efforts in the management of SUDs have paralleled those in diabetes care—moving from sole emphasis on the most severely affected to address those with emerging substance use problems.

Patients with SUDs also face challenges in overcoming environmental vulnerabilities to relapse such as situational, emotional and interpersonal cues that trigger drug cravings and withdrawal. As is true in diabetes management, research on the management of SUDs has shown little behavioral change from simple disease education and even less from scolding or confrontation. Healthcare settings cannot offer all the resources needed to fully manage chronic illnesses.

Thus, an important aspect of CCM involves linking patients and their families with community resources such as wellness programs, exercise groups, assisted living arrangements and health fairs to help patients manage their illness. Community resources play an important role in diabetes management. For example, the Diabetes Prevention and Control Alliance 50 is a partnership between United Health Group, the YMCA, and retail pharmacies to enhance linkages between clinical and community-based diabetes prevention and control services.

The initiative consists of two parts. The Diabetes Prevention Program helps people with pre-diabetes eat healthier, increase physical activity, and learn about other health-promoting behavior modifications. Facilitating linkages to community resources is a critical component of managing SUDs.

Research shows that SUD patients assigned case managers who coordinated and expedited access to community resources such as exercise, nutrition, housing, parenting and employment services, had significantly better social functioning, and less substance use at six month follow-up than did patients who received standard substance use-focused care. Research shows that participation in these peer-support activities is associated with decreased substance use, enhanced psychosocial adjustment, and lower health care costs.

Lower severity or earlier onset cases of medically harmful alcohol and other substance use are ubiquitous, commonly affecting over 20 percent of patients seen in primary care settings. However, they are not easily recognized and thus often under-addressed. As a consequence, they interfere with treatment of other illnesses, reduce adherence to medication and care plans, and contribute to hospital readmissions at great expense.

Brief advice and monitoring can prevent the progressive behavioral and brain changes that often become the chronic illness of addiction. Because chronic illness management is a central part of the new healthcare reform legislation in the US, and because the CCM has been recognized as an effective management framework, we examined the extent to which CCM could be an appropriate framework for the primary care management of SUDs.

Our findings led to three conclusions. First, it appears possible, practical and worthwhile to manage most SUDs within primary care. Research shows that this type of integrated management within primary healthcare settings can significantly reduce substance use, but also improve the clinical outcomes of many common chronic illnesses and reduce healthcare costs. The most severe, chronic and complex cases of addiction will usually require specialty care, but even in these cases primary care teams should be able to provide appropriate referral and support continuing management following the specialty care episode.

The second conclusion is that the CCM appears to be an appropriate platform to integrate care management of SUDs within primary care. Again, because this is still a relatively new concept, there has been little testing of the CCM among patients with SUDs or in primary care settings. Nonetheless findings to this point suggest that clinical and health services research in this area is warranted.

Finally, our comparative review strategy suggested that experience with the CCM in type 2 diabetes offered appropriate clinical and research guidance as well as practical solutions that could be systematically adapted in the management of SUDs.

Treatment for Substance Use Disorder: Opportunities and Challenges under the Affordable Care Act

Of course there are important special clinical issues associated with SUDs; but this is true of all chronic illnesses. Until there are systematic CCM research initiatives in the SUDs field, we recommend that primary care teams adopt and evaluate three practices that are consonant with both the CCM and with good clinical practice in the SUD field:. Healthcare reform legislation, advances in scientific and clinical understanding, and the potential for significantly improving general healthcare quality and efficiency, provide ample reason to begin integrating the management of SUDs into primary care using the CCM.

National Center for Biotechnology Information , U. Author manuscript; available in PMC Nov Corresponding Author Contact Information: Thomas McLellan at gro. See other articles in PMC that cite the published article. Abstract Brain imaging and genetic studies over the past two decades suggest that substance use disorders are best considered chronic illnesses. Substance use disorders, chronic illness, chronic care model, type 2 diabetes management, electronic health records, healthcare reform. Evolution in the Management of Chronic Illness Despite the clear clinical need and legislative mandate, actualizing this change will be complicated for two reasons.

Expert-Informed Decision Support Provision of expert input to generalist clinicians to help manage cases without need for separate specialty treatment. Improving Clinical Information Systems Track and coordinate care , facilitate information flow among clinical sources, the clinical team and patients. Open in a separate window. Management of SUDs within the CCM To prepare for integration of SUD treatment into mainstream healthcare and to set needed research priorities in this area, the National Institute on Drug Abuse convened a panel of experienced primary care providers and researchers to perform a two-stage, systematic examination of whether and how well the CCM could be applied in the treatment of SUDs.

Application in the Management of Diabetes Preventive diabetes care includes screening at-risk but asymptomatic adults e. Application in the Management of SUDs The CCM appears to offer a good framework for achieving evidence-based care for SUDs using the same care team, deployed in essentially the same ways as for diabetes management.

Evidence Based Care Models for Recognizing and Treating Alcohol Problems evaluating a chronic care model for alcohol problems in primary care settings. Editorial Reviews. About the Author. Katherine Elizabeth Watkins (UCLA School of Public Buy Evidence Based Care Models for Recognizing and Treating Alcohol Problems in Primary Care Settings: Read Kindle Store Reviews.

Healthcare Organization Support Relevance in the CCM Senior leadership must perceive the value of investing in proactive, team treatment, information systems and outcomes measurement through a strong business case justifying commitment of resources; as has been demonstrated in various evaluations of the CCM see ref. Application in the Management of Diabetes Research indicates team treatment re-organization provides significantly better disease management and can also produce cost savings.

Application in the Management of SUDs There have not yet been cost-effectiveness evaluations of treating SUD in a CCM, but proactive, team-based treatment of opioid dependence with buprenorphine has produced significant cost reductions—for both inpatient and emergency department utilization—compared with untreated individuals. Expert-Informed Decision Support for Providers Relevance within the CCM Expert-informed decision support to primary care teams can include provider education, facilitated expert consultation, standardized assessment tools, and evidence-based treatment algorithms. Application in the Management of Diabetes Specialty techniques to manage diabetes have been widely translated into routine primary care practice through EHR prompts to assess for microalbuminuria, links to expert guidelines, embedded expert protocols, and facilitated consultation with endocrinologists for patients with refractory disease.

Application in the management of SUDs Expert-informed decision support for providers may be even more important care for SUDs than for other medical conditions because of the relative lack of medical education and training in this area. Betty Tai and Nora D. There is no conflict of interests.

There are now evidence-based decision supports in the form of: Finally, our comparative review strategy suggested that experience with the CCM in type 2 diabetes offered appropriate clinical and research guidance as well as practical solutions that could be systematically adapted in the management of SUDs. However, a recent systematic review of CCM studies in behavioral health conditions did not identify any randomized controlled trials comparing CCM to other models of care for the treatment of SUDs see ref. Application in the Management of SUDs Recent efforts in the management of SUDs have paralleled those in diabetes care—moving from sole emphasis on the most severely affected to address those with emerging substance use problems. Expert-informed decision support for providers may be even more important care for SUDs than for other medical conditions because of the relative lack of medical education and training in this area. Wellstone P, Domenici P. Preventive Services Task Force.

The opinions expressed in this manuscript are those of the authors and do not represent the official position of the U. National Center for Biotechnology Information , U. Soc Work Public Health. Author manuscript; available in PMC Apr See other articles in PMC that cite the published article. Abstract Addiction is a chronic brain disease with consequences that remain problematic years after discontinuation of use.

Substance use disorder, Affordable Care Act, chronic care model, health information technology, social workforce, screening brief intervention and referral to treatment. Open in a separate window. Coordinated SUD Treatment in a Chronic Care Model CCM Patients screened positive or diagnosed with substance abuse or dependence in first-line care settings should immediately begin a planned and coordinated chronic care treatment program with evidence-based treatment strategies.

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Adoption of Modern Health Information Technologies HITs Chronic care management can be significantly hampered without effective health information exchange Marchibroda, Changing the chronic care system to meet people's needs. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence. Reduction of alcohol consumption by brief alcohol intervention in primary care: Systematic review and meta-analysis. Archives of Internal Medicine.

New England Journal of Medicine. Improving primary care for patients with chronic illness. Journal of the American Medical Association. Improving primary care for patients with chronic illness: The chronic care model, Part 2.

INTRODUCTION

Economic costs of excessive alcohol consumption in the U. American Journal of Preventive Medicine. Implementation of evidence-based alcohol screening in the Veterans Health Administration. American Journal of Managed Care. Pharmacotherapy and the primary care physician.

Clinics in Office Practice. JCT technical explanation of P. Overdoses of prescription opioid pain relievers—United States, — Morbidity and Mortality Weekly Report. Evidence on the chronic care model in the new millennium. An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Implementing a multidisease chronic care model in primary care using people and technology. Meta-analysis of the effectiveness of chronic care management for diabetes: Investigating heterogeneity in outcomes. Journal of Evaluation in Clinical Practice.

Evaluation of the Washington state screening, brief intervention, and referral to treatment project: Cost outcomes for Medicaid patients screened in hospital emergency departments.

Quality-improvement strategies for the management of hypertension in chronic kidney disease in primary care: British Journal of General Practice: Redesigning primary care practice to incorporate health behavior change: Prescription for health round-2 results. Economic costs of nonmedical use of prescription opioids. Clinical Journal of Pain.

Prevalence of positive substance abuse screen results among adolescent primary care patients. Archives of Pediatrics and Adolescent Medicine. Impact of brief interventions and brief treatment on admissions to chemical dependency treatment. Cost-effectiveness of implementing the chronic care model for diabetes care in a military population. Journal of Diabetes Science and Technology. Regular outpatient medical and drug abuse care and subsequent hospitalization of persons who use illicit drugs.

New winds blowing for American drug policies. Costs and incentives in a behavioral health carve-out. Screening, brief interventions, referral to treatment SBIRT for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: Does implementing the chronic care model improve processes and outcomes of care?

The impact of health information technology on collaborative chronic care management. Journal of Managed Care Pharmacy. Will primary care doctors help implement primary services in addiction prevention and treatment? Is there a case for extended interventions for alcohol and drug use disorders? Have we evaluated addiction treatment correctly? Implications from a chronic care perspective. Treatment given high priority in new White House drug control policy. Interview by Bridget Kuehn. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation.

Reconsidering the evaluation of addiction treatment: From retrospective follow-up to concurrent recovery monitoring. The expanding role of general internal medicine. Journal of General Internal Medicine. Utilization and cost impact of integrating substance abuse treatment and primary care. Drug-induced deaths—United States, — Screening for alcohol and drug use disorders among adults in primary care: Substance Abuse and Rehabilitation. Integrated care needs integrated information management and technology. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.

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Cochrane Database of Systematic Reviews. Providers' incentives for quality improvement. Screening and brief intervention for unhealthy drug use in primary care settings: Randomized clinical trials are needed. Journal of Addiction Medicine. Screening and brief intervention for substance misuse among older adults: