Connecting LEGACY PRIMARY CARE and depaul treatment centers Chris Farentinos, MD, MPH, CAC II Director of Adult Outpatient Services, DePaul Treatment Centers Rick Ralston, LCSW, Manager Legacy Clinics Care Management

Agenda Intro/Overview of initiative Prevalence & health impacts of substance use disorders (SUD) Signs/symptoms of patients that suggest a SUD Connecting patients to treatment Plan for implementation in Legacy Clinics Collaboration between Legacy and De Paul Treatment Centers Q & A

Currently… 23.6 million people in the US meet clinical standards for substance use disorders (alcohol & drug) Only 2.3 million in treatment at any given time 90% are not getting treatment! Where are the other 20 million? Are they in primary care clinics, emergency rooms, the workplace, etc.

Prevalence Alcohol-related disorders occur in up to 26%of general population, a prevalence rate similar to those for other chronic diseases such as hypertension and diabetes  (Fleming and Barry, 1992)

FIGURE 1: Prevalence of substance abuse and dependence in the general population. (Adapted from Kessler RC, McGonagle KA, Zhai S et al.)

Health Impacts Alcohol and Drugs “72 conditions requiring hospitalizations are wholly or partially attributable to substance abuse“ (Center on Addiction and Substance Abuse, 1993, p. 21).

Source: Alcohol-Attributable Deaths Report, Average for United States 2001-2005, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.

Deaths and Alcoholism Excessive alcohol use causes an estimated 79,000 deaths per year in the United States. Close to half of these deaths (approximately 36,000 annually) result from chronic alcohol-related illnesses rather than acute causes such as motor vehicle crashes and falls. In the cancer category, the top alcohol-related deaths are from cancer of the liver, head and neck, esophagus, and female breast.

In 2004, 24 percent of stays in community hospitals were for patients with principal and/or secondary Mental Health and Substance Abuse diagnoses, almost 7.6 million hospitalizations. The second most common MHSA diagnosis for adults ages 18–64 was substance-related disorders, which was noted in about 10 percent of all hospital stays for this age group. (HCUP Fact Book No 10 – Care of Adults With Mental Health and Substance Abuse Disorders in the US Community Hospitals, 2004)

Health Impacts Alcohol and Drugs The higher the levels of consumption, the greater the risk of negative health effects including cirrhosis, cancer, heart disease, stroke, traumatic injury, and depression. Hypertension is associated with heavy drinking Trauma, disability Sexual dysfunction HIV/AIDS, other STDs Weight gain (alcohol) , weight loss (stimulants)

Signs/Symptoms of Patients That Suggest Substance Use Disorder (SUD) DUII, falls, accidents, injuries Dysphoria, depression, anxiety, irritability, mood swings, hostility Marital or family dysfunction Frequent lateness to work, absences, decline in job performance, frequent job changes Financial strain

Recommendation National Institute on Alcohol Abuse and Alcoholism describes healthy drinking as: Men -- No more than two drinks per day Women -- No more than one drink per day Men and women over age 65 -- No more than one drink per day (National Institute on Alcohol Abuse and Alcoholism, 1995b)

HOW DO PEOPLE GET TO TREATMENT? (Thomas McLellan) Source 1990 2004 Criminal Justice 38% 59% Employers/EAP 10% 6% Welfare/CPS 8% 16% Hosp/Phys 4% 3% Who refers patients to specialty programs? Mainly criminal justice system. Hence, there are lots of people with substance use disorders that never get identified or referred to treatment.

Are Substance Use Disorders Chronic Relapsing Conditions?

A Comparison With Three Chronic Medical Illnesses Hypertension Diabetes Asthma There are no doubt chronic medical illnesses in which patients are subject to frequent relapses and where behavior modification is fundamental to achieve long term control, such as diet, exercise, medication compliance.

Hereditability Estimates Twin Studies Eye Color 1.00 ASTHMA (adult only) .35 - .70 DIABETES (insulin dep) .70 - .95 (males) HYPERTENSION .25 - .50 (males) So substance use disorders also have a large genetic component. ALCOHOL (dependence) .55 - .65 (males) OPIATE (dependence) .35 - .50 (males)

HYPERTENSION Adherence to medication regime: < 60% Adherence to diet and exercise: < 30% Retreated in 12 months: 50 - 60% (by Physician, ER, or Hospital) Treatment Research Institute

DIABETES (Adult Onset) Adherence to medication regime: < 50% Adherence to diet and exercise: < 30% Retreated in 12 months: 30 - 50% (by Physician, ER, or Hospital) Treatment Research Institute

ASTHMA Adherence to medication: < 30% Retreated in 12 months: 60 - 80% (by Physician, ER, or Hospital) Treatment Research Institute

Predictive Factors - All 3 Illnesses RELAPSE Predictive Factors - All 3 Illnesses #1 - Lack of Adherence to diet, medications, or behavior change #2 - Low Socioeconomic status #3 - Low Family Supports #4 - Psychiatric Co-Morbidity Sources: Natl Ctr Health Stats; Harrison, 13th Ed.; 30+ studies

Does treatment for substance use disorders work? Yes, as well as treatment for: Hypertension Diabetes Asthma

Treatment is effective Alcohol treatment results in: Reduced drinking Less Frequent relapses Fewer alcohol-related consequences Reduced hospital stays and medical complications

So, what can we do about it So, what can we do about it? How can we increase the number of substance use disorder patients who receive care?

Screen Patients (self-screening) in Legacy Clinics with 3 Simple Questions Sensitivity and Specificity = 81% for alcohol or drug abuse or dependence. (Brown, JABFP: Vinson, Annals of Family Med, 2004)

The 3 Questions Are………. 1) In the past year, have you ever drunk alcohol or used drugs more than you meant to?* 2) In the past year, have you ever thought you should cut down on your alcohol and drug use?* * Positive response = anything but a definite “no.” 3) Men – when was the last time you had more than 5 drinks at one time (positive response = within last 3 months) 3) Women – when was the last time you had more than 4 drinks at one time (positive response = within last 3 months)

Clinic Care Manager talk to patient Brief, more in-depth, assessment Brief Intervention (depending on Stage of Change patient is at) Referral to De Paul Treatment Centers, if warranted Training is being provided to clinic care managers CM talk live or by phone with pt. Brief, more in-depth assessment will involve about 5 additional minutes. Will follow algorithm for Brief Intervention

Benefits to Primary Care Physicians Enhanced care for your patient (refer to Health Impacts slide) without increased physician time Significant health issue potentially addressed (90% untreated!) Care Manager will do the work, report back to you Referral source – breadth of resources in a minute

Sharing Patients INTEGRATION OF WARM HANDOFF APPROACH (clinic care manager coordinate with De Paul) DOCUMENTED BENEFITS: 80% follow up vs. 40% without Patient feels part of team Assures good communication No time gap in referral process Magic moment

Warm Handoff con’t What De Paul Can Do: Telephone Consultation Level of Care Assessment Appointment and Admission Feedback to Primary Care A menu of options including Meet with concerned family members Share patient with primary care

De Paul Services: Men and Women (Downtown) Youth – NE Portland Assessment Information and Referral Detox – insured adult only Outpatient and Intensive Outpatient Treatment Residential Treatment Integrated mental health and substance use disorder treatment Continuing Care Recovery Support – in-house AA and NA meetings and case management Alumni group Family Treatment with or without identified patient

WHO ARE OUR PATIENTS: Outpatient Residential 36% DUII 12.9% Self Pay 15.2% Insurance 35% County Funded Residential 76%County and State Funded 12% Insurance 12% Self-Pay

DE PAUL CONTACT PERSON: CHRIS FARENTINOS: 503-535-1195 chrisf@depaultreatmentcenters.org