1. 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

2. 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

3. 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.

4. 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)

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

7. 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).

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

9. 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.

10. 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)

11. 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)

12. 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

13. 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 No more than one drink per day
(National Institute on Alcohol Abuse and Alcoholism, 1995b)

14. HOW DO PEOPLE GET TO TREATMENT? (Thomas McLellan)
Source 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.

15. Are Substance Use Disorders Chronic Relapsing Conditions?

16. 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.

17. Hereditability Estimates
Twin Studies
Eye Color
ASTHMA (adult only)
DIABETES (insulin dep) (males)
HYPERTENSION (males)
So substance use disorders also have a large genetic component.
ALCOHOL (dependence) (males)
OPIATE (dependence) (males)

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

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

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

21. 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

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

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

24. 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?

25. 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)

26. 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)

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. DE PAUL CONTACT PERSON:
CHRIS FARENTINOS: