1. An integrated approach to dealing with alcohol & drug issues Dr. Susanna Galea, Clinical Director, CADS Dr. David Newcombe, University of Auckland Dr. Vicki MacFarlane, Clinical Lead, CADS

2. Structure of the workshop Opportunity to discuss how we could work better together for a more meaningful client journey Short presentation:Short presentation: –How big is the problem? –Models of integrated delivery Case presentationsCase presentations Floor discussionFloor discussion The way forwardThe way forward

3. How big is the problem?

4. Alcohol - The global picture  3.8% of all global deaths  Responsible for >2.3 million premature deaths  4.6% of global burden of disease  A risk factor for more than 60 different disorders  Drinking >2 standard drinks per day increases risk of death to over 1 in 100

5. Alcohol – NZ scene  85.2% of the adult population drink  8.7 – 9.4 l per capita  Cost of harm: $4.8 - $5.3bn/year  Days off work: 5.6% of all adults; Lost productivity $1.17 billion per annum  Immeasurable pain & suffering for individuals, families & friends

6. Alcohol: health  3 out of 5 (61.6%): >recommended guidelines at least once in last year  1 in 6 (17.7%): hazardous drinking Hazardous drinkers: 17.7% 254, 260 in Auckland Alcohol dependence:1.3% 18, 674 in Auckland

7. Effects of high risk drinking

8. Alcohol related crime: NZ

9. Drug use in NZ SUBSTANCE % Lifetime Use Majority Start At % In Past Year Ethnicity Groups (comp. with gen. pop.) CANNABIS46.4%18-20 yrs14.6%European & Maori ECSTACY6.2%21 yrs +2.6%European STIMULANTS7.2% (amph)21 yrs +3.9% (‘P’ – 1%) European HALLUCINOGENS7.3%18-20 yrs3.2% (LSD) European SEDATIVES6.3% (kava)21 yrs +1.7%Pacific men (3x) OPIATES3.6%21 yrs +1.1%No difference BZP Party Pills13.5%21 yrs +5.6%European & Maori

10. Alcohol & Drugs Impact on the Health Services

11. 23,000 people are treated in publically funded health system for alcohol and other drug addiction (NCAT 2008)

12. CADS, Te Atea Marino and Tupu treated 15,694 clients in total through 86,817 appointments (50,936 in a one-to-one, and 35,881 in a group setting). This amounts to an average of 5.5 face-to-face appointments per open referral or 6.9 face-to-face appointments per client who had at least one face-to-face contact.

19. Emergency Departments  UK study & Auckland studies: 18-35% of people with injuries in ED 60-70% of weekend admissions  Scotland study: Self-harm: 2/3 men; ½ women Assault: 70% Under age of 17: 15 kids/day  Auckland study: Injuries 35% of injured patients; Violence in 17%; perpetrator in 79% Risk of sustaining an injury was 2.8 x higher

20. Hospital inpatients 20% of inpatients have some form of alcohol related problem20% of inpatients have some form of alcohol related problem Doubled in 10 yearsDoubled in 10 years 2008: Primary alcohol diagnosis admissions2008: Primary alcohol diagnosis admissions10,290

21. Primary care 80% of NZ population visit GP every 12 months80% of NZ population visit GP every 12 months 65 – 82% of those with an Alcohol related problems go undetected65 – 82% of those with an Alcohol related problems go undetected 49% of those with alcohol problems visited their doctor but < 10% talked about it49% of those with alcohol problems visited their doctor but < 10% talked about it 17% of injury presentations; 64% hazardous drinkers17% of injury presentations; 64% hazardous drinkers 20% of all primary care presentations consume alcohol at excessive levels:20% of all primary care presentations consume alcohol at excessive levels: 98% not identified (UK study)

22. We need to work together better!!!

23. Current practice Primary Care Services Addiction Services Referrals Letters Phone Shared care

24. How can we work together? Integrated care Integrated care is a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency.

25. Integrated care vs. collaborative care Collaborative care: Working with primary care; Patients perceive they are getting a separate service from a specialist, albeit one who collaborates closely with their physician. Integrated care: Working within and as a part of primary care; Health care is part of the primary care and patients perceive it as a routine part of their health care.

26. Model 1: Separate providers – primary care as primary Focus:Primary care as the primary providers Enhance primary care’s ability to treat within a primary care setting Descriptors:Least amount of change Separate systems Stepped care model Screening & Brief intervention Consultation via phone Information sharing practices can be formalized Barriers:Financial; Access; Time; Relationship; Capacity for seamless transition; System culture; Confidentiality; Communication difficulties

27. Model 2: Separate providers – addiction services as primary Focus:Addiction services as the primary providers Enhance specialist care’s ability to treat holistically Descriptors:Least amount of change Separate systems Consultation-liaison via phone Structured care planning Barriers:Financial; Time; Relationship; Capacity for seamless transition; Confidentiality; Communication difficulties

28. Model 3: Co-location Addiction Services Primary care services Primary care services Addiction Services

29. Model 3: Co-location Focus:Same sites but separate systems Primary care or addiction as the primary providers Enhance access & Referral acceptance Descriptors:One-stop shop approach Separate systems Enhance delivery of package of care Screening & Brief intervention Consultation in the corridor Early identification Barriers:Geographical collaboration; Location; Different speeds; Financial; Time; System culture; Confidentiality;

30. Model 4: Same service providing primary & specialist care Focus:Same sites and same systems Specialist is part of the primary care team Public health focus Descriptors:One-stop shop approach Triage system Emergency department approach Consultation minimal Barriers:No skill transfer; System culture; Confidentiality; Boundary blurring

31. Case presentations 17yr old Marvin: Harmful drinking & cannabis & diazepam dependenceHarmful drinking & cannabis & diazepam dependence Mild depression & perceptual abnormalitiesMild depression & perceptual abnormalities Family hx of substance abuse & MH problemsFamily hx of substance abuse & MH problems Diazepam prescribed by GP for anxietyDiazepam prescribed by GP for anxiety Doctor shoppingDoctor shopping  Co-ordination & support to GP re managing client’s Diazepam: Guidance given & guidelines sent; Phone support; Meeting between GP, specialist clinician & client to discuss & develop an effective/safe and realistic withdrawal management plan.

32. Floor discussion