1. A Strategy for Inpatient Integration Terry Horton, MD, FACP Delaware Valley Node September 21, 2010

2. Hospitals Inpatient Services Aggregate the Highly Disordered Much higher rates of AUD and SA compared to general society, most are dependent* Significant medical comorbidities Expensive revolving door higher use of ER (2.3x), inpatient care (6.7x)** Increased AMA, readmissions * Saitz, 2007; Bertholet, 2010 ** Stein, 1993

3. Hospitals have an Emerging Imperative Need to Improve: Safety Health care costs Joint Commission compliance

4. Hospitals Need Best Methods/tools to: Screen and diagnose – must be pragmatic Effectively treat withdrawal Engage and transition into ongoing drug tx SBIRT not effective for inpatients but Linkage to tx improves outcome* * Bertholet, 2010

5. Delaware’s Epidemiology Estimated 2009 population of 885,000 9% of adults alcohol/drug abusing or dependent* 65,000 in need of alcohol/drug treatment** 8,216 admissions to publicly-funded SA treatment services statewide 2006*** * 2004-2005 NSDUH data ** Wright et al. 2007 *** Delaware Department of Health and Social Services, Division of Substance Abuse and Mental Health, 2007 Tx gap

6. Delaware’s Primary Hospital System Wilmington/Christiana Hospitals 1100 beds 160,491 ER visits 54,597 admissions* No in-house substance abuse/etoh service *2009 data

7. CCHS prior to 2009 No standardized ETOH/Substance abuse screening SBIRT for trauma service only No standardized withdrawal treatment protocols or monitoring Social Work consult for referral 3 root cause analyses in 2007-8 directly related to delirium and tremens

8. 2008-9 CCHS Epidemiology Less than expected rates of ETOH withdrawal ( 0.75% actual vs. 0.9-1.25% calc) 2x more DTs than expected (0.2% vs. 0.05-.125%) Majority of DTs are secondary dx’s 115/179 (64%) 1/1/08-7/31/09 23% >= 65 years old Deaths more common in secondary dx: 19/20

9. The Intervention ETOH Withdrawal Symptom Order Set launched on October 6, 2009 for med/surg inpatients includes screening tool for risk of AW CIWA clinical assessment/scoring Score triggered treatment and monitoring protocol

10. Outcomes: Improved Safety No Sentinel Events since launch Significant reduction of submitted cases to DOM No cases to date associated with over- treatment

11. Quarterly Outcomes Data Protocol launch

12. Restraints Use

13. ICU Transfers

14. Length of Stay Protocol launch

15. Project Engagement Community partner imbedded at WH Peer-to-peer inpt/outpt intervention Data Review N = 313 (9/1/08- 6/10/10) 35% successfully admitted into 33 inpt/out drug/alcohol treatment programs

16. Project Engagement: Partnering with DPCI/Aetna Claims from June 1, 2009 - November 30, 2009 3 months before and after claims review, n = 18 MetricPrePostFinding Medical inpatient admits12833% decrease ER visits543338% decrease BH/SA inpatient admits71043% increase BH/SA outpatient visits121633% increase PCP office visits275188% increase Delaware Physicians Care Inc, May, 2010

17. CTN Opportunities for Inpatient-based Research Define/develop pragmatic tools and protocols to screen and improve safety Develop and test methods to engagement and link into ongoing drug/etoh treatment Study clinical and fiscal outcomes