Facilitatorsand obstaclesin the. Catalonia

Transcription

1 Facilitatorsand obstaclesin the implementationofalcoholeibi in Catalonia SeguraL 1, Diaz E 1, PalacioJ 1, FreixedasR 3, BastidaN 3, Duran E 3, GualA 2, ColomJ 1 1 Programon SubstaceAbuse, DepartmentofHealth, Government of Cataloni, Barcelona. Spain. 2 Hospital Clínic. Barcelona. Spain. 3 AlcoholGroup. CAMFIC and AIFICC. Barcelona. Spain.

2 Index Catalonia and the Health Care System Implementation Evaluation Facilitators Obstacles Conclusions and Way forward

3 1 Catalonia and the catalan health system

4 Catalonia Catalonia

5 General Caracteristics Characteristics of the Catalan Health System Free & universal, financed through taxes Guidelines of the Program on Substance Abuse Addictions are diseases and must be treated within the Health System The Drugs Plan must deal with all drugs, including alcohol and tobacco Drug and alcohol related problems must be approached from a Public Health perspective

6 TREATMENT NETWORK PRIMARY HEALTH CARE CENTRES 347 ADDICTION TREATMENT CENTRES 60 Therapeutic Communities Detox Units Rehabilitation Programs

7 2 Implementation

8 WHO collaborative study Phases Objectives Phase I ( ) Validation of the AUDIT screening tool Phase II ( ) Demonstration of the efficacy of Brief Interventions Phase III Evaluation of the most efficacious strategies for ( ) implementing brief advice in PHC Phase IV Dissemination and implementation of ( ) Brief interventions for risky drinking in PHC settings Action research

9 Barriers Lack of positive reinforcement Sensation of intrusion Lack of training* Lack of time* Lack of economic backing Lack of protocols and strategies Lack of materials Little support (Anderson, 1996) * Phase III. Catalonia. 1998

10 An iterative implementation process Adaptation of the training programme Training the trainers Adaptation of intervention materials DISSEMINATION BHA Centres PHC Professionals Creation XaROH IMPLEMENTACIÓ Adaptation of the training programme Training the trainers Grup de Treball Alcohol CAMFiC-AIFICC Adaptation of intervention materials

11 Implementation strategy Number of patients treated Training on alcohol Supportive work-place Availability of screening and intervention materials, training and support for severe cases (referral of alcohol dependents) Positive attitudes Increasing preventive activities on alcohol by PHC professionals. Source: Anderson et al 2003, WHO Phase III Collaborative project.

12 The Beveu Menys Program RESEARCH TOP-DOWN APPROACH ACTION RESEARCH TOP-DOWN APPROACH DISEMINATION TOP-DOWN APPROACH ?? ITERATION INSTITUTIONALIZATION BOTTOM-UP APPROACH BOTTOM-UP APPROACH ROUTINE PRACTICE

13 3 Evaluation

14 Where we are now Adapted from Siw Carlfjord Drink Less Programme

15 Implementation rate 338 PHC with references in Catalonia

16 Network of alcohol referents 77% 97% % % % % % % coverage 60 especialistes de 57 CS 487 professionals de 295 ABS

17 Growing screening rate Source: Sistema d informació de drogodependències ( ).

18 Referral rate Source: Sistema d informació de drogodependències ( )

19 4 Facilitators

20 Motivational approach Use motivational strategies not only to approach patients but also when we approach the whole Health System (GPs, trainers, Health Authorities, etc) Enable changes in the implementation: Customization, flexibility. PHC professionals are seen as the key actors in play

21 Facilitators: Network of alcohol referents specialists from 57 CAS 562 professionals from 338 ABS 56 % nurses and 44 % doctors

22 Continued training strategy Training the trainers course by peers ( XX editions) Basic course -8h (mandatory) on EIBI + 10h (recommended) on MI In the territory Continuous training Thematic courses - 4h (optional) - 16 editions (cancer, youth, etc) Network meeting 4h (optional) 2 editions (one per year) Training courses: Basic course - 4h (205 editions) Online course equivalent (5 editions)

23 Facilitators: continued activities and support Raising awareness: Screening week Research: Validation of new tools Community acctions

24 Alcohol target incentivized % of the population of users aged between 15 and 79, having been screened for consumption of alcohol at least once in the last 24 months, or having a health problem related to alcohol consumption

25 5 Obstacles

26 Poor economical incentives Management by objectives framework Result from setting up individualized improvement targets at center/group (20%-60 health targets) and at individual level (80%-28) Representing from 10 to 20% of the annual salary of medical doctors Feedback on achievement is essential for its impact Alcohol target achievement means less than 20 euros Differences among professions -high among nurses and low among doctors

27 Diversity of medical records 277 PHC (79% del total d ABS) using E-CAP 79 PHC (21% de les ABS totals) using other programmes: HP-HCIS HCIS GOWIN GAVINA IMASIS SINAPSIS CHAMAN ALTRES (programes propis)

28 Diversity of medical records Different measure units (grams, SDU) Not harmonized differentiation between types of drink Not harmonized differentiation between regular and occasional consumption Special risk conditions (pregnancy, job risk...) not always taken into account Data entry not easy, either in screening or intervention activities.

29 Monitorization Lack of quality control of professionals activity registered in the medical records Data is not accessible and easy to analyze Lack of monitorization and follow up

30 Screened population

31 Screened population

32 Infradetection

33 Population intervened

34 Intervention not consistent with guidelines low-risk drinkers riskydrinkers

35 Risky drinkers intervened

36 Conclusions Tackling alcohol and drugs represents a challenge for the healthcare system. Changes do not happen quickly, but rather slowly and with the need of continuous effort. A motivational approach increases the acceptability of the program Nurses are becoming a central part of the institutionalization strategies New technologies offer a new wide range of possibilities that need to be tested and implemented. The final aim is to transfer the program to the health system, so that it becomes regular standard practice but also to settings other than PHC: workplace, antenatal system, hospitals, etc.

37 Way forward Recommendations on medical records structure and contents and flow-chart for each of the providers Proposal to main provider to facilitate access Specific training to register in medical records Regular monitoring of data accummulated