Alcohol Misuse Clinical Pathway Outline

Transcription

1 Alcohol Misuse Clinical Pathway Outline 1. Identification of Patients for Alcohol Misuse Pathway a. Criteria for inclusion into alcohol misuse clinical pathway: Patients meeting the following criteria should be asked to attend an IBHC appointment as part of their standard evidence-based team healthcare: i. Patients with elevated scores on AUDIT-C: 4 or greater for women and 6 or greater for men ii. Patients scoring positive on AUDIT-C per the above criteria and not currently seeing IBHC in specialty behavioral health care or in specialty substance use program iii. Patients previously diagnosed with an Alcohol Use Disorder as defined in the DSM-5 and not currently seeing IBHC in specialty behavioral health care or in specialty substance use program b. Process for identification: Multiple methods should be used to identify patients with potential alcohol misuse problems for referral to the IBHC. i. Morning huddle review of PCM patient roster ii. Identification of patient by nurse/tech during AUDIT-C screening at PCM appointment iii. Identification of patient by PCM during PCM appointment iv. Patient self-referral iv. Referral of patient by other v. Care Point or AHLTA data pull from last 12 months (AUDIT-C, diagnosis, etc.). Data is pulled monthly by designated team member. 2. Methods of Linking Identified Patients with the IBHC a. During a PCM appointment with a patient who meets any of the inclusion criteria, the PCM, nurse, and/or other designated team member ensures the patient receives a sameday appointment with IBHC (warm handoff) or schedules a future IBHC appointment. b. If patients are identified through monthly data pull from AHLTA or Care Point: i. PCMH nurse or technician calls patient to schedule a future IBHC appointment. Caller uses standard pathway telephone script. ii. PCMH nurse, technician, PCM, or IBHC may also send secure to encourage an IBHC appointment. c. If patient refuses to see the IBHC the PCM, nurse, or technician will ask the IBHC to review the available medical record and information and document recommendations for care based on the available medical data. 3. Initial IBHC Appointment a. Biopsychosocial functional assessment questions specific to alcohol misuse management:

2 i. How often do you drink alcohol? ii. When you are drinking, how many drinks do you typically have? iii. Have you ever felt like you ought to cut down on your drinking? iv. How do you know when you have had too much to drink? v. Describe a typical time when you drink? vi. Do you have a preferred drink? What is it? vii. What do you like about drinking? viii. Does your drinking frequency and amount ever change? ix. What factors are associated with an increase or decrease in your drinking? For example, do you drink more alone or with friends? Do certain situations (e.g., when nervous, bored, sad) or environments (e.g., sports bars, happy hours, gathering with certain friends) impact your drinking? x. How do you feel emotionally if you don t drink alcohol? xi. How do you feel physically if you don t drink alcohol? xii. When did you first start drinking? xiii. Do your friends drink? a. If yes, do they drink more/less/about the same as you? xiv. Do immediate family members drink? a. If yes, do they drink more/less/about the same as you? xv. How do others respond to your drinking? xvi. Do others notice when you drink more or less? What do they say about it? xvii. Have you ever felt negative physical effects from drinking? a. If yes, when do you typically feel them? xviii. What impact has drinking had on your functioning (at work, at home, in recreational/social activities)? b. Differential diagnosis: To determine appropriate treatment level the IBHC assesses patient for the more severe Alcohol Use Disorder as defined in the DSM-V. If brief assessment suggests that the patient may meet criteria for Alcohol Use Disorder, IBHC will recommend additional resources beyond those available to patients in primary care. i. To assess for Alcohol Use Disorder the IBHC will inquire if the patient has experienced any of the following during the past 12 months. a. If the patient answers yes to 2 or more criteria he/she meets Alcohol Use Disorder criteria (b.ii.). i. MILD: The presence of 2 to 3 criteria ii. MODERATE: the presence of 4 to 5 criteria iii. SEVERE: the presence of 6 or more criteria ii. Alcohol Use Disorder criteria a. Alcohol is often taken in larger amounts or over a longer period than was intended b. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use c. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects d. Craving, or a strong desire or urge to use alcohol e. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home

3 f. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol g. Important social, occupational or recreational activities are given up or reduced because of alcohol use h. Recurrent alcohol use in situations in which it is physically hazardous i. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol j. Tolerance, as defined by either of the following: i. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect ii. A markedly diminished effect with continued use of the same amount of alcohol k. Withdrawal as manifested by either of the following: i. The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal ii. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms c. Assessment Measures i. The Behavioral Health Measure (BHM-20), a broad spectrum measure of physical, emotional, and social health must be given at each IBHC appointment ii. AUDIT-C (if not administered in prior week at PCM appointment) a. IBHC should consider administering the full AUDIT to conduct a more robust formal screening of alcohol problems d. Intervention Options: There are numerous evidence-based interventions that can be helpful for improving alcohol misuse. The IBHC and patient should collaboratively select the intervention(s) that are most appropriate given the nature of the patient s difficulties as well as readiness for change. Possible interventions include: i. Self-monitoring to allow patient to more accurately document drinking habits and patterns ii. Patient education a. Educate patient on size of standard drink i. 1 drink = 12 fl. oz. beer ii. 1 drink = 8-9 fl. oz. malt liquor iii. 1 drink = 5 fl. oz. table wine iv. 1 drink = 1.5 fl. oz. shot of 80 proof spirit b. Educate patient on safe daily/weekly drinking amounts i. Women = no more than 3 drinks/day; 7 drinks/week ii. Men = no more than 4 drinks/day; 14 drinks/week c. Identify links between patient s alcohol use and problems in patient s work/life functioning iii. Recommend patient limit or abstain from use a. Introduce concept of decreased drinking goal b. Introduce concept of alcohol abstinence

4 iv. Discuss with patient alcohol s possible impact on: a. Career/work b. Social/family c. Health d. Risky behavior (e.g., drinking and driving, unsafe sex, risky partying) e. Sleep: poor suitability as a self-medication for sleep and stress v. Establish drinking goals: Assist the patient in developing a drinking goal a. IBHC uses motivational interviewing to enhance patient s readiness to set goals or accept specialty referral if indicated i. Patient agrees to goal of drinking drinks/day; drinks/week ii. Patient agrees to goal of abstinence iii. Patient agrees to not use alcohol to self-medicate (e.g., calm down, get to sleep) b. Tools to assist with achieving goals and /or tools to overcome barriers to achieving goals are explored (e.g., self-monitoring tools; avoiding triggers) vi. Review ways to pace drinking a. Putting the glass or bottle down between drinks b. After drinking half a drink, waiting five minutes before resuming c. Drink a non-alcoholic drink in between drinks d. Have no more than one drink per hour e. Delay when drinking starts vii. Review the Four A s For Managing Alcohol Consumption a. AVOID: have patient identify highly tempting situations in which he or she may drink more than they wish or plan to b. ALTER: discuss ways patient my change or alter unavoidably tempting situations c. ALTERNATIVES: discuss what he or she can do with their mouth and hands when they are tempted to drink more than planned or are choosing not to drink at all d. ACTION: discuss with the patient ways to keep busy when feeling the urge to drink viii. Discuss with patient information on alcohol use handouts (may integrate into interventions listed above) a. Alcohol Effects and Safe Drinking Habits: education about alcohol absorption, tolerance, the effect on the body, and how to moderate one s drinking b. A Guide to Low Risk Drinking: education about low and high risk drinking, short and long-term risks of high risk drinking, a detailed graphic of the specific physical effects of high risk drinking, and a selfguided change tool c. Maintaining Behavior Change: Alcohol Use: education about how to avoid regressing into old drinking habits and how to respond when a slip occurs ix. Review assertive communication skills to help patient refuse drinks

5 x. Review stress and anxiety management strategies that can take the place of drinking for relaxation xi. Discuss and/or refer patient to other alcohol programs or support organizations including AA and on-base classes xii. Refer patient to specialty substance abuse treatment xiii. If a patient is active duty and there is a suspicion that there is an alcohol abuse or dependence problem that individual should be referred for a specialty alcohol evaluation. 4. Follow-up IBHC Appointments a. Recommended follow-up interval i. The time between appointments with the IBHC will vary depending on the IBHC s assessment of the patient s readiness to change, their ability to successfully make changes with self-management approach, and the nature of the intervention(s) selected. ii. For many patients the follow-up interval is between 2 to 4 weeks. b. Recommended number of IBHC appointments: i. 1 to 4 IBHC appointments may be sufficient for some patients to improve and maintain aspects of their alcohol misuse management. ii. Other patients may benefit from continuity consultation (more than 4 appointments) to maintain behavior changes. For patients receiving continuity consultation, consider the following structure: a. Initial phase of consultation: 4 appointments, spaced at 2 week intervals b. Continuity consultation: 1. Appointments with IBHC at more spaced intervals (e.g., monthly, every other month, quarterly). 2. Consider alternating monthly appointments with IBHC and PCM iii. If upon reaching 4 appointments and patient is experiencing any of the below, consider referring patient to more specialized services such as specialty behavioral health or specialty substance abuse treatment either: a. Patient is not improving as expected b. Patient is in need of greater support for alcohol misuse beyond continuity consultation c. Patient appears to be experiencing co-morbidities including depression, anxiety, or other behavioral health problems indicating more intensive care is required c. Assessments at Follow-up IBHC Appointments i. BHM-20 ii. AUDIT-C iii. AUDIT as indicated