Can you really do this in primary care? The DA VINCI Project. MBBS (Lond),MA (Cantab), MRCPsych(UK)

Transcription

1 Can you really do this in primary care? The DA VINCI Project Dr. Nadeem Akhtar MBBS (Lond),MA (Cantab), MRCPsych(UK) Dr. Jehaan Illyas MD, F.R.C.P.C. Brad LaForme MSW RSW Katie Davidman MSW RSW

2 PRESENTER DISCLOSURE Presenter: Nadeem Akhtar MA (Cantab), MBBS (Lond), MRCPsych (UK) Assistant Professor, Department of Psychiatry, McMaster University Staff Psychiatrist, Hamilton Family Health Team Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none Other: none Department of Family Medicine Department of Psychiatry

3 PRESENTER DISCLOSURE Presenter: Dr. A. Jehaan Illyas M.D., F.R.C.P.C. Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: Sunovion, Allergan Consulting Fees: Sunovion, Allergan, Lundbeck Other: None Department of Family Medicine Department of Psychiatry

4 PRESENTER DISCLOSURE Presenters: Brad LaForme MSW RSW Katie Davidman MSW RSW Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None Department of Family Medicine Department of Psychiatry

5 LEARNING OBJECTIVES 1) Describe an Integrated Care Pathway (ICP) for treating major depression and alcohol use disorders concurrently, and how to make it fit for primary care. 2) Describe how collaboration between all clinical parties, (Family Physician, Psychiatry, Mental Health, Pharmacy, and Nutrition) were developed, refined, and organized for improved patient care. 3) Describe how technology was utilized for ongoing patient screening/assessment and how this data informed medication changes when indicated by the algorithm. Department of Family Medicine Department of Psychiatry

6 Can you really do this in primary care?

7 PART ONE: The Group We took a 16-session out-patient hospital-based program and transformed it into a 17-week primary care psychotherapy group. The core elements of the pathway include: measurement-based care, pharmacological and psychotherapeutic interventions, and a clinical workflow that incorporates an inter-professional team.

8 Program Structure o Concurrent Treatment of Major Depressive Disorder and Alcohol Use Disorder as defined by DSM V o 17 2-hour weekly group psychotherapy sessions. o Pharmacological intervention via anti-depressant and anti-craving medication. o Pre and Post group assessment tools, as well as. o Bi-weekly screens for depression symptoms, alcohol cravings scales, and weekly drinking results. o Bi- weekly medical visits with team psychiatrist to review screening tools scores and adjust medication as informed by the DA VINCI anti-depressant and anti-craving medication algorithm.

9 DA VINCI: Psychosocial Therapy Overview Session: 0-2 Introduction & Motivational Enhancement Session: 3-6 Behavioural Focus: Behavioural Activation Skills Building for High-Risk Situations Session: 7-11 Cognitive Focus: Cognitive Restructuring, Maladaptive Assumptions, Problem Solving, Session: Relapse Prevention Lapse Management Session: Comprehensive Review Building Social Supports Aftercare Planning Action Planning

10 Standardized Assessments Assessment Tools Measures Alcohol Use Disorders Identification Test (AUDIT) Enter the Pathway Exit the Pathway Penn Alcohol Craving Scale (PACS) Quick Inventory of Depressive Symptomatology (QIDS) Suicide Risk Assessment Enter the Pathway Biweekly Exit the Pathway Enter the Pathway Biweekly Exit the Pathway Enter the Pathway If required Exit the Pathway Quality of Life Scale (EQ-5D-5L) World Health Organization Disability Assessment Schedule (WHODAS 2.0) Enter the Pathway Exit the Pathway

11 Ocean Tablet Weekly Drinking Record Session Number: 14 Date: April 19, 2017 Name: This past week SDDD (Standard Drinks per Drinking Day) When you drank, how many drinks did you have on average? DDW (Drinking Days per Week) How many days did you drink? SSW (Standard Drinks per Week) How many drinks did you have in total? HDDW (Heavy Drinking Days per Week) How many days did you have (Men: 5 or more; Women: 4 or more)

12 Group Materials Patient Therapeutic Modalities Cognitive Behavioural Therapy (CBT) Motivational Interviewing (MI) Structured Relapse Prevention (SRP) Dialectic Behaviour Therapy (DBT)

13 Referral/Screening

14 Role of Multidisciplinary Team Clinical Family Doctor Psychiatrist Dr. Nadeem Akhtar Dr. Jehaan Illyas Pharmacist Dr. Antony Gagnon Non-Clinical Sari Ackerman Coordinator/Administrator Jesse Lamothe Quality Improvement Decision Support Specialist Kathy & Emily Admin/Reception Group Therapists Brad LaForme MSW RSW Katie Davidman MSW RSW Cynthia Forrest RN BScN CPMHN(C) Registered Dietitian Susan Smith RD CDE Organization Leadership Catherine McPherson-Doe Manager, Mental Health and Nutrition Programs Dr. Lindsey George Clinical Director and Lead Psychiatrist

15 Pre and Post Group Measures Standard Drinks Per Week (SDW) SDW were self-reported by participants every 2 weeks from week 0 (orientation) to week 16 (end of treatment) SDW Bi-Weekly Scores Group 1 Group 2 Combined Pre and Post SDW Mean pre score Mean post score Wk 0 Wk 2 Wk 4 Wk 6 Wk 8 Wk 10 Wk 12 Wk 14 Wk 16 0 Group 1 Group 2 Combined Group 1 (n=13) Group 2 (n=7) Combined (n=20) Mean SDWs at orientation Mean SDWs at end of treatment Percent decrease from pre- to post-group 38.6% 90.0% 46.4%

16 Pre and Post Group Measures Standard Drinks Per Drinking Day (SDDD) SDDD were self-reported by participants every 2 weeks from week 0 (orientation) to week 16 (end of treatment) SDDD Bi-Weekly Scores Wk 0 Wk 2 Wk 4 Wk 6 Wk 8 Wk 10 Wk 12 Wk 14 Wk 16 Group 1 Group 2 Combined Pre and Post SDDD Group 1 Group 2 Combined Mean pre score Mean post score Group 1 (n=13) Group 2 (n=7) Combined (n=20) Mean SDDDs at orientation Mean SDDDs at end of treatment Percent decrease from pre- to post-group 42.5% 81.7% 54.9%

17 Pre and Post Group Measures Penn Anti-Craving Scale (PACS) (min=0, max=30) The PACS was administered every 2 weeks from week 0 (orientation) to week 16 (end of treatment) PACS Bi-Weekly Scores 25 PACS Pre and Post Scores Group 1 Group 2 Combined Mean pre score Mean post score Wk 0 Wk 2 Wk 4 Wk 6 Wk 8 Wk 10 Wk 12 Wk 14 Wk 16 0 Group 1 Group 2 Combined Group 1 (n=13) Group 2 (n=7) Combined (n=20) Mean score at orientation Mean score at end of treatment Percent decrease from pre- to post-group 16.6% 32.7% 22.3%

18 Pre and Post Group Measures Quick Inventory of Depressive Symptomology (QIDS) (min=1, max=27) The QIDS was administered every 2 weeks from week 0 (orientation) to week 16 (end of treatment). QIDS Bi-Weekly Scores QIDS Pre and Post Scores Wk 0 Wk 2 Wk 4 Wk 6 Wk 8 Wk 10 Wk 12 Wk 14 Wk 16 Group 1 Group 2 Combined Group 1 Group 2 Combined Mean pre score Mean post score Group 1 (n=13) Group 2 (n=7) Combined (n=20) Mean score at orientation Mean score at end of treatment Percent decrease from pre- to post-group 29.4% 15.5% 24.2%

19 But the numbers don`t tell the whole story

20 Group Personality More than just alcohol and depression Other substance use Other mental health issues (anxiety) Personality issues (BPD) Relationship issues Trauma Physical health Chronic pain Employment Like opening Pandora's box

21 Group Personality What does success look like? Initiating friendships with other group members outside of group is not recommended. If conflict or disagreement between group members occurs this can interfere with your comfort level and attendance at treatment. DAVINCI Psychotherapy Group Workbook: Guidelines and Expectations for Group Members Support beyond the confines of the group a pleasant discovery! DA VINCI Duckpins

22 A Patient's Story Depression & Craving Scales Drinking Scales Sep Sep-16 5-Oct Oct Nov Dec-16 PACS QIDS # Drinks per Drinking Day Drinking Days per Week Standard Drinks per Week 14- Sep Sep Oct Oct Nov Nov Nov Dec

23 A Patient's Story Depression & Craving Scales Drinking Scales Sep Oct- 19-Oct- 2-Nov Sep Nov-16 Nov-16 Dec-16 Dec-16 PACS QIDS # Drinks per Drinking Day Drinking Days per Week Standard Drinks per Week 14- Sep Oct Oct Nov Nov Nov Dec Dec

24 Therapist Experience Therapist and system that suits the client population Going beyond the Manual Adapting to meet the evolving need for support It can be exhausting!!

25 PART TWO: The Medical Visit Before Starting Preparation Psychiatric History Medication Reconciliation

26 DA VINCI: The Medical Visit Before Starting Preparation Genetic Testing PRIME, Pillcheck Done by A. Gagnon (Pharmacy) Medical History Laboratory Testing

27 DA VINCI: The Medical Visit Before Starting Preparation Medical History Laboratory Testing Liver function testing, CBC, Kidney Function, Urine DS Other labs as necessary eg. TSH, Ferritin, Vitamin B12 Other Substance History Cannabis Opioid Use exclusion for Naltrexone

28 DA VINCI: The Medical Visit Week 0 Visit Explanation of medical role to group Questions/ Clarifications Brief Discussion on Agents Used Antidepressants Anti-Craving Drugs

29 DA VINCI: The Medical Visit Weeks 2, 4, 6, 8, 10, 12, 14, 16 Brief Medical Interview Charting Medication Titration Psychosocial Stressors Management of Comorbidities

30 DA VINCI: The Medical Visit Weeks 2, 4, 6, 8, 10, 12, 14, 16 Algorithm: Antidepressants Sertraline Fluoxetine Venlafaxine XR Mirtazapine

31 DA VINCI: The Medical Visit Weeks 2, 4, 6, 8, 10, 12, 14, 16 Algorithm: Anticraving Naltrexone; Acamprosate; Topiramate

32 DA VINCI: The Medical Visit Weeks 2, 4, 6, 8, 10, 12, 14, 16 Scales Used QIDS Quick Inventory of Depressive Symptomatology Scale PACS Penn Alcohol Craving Scale Guide for Pharmacotherapy

33 DA VINCI: The Medical Visit Discharge Planning Charting completed and sent to Primary Practice Follow-up Planning Aftercare: Community Resources Within Family Health Team Complex Care Referral Concurrent Disorders Treatment Residential Treatment planning Indirect Support of Primary Practice

34 The HFHT DAVINCI Pilot Group Lessons Learnt

35 The First Session: ORIGINAL ISSUE LESSON, CHANGES Time Constraints. One hour for 20 patients psychiatric review. Two psychiatrists Group size limited to 10 total. Review time increased to 1.5 hrs. 1 hr. paperwork prep before review. Group medical visit vs individual review Group medical not billable. Complex cases need individualized care. Opted for brief individual review every 2 weeks. Medical co-morbidity-impacting treatment choice History unclear. Often complex array of diagnoses. Now opting for psych consultation at the point of acceptance of the group.

36 The First Session: ORIGINAL ISSUE LESSON, CHANGES Patient history, narrative, diagnosis History unclear. Often complex array of diagnoses. Now opting for psych consultation at the point of acceptance of the group. Physical health/medication reconciliation Clarify opiate prescribing-impact on Naltrexone prescription Records from family doctor, pharmacist led medication reconciliation prior to first week

37 Practical issues: ORIGINAL ISSUE LESSON, CHANGES Not sure if coverage for medication Acamprosate and Naltrexone cost Pharmacist reconciliation and interview Prior to first session. Compassionate access Support in linking to this No clear structure for reporting to family doctor Template for initiation and discharge. Family physician to be updated at any critical change

38 During the Programme: ORIGINAL ISSUE Appointment expectations Issues between psychiatric review Titration schedule Scale scores not aligned with progress Coverage if one psychiatrist away Flow of information within the team LESSON, CHANGES Clarify psychiatrist role from outset Delineate time limitations Facilitators go-between outside of Scheduled reviews Individualise as per standard practice Clinical perspective given greater weight Discuss discrepancy with pt. and facilitators Facilitators go-between outside of Scheduled reviews. Cross coverage review In unscheduled week for urgent issues Check in at end of group every other week, updates as they may arise

39 The End of the Group: ORIGINAL ISSUE LESSON, CHANGES AFTERCARE For higher risk patients connect to Concurrent Disorders counselling and psychiatric review within the HFHT until care assumed by a secondary care service. Link to Drinkwise, other HFHT groups, community resources Drop-in after-care group/?peer support group Encourage follow-up with family physician and practice mental health counsellor

40 Quite the Journey BUT it could HAVE BEEN worse!!

41 Contact Can you really do this in primary care? The DA VINCI Project Dr. Nadeem Akhtar MBBS(Lond), MA(Cantab), MRCPsych(UK) Psychiatrist Hamilton Family Health Team Brad LaForme MSW RSW Substance Use Program Coordinator Hamilton Family Health Team ext. 146