To present common barriers of why patients do not receive treatment services. â¢. To examine how to identify .... Txp p
Referral To Treatment Part II
Geneva Sanford, MSW, LSW, LICDC-CS Substance Abuse Coordinator 111 S. Grant Ave, 7th FL. (614) 566-9863
[email protected]
May 22, 2013
Objectives •
To explore where patients commonly seek treatment interventions
•
To present common barriers of why patients do not receive treatment services
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To examine how to identify patients who need a referral for further evaluation and/or treatment
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To point out essential collaborative efforts between medical and treatment providers within communities
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To identify ASAM treatment levels of care
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To examine treatment options for specific patient populations
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Referral
3
Establishing Referral Process •
Identify pts that meet substance abuse and dependence criteria
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Ability to identify appropriate treatment (txp) programs
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Facilitate engaging pts into txp programs
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Develop a strong referral linkage through proactive collaboration efforts with specialty txp facilities
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Opportunity to engage pts in appropriate levels of care
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If a referral process is not developed, it can be a significant barrier to the adoption of SBIRT
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Lack of proper referral will and can prevent access to to txp and opportunity for pts to address other psychosocial and medical issues.
4 SAMSHA
Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older: 2002-2011
NSDUH
5
Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2011
NSDUH
6
Substances for Which Most Recent Treatment Was Received in the Past Year: 2010
NSDUH
7
Received Most Recent Treatment in the Past Year for the Use of Pain Relievers 2002-2010
NSDUH
8
SUBSTANCE ABUSE 1. Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home. 2. Recurrent substance use in situations in which it is physically hazardous. 3. Recurrent substance‐related legal problems 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused by the effects of the substance.
DSM-IV
9
SUBSTANCE DEPENDENCE •
Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect
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Withdrawal
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The substance is often taken in larger amounts or over a longer period than was intended
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There is a persistent desire or unsuccessful efforts to cut down or control substance use
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A great deal of time is spent in activities necessary to obtain the substance
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Important social, occupational, or recreational activities are given up or reduced because of substance use
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The substance 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 the substance.
DSM-IV
10
McLellan & Dembo, 1992, Tarter, Ott & Mezzich, 1991
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Barriers to Change
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Motivational Interviewing •
Patient-centered
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Collaborative
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Focus on motivation
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Explore ambivalence
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Individual feedback
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Elicit reasons to change
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Listen, Listen, Listen
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Motivational Interviewing
Frequency behavior exhibited by client
Motivational Interviewing style by therapist and client behavior: Miller, Benefield & Tonigan (1993)
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Pros versus Cons
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Collaboration (Internal & External)
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Elements of Collaboration •
Underlying Values & Principles
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Working with AOD Agencies
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Daily Practice: SBIRT
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Working with Related Agencies
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Daily Practice: Services to Patient
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Information Sharing & Data Systems
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Training & Staff Development
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Joint Accountability & Shared Outcomes
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Budgeting & Sustainability
NCSACW
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Considerations for Referral – Patient’s Stage of Change – Patient’s plan on how to address the issue
– Insurance provider/Self-pay – Knowledge of treatment levels of care (ASAM) – Release of information – Case management tasks
– Treatment providers/contact person within the community – Collaboration agreements with treatment providers – 12 Step support meeting schedule, Celebrate Recovery – Patient’s support system (family, friends, church)
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CONFIDENTIALITY •
PATIENT PRIVACY DURING INTERVENTION
•
FAMILY/FRIEND INVOLVEMENT • PATIENT PERMISSION
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DOCUMENTATION • CONSULT FORM
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MEDICAL RECORDS • POLICY AND PROCEDURES • RELEASE OF INFORMATION 19
Referral Challenges • Precontemplation & Contemplation Stage
• Indigent status, limits access to all facilities
• Waiting list
• Medically unstable for txp setting
• Txp providers reluctance to take referral, must speak to patient • Txp providers voicemail system maze
• Insurance lifetime cost standard
• Hospital discharge demands
• Pts on prescribed pain medications • Lack of resources to followup with patients 20
2006-2009: Reasons for Not Receiving Substance Use Treatment
NSDUH
21
Population Specific Referrals • • • • • • • • •
Adolescent Adult Older Adult/Seniors Dual-Diagnosis (IDDT) Pregnant Long-term Txp Traumatic Brain Injury Homeless Incarceration
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Treatment (TXP)
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2009: Locations Where Past Year Substance Use Treatment Was Received
NSDUH
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Effectiveness of Txp • Goal of txp is to return to productive functioning • Reduced drug use by 40-60%
• Reduces crime by 40-60% • Increases employment prospects by 40% • Txp is as successful as treatment for other diseases (diabetes, asthma, hypertension)
NIDA
25
Comparison of Relapse Rates Between Drug Addiction & Other Chronic Diseases
NIDA
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What is Treatment?
SAMHSA
27
Treatment/Intervention Referrals • Traditional Txp
• Primary Care Physician
• Medication Assisted Txp (MAT)
• Traditional Support Groups
• Drug Court Programs • Dual-Diagnosis (IDDT)
• Non-Traditional Support Groups
• Treatment/Child Welfare/Legal(NCSACW)
SAMHSA
28
Providers of Txp Services • Physician
• Marriage & Family Therapist
• Nurse
• Psychiatrist
• Chemical Dependency Counselors
• Psychologist • Recovery Coaches
• Social Workers • Licensed Professional Counselor
• Interns from a variety of professions
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Treatment Levels of Care
ASAM
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ASAM
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Outpatient Services • Afternoon/Evening/weekend programming • Attend program at a specific location
• Weekly attendance, 1 to 2 times per week, 2 months or longer • Substance use monitoring (urine tests) • Individual/Group counseling • Family Education/Support
SAMHSA
32
Intensive Outpatient/Partial Hospitalization Services • Morning/Evening programming
• (Partial) – daily attendance, 4 to 8 hours,
• Attend at a specific location, reside at home
• Substance use monitoring (urine tests)
• (IOP) - Weekly attendance, 9 to 20 hours of program activities, 2 months or longer
• Individual/Group counseling
• Family Education/Support groups
SAMHSA
33
Inpatient Services •
• •
Located at special facilities or units of hospitals or specialty clinics
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Family Education/Support groups
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In-house 12-step meetings
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Art Therapy/Physical Therapy
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Field Trips
7 to 28 days inpatient Daily programs/activities
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Earn weekend passes to transition back into the community and home setting
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Substance use monitoring
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Individual/Group counseling SAMHSA
34
Residential Services •
•
Living environment with treatment services
Individual/Group counseling
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Family Education/Support groups
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12-step meetings on site or remote location
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Therapies (Art, Physical, Meditation)
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Field Trips/Home passes
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Vocational Trainings, etc.
Duration: 1 to 12 months or longer
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Daily programs/activities
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Phases of treatment to determine restrictions & privileges
•
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Substance use monitoring (routine urine test)
SAMHSA
35
Medically Managed Intensive Inpatient Services •
Setting: Freestanding facility, hospital setting or outpatient basis
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Duration: 3 to 7 days or longer depending on withdrawal protocol
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Utilization of medications to assist patients withdrawing from alcohol and/or drugs
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Program: medication management, individual counseling, educational groups, speakers, videos
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Patient stays at the facility until medically cleared for discharge
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Introduction to 12-step programming on site
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Medically supervised withdrawal
SAMHSA
36
Medication-Assisted Txp (MAT)
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Medication-Assisted Txp Settings:
Services:
•
Treatment facility
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Outpatient
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Clinics
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Individual/Group
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Physician Office
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Urine test
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Urgent Care
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Medication management (daily, weekly, monthly)
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Primary Care Physician •
Administration: pill, liquid, injection
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12-Step attendance (proof of attendance)
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Abstinence from alcohol and drugs38
• •
Addictionologist Any physician certified/licensed to prescribe the medication
Integrated Dual Diagnosis Txp (IDDT) Service
Description
Integrated Services
Mental Health and substance abuse treatment are integrated to meet the needs of people with co-occurring disorders
Cross-trained Practitioners
Specialist are trained to treat both substance use disorders and serious mental illnesses
Stage-Wise Treatment
Services are matched to consumer’s stage of consumers
Motivational Interventions
Interventions used to help consumer’s identify and pursue personal recovery goals
Cognitive-behavioral Approach
Approach used to help consumers identify and change their thoughts, feelings, and behaviors related to their co-occurring disorders.
Multiple Formats
Services are available in individual, group, self-help and family formats
Integrated Medication Services
Medication services are integrated with other services
39 SAMHSA
Principles of Drug Addiction Treatment
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Principles of Drug Treatment 1. Addiction is a complex but treatable disease that affects brain function and behavior 2. No single treatment is appropriate for everyone 3. Treatment needs to be readily available 4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse 5. Remaining in treatment for an adequate period of time is critical 6. Behavioral Therapies (individual, family and/or group counseling) are the most commonly used forms of drug abuse treatment 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. NIDA
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Principles of Drug Treatment 7. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his/her changing needs. 8. Many drug-addicted individuals also have other mental disorders. 9. Medically-assisted detoxification I only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 10. Treatment does not need to be voluntary to be effective
11. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 12. Treatment programs should test patients for the presence of other diseases, as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary. NIDA
42
Components of Comprehensive Drug Addiction Txp
NIDA
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Training Resources • SAMHSA • NIAAA (online)
• NidaMed (online) • IRETA (online, ireta.org) • NAABT.ORG • PainEdu.org
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