Referral To Treatment Part II - IRETA

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To present common barriers of why patients do not receive treatment services. •. 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



To examine how to identify patients who need a referral for further evaluation and/or treatment



To point out essential collaborative efforts between medical and treatment providers within communities



To identify ASAM treatment levels of care



To examine treatment options for specific patient populations

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Referral

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Establishing Referral Process •

Identify pts that meet substance abuse and dependence criteria



Ability to identify appropriate treatment (txp) programs



Facilitate engaging pts into txp programs



Develop a strong referral linkage through proactive collaboration efforts with specialty txp facilities



Opportunity to engage pts in appropriate levels of care



If a referral process is not developed, it can be a significant barrier to the adoption of SBIRT



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

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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

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Substances for Which Most Recent Treatment Was Received in the Past Year: 2010

NSDUH

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Received Most Recent Treatment in the Past Year for the Use of Pain Relievers 2002-2010

NSDUH

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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

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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



Withdrawal



The substance is often taken in larger amounts or over a longer period than was intended



There is a persistent desire or unsuccessful efforts to cut down or control substance use



A great deal of time is spent in activities necessary to obtain the substance



Important social, occupational, or recreational activities are given up or reduced because of substance use



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

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McLellan & Dembo, 1992, Tarter, Ott & Mezzich, 1991

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Barriers to Change

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Motivational Interviewing •

Patient-centered



Collaborative



Focus on motivation



Explore ambivalence



Individual feedback



Elicit reasons to change



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



Working with AOD Agencies



Daily Practice: SBIRT



Working with Related Agencies



Daily Practice: Services to Patient



Information Sharing & Data Systems



Training & Staff Development



Joint Accountability & Shared Outcomes



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



DOCUMENTATION • CONSULT FORM



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

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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

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Comparison of Relapse Rates Between Drug Addiction & Other Chronic Diseases

NIDA

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What is Treatment?

SAMHSA

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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

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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

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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

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Inpatient Services •

• •

Located at special facilities or units of hospitals or specialty clinics



Family Education/Support groups



In-house 12-step meetings



Art Therapy/Physical Therapy



Field Trips

7 to 28 days inpatient Daily programs/activities



Earn weekend passes to transition back into the community and home setting



Substance use monitoring



Individual/Group counseling SAMHSA

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Residential Services •



Living environment with treatment services

Individual/Group counseling



Family Education/Support groups



12-step meetings on site or remote location



Therapies (Art, Physical, Meditation)



Field Trips/Home passes



Vocational Trainings, etc.

Duration: 1 to 12 months or longer



Daily programs/activities



Phases of treatment to determine restrictions & privileges





Substance use monitoring (routine urine test)

SAMHSA

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Medically Managed Intensive Inpatient Services •

Setting: Freestanding facility, hospital setting or outpatient basis



Duration: 3 to 7 days or longer depending on withdrawal protocol



Utilization of medications to assist patients withdrawing from alcohol and/or drugs



Program: medication management, individual counseling, educational groups, speakers, videos



Patient stays at the facility until medically cleared for discharge



Introduction to 12-step programming on site



Medically supervised withdrawal

SAMHSA

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Medication-Assisted Txp (MAT)

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Medication-Assisted Txp Settings:

Services:



Treatment facility



Outpatient



Clinics



Individual/Group



Physician Office



Urine test



Urgent Care



Medication management (daily, weekly, monthly)



Primary Care Physician •

Administration: pill, liquid, injection



12-Step attendance (proof of attendance)



Abstinence from alcohol and drugs38

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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

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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

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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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