Telephone Based Care Management for Alcohol Misuse and Dependence

1
Telephone Based Care Management for Alcohol
Misuse and Dependence
F. Zanjani2, J.T. Ross1,2, C.Beswick1, V.
Kamath1, M. Patterson1, I.R. Katz1,2, J.
Seppelt1, V. Kane1, D.W. Oslin1,2,3
1. Mental Illness Research, Educational, and
Clinical Center (MIRECC) at the Philadelphia VA
Medical Center 2. Section of Geriatric
Psychiatry, University of Pennsylvania,
Philadelphia, PA 3. Center for the Study of
Addictions, University of Pennsylvania,
Philadelphia, PA
Abstract
Methods
Results cont.
Results cont.

• Screening is conducted by primary care staff
  using the AUDIT-C. For all patients who screen
  positively, the clinical reminder allows a direct
  referral to the BHL at the time of completing the
  screen.
• Conducting the BHL Assessment Health Technicians
  receive and register patient information from the
  consult in to the BHL database. Several attempts
  are made for each patient. If unsuccessful by
  phone, a letter is sent to the patients home
  address. All results, including those unable to
  contact, are documented to the PCP. (Table 1)
• Assessments Conducted.
• Blessed Orientation-Memory-Concentration Test
• International Neuropsychiatric Interview (MINI)
  for mania, psychosis, panic disorder, generalized
  anxiety disorder, PTSD, and alcohol abuse
• PHQ-9 for depression
• 5 item Paykel scale for suicide ideation
• Current Anti-depressant Medication
• Past and Current Use of Illicit Substances
• Medical Outcomes Study (SF-12)
• 4 item Patient Satisfaction scale
• Assessment Outcomes The computer algorithm
  scores all assessments and assigns patients into
  appropriate categories at completion of BHL
  assessment (Ongoing monitoring by PCP, appt in
  MH/SA clinic, or specialty care). Both the
  provider and the patients are sent a report of
  the outcomes of the assessment.
• Care Management for those with appointments
  Twenty patients given appointments with the
  mental health clinic were consented to be
  assisted with attending the appointment. Care
  Management consisted of three contacts with the
  patient throughout their treatment. Three
  telephone contacts were made, and involved
  obtaining the patients general goals,
  identifying substance abuse patterns, assessment
  of patients attitudes and obtaining a verbal
  agreement to attend the appointment.
• Medical Record Abstraction and chart reviews
  Medical Record Abstraction and chart reviews
  Data from the clinical reminder for alcohol
  misuse screening (Audit-C) was retrieved from the
  electronic medical records. Chart reviews were
  conducted on those patients who required an
  appointment to be made for specialty MH/SA care.
  The chart reviews examined if the patients
  attended the appointments that the BHL staff
  made.
• Data Analysis Analysis was conducted on the
  Audit-C data, data from the BHL assessments, and
  data from chart reviews for the time period of
  July-October 2004.
• Statistics Descriptive Statistics (means,
  standard deviations, and frequencies), t-tests,
  Chi Square tests, and logistic regressions were
  used to examine outcomes. Analysis was conducted
  on the Audit-C data, data from the BHL
  assessments, and data from chart reviews for the
  time period of July-October 2004.

• Table 1. Characteristics of patients interviewed
  by the BHL
• All patients are categorized into one of 4
  categories of severity based on the completed
  interview. Differences between severity groups
  are presented in Table 2.

• Objectives The purpose of this project was to
  assess the utility and feasibility of a telephone
  based systematic clinical assessment service, the
  Behavioral Health Laboratory (BHL), in the
  context of primary care for patients with alcohol
  misuse. The BHL is a service that provides
  Primary Care Providers (PCPs) with a summary of
  mental health and substance abuse (MH/SA)
  symptoms and provides treatment recommendations,
  including triage to specialty MH/SA services.
• Methods Results from AUDIT C screening of
  primary care patients were extracted during a
  period of 4 months. Descriptive results of the
  94 BHL evaluations conducted during this time
  were available as well as information about
  treatment engagement.
• Results Results demonstrate both the severity
  of problems but also the type of provider are
  important determinants of referral to the BHL.
  Referral for further assessment is low with an
  overall rate of 13 for those screening positive.
  This compares to approximately 60 referral rate
  for depression. However, the BHL was successful
  in assessing 78.9 of those referred and
  comorbidity was quite common among all referrals.
  While rates of engagement in care are low
  Telephone Care Management showed promise in
  engaging patients in treatment.
• Conclusions The BHL offers a practical, low
  cost method of assessment, monitoring, and
  treatment planning for patients, identified in
  primary care, with MH/SA needs. Referral patterns
  for alcohol use appear very different than for
  depression suggesting significantly greater
  barriers to accessing alcohol care than
  depression care. Telephone monitoring and brief
  interventions appear effective in engaging
  patients in care.

Conclusions
Figure 2. Rate of Referral as a function of
AUDIT- C Score
Introduction

• The BHL offers a practical and face-valid method
  of providing assessment and monitoring of mental
  health and substance abuse problems within
  primary care.
• The BHL also offers the possibility of ongoing
  monitoring of symptoms for patients with specific
  MH needs.
• In a cost effective manner, The BHL can overcome
  some of the problems in delivering quality mental
  health care, such as the already heavy demand on
  clinician time, availability of clinicians to
  conduct brief but frequent follow-up assessments,
  and the demand on patients for attending frequent
  follow-up visits. The BHL allows for rapid and
  systematic assessment of patients and can be an
  important tool for improving the management of
  depression and other mental health problems
  common in primary care.

Results

• Routine screening for alcohol misuse in primary
  care settings is an important mechanism for
  reducing morbidity and mortality. Alcohol misuse
  includes a spectrum that ranges from risky
  drinking to alcohol dependence and has a
  well-demonstrated association with disability,
  increased health care utilization, and mortality.
• Since the prevalence of alcohol misuse is
  significantly higher among patients visiting a
  primary care practitioner than among the general
  population, primary care clinicians have the
  opportunity to play a key role in detecting
  alcohol misuse and in initiating prevention or
  treatment efforts. However, approximately half
  of primary care physicians rely only on clinical
  impressions to identify misuse. Therefore, many
  patients with alcohol misuse go unrecognized.
• Past research has shown that brief interventions
  within a primary care setting are effective in
  treating alcohol misuse, leading to sustained
  reductions in alcohol use, health care
  utilization, and alcohol related problems.
• The Behavioral Health Laboratory was developed as
  a clinical service to assist with providing
  comprehensive assessments for patients either by
  their clinician, or identified during routine
  care as potentially in need of mental health
  care. The BHL conducts all tests by telephone
  when ordered by the Primary care providers and
  sends test results back to PCPs together with
  guidelines for their interpretation and
  recommendations to assist in clinical
  decision-making.
• The purpose of this service was to implement a
  cost effective model that would substantially
  increase the feasibility of providing further
  evaluations and triage to the majority of
  patients referred to this service.

Screening and Clinical Referral Using a
logistic regression model, we explored the
likelihood of referring patients who screened
positive for alcohol misuse to the BHL for the
variables of total score and if the clinician was
an MD or not. For every one point increase in
total Audit-C score, the clinicians were 1.36
times more likely to refer to the BHL (plt.001)
(Figure 1). If the clinician was an MD, the
clinician was 3.62 times more likely to refer to
the BHL than if the clinician were not an MD
(plt.001) (Figure 2).
Figure 1. Screening and Clinical Referral by
provider type.
Selected References
Clinical Referral Based on the telephone
assessment, 56.4 of those referred required
additional evaluation in the MH/SA clinic. Of
the 58 patients, 5 refused an appointment. Of
the 53 patients given an appointment, 52.8
attended a visit in the clinic within 3 months.

• U.S. Preventive Services Task Force (USPSTF).
  Screening and Behavioral Counseling Interventions
  in Primary Care to Reduce Alcohol Misuse.
  Available at http//www.ahrq.gov/clinic/3rduspstf
  /alcohol/alcomisrs.htm.
• NIAAA. Screening for Alcohol Problems-An Update
  2002.
• American Society of Addiction Medicine. Screening
  for Addiction in Primary Care Settings 2001.
• Wilk AI JN, Havighurst TC. Meta-analysis of
  randomized control trials addressing brief
  interventions in heavy alcohol drinkers. J Gen
  Intern Med. 199712274-283.
• Moyer A, Finney JW, Swearingen CE, Vergun P.
  Brief interventions for alcohol problems a
  meta-analytic review of controlled investigations
  in treatment-seeking and non-treatment-seeking
  populations. Addiction. Mar 200297(3)279-292.
• Fleming M, Barry K, Manwell L, Johnson K, London
  R. Brief physician advice for problem alcohol
  drinkers A randomized controlled trial in
  community-based primary care practices. Journal
  of the American Medical Association.
  19972771039 - 1045.

Referral Management Of the 20 patients enrolled
in Care Management, 70 (n14) engaged in
outpatient care, 45 (n9) attended two
appointments, and 40 (n8) attended three or
more appointments. TDMII Of those with who were
eligible for a VA sponsored research study,
Telephone Disease Management for At-Risk Drinking
(n8), 4 agreed to participation.  This study is
based on brief alcohol intervention literature
and aims at reducing alcohol use or engaging
patients in more formal treatment.
Values represent means (standard deviations) for
continuous measures and percentages for
categorical measures.
BHL Assessment Within the timeframe between
August 1, 2004-October 31, 2004, of the 906
patients who screened positive for alcohol
misuse,118 patients were referred to the BHL. Of
those 118 patients that were referred to the BHL,
78.9 completed the assessment, 5.9 refused and
14.4 were unable to contact. For the 118
referred to the BHL, the mean age was 54.19
(12.46), 12.7 were over 65, and 98.3 were male
(Table 1).
Costs of Assessments Considering cost of
staffing, laboratory maintenance, administrative
expenses, and program level expenses, the total
cost of the BHL per assessment is approximately
45.26 per initial assessment and 25.13 per
follow-up assessments.