A middle-aged man is being seen weekly in primary care for severe complications from uncontrolled diabetes. But at his next visit, something out of the ordinary happens: A member of his primary care team asks him to fill out a validated screening questionnaire that includes questions about his alcohol use.
The screening reveals a serious health concern that had previously gone undetected: This patient drinks a fifth of vodka every day. Thanks to a new approach to integrating alcohol-related care into primary care at Group Health, his primary care team was able to take immediate action.
“I had seen this patient several times, but I never realized alcohol was a problem for him,” explains his doctor, Mark Spee, MD, a primary care physician at Group Health Olympia Medical Center. “So I paged a social worker, Mithila Pathare, who spent an hour with him—engaging him in shared decision making about treatment options. I prescribed medications to help him manage withdrawal symptoms, while the social worker collaborated with him on a good care plan and scheduled follow-up appointments. I probably spent a total of 30 minutes caring for this patient, and together we made a world of difference.”
Previously, people who had problems due to drinking were offered only referral to alcohol treatment programs or Alcoholics Anonymous. But many new proven approaches exist to help people manage unhealthy alcohol use. Some approaches target people who drink at unhealthy levels—to prevent harm due to drinking. Others help people who have developed an addiction to alcohol, now called alcohol use disorders (AUDs).
Roughly 7 percent of U.S. adults—about 16.6 million people—have AUDs. Yet 90 percent of them never receive any treatment. That’s in part because, unlike other common health conditions, AUDs have traditionally not been managed in primary care. Many doctors erroneously believe nothing can effectively help people with AUDs—until they are “ready” for traditional alcohol treatment. As a result, most people with AUDs remain untreated.
GHRI Senior Investigators and Group Health Physicians Kathy Bradley, MD, MPH, and Paula Lozano, MD, MPH, and GHRI Senior Research Associate Evette Ludman, PhD, are working with Group Health leaders including Medical Director of Behavioral Health Support Services (BHSS) Larry Marx, MD, to change this paradigm. (Dr. Lozano also serves as Group Health’s associate medical director of research and translation.)
With a four-year, $1.9 million grant from the Agency for Health Research and Quality (AHRQ), their GHRI research team is leading a pragmatic implementation trial of evidence-based alcohol-related care in all Group Health primary care clinics. The trial launched in three pilot clinics over the past year: Olympia, Everett, and Northgate.
This work is part of Group Health’s Behavioral Health Integration (BHI) initiative, overseen by leaders in BHSS: Chief of Chemical Dependency Services and Consultative Psychiatry Ryan Caldeiro, MD, and Behavioral Health Integration Consultant and Social Work Manager Tory Gildred, LICSW, CDP.
Group Health is one of hundreds of U.S. health systems working to integrate care for behavioral health into routine primary care as part of health care reform. Group Health’s BHI initiative is unique because it aims to offer care for AUDs and other substance use disorders in primary care—and it’s being supported and evaluated with funding from federal and foundation grants.
With a Partnership for Innovation grant from the Group Health Foundation, Dr. Caldeiro, Ms. Gildred, and the GHRI research team are also developing a new care model in which primary care social workers engage patients in care for addictions, including AUDs. Social workers at three more Group Health primary care clinics—Silverdale, Burien, and Rainier—are learning to use a new registry in Group Health’s electronic medical record built in collaboration with Group Health’s Care Delivery IT department. The registry alerts social workers to patients with new addiction diagnoses.
This model of care has been so successful that BHSS leaders are integrating the social work training into implementation of BHI.
“It takes a village to implement and evaluate an effort like this,” Dr. Bradley explains. “We are incredibly fortunate to have such fabulous partners at Group Health, including BHSS leadership, primary care champions, medical assistants, social workers, nurses, and leaders in the clinics that have undertaken this important work.”
The full AHRQ-funded pragmatic trial is expected to launch in 2016 and will be informed by successes and challenges experienced in the pilot clinics. Additional research funding will help expand the effort: The National Institute on Drug Abuse (NIDA) is supporting an evaluation of care for marijuana and drug use during the pilot, while the National Institute on Alcohol Abuse and Alcoholism (NIAAA) is funding development of a patient-centered decision aid for AUDs.
What has this effort taught the BHI team so far?
“Not only have patients repeatedly told us how much the program means to them, but we’ve heard from primary care providers that it usually doesn’t take more of their time—and sometimes less time because they have critical information before they enter the room,” says Dr. Caldeiro. “We’ve even heard that some primary care clinicians in Olympia have said that BHI has made their work more satisfying. They are happier to come to work!”
by Jessica Ridpath