Making Successful Referrals for S by wulinqing


									Making Successful Referrals
    for Substance Use

 UCSF Collaborative Education Project
   Elinore McCance-Katz, MD, PhD
         Learning Objectives
1.   Compare and contrast the different levels of
     care available for substance use disorders.
2.   Determine the appropriate level of care
     required based on severity of use, availability
     of resources, and patient willingness.
3.   Understand the process of making referrals to
     specialty care for substance use disorders.
4.   Be able to successfully refer patients to Bay
     Area treatment facilities and programs.
   Levels of care for substance use
    disorders (SUD)
   How to assess appropriate level of care
   How to make a referral
   Local resources
   Best practices, clinical tips
    Acute Care Continuum
   Inpatient medical withdrawal: For use with alcohol,
    benzodiazepines, complicated opioid withdrawal (i.e.:
    with other co-occurring illnesses such as polysubstance
    dependence, HIV, or other significant medical illness)
   Outpatient medical withdrawal: For use with opioids
    (uncomplicated), stimulants (cocaine/ amphetamines)
   Residential treatment: Often can undertake medical
    withdrawal and other medical needs while providing
    ongoing substance abuse treatment after initial
    withdrawal is completed
   Intensive outpatient treatment: Usually takes those
    without acute medical needs, but with the need for
    intensive treatment of substance use disorder (any of
    the abuse disorders (i.e.: abuse of any substance that
    does not rise to level of substance dependence)) or non-
    physiological substance dependence
       Chronic Care Continuum
(After any medical withdrawal needs have been attended to)
Type of Treatment Key Features
Intensive Outpatient     Defined as at least 2 hours of treatment per day;
Programs (IOP)           at least 3 days/wk; treatment is usually for about
                         12 weeks
Partial Hospital/Day     Usually for patients with more severe illness often
Treatment Programs       defined by co-occurring mental illness; 5 d/wk with
                         varying hours depending on patient needs
Residential Facilities   24 h facility; patient resides there; usually has
                         skilled medical staff available 24/7; up to 90 days
                         of treatment
Individual or Group      For those with less severe substance abuse
Counseling; Addiction    problems; or often used as a referral for ongoing
Psychiatry               treatment after completion of more intensive
                         programs such as IOP or residential
12 Step Mutual Help      Supportive groups, abstinence based for the most part; sponsors
                         available to provide support to individuals; big advantage is that
Groups                   these groups are free of charge; are available for lifetime; can go
                         multiple times a day every day if wanted; can be the basis of a new
                         and healthier support system for patient
Overview: Continuum of Care for
   Substance Use Disorders
   Substance abuse treatment modalities may be mixed; i.e.: include
    multiple types of treatment interventions in each setting
   Inpatient short term (days to a few weeks); Residential (30-90 days);
    IOP (approx. 12 wks) Will include multiple modalities:
        Medical management
        Medical withdrawal
        Psychiatric assessment/treatment if needed
        Psychological testing
        Individual assessment and therapy
        Group therapy
        Family therapy
        12 Step groups
        Vocational assessment
   Once inpatient, residential or IOP program is completed; a patient will
    be referred for a less intensive, but ongoing treatment:
   ―Aftercare‖ – usually low intensity 1/wk individual or group therapy
   Those without a sober living environment to return to may need long-
    term residential:
   Half-way house: a group residential facility where recovering people
    can get support for sobriety from each other. Not staffed by addiction
    professionals. Not a treatment program.

           But Does Treatment
               Even Work?
   Providers sometimes feel discouraged about referring pts for
    SUD treatment. Sometimes it seems like it just isn’t worth the
    effort. But relapse rates are really no different than other
    chronic diseases:
   So how do you maximize the likelihood of success? You
    must first know what level of care you should be
    referring to.
      Determine if patient is drug or alcohol dependent
       (and needs medical withdrawal) (inpatient) or is a
       substance abuser (outpatient unless has other risk
      Determine if patient has other risk factors that would
       make them better candidates for inpatient treatment
       than outpatient treatment:
           Co-occurring mental illness (may need a psych consult)
           Polysubstance use and dependence on multiple
           Serious medical illnesses that may be exacerbated
            when substance use changes (i.e.: when the patient
            stops abusing); e.g.: HIV/AIDS, active HCV, cirrhosis,
            other serious illnesses)
    Other Factors to Consider
   Insurance coverage
        Private: must check with insurer to determine what kind of
         treatment and what facilities they will pay for
        Public: Medi-CAL/City/County: Refer to public treatment
         facilities in city or county where the patient resides
   Language ability/cultural competence
   Treatment history (have they failed outpatient treatment in
   Location/transportation: can the patient and their family easily
    access the treatment facility
   Family support
   Can the facility treat both substance use disorders and mental
   Can the facility treat both substance use disorders and medical
   Does the facility offer/support pharmacotherapy for
    maintenance of abstinence?
   Does the facility have a good record of keeping referring
    medical staff informed of patient progress and ongoing needs?
    Assessment Domains for
      Treatment Planning
Determining the appropriate level of care, requires a multilevel
  assessment of many factors. These factors include:
 Severity:
    substance type
    amount, frequency, duration
            Alcohol ―at risk‖ or ―hazardous‖= drinking
               Men: >5 drinks/day; >14 drinks/wk
               Women: >4 drinks/day; >7 drinks/wk
      Route of administration
      Consequences of use
   Comorbidity:
      Medical
      Psychiatric
   Social support/environment/triggers for relapse (i.e.: will they
    need a sober living facility after finishing treatment?)
   Motivation
   External obstacles: insurance, location of treatment program

                     Case Study
   Paul is a 35 y.o. man with two children aged 12 and 15. He
    has been your patient for the past 2 years and has seen you
    for regular healthcare/physical examinations. He has no
    ongoing medical problems noted. He drinks nightly after work,
    as has been his habit for many years and has reported
    drinking 1-3 drinks per sitting. He presents today asking if
    there is a medication he can take for his nerves as he has
    noticed that he is losing his temper with his children more
    often. He recently got into a physical fight with his 15 y.o.
    after several drinks that resulted in a neighbor calling police.
    Other complaints include problems with sleep—he notes that
    he often falls asleep after 4-5 beers in the evening, but wakes
    up at 2 or 3 AM and has problems returning to sleep. He
    sometimes feels anxious and at times has sweats in the
    mornings and wonders if he is ―going crazy‖. Physical
    examination is normal except for increased blood pressure at
    150/92 and heart rate of 95 bpm. His last drink was at 10 PM
    the night before and you are seeing him at 3 PM. He admits
    that his drinking has increased ―some‖ since you saw him last
    and he thinks he now drinks about 5 beers daily.
                      Case Study
   What is the likely diagnosis and where should he be sent for
       Diagnosis: Alcohol dependence. Physical examination shows
        only mild hypertension which could occur as a result of alcohol
        withdrawal (it has been 17 hours since his last drink). Although
        he could also have a mental disorder and this should be
        evaluated further as should the hypertension once medical
        withdrawal is completed, his current symptoms are most
        consistent with alcohol dependence. Based on his history of
        withdrawal symptoms, he is a good candidate for care at a
        substance abuse treatment program that can offer inpatient
        medical withdrawal or this can be accomplished at a local
        inpatient hospital (psychiatry may take such a patient given
        the question of depression and anxiety with consequences
        (i.e.:police involvement, social work involvement needed)). His
        symptoms indicate that he is likely to need medication to
        assist with withdrawal symptoms. After medical withdrawal he
        will need ongoing substance abuse treatment, most likely in an
        IOP setting.
      After the Assessment:
          Nuts and Bolts
   Who do you call? see Provider Listing in attached excel
    file for this module.
   What form do you fill out? May use a standard UCSF
    specialist referral form or you may be able to give a
    verbal report to the receiving institution
   Need to get authorization? You will likely not do this; but
    if you do the actual referral you may be asked what
    insurance the patient has—the facility will know
    immediately if they can take the patient or not; if they
    can’t they may be able to direct you to another facility
    that will take the patient’s insurance.
   What support staff can help? Clinic nursing or
    administrative staff may be able to help with
    determination of insurance and whether a facility would
    be able to take the patient. Medical information will need
    to come from the clinician.
    The Referral “Package” (1)
   A strong referral to appropriate specialty care is key but that’s
    not all…
        How will you interact/communicate with the specialist? Have
         the patient sign a release of information form before they go to
         substance abuse treatment.
        What is your follow-up plan with the patient? Arrange follow-
         up contacts and appointments with you since there may be a
         waitlist for specialty care.
        What ongoing management strategies will you use? Monitor
         labs? Look for medical symptoms of ongoing use? (Look for
         physical/psychological symptoms and use POS urine drug
         screens) Medication to reduce cravings ? (speak with
         treatment facility to determine need and type of
         pharmacotherapy) Make plan for harm reduction? (Determine
         patient’s goals (do they intend to stay abstinent? ―controlled‖
         use? Be prepared to counsel regarding whether ―controlled‖
         use is possible given extent of their disease; realize SUDs are
         chronic, relapsing diseases and the patient may need more
         than a single treatment—so you may, at some point, have to
         reassess and refer to treatment again)
The Referral Package (2)
   Encourage continued use of 12 step programs or support
    groups as well as ongoing group and/or individual therapy.
        Remember that giving the patient a list of local 12 step
         meetings is far more effective that just vaguely suggesting
         they go. You can find updated SF meeting lists at Ask for commitment to attend a specific
         meeting on a specific day.
   Impress on receiving facility that you want regular updates
    starting with their assessment of the patient’s needs and the
    treatment they provide as well as their plan for ongoing care
    after the patient leaves their facility. Note: Most substance
    abuse treatment programs and providers are eager to provide
    ongoing input about your patient. They realize that you are
    looking to them to effectively treat the substance use disorder
    and to make a comprehensive discharge plan. They are also
    aware that you can refer to a number of facilities (and they
    usually are appreciative of your referral), so they will try to
    give you the updates and information you need to so that you
    can make sure that the patient’s ongoing treatment needs are
    met. If you refer to a facility that does not provide you
    updates; don’t refer to them again.
         So What’s Available
   See the Attached Listing for SF Bay Area
    Treatment Facilities (excel file in the folder for
    this module)
     Provides type of facility
     Services offered
     Medicare/Medi-Cal acceptance
     Languages/special populations served
     Differentiates public and private facilities
     Websites for many 12 step and self-help groups
    Preparing the Pt for the
   Assess the appropriate level of care
    needed and finding the right facility is
    really just half the battle. All that work
    will be lost if the pt is unable or
    unwilling to follow through.
   What would you do to help prepare the
    pt for treatment?
   Would this differ depending on the level
    of care?
     Preparing the Pt for the
    Referral: Our Suggestions
   Motivation – recall the discussion of motivation (and how to build it) in
    Module 6. Be sure the pt is motivated and willing to attend before
    making the referral.
   Ask the pt to ―look ahead‖ and identify any potential obstacles or
    roadblocks. Do some advance problem-solving on how to address
    these issues.
   Ask the pt to share his/her worries or what they imagine treatment will
    be like. Provide corrective information.
   Use testimonials from other pts, use the weight of your professional
    opinion and your relationship with the pt.
   Normalize anxiety and ambivalence.
   Remind pt that he/she has choice. If one program doesn’t fit, try
    another. There are many options.
   Reassure pt you won’t abandon them regardless of how tx turns out.
   Enlist the support of family members to help get the patient to
    treatment (obtain releases of information to be able to speak with
    family members the patient identifies as important in their lives).
              Common Mistakes
1.     PCP rushes into ―action‖ and makes a tx referral when
       the pt isn’t interested.
2.     PCP refers to an overfull program or to a program that
       doesn’t take the pt’s insurance. Pt feels unheard and
3.     PCP doesn’t create a referral ―package‖ – i.e. other
       strategies/programs or homework the pt can try while
       they are on a tx program waitlist.
4.     PCP doesn’t consider pharmacotherapy to reduce
       cravings and/or reduce suffering.
5.     PCP gets frustrated and sees the pt as ―resistant‖ or
       ―self-sabotaging‖ instead of having a difficult chronic

     What could you do to avoid each of these mistakes? How
                    will you assess your success?
          Take Home Points
   Substance abuse treatment works and there
    are ways to maximize the likelihood of a
    successful referral.
   Substance abuse treatment occurs on a
    continuum with several modalities overlapping
    in multiple treatment settings
   Level of care is determined by severity of
    illness: is patient dependent or do they have
    substance abuse. Comorbidities?
   Inpatient treatment reserved for those with
    more serious illness (dependence, more than
    one substance, medical/psychiatric illness co-
            Take Home Points
   Substance abuse treatment facilities should provide you
    ongoing updates with a valid release of information; if
    they do not; don’t refer to them again
   Substance abuse treatment facilities should provide you
    with a structured discharge plan discussing the patient’s
    ongoing treatment needs and making specific
    recommendations as to what and where the patient
    might access those interventions
   Addiction is a chronic relapsing illness; continued
    monitoring after substance abuse treatment is needed
    and you may have to refer to substance abuse treatment
    more than one time for any particular patient
            Related Tools and
   See Excel Spreadsheet Listing for Local Alcohol
    and Drug Treatment Facilities and Programs
       SF Bay Area
   SF County Treatment Access Program 1-800-
   CA ADP resource website listings:
   SAMHSA Treatment Facility Locator Tool

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