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 ‹#›    10/7/2005
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------=_NextPart_01C64C14.31468580 Content-Location: file:///C:/506945D7/Watkinsbriefing10-7_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C64C14.31468580 Content-Location: file:///C:/506945D7/Watkinsbriefing10-7_files/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" No Slide Title
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 1    10/7/2005
Recognizing and Treating = Alcohol Problems in=
= Primary Care
•Katherine Watkins, M.D.
•Harold Alan Pincus, M.D.
•Terri Tanielian, M.A.
•
• <= /i>
This p= roject developed out of discussions between RAND and a federal agency, the Center for Substance Abuse Treatment.  A= group in Washington State had articulated a model to improve chronic illness ca= re, and was revolutionizing the way people think about the delivery of health care.  Both RAND and CSAT recogni= zed that this model could be applied to alcohol use disorders, and CSAT contracted with RAND to do this work.  Both RAND and CSAT felt that if we could adapt and implement this model for alcohol problems it  wo= uld transform the delivery of treatment for alcohol problems in primary care = setting.  It would also take advantage of some = of the most cutting edge thinking in health services research today.
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=
=
=
 2    10/7/2005
Alcohol= Use Disorders Are a Significant
Public Health Concern
– = ;
–Su= ch disorders are common
•14 million peopl= e are addicted to alcohol or abuse i= t
•33 million engage in binge-drinking at least once
a month
–Th= ey have serious health-related and social consequences
•They increase morbidity a= nd mortality
•Alcohol-related lost productivity, vehicle crashes, and heal= th care come to $150 billion annuall= y
First = some background about why alcohol use disorders are important.

First = of all, alcohol use disorders are common.  Many people drink above the recommended limits: of those who drink almost 1/10= th are addicted to alcohol or abuse it and an additional 1/4th re= port hazardous alcohol use.

Second= , there are many negative consequences associated with drinking too much.  These include health related conseque= nces such as increased liver disease, stroke, heart disease, depression and trauma, and negative social consequences, including missed days of work, decreased productivity at work, motor vehicle accidents, domestic violence and child abuse and neglect.  The economic costs of alcohol use disorders are enormous, and are estimated at $150 billion annually.

((Prob= lematic alcohol use can be described in a variety of ways ranging from problem or hazardous drinking to alcohol abuse and dependence.  Problem drinking is drinking that exc= eeds an established threshold, generally 14 drinks a week for men and 7 drinks= a week for women, or more than 3 or 4 drinks at a time. ))


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=
=
=
 3    10/7/2005
Alcohol Use Disorders Can Be Treated
but Often Are Not
–= There are effective treatments for the entire spectrum of alcohol-related problems
–= Most individuals needing treatment do not receive it
–= Primary care represents a missed opportunity
•70 percent of the population visits such a provider at least once every two years
•One in five men and one in ten women visiting <= span style=3D'position:absolute;top:67.75%;left:16.1%;width:80.89%;height:5.25%= '>their PCP have alcohol problems
•Fewer than 1 percent receive counseling
Effect= ive treatments exist for the range of alcohol use disorders.  These include brief interventions for problem or hazardous drinkin= g, to specialty alcohol treatment for people with alcohol abuse or dependenc= e.  These treatments that have been shown= in numerous studies and in numerous settings to reduce drinking and the subsequent negative health and social consequences.  But although we have effective treatm= ents,, fewer than half of those people who need treatment actually receive it.

This g= ap between what we know, and what we do is particularly apparent in primary care settings, and represents a missed opportunity.  Many people visit a primary care prov= ider and 10-20 % have an alcohol related problem.  Fewer fewer than 1% of patients receive counseling for alcohol problems.

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=
=
=
 4    10/7/2005
Why Are Al= cohol Problems Not
Widely Treated?
•
–= Alcohol disorders are rarely the main reason for a visit to a primary-care provider
•Provider focuses on acute problem at hand, not = bigger chronic-condition picture
–= Chronic conditions of any kind are generally not well treated
– =
Now, w= hy are alcohol use disorders not widely treated in primary care settings?

There = are a number of reasons, ranging from the lack of reimbursement for screening and brief interventions, to competing demands for a providers time and resources.  Usually the patients doesn’t come in complaining of drinking too much, but their alcohol use contributes indirectly to the presenting problem.  The provider generally is focused on the acute problem before them, and doesn’t have the time or resources to look at the big picture.  This problem is not unique to the tre= atment of alcohol problems, but is a problem that characterizes the delivery of = most health care for chronic conditions in the US today.  Chronic conditions of any kind are generally not well treated.


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=
=
=
 5    10/7/2005
Outline
–= A model has been proposed for improving chronic care
<= span style=3D'font-weight:normal'>–We applied this model to al= cohol use disorders
Here w= e show how a model for improving chronic illness care can contribute to better alcohol= use disorder treatment.  In this brie= fing, I am going to tell you first about a model that was developed for improvi= ng chronic illness care by some people at the McColl Institute.  Then I will tell you how we have adap= ted it for alcohol use disorders.

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=
=
=
 6    10/7/2005
Outline
–= A model has been proposed for improving chronic care
<= span style=3D'font-weight:normal'>–We applied this model to al= cohol use disorders
I’m go= ing to begin by describing the general chronic care model.  The model suggests that we need to completely rethink the way we organize and deliver health care.
While = some elements of the model may be applicable to small provider groups, it is particular= ly relevant to large health care systems such as HMO’s or the VA.
------=_NextPart_01C64C14.31468580 Content-Location: file:///C:/506945D7/Watkinsbriefing10-7_files/slide0078_image006.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhtgE3AHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQC1 ATYAgQAAAJnMAP///wECAwL/lI+py+0Po5y02ouz3rz7D4ZHQJbmiabqyrbuC8fyTNf2jef6zvf+ b/gJh8Si8YhMKpfMW7AJjUqn1Kr1ChRgt9yu9wsOp57isvmMTqtR5LX7DY/Le+25/Y7Pu+v6vv8P yMQXSFhoeAgziLjI2Oin6BgpOXkGSXmJmSllqdnp+UmnBTpKWmrDaZqqOoq66vo62Qo7S1soW4ub e3er2+ubxvsrPNwVTHyMHGWczNxctOwcLZ0DPW19/VKNvc1dot0Nbv0dTt48Xo5OfJ7O3rveDk/7 Hk+/Ol+PT3qfz9+53w+Q0r+ABBsNLIjQ0MGEDP8sbAgRz8OIFONMrIhRzcWMQxzLbOwI0svHkCSv jCyJcpOolCwfrWwJc9fLmDThnKyJM1TOnRpn8vz55SbQoYl8Ej1KRYTSpUybOn0KNarUqVQhFAAA Ow== ------=_NextPart_01C64C14.31468580 Content-Location: file:///C:/506945D7/Watkinsbriefing10-7_files/slide0043.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" No Slide Title
=
=
=
 7    10/7/2005
Usual Chronic Illne= ss Care
–15-= minute visit, poorly organized
–Dis= cussion and exam focus on symptoms and lab results,
not preventive assessment
–Pati= ent’s attempts to discuss difficulties in living
with= the condition are discouraged
–Foc= us is on physician’s treatment, not patient’s role
in management
–Tre= atment plan is limited to prescription refill and encouragement to make an appointment = if not feeling well
–Vis= it ends with physician rifling through drawers, looking
for a pamphlet
While = the US health care system is unsurpassed in the delivery of acute care, an enormous gap exists between the care patients with chronic illnesses usually receive, = and the availability of known, effective health services. There are a variety= of problems with usual chronic illness care.   Visits are short, and driven by symptoms and lab results, not preventive assessment.  Little ti= me is spent helping the patient learn to manage their illness, and agreeing on common goals and strategies.   Treatment generally consists of a prescription refill, and if the physician does want to give the patient some additional information, generally this is in the form of an education pamphlet, which the clinici= an may or may not be able to find.

Take t= he example of hypertension.  The physician may = focus on the blood pressure, and perhaps on the side effects of any medications.  Little attention is= paid to diet and stress management, and even less to assessing for alcohol use= and how it may contribute to the hypertension.  If the physician does screen for alcohol use, usually the only intervention provided is a referral to AA—if the physician can find an AA pamphlet.
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=
=
=
 8    10/7/2005
Informed, Activated
= Patient
= Productive
= Interactions
Better Functional and Clinic= al Outcomes
What the New M= odel Hopes to Achieve
= Prepared
Treatment Team
The mo= del seeks to do three things.  First it tries = to transform the patient from an uninformed,  passive recipient of services to an informed activated collaborato= r.  Second, it takes an unprepared treatm= ent team and organizes it into one which is prepared and pro-active.  Third, it transforms frustrating, problem-centered interactions into productive interactions in which recommended care is delivered, and in which both parties take responsibil= ity for their role.  This leads to im= proved functional and clinical outcomes.
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=
=
=
 9    10/7/2005
Why the New Model Is Important
<= span style=3D'font-weight:normal'>–Applies to the majority of illnesses
–Would revolutionize the way= the health system thinks about car= e –Is synthesized from demonst= ration projects and other evidence i= n the literature
<= span style=3D'font-weight:normal'>–Has been heartily embraced = by many in the field
Why is= this new model important, and of what relevance is it for alcohol use disorders?  The model recognizes that most illnes= ses today are chronic, and most of the care for chronic illnesses is provided= by patients and their families, not by health care providers.  The model was developed by looking at= a variety of successful disease specific chronic illness interventions, and noticing that they shared certain characteristics.  These were then organized into a prescriptive model, the chronic care model, which completely reorganizes = the way health care is organized and delivered.  The model has been embraced by many health services researchers, concerned about the poor quality of chronic illness care.


------=_NextPart_01C64C14.31468580 Content-Location: file:///C:/506945D7/Watkinsbriefing10-7_files/slide0065.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" No Slide Title
=
=
=
 10    10/7/2005
The New Chronic C= are Model
Guidelines
Evidence-Based, =
Planned Care
Practice/deliver= y
system redesign
Clinical
information
systems
Decision
support
for providers
Collaborative
management
Here i= s the model.  Guidelines describe recom= mended care for a particular condition.  Then the practice has to adapt the guidelines for use in a particular setting = and with particular types of clients.  A plan is developed that states what needs to be done for patients, by whom= and when.  This plan  has four essential components which I= will walk you through.
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=
=
=
 11    10/7/2005
The New Chronic C= are Model
Guidelines<= /span>
= Practice/deliver= y
system redesign
Clinical
information
systems
De= cision
support
for providers
Co= llaborative
management
Ev= idence-Based,
Planned Care
<= /span>
=
=
= Staffing: Who does what to whom?
<= span style=3D'font-family:Arial;font-size:75%'>·Allocation of tasks
= ·Roles
<= span style=3D'position:absolute;top:65.25%;left:39.7%;width:23.78%;height:4.0%'= >·Appointments
and follow-up
= ·Incentives
Succes= sful delivery systems are organized to comply with guidelines, and to meet the needs of their patients with chronic health problems.  This means that clinicians need to plan how they organize their practice and do their work.  This includes allocating tasks, identifying roles and managing appointments and follow-up.

Take t= he example of diabetes.  Adhering to a recommen= ded diet is an essential part of diabetes care.  Patients need to learn about how to manage their diet, and what to= eat and not eat.  Rather than the phy= sician doing this, the model suggests that the practice look at who would be best suited to this task.  Usually it = is not the physician but rather a nurse educate, or a nutritionist.  This frees up resources at the physic= ian level and puts a more skilled individual for the particular task in place= .
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=
=
=
 12    10/7/2005
The New Chronic C= are Model
Guidelines<= /span>
Pr= actice/delivery
system redesign
Clinical
information
systems
De= cision
support
for providers
Collaborative
management
= Evidence-Based,
Planned Care=
<= /span>
=
=
= Provider and patient
<= span style=3D'position:absolute;top:52.25%;left:62.54%;width:26.4%;height:4.0%'= >·Identification of problems and  treatment strategies =
<= span style=3D'position:absolute;top:64.25%;left:62.54%;width:26.4%;height:4.0%'= >·Self-management training and support activities <= /b>
<= span style=3D'position:absolute;top:76.25%;left:62.54%;width:26.4%;height:4.0%'= >·Patient role
in follow-up
Patien= ts and families provide most of the care in chronic illness, however for effecti= ve self-care to occur, patients and providers must manage the care collaboratively.  Together the pa= tient and the provider decide on which problems to focus, set realistic goals a= nd objectives, decide on treatment strategies and identify services that tea= ch the patient skills in how to manage their illness, in the context of pati= ent preferences and readiness.

Take t= he example of asthma.  While it is much easier = to control an asthma exacerbation early, many patients wait too long to take their inhalers, or use the inhalers incorrectly.  The collaborative management approach= would identify this as a problem and the patient and provider would work togeth= er to help the patient identify early warning signs and treatment options.
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=
=
=
 13    10/7/2005
The New Chronic C= are Model
Guidelines<= /span>
= Pr= actice/delivery
system redesign
Clinical
information
systems
Decision
support
for providers
Co= llaborative
management
Evidence-Based,
Planned Care
<= /span>
=
=
= To optimally care for specific patients, PCP must have access= to
<= span style=3D'font-family:Arial;font-size:75%'>·Provider education
= ·Decision support
= ·Feedback
= ·Consultation
·Link to specialty care
Decisi= on support means the expertise primary care providers need to have available to optimally care for specific patients.  This can take a number of forms-provider education, computerized decision support systems, the availability of on site feedback and consultation, or of off-site specialty referrals.
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=
=
=
 14    10/7/2005
The New Chronic C= are Model
Guidelines<= /span>
Pr= actice/delivery
system redesign
Clinical
information
systems
De= cision
support
for providers
Co= llaborative
management
= Evidence-Based,
Planned Care
<= /span>
=
=
= Practices must develop a registry of all patients to track and monitor health
= ·Key clinical data
= ·Reminders
= ·Outcomes
The fo= urth element of the care plan is a clinical information systems that helps providers k= eep track of what needs to be done when, and prompts for recommended elements= of care.  So for example, when a pat= ient with diabetes comes in, the system would prompt the physician to assess whether the patient has had her yearly eye exam.    This system usually starts with a registry, which is a list of all patients with a particular condition.
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charset="windows-1252" No Slide Title
=
=
=
 15    10/7/2005
Outline
–= A model has been proposed for improving chronic care
<= span style=3D'font-weight:normal'>–We applied this model to al= cohol use disorders
Now I = am going to tell you about how this model might be applied to care for alcohol use disorders in primary care settings.
The im= plementation of this model for alcohol use disorders has the potential to revolutionize the delivery of care for alcohol problems.  No longer would alcohol use disorders be addressed as an afterthou= ght, but the whole system would be reorganized to increase the likelihood or recommended care occurring.

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=
=
=
 16    10/7/2005
Why Is This Task Important Now?
•
–= We have a chance to put care for alcohol use disord= ers into the mainstream of medical care
–= We must catch this new wave of chronic care improv= ement as it goes by
Why is= this an important task now?

Becaus= e many health care systems are thinking right now about how to deliver chronic illness care, it is important that alcohol use disorders be identified as a chron= ic condition, and be included in the implementation of this model.  This is something that the alcohol treatment community needs to stay on top of, in order to take advantage of the current momentum.
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=
=
=
 17    10/7/2005
Alcohol Use Disorders Are Like
Other Chronic Conditions
–A spectrum of severity must be accommodated
–= Condition is not obviously symptomatic at first
–= Course is unpredictable
–= Etiologies are complex
•Include genetic component (for dependence) =
–= Treatments are behaviorally oriented
–= There are significant problems in compliance, dropout, and relapse
AUD’s<= span style=3D'mso-spacerun:yes'>  have a range of severity, from proble= m, or at-risk drinking, to alcohol abuse to dependence.  They share many of the characteristic= s of other chronic illnesses, included the late onset of symptoms, an unpredictable course and complex etiologies.  For alcohol dependence, research suggests a significant genetic component, comparable to other chronic illnesses.  Most treatments for alcohol use disor= ders are behavioral, and require that the patient change their behavior.

While = you might suspect that problems with compliance, drop out and relapse would be more severe for AUD’s, in fact studies suggest that people with alcohol proble= ms are no different from those with other chronic illnesses who also need to change their behaviour.
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=
=
=
 18    10/7/2005
Adapting the Chro= nic Care Model
Guidelines
= Pr= actice/delivery
system redesign
Clinical
information
systems
De= cision
support
for providers
Co= llaborative
management
Evidence-Based,
= Planned Care
Now I = am going to tell you about the types of issues that come up when one applies the mode= l to AUD’s.  The first thing we did was identify guidelines for recommended care.  These guidelines tell you what interventions are useful for whom, = and the components of recommended care.  These include information on when to use a brief intervention, the= use of motivational interventions and guidelines on speciliaty treatment for abuse and dependence.
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=
=
=
 19    10/7/2005
Adapting the Chro= nic Care Model
Guidelines<= /span>
Pr= actice/delivery
system redesign
Clinical
information
systems
De= cision
support
for providers
Co= llaborative
management
= Evidence-Based,
= Planned Care
=
= •Screening
<= span style=3D'position:absolute;top:35.0%;left:75.65%;width:26.59%;height:4.0%'= >•Assessment
= and diagnosis
= •Treatment
<= span style=3D'position:absolute;top:47.25%;left:75.65%;width:26.59%;height:4.0%= '>•Long-term
= management
= support
While = the guidelines tell a provider in general what to do, they need to be adapted for use in= a particular setting, by a particular treatment team.  The four components of clinical care = as they relate to alcohol problems include…

Next I= am going to walk through each of these boxes and show the types of questions providers need to consider as they think about implementing this paradigm shift.  These question follow the components = of clinical care: screening, assessment etc. In adapting the model, providers need to think about how each item applies to them-we don’t provide the answers, just suggest that these are questions the practice will need to address as they think about improving the delivery of care for AUD’s.
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=
=
=
 20    10/7/2005
= Evidence-Based,
Planned Care
Adapting Chronic = Care Components
Guidelines<= /span>
Practice/deliver= y
system redesign
Clinical
information
systems
Dec= ision
support
for providers
Co= llaborative
management
=
=
<= span style=3D'position:absolute;top:45.5%;left:38.01%;width:51.31%;height:4.0%'= >·How are patients screening positive tracked?
<= span style=3D'position:absolute;top:53.5%;left:38.01%;width:54.11%;height:4.0%'= >·Who is responsible for assessing and discussing optio= ns with patients?
<= span style=3D'position:absolute;top:61.5%;left:38.01%;width:59.36%;height:4.0%'= >·Who determines whether patients receive an intervention = or a referral to specialty care? <= /div>
<= span style=3D'position:absolute;top:73.5%;left:38.01%;width:52.43%;height:4.0%'= >·Are there referral linkages to alcohol treatment?
Now I = will show you the types of questions that come up when you think about how delivery sys= tem redesign might impact the four components of clinical care.   For example, if screening and assess= ment are not done at one time by one person, how are patients screening positi= ve tracked?  If someone screens posi= tive, who assesses them and talks with them about treatment options.  Who decides what type of treatment a patient needs, and what types of referrals are available for patients with alcohol abuse or dependence?  Are= their formal linkages with specialty treatment programs?
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=
=
=
 21    10/7/2005
Adapting Chronic = Care Components
Guidelines<= /span>
Evidence-Based, Planned Care
Screening
Assessment and diagnosis
Treatment
Long-term management support
Pr= actice/delivery
system redesign
Clinical
information
systems
De= cision
support
for providers
Collaborative
management
=
=
<= span style=3D'position:absolute;top:28.49%;left:13.67%;width:54.11%;height:4.0%= '>·Can patients choose how to complete
the screening instrument?
<= span style=3D'position:absolute;top:36.5%;left:13.67%;width:56.55%;height:4.0%'= >·Are patients encouraged to take charge
of their conditions and given a chance
to ask questions?
<= span style=3D'position:absolute;top:48.5%;left:13.67%;width:59.73%;height:4.0%'= >·What self-management support programs are available to patients?
<= span style=3D'position:absolute;top:56.49%;left:13.67%;width:56.74%;height:4.0%= '>·What links are established with support groups?
Are th= ere different ways a patient can choose to carry out the screening—for example paper and pencil, computerized, or by interacting with a provider?  Are patients given a chance to identi= fy their own strengths, and what skills they need to manage their condition?  What self-management support programs are available to patients, and are their established lin= ks with AA?
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=
=
=
 22    10/7/2005
Adapting Chronic = Care Components
Guidelines<= /span>
Evidence-Based, Planned Care
Screening
Assessment and diagnosis
Treatment
Long-term management support
Pr= actice/delivery
system redesign
Clinical
information
systems
Decision
support
for providers
Co= llaborative
management
=
=
<= span style=3D'position:absolute;top:32.0%;left:38.01%;width:52.43%;height:4.0%'= >·Is the screening instrument reliable
and valid for the population?
<= span style=3D'position:absolute;top:40.0%;left:38.01%;width:60.29%;height:4.0%'= >·How do PCPs obtain help from specialists
when diagnoses are complicated?
<= span style=3D'position:absolute;top:48.25%;left:38.01%;width:52.43%;height:4.0%= '>·Do the treatment guidelines cover simultaneous conditions?
<= span style=3D'position:absolute;top:56.25%;left:38.01%;width:58.42%;height:4.0%= '>·How do additional providers gain access
to the shared care plan?
Practi= ces would want to look at what screening instrument to use, given their particular population.  For example, a pract= ice that sees many adolescents may want to consider which is the best screeni= ng tool for that population.  What s= ystems are in place to get help with complicated patients-patients with a co-occurring mental illness for example.  Are their on –site specialists available, or is consultation only available through a referral process?  If there are additional providers outside of the treatment team, h= ow do they get access to the shared care plan, so that every provider is on = the same page?
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=
=
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 23    10/7/2005
Evidence-Based,
Planned Care
Adapting Chronic = Care Components
Guidelines<= /span>
Pr= actice/delivery
system redesign
Clinical
information
systems
De= cision
support
for providers
Co= llaborative
management
=
=
<= span style=3D'position:absolute;top:38.75%;left:16.29%;width:52.62%;height:4.0%= '>·Does the information system prompt
for repeated screening?
<= span style=3D'position:absolute;top:46.75%;left:16.29%;width:52.24%;height:4.0%= '>·Can the system track subgroups
of patients based on severity?
<= span style=3D'position:absolute;top:54.75%;left:16.29%;width:60.11%;height:4.0%= '>·Does it remind providers of when patients require follow-u= p? 
<= span style=3D'position:absolute;top:62.74%;left:16.29%;width:54.11%;height:4.0%= '>·How is confidentiality protected when information is s= hared between providers?
Does t= he information system help the PCP remember when and who to screen, at what intervals, a= nd can it keep track of patients based on severity and co-morbidities?  Does it remind providers when patients require follow-up, or when a patient has missed an appointment?  How are issues of patient confidentia= lity addressed, when the treatment plan is shared with specialty providers?
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 24    10/7/2005
Identifying Next St= eps
–= Prepare for feasibility study
•Develop patient activation tools
•Outline concrete research plan to pilot test model= in 1 to 3 sites
–Consider integrating model with care for other = chronic conditions
–Identify barriers to implementation and devise = strategies to lower them
–= Be cognizant of cost and efficiency issues
What w= e have done is show you how the CCM might be adapted to improve the delivery of treatmen= t of alcohol use disorders in primary care settings.  This is only a beginning.  Our next steps are to prepare for a feasibility study.

These = could be barriers at the health care system level, such as a limited availability = of specialty services or of a disease management system; barriers at the provider level such as the pcps lack of time and financial incentives, and patient level barriers such as lack of social support and stigma
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This project developed out of discussions between RAND and a federal agency, the Center for Substance Abuse Treatment.  A group in Washington State had articulated a mod= el to improve chronic illness care, and was revolutionizing the way people think about the delivery of health care.  Both RAND and CS= AT recognized that this model could be applied to alcohol use disorders, and CSAT contracted with R= AND to do this work.  Both RAND and CSAT felt that if we cou= ld adapt and implement thi= s model for alcohol problems it  would transform the delivery of treatment = for alcohol problems in pri= mary care setting.  It would also take advantage of some of th= e most cutting edge thinking in health services research today.  <= /span>
First some background about why alcohol use disord= ers are important. 
First of all, alcohol use disorders are common.  Many people drink above the recommended limits: of those who drink almost 1/10= th = are addicted to alcohol or abuse it and an additiona= l 1/4th = report hazardous alcohol use.
Second, there are many negative consequences associated= with drinking too much.  T= hese include health related consequences such as incr= eased liver disease, stroke, heart disease, depression and trauma, and negative social consequences, including missed days of wo= rk, decreased productivity at work, motor vehicle accidents, dome= stic violence and child abuse and neglect.  The economic costs of alcohol <= span lang=3DEN-US>use disorders are enormous, and are estimated at $150 billion annually.
((Problematic alcohol use can be described in a variety= of ways ranging from problem or hazardous drinking = to alcohol abuse and dependence.  Problem drinking is drinking that exceeds an established thre= shold, generally 14 drinks a week for men and 7 drinks = a week for women, or more than 3 or 4 drinks at a time. ))
Effective treatments exist for the range of alcohol use disorders.  These include brief interventions for problem or hazardous drinking, to specialty alcohol treatmen= t for people with alcohol abu= se or dependence.  These treatments that= have been shown in numerous studies = and in numerous settings to re= duce drinking and the subsequent negative health and social consequences.  But although we have effective treatments,, fewer than half of those people who need treatment actually receive it. 
This gap between what we know,= and what we do is particula= rly apparent in primary care settings, and represents a missed opportunity.  Many people visit a primary care provider and 10-20 % have an alcohol related problem.  Fewer fewer than 1% of patients receive counseling for alcohol problems. 
Now, why are alcohol use disorders not widely treated in primary care settings?
There are a number of reasons,= ranging from the lack of reimbu= rsement for screening and brief interventions, to competing demands for a providers time and resources.  Usually the patients doesn’t come in complaining = of drinking too much, but = their alcohol use contributes indirectly to the presenting problem.  The provider generally is focused on the acute problem before them, and doesn’t have the t= ime or resources to look at th= e big picture.  This problem is not unique to the treatment of alcohol p= roblems, but is a problem that characterizes the delivery of most health care for chronic conditions in the US today.  Chronic conditions of any kind are generally not well treated.  
Here we show = how a model for improving chronic illness care can con= tribute to better alcohol use disorder treatment.  In this briefing, I am going to tell you = first about a model that was developed for improving c= hronic illness care by some people at the McColl Institute.  Then I will = tell you how we have adapted it for alcohol use disorders.  
I’m going to = begin by describing the general chronic care model.  The model suggests that we need to comple= tely rethink the way we organize and deliver health care.  While some elements of the model may be applicable to small provider groups, it is particularly relevant to large health care syst= ems such as HMO’s or the VA. 
While the US = health care system is unsurpassed in the delivery of acute care, an enormous gap exists between the care patients with chronic illnesses usually receive, and the availability of known, eff= ective health services. There are a variety of problems= with usual chronic illness care.   Visits are short, and driven by symptoms and lab results, not preventive assessment.  Little time is spent helping the patient learn to manage their illness, and agreeing on common goals and strategies.   Treatment g= enerally consists of a prescription refill, and if the physician does want <= span lang=3DEN-US>to give the patient some additional information, generally th= is is in the form of an education pamphlet, which the clinician may or may not be able to find. 
Take the example of hypertension.  The physician may focus on the = blood pressure, and perhaps on the side effects of any medications.  Little attention is paid to diet and stress management, and even less to <= span lang=3DEN-US>assessing for alcohol use and how it may contribute to the hypertension.  If the physician does screen for alcohol use, usually the only intervention <= /span>provided is a referral to AA—if the physician can find an AA pamphlet. 
The model see= ks to do three things.  First it tries to transform the patient from an uninformed,  passive recipient of services to an in= formed activated collaborator.  Second, it takes an unprepared treatme= nt team and organizes it into one which is prepared= and pro-active.  Third, it transforms frustrating, problem-centered interactions into productive interactions in which recommended car= e is delivered, and in which both parties take responsibility for their role.  Th= is leads to improved functional and clinical outcom= es.
Why is this n= ew model important, and of what relevance is it for alcohol use disorders?  The model recognizes t= hat most illnesses today are chronic, and most of th= e care for chronic illnesses is provided by patients and their families, not by health care providers.  The model was developed by looking at a v= ariety of successful disease specific chronic illness interventions, and noticing that they shared certain characteristics.  These were then organized into a prescriptive model, the chronic care model, which completely reorganizes the way health care is organized and delivered.  The mode= l has been embraced by many health services researcher= s, concerned about the poor quality of chronic illn= ess care.
 
Here is the m= odel.  Guidelines describe recommended care f= or a particular condition.  Then the practice has to adapt the guidelines for use= in a particular setting and with particular types of clients.  A plan is de= veloped that states what needs to be done for patients, by whom and when.  This plan  has four essential components which I = will walk you through.
Successful de= livery systems are organized to comply with guidelines, and to meet the needs of their patients with chronic health problems.  This means t= hat clinicians need to plan how they organize their practice and do their work.  T= his includes allocating tasks, identifying roles and managing appointments and follow-up.  =
Take the example of diabetes.  Adhering to a recommended diet is an esse= ntial part of diabetes care.  Patients n= eed to learn about how to manage their diet, and what t= o eat and not eat.  Rather than the physician doing this, the model suggests that the practice lo= ok at who would be best suited to this task.  Usually it is not the physician but rather a nurse educate, or a nutritionist.  This frees up resources at the = physician level and puts a more skilled individual for the particular task in place.
Patients and = families provide most of the care in chronic illness, however for effective self-care to occur, patients and providers must manage the care collaboratively.  Together the patient and the provider decide on which problems to focus, set realistic goals and objectives, = decide on treatment strategies and identify services th= at teach the patient skills in how to manage their illness, in the context of patient preferences and readiness. 
Take the example of asthma.  While it is much easier to control an ast= hma exacerbation early, many patients wait too long to take their inhalers, or use the inhalers incorrectly.  The collaborative management approach would identify this as a problem and the patient and provider would work together to help the patient identify early warning signs and treatment options. 
Decision supp= ort means the expertise primary care providers need to have available to optimally care for specific patients.  This can take a number of forms-provider education, computerized decision support systems, the availability of on site feedback and consultatio= n, or of off-site specialty referrals.
The fourth el= ement of the care plan is a clinical information systems that helps providers keep track of what needs to be done when, and prompts for recommended elements of care.  So for example, when a patient with diabe= tes comes in, the system would prompt the physician to assess whether the patient has had her yearly eye exam.    This system usually starts with a registry, which is a list of all patients with a particular condition.
Now I am goin= g to tell you about how this model might be applied to care for alcohol use disorders in primary care settings. The implementation of this model for alcohol use disorders has the potential to revolutionize the delivery of care for alcohol problems.  No longer would alcohol use disorders be addressed as an afterthought, but the whole system would be reorganized to increase the likelih= ood or recommended care occurring.
Why is this an important task now?
Because many health care systems are thinking right now= about how to deliver chronic illness care, it is impor= tant that alcohol use disorders be identified as a ch= ronic condition, and be included in the implementation of this model.  This is something tha= t the alcohol treatment community needs to stay on top= of, in order to take advantage of the current moment= um.
AUD’s  have a range of severity, from problem= , or at-risk drinking, to al= cohol abuse to dependence.  They share m= any of the characteristics of other chro= nic illnesses, included the late onset of symptoms, an unpredictable course and complex etiologies.  For alcohol dependence, research suggests a significant genetic component, comparable to other chronic illnesses.  Most treatments for alcohol use disord= ers are behavioral, and req= uire that the patient change their behavior. 
While you might suspect that p= roblems with compliance, drop o= ut and relapse would be more severe for AUD’s, in fact studies suggest that people with alcohol problems= are no different from those= with other chronic illnesses who also need to change their behaviour.
Now I am goin= g to tell you about the types of issues that come up when = one applies the model to AUD’s.  The f= irst thing we did was identify guidelines for recomme= nded care.  These guidelines tell you w= hat interventions are useful for whom, and the components of recommended care.  These include information on when to use a brief intervention, the = use of motivational interventions and guidelines on speciliaty treatment for abuse and dependence.
While the gui= delines tell a provider in general what to do, they need to be adapted for use in a particular setting, by a particular trea= tment team.  T= he four components of clinical care as they relate to alcohol problems include…
Next I am going to walk through each of these boxes and= show the types of questions providers need to conside= r as they think about implementing this paradigm shift.  These question follow the components of clinical care: screening, assessme= nt etc. In adapting the model, providers need to th= ink about how each item applies to them-we don’t pro= vide the answers, just suggest that these are questions the practice will need to address as they think about improving the delive= ry of care for AUD’s.
Now I will sh= ow you the types of questions that come up when you think a= bout how delivery system redesign might impact the four components of clinical care.   F= or example, if screening and assessment are not done at one time by one person, how are patients screening positive tracked?  If someone s= creens positive, who assesses them and talks with them = about treatment options.  Who decides wh= at type of treatment a patient needs, and what type= s of referrals are available for patients with alcohol abuse or dependence?  Are their formal linkages with specialty treatment programs?
Are there dif= ferent ways a patient can choose to carry out the scree= ning—for example paper and pencil, computerized, or by in= teracting with a provider?  Are patients giv= en a chance to identify their own strengths, and what skills they need to manage their condition?  What self-management support programs are available to patients, and are their established= links with AA?
Practices wou= ld want to look at what screening instrument to use, given = their particular population.  For exampl= e, a practice that sees many adolescents may want to consider which is the best screening tool for th= at population.  What systems are in p= lace to get help with complicated patients-patients w= ith a co-occurring mental illness for example.  Are their on –site specialists available,= or is consultation only available through a referral process?  If there are additional providers outside of the treatment team, how do = they get access to the shared care plan, so that every provider is on the same page?
Does the info= rmation system help the PCP remember when and who to scr= een, at what intervals, and can it keep track of patients based on severity and co-morbidities?  Does it remind providers when patients re= quire follow-up, or when a patient has missed an appointment?  How are issu= es of patient confidentiality addressed, when the treatment plan is shared with specialty providers?
What we have done is show you how the CCM might be adapted to improve the delivery of treatment of a= lcohol use disorders in primar= y care settings.  This is only a beginning.  Our next steps are to prepare for a feasibility study.
These could be barriers at the= health care system level, such as a limited availability of specialty services or of a disease management system; barriers at the p= rovider level such as the pcps = lack of time and financial incentives, and patient level barriers such as lack of social support and stigm= a
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