C. Implement/Continue Care Management Plan In Specialty Care Or Arrange In Primary Care
OBJECTIVE
Begin care management in the setting most conducive to treatment engagement and management of co-morbid conditions.
ANNOTATION
Care management is a clinical approach to the management of chronic SUDs where full remission (e.g., abstinence) is not a realistic goal or one the patient endorses. Conceptually, the care management approach is similar to managing other chronic illnesses, such as diabetes or schizophrenia. Practically, the care management framework provides specific strategies designed to enhance motivation to change, relieve symptoms and improve function, where possible, and monitor progress towards goals. Care management is a flexible approach that may be integrated into medical and psychiatric care in any setting. In some cases, care management will lead to remission of the SUD or referral for specialty care rehabilitation, while in others it serves a more palliative function.
Care management components1. Monitor and record specific substance use at each contact by patient report (e.g., drinking days during the past month, days of any substance use during the past month, and typical and maximum number of drinks per occasion). 2. Monitor biological indicators (e.g., transaminase levels and urine toxicology screens). 3. Encourage abstinence or reduced substance use. 4. Enhance motivation to change using non-confrontational motivational interviewing techniques. 5. Educate about substance use and associated problems. 6. Recommend self-help groups. 7. Address or refer for social functioning needs. 8. Address or refer for financial and housing needs. 9. Address nicotine use as appropriate. 10. Initiate crisis intervention as needed. 11. Provide care coordination.
Encourage regular visits with medical or behavioral health care provider 1. Encourage patients to return for medical or psychiatric visits even if they will not accept specialty care for SUDs. 2. Encourage reduction or cessation of use at each subsequent visit and support motivation to change. 3. Address substance use as a health care issue in all health care settings: § Obtain and record specific usage patterns at each visit (e.g., drinking days during the past month, days of any substance use during the past month, and typical number of drinks per occasion). § Clarify the link between presenting medical and psychiatric conditions and substance use, with feedback about physical findings and lab results (e.g., blood pressure and GGT). § Use a non-confrontational, health education approach to enhance the patient's motivation for change.
DISCUSSION
The care management approach to alcohol use disorders has been shown to improve outcome in two randomized controlled trials. One trial (Kristensen et al., 1983) involved middle-aged male heavy drinkers, some of whom were alcohol dependent, with elevated GGT activity. Patients were randomized to either usual medical care or monthly visits with a nurse combined with feedback about GGT levels and advice to reduce or stop drinking. Patients receiving the intervention had substantially lower rates of hospital use, morbidity, and mortality over the two to five year follow-up period. In a quasi-experimental comparison, severely medically ill heavy drinkers were willing to engage in an integrated brief alcohol intervention through a clinic offering medical care (Willenbring et al., 1995). Patients in the integrated clinical approach had a lower two-year mortality rate. In a subsequent randomized controlled trial, integrated clinic patients had a 75% abstinence rate after two years, compared to 50% in subjects receiving routine medical care and a referral to alcohol treatment (Willenbring et al., 1999). Integrated clinic patients also had a lower two-year mortality rate, although this finding was confounded by an age difference between groups.
On a pragmatic basis, little is to be lost by systematically addressing alcohol use in the course of medical care and these studies strongly suggest that doing so can improve outcomes. Clinical consensus increasingly favors integrating psychiatric and addiction treatment for patients with concurrent disorders, with limited empirical support for greater efficacy compared to separate treatments (Drake & Mueser, 2000; U.S. DHHS, 1994). Even for patients who are not currently engaged in formal treatment for their substance-related problems, much can be accomplished in a psychiatric or general medical setting, especially when it comes to enhancing the patient’s willingness to address his or her substance-related problems (Bien et al., 1993; Drake & Mueser, 2000; U. S. DHHS, 1994; Ziedonis & Brady, 1997). Although less well documented than similar approaches for medical patients, it is likely that this approach will work with psychiatric patients as well. On a pragmatic basis, it is better than simply ignoring substance use among seriously ill patients. For patients with major depressive disorders (MDD) or psychotic disorders, please refer to the sections in the VHA/DoD Clinical Practice Guideline for the Management of MDD in Adults and the VHA Clinical Practice Guideline For the Management of Persons with Psychoses. For a more specific module for management of psychiatric co-morbidity, refer to the VHA Clinical Practice Guideline For the Management of Persons with Psychoses.
While developing a care management plan, it is essential to recognize that this patient does not see abstinence as his or her immediate goal. The provider cannot expect the patient to meet goals the therapist would like to see accomplished, but that the patient sees as out of reach or undesirable at this time. The primary purpose is to engage the patient in the broader health care process and devise a plan that meets the patient's immediate goals. The plan must also spell out the treatment team's long-term expectation and use of appropriate services. This approach may result in reduction in substance use and associated problems, or it may result in a willingness to accept a referral to rehabilitation. In many respects, care management is similar to the approach used for most other chronic illnesses, such as diabetes mellitus, hypertension, or cancer. In fact, compliance with SUD treatment recommendations is generally comparable to that for many other chronic illnesses (McLellan et al., 1996).
EVIDENCE TABLE
QE = Quality of Evidence; R = Recommendation (See Introduction)
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