An integrated An integrated approach to dealing approach to dealing with alcohol & drug with alcohol & drug

issuesissues

Dr. Susanna Galea, Clinical Director, Dr. Susanna Galea, Clinical Director, CADSCADS

Dr. David Newcombe, University of Dr. David Newcombe, University of AucklandAuckland

Dr. Vicki MacFarlane, Clinical Lead, Dr. Vicki MacFarlane, Clinical Lead, CADSCADS

Structure of the Structure of the workshopworkshop

Opportunity to discuss how we could Opportunity to discuss how we could work better together for a more work better together for a more

meaningful client journeymeaningful client journey

• Short presentation:Short presentation:– How big is the problem?How big is the problem?– Models of integrated deliveryModels of integrated delivery

• Case presentationsCase presentations• Floor discussionFloor discussion• The way forwardThe way forward

How big is the problem?How big is the problem?

Alcohol - The global Alcohol - The global picturepicture

3.8% of all global deaths3.8% of all global deaths Responsible for >2.3 million premature Responsible for >2.3 million premature

deathsdeaths 4.6% of global burden of disease4.6% of global burden of disease A risk factor for more than 60 different A risk factor for more than 60 different

disordersdisorders Drinking >2 standard drinks per day Drinking >2 standard drinks per day

increases risk of death to over 1 in 100increases risk of death to over 1 in 100

Alcohol – NZ Alcohol – NZ scenescene

85.2% of the adult population drink85.2% of the adult population drink

8.7 – 9.4 l per capita8.7 – 9.4 l per capita

Cost of harm: $4.8 - $5.3bn/yearCost of harm: $4.8 - $5.3bn/year

Days off work: 5.6% of all adults; Days off work: 5.6% of all adults; Lost productivity Lost productivity $1.17 billion per annum$1.17 billion per annum

Immeasurable pain & suffering for individuals, Immeasurable pain & suffering for individuals, families & friendsfamilies & friends

Alcohol: Alcohol: healthhealth

3 out of 5 (61.6%): >recommended 3 out of 5 (61.6%): >recommended guidelines at least once in last yearguidelines at least once in last year

1 in 6 (17.7%): hazardous drinking1 in 6 (17.7%): hazardous drinking

Hazardous drinkers: Hazardous drinkers: 17.7%17.7%254, 260 in Auckland254, 260 in Auckland

Alcohol dependence:Alcohol dependence: 1.3%1.3%18, 674 in Auckland18, 674 in Auckland

Effects of high risk Effects of high risk drinkingdrinking

Alcohol related crime: Alcohol related crime: NZNZ

Drug use in Drug use in NZNZ

SUBSTANCESUBSTANCE % % Lifetime Lifetime

UseUse

Majority Majority Start AtStart At

% In % In Past Past YearYear

Ethnicity Ethnicity GroupsGroups

(comp. with (comp. with gen. pop.)gen. pop.)

CANNABIS 46.4% 18-20 yrs 14.6% European & Maori

ECSTACY 6.2% 21 yrs + 2.6% European

STIMULANTS 7.2% (amph)

21 yrs + 3.9% (‘P’ – 1%)

European

HALLUCINOGENS 7.3% 18-20 yrs 3.2% (LSD)

European

SEDATIVES 6.3% (kava)

21 yrs + 1.7% Pacific men (3x)

OPIATES 3.6% 21 yrs + 1.1% No difference

BZP Party Pills 13.5% 21 yrs + 5.6% European & Maori

Alcohol & DrugsAlcohol & DrugsImpact on the Health Impact on the Health

ServicesServices

23,00023,000 people are treated people are treated in publically fundedin publically funded

health system for alcohol health system for alcohol and other drug addictionand other drug addiction

(NCAT 2008)(NCAT 2008)

CADS, Te Atea Marino and Tupu treated 15,694 clients in total through 86,817 appointments (50,936 in a one-to-one, and 35,881 in a group

setting). This amounts to an average of 5.5 face-to-face appointments per open referral or 6.9 face-to-face appointments per client who had at

least one face-to-face contact.

All 3 DHB's - CADS, Te Atea Marino, TupuOpen Referrals (18,578) Jan-Dec 2011 (PIMS)

0500

1000150020002500300035004000

All CADS, Te Atea Marino, TUPU Average Number of Sessions per Treatment Episode by DHB 2007 - 2011

0.001.002.003.004.005.006.007.008.009.00

10.00

2007 2008 2009 2010 2011

aver

age

nu

mb

er o

f se

ssio

ns

per

tr

eatm

ent

epis

od

e

WDHB

ADHB

CMDHB

Deprivation Index of all CADS, Te Atea Marino, Tupu Clients: Jan-Dec 2011 by DHB

0500

10001500

20002500

30003500

Deprivation Index

Nu

mb

er

of

Clien

ts

CMDHB

ADHB

WDHB

Age of all CADS, Te Atea Marino and Tupu Clients Jan-Dec 2011 by DHB (PIMS)

0

500

1000

1500

2000

2500

3000

3500

4000

4500

13-20 21-30 31-40 41-50 51-60 61-64 65+

Age in years

Nu

mb

er

of

cli

en

ts

CMDHB

ADHB

WDHB

Ethnicity of all CADS, Te Atea Marino and Tupu Clients Jan-Dec 2011 by DHB (PIMS)

1226 944 1547497 800

42172885

1957

1224

01000200030004000500060007000

WDHB ADHB CMDHB

Other - IncludesEuropean and Asian

Pacific

Maori

Distribution of Positive AOD Screens in % (n = 3262)

0102030405060708090

100

AOD Screens

%

Alcohol 70.9%

Cannabis 16.1%

Methamphetamine 8.0%

Opiates 1.4%

Benzodiazepines 0.3%

Other 3.3%

Referral Source All Clients CADS, Te Atea Marino, Tupu: Jan - Dec 2011 (Total of 18,461 Referrals)

010002000300040005000600070008000

Emergency DepartmentsEmergency Departments UK study & Auckland studies:UK study & Auckland studies:

18-35% of people with injuries in ED18-35% of people with injuries in ED60-70% of weekend admissions60-70% of weekend admissions

Scotland study: Scotland study: Self-harm: Self-harm: 2/32/3 men; ½ women men; ½ womenAssault: 70%Assault: 70%Under age of 17: 15 kids/dayUnder age of 17: 15 kids/day

Auckland study: Auckland study: InjuriesInjuries35% of injured patients; 35% of injured patients; Violence in 17%; perpetrator in 79%Violence in 17%; perpetrator in 79%Risk of sustaining an injury was 2.8 x higherRisk of sustaining an injury was 2.8 x higher

Hospital inpatientsHospital inpatients

• 20% of inpatients have some 20% of inpatients have some form of alcohol related problemform of alcohol related problem

• Doubled in 10 yearsDoubled in 10 years

• 2008: Primary alcohol diagnosis 2008: Primary alcohol diagnosis admissionsadmissions

10,29010,290

Primary carePrimary care• 80% of NZ population visit GP every 12 months80% of NZ population visit GP every 12 months

• 65 – 82% of those with an Alcohol related 65 – 82% of those with an Alcohol related problems go undetectedproblems go undetected

• 49% of those with alcohol problems visited their 49% of those with alcohol problems visited their doctor but < 10% talked about it doctor but < 10% talked about it

• 17% of injury presentations; 64% hazardous 17% of injury presentations; 64% hazardous drinkersdrinkers

• 20% of all primary care presentations consume 20% of all primary care presentations consume alcohol at excessive levels: alcohol at excessive levels: 98% not identified (UK study)98% not identified (UK study)

We need to work We need to work together better!!!together better!!!

Current practiceCurrent practice

Primary Care Services Addiction Services

ReferralsLettersPhone

Shared care

How can we work How can we work together?together?

Integrated careIntegrated care

Integrated care is a concept bringing Integrated care is a concept bringing together inputs, delivery, management and together inputs, delivery, management and organization of services related to diagnosis, organization of services related to diagnosis, treatment, care, rehabilitation and health treatment, care, rehabilitation and health promotion. Integration is a means to improve promotion. Integration is a means to improve services in relation to access, quality, user services in relation to access, quality, user satisfaction and efficiency.satisfaction and efficiency.

Integrated care vs. Integrated care vs. collaborative carecollaborative care

• Collaborative care:Working with primary care; Patients perceive they are getting a separate service from a specialist, albeit one who collaborates closely with their physician.

• Integrated care: Working within and as a part of primary care;Health care is part of the primary care and patients perceive it as a routine part of their health care.

Model 1: Separate providers Model 1: Separate providers – primary care as primary– primary care as primary

Focus:Focus: Primary care as the primary providers Primary care as the primary providers Enhance primary care’s ability to treat within a Enhance primary care’s ability to treat within a

primary care settingprimary care setting

Descriptors:Descriptors: Least amount of changeLeast amount of changeSeparate systemsSeparate systemsStepped care modelStepped care modelScreening & Brief interventionScreening & Brief interventionConsultation via phoneConsultation via phoneInformation sharing practices can be Information sharing practices can be

formalizedformalized

Barriers:Barriers: Financial; Access; Time; Relationship; Capacity for Financial; Access; Time; Relationship; Capacity for seamless transition; seamless transition; System culture; Confidentiality; System culture; Confidentiality; Communication difficultiesCommunication difficulties

Model 2: Separate providers Model 2: Separate providers – addiction services as – addiction services as

primaryprimaryFocus:Focus: Addiction services as the primary providers Addiction services as the primary providers

Enhance specialist care’s ability to treat Enhance specialist care’s ability to treat holisticallyholistically

Descriptors:Descriptors: Least amount of changeLeast amount of changeSeparate systemsSeparate systemsConsultation-liaison via phoneConsultation-liaison via phoneStructured care planningStructured care planning

Barriers:Barriers: Financial; Time; Relationship; Capacity Financial; Time; Relationship; Capacity for seamless for seamless transition; Confidentiality; transition; Confidentiality; Communication Communication difficultiesdifficulties

Model 3: Co-locationModel 3: Co-location

Addiction Services

Primary care

services

Primary care services

AddictionServices

Model 3: Co-locationModel 3: Co-locationFocus:Focus: Same sites but separate systemsSame sites but separate systems

Primary care or addiction as the primary providers Primary care or addiction as the primary providers Enhance access & Referral acceptanceEnhance access & Referral acceptance

Descriptors:Descriptors: One-stop shop approachOne-stop shop approachSeparate systemsSeparate systemsEnhance delivery of package of careEnhance delivery of package of careScreening & Brief interventionScreening & Brief interventionConsultation in the corridorConsultation in the corridorEarly identificationEarly identification

Barriers:Barriers: Geographical collaboration; Location; Different Geographical collaboration; Location; Different speeds; Financial; speeds; Financial; Time; System culture; Confidentiality; Time; System culture; Confidentiality;

Model 4: Same service Model 4: Same service providing primary & providing primary &

specialist care specialist care Focus:Focus: Same sites and same systemsSame sites and same systems

Specialist is part of the primary care Specialist is part of the primary care teamteam

Public health focusPublic health focus

Descriptors:Descriptors: One-stop shop approachOne-stop shop approachTriage systemTriage systemEmergency department approachEmergency department approachConsultation minimalConsultation minimal

Barriers:Barriers: No skill transfer; System culture; No skill transfer; System culture; Confidentiality; Boundary blurringConfidentiality; Boundary blurring

Case presentationsCase presentations17yr old Marvin:17yr old Marvin:

• Harmful drinking & cannabis & diazepam dependenceHarmful drinking & cannabis & diazepam dependence• Mild depression & perceptual abnormalities Mild depression & perceptual abnormalities • Family hx of substance abuse & MH problemsFamily hx of substance abuse & MH problems• Diazepam prescribed by GP for anxietyDiazepam prescribed by GP for anxiety• Doctor shoppingDoctor shopping Co-ordination & support to GP re managing client’s Co-ordination & support to GP re managing client’s

Diazepam:Diazepam:Guidance given & guidelines sent; Guidance given & guidelines sent; Phone support; Phone support; Meeting between GP, specialist clinician & client to Meeting between GP, specialist clinician & client to

discuss & develop discuss & develop an effective/safe and realistic an effective/safe and realistic withdrawal management plan.withdrawal management plan.

Floor discussionFloor discussion