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Helping Patients Who Drink Too Much: A Clinician's Guide

Author/s: 
National Institute on Alcohol Abuse and Alcoholism

Why screen for heavy drinking?

  • At-risk drinking and alcohol problems are common. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. Of these heavy drinkers, about 1 in 4 currently has alcohol abuse or dependence.All heavy drinkers have a greater risk of hypertension, gastro - intestinal bleeding, sleep disorders, major depression, hemorrhagic stroke, cirrhosis of the liver, and several cancers. 
  • Heavy drinking often goes undetected. In a recent study of primary care practices, for example, patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10 percent of the time.
  • Patients are likely to be more receptive, open, and ready to change than you expect. Most patients don’t object to being screened for alcohol use by clinicians and are open to hearing advice afterward. In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorders show some motivational readiness to change, with those who have the most severe symptoms being the most ready.
  • You’re in a prime position to make a difference. Clinical trials have demonstrated that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who aren’t alcohol dependent.8 Some drinkers who are dependent will accept referral to addiction treatment programs. Even for patients who don’t accept a referral, repeated alcohol-focused visits with a health care provider can lead to significant improvement.
  • If you’re not already doing so, we encourage you to incorporate alcohol screening and intervention into your practice. With this Guide, you have what you need to begin.
Keywords 
alcohol alcohol abuse

Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care

Most patients taking opioids for chronic pain are managed by primary care providers and their staff. Many practices are looking for help in managing their patients using chronic opioid therapy. To meet this need, AHRQ funded the Six Building Blocks project  through grant number R18HS0237850. Additional funding was provided by Washington State Department of Health subcontract (HED23124) of Cooperative U17CE002734, funded by the Centers for Disease Control and Prevention.

Keywords 
opioids chronic pain primary health care patient care

Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program

Author/s: 
Wallace, Neal T., Cohen, Deborah J., Gunn, Rose, Beck, Arne, Melek, Steve, Bechtold, Donald, Green, Larry A.

PURPOSE:

Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions.

METHODS:

Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention.

RESULTS:

Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions.

CONCLUSIONS:

ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim-oriented reimbursement and purchasing mechanisms are likely needed.

Keywords 
delivery of health care integrated primary care primary health care behavioral medicine

Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care

Author/s: 
Davis, Melinda M., Balasubramanian, Bijal A., Cifuentes, Maribel, Hall, Jennifer, Gunn, Rose, Fernald, Douglas, Gilchrist, Emma, Miller, Benjamin F., DeGruy, Frank, III

PURPOSE:

To examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice's approach to delivering integrated care.

METHODS:

Observational cross-case comparative analysis of 17 primary care practices in the United States focused on implementation of integrated care. Practices varied in size, ownership, geographic location, and integrated care experience. A multidisciplinary team analyzed documents, practice surveys, field notes from observation visits, implementation diaries, and semistructured interviews using a grounded theory approach.

RESULTS:

Across the 17 practices, staffing ratios ranged from 1 BHC covering 0.3 to 36.5 primary care clinicians (PCCs). BHC scheduling varied from 50-minute prescheduled appointments to open, flexible schedules slotted in 15-minute increments. However, staffing and scheduling patterns generally clustered in 2 ways and enabled BHCs to be engaged by referral or warm handoff. Five practices predominantly used warm handoffs to engage BHCs and had higher BHC-to-PCC staffing ratios; multiple BHCs on staff; and shorter, more flexible BHC appointment schedules. Staffing and scheduling structures that enabled warm handoffs supported BHC engagement with patients concurrent with the identification of behavioral health needs. Twelve practices primarily used referrals to engage BHCs and had lower BHC-to-PCC staffing ratios and BHC schedules prefilled with visits. This enabled some BHCs to bill for services, but also made them less accessible to PCCs in when patients presented with behavioral health needs during a clinical encounter. Three of these practices were experimenting with open scheduling and briefer BHC visits to enable real-time access while managing resources.

CONCLUSION:

Practices' approaches to PCC-BHC staffing, scheduling, and delivery of integrated care mutually influenced each other and were shaped by the local context. Practice leaders, educators, clinicians, funders, researchers, and policy makers must consider these factors as they seek to optimize integrated systems of care.

Keywords 
integrated behavioral medicine delivery of health care primary health care primary care

How to Excel at Access — and Why It Matters

Author/s: 
Mils, Terry

Health care spending in the United States totaled $3.3 trillion in 2016, more than double the amount spent in 2000. Twenty percent of the cost went toward physician services, with primary care accounting for approximately 7 percent.

These rising costs have real consequences for patients. A Kaiser Family Foundation survey found that, because of cost, 67 percent of the uninsured and 21 percent of the insured had forgone needed medical care. To address costs, payers are increasingly adopting reimbursement models that reward or penalize physicians based on their ability to keep costs down.

Now here’s the good news: When it comes to rising health care costs, we in primary care are not the main problem, but we are a key part of the solution. This article will explain how improving access to primary care can reduce costs and the steps practices should begin taking now.

Keywords 
primary health care access
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