Integrating Chronic Care for AUDs Into Primary Care Settings

This is the conclusion of a two-part series begun in the January 1 issue.

Over the past five years, our research teams in the Veterans Affairs (VA) Puget Sound Health Care System and Group Health, an integrated health care delivery system in the Pacific Northwest, have begun studying models of care that manage alcohol use disorders (AUDs) in primary care based on the Chronic Care Model. Below are some of the lessons we have been taught to date by patients and clinicians.

We recently completed the Choosing Healthier drinking Options In Primary CarE (CHOICE) trial, which compared a 12-month collaborative care program—based on the Chronic Care Model—with usual primary care for VA outpatients at high risk for AUDs. VA outpatients were recruited into this trial, which was funded by the National Institutes of Health, based on frequent heavy drinking. Further, patients who consented only agreed to be offered care relating to drinking from a nurse. While we are just starting data cleaning, the experience of supervising the CHOICE collaborative care nurses weekly was informative. A year ago we began testing a similar model as part of quality improvement in Group Health. In Group Health, social workers are alerted to patients with new addiction diagnoses through an electronic health record registry so that they can reach out and engage patients in care.

Training for both the CHOICE nurses and Group Health social workers focused on motivational interviewing (MI) skills and research on effective interventions summarized in the first part of this series. In both the CHOICE trial and Group Health, an interdisciplinary team of primary care internists, psychologists, and addiction psychiatrists supervised nurses or social workers weekly. Here are some of our thoughts on elements of effective primary care interventions for AUDs based on our experiences to date.

• Proactive outreach matters irrespective of patients’ “readiness”: Patients report that having someone reach out to them matters. Even short contacts can be meaningful to patients, serving as a wake-up call prompting self-assessment. For example, a veteran who declined telephone screening for CHOICE called several months later to thank us: the call had prompted him to reflect on his drinking. He had decided to stop drinking and wanted us to know what a difference it made: he felt great!

• Change is not predictable and often takes time: Patients who said at the start they would never change their drinking consumption decided to stop drinking during the one-year CHOICE intervention. A patient who seemed to be “just coming to talk” and made a social worker wonder whether she was wasting her time, suddenly stopped drinking.

• Unconditional positive regard has an impact: Nurses or social workers focus on patients’ own goals and priorities without judgment. In the March 2000 issue of Psychology of Addictive Behaviors, William Miller has hypothesized that the active ingredient in brief interventions might be unconditional positive regard, or agape—nonromantic love (see reference at end of story).

• Supporting patients’ own self-assessment can initiate change: In the CHOICE trial, a baseline assessment included questions about symptoms and readiness to change, people who were important to them and those people’s feelings about the patient’s drinking, as well as diagnostic assessments for AUDs, drug use disorders, and screens for common mental health conditions. At their first visit with the intervention nurse, a number of patients arrived having already made changes in their drinking prompted by completing study instruments. One patient said that the study had been a real “life changer” even though he had started out thinking that his drinking was not a problem and that the study did not apply to him.

• Expressions of hope and optimism make a difference: Many people who are important to patients with AUDs have given up on them, including primary care providers. Some of our patients who had been struggling with AUDs for a long time told us how much it meant that staff expressed hope and confidence in their ability to make changes to attain goals that were personally important to them.

• Longitudinal population-based care works: Even when patients do not answer their phones, CHOICE participants reported nurse calls helped them. One patient who seldom answered the nurse’s calls reported at the end of the year that the study had been helpful and that the messages left by the nurse reminded him of his goals.

• Patients are interested in medications, and primary care providers need support: In both projects, patients were provided education about the option of using medications to help reduce or stop drinking. Some patients’ primary care providers initially did not know about medication options or were unwilling to prescribe medications for AUDs. In Group Health, an addiction psychiatrist provided consultation to primary care providers, supporting them in prescribing appropriate medications for AUDs when patients were interested.

These lessons have implications for primary care teams as they integrate addictions into primary care. Certainly, primary care providers—trained in the above approaches and in MI skills—can play an important role in this model of care, as do addictions psychiatrists who act as consultants. However, the proactive, population-based, longitudinal nature of the CHOICE model of care requires other members of the primary care team such as chronic care nurses or behavioral health care managers to take a lead role. In addition, given the prevalence of AUDs and the limited number of psychiatrists trained in addictions, ultimately there will be a need for consulting psychiatrists to play a central role in supporting primary care for patients with AUDs. ■