Models of Integrated Care for Adolescent Alcohol and Drug Use in Pediatrics: Predictors and

Implications for Practice and Policy

Stacy Sterling, MSW, MPH,1 Andrea H. Kline Simon, MS,1 Constance Weisner, DrPH, 1,2

1, KPNC Division of Research, Drug and Alcohol Research Team2, UCSF, Department of Psychiatry

HMO Research Network ConferenceMay 1, 2012

Studies funded by NIAAA, NIDA, and Community Benefits, Kaiser Permanente Northern California

SBIRT

DART studies

NIAAA Study of Pediatricians’ Alcohol and Drug Screening Practices

Feasibility Pilot of Teen SBIRT

NIAAA effectiveness and cost-effectiveness trial of Adolescent SBIRT

Primary Care as Medical Home

Adolescent Alcohol and other Drug (AOD) Problems

AOD problems are major causes of mortality and morbidity for adolescents.

Three-quarters of adolescent deaths are behavior-related: accidents (51.7%); assaults (13.7%) and suicide (11.0%), and a high percentage of these involve alcohol and/or drug use (Chaisson, 2005).

In many cases, addiction is a pediatric-onset disease.(Riggs, 2012)

The earlier a person initiates substance use, the more likely they are to develop problems.(Grant, 1997 & 1998; Placzek, 2009)

AOD problems which persist into adulthood often begin in adolescence (NIAAA, 2006; Brindis, 2002; Blum, 1987; Shrier, 2003).

Integrated health care (Primary Care and specialty AOD and Mental Health treatment) can improve access and outcomes (Sterling, 2005; Sterling, 2009; Bickman, 1996; Kaplan, 1998; Summerfelt, 1996).

Screening, Brief Intervention and Referral to Treatment (SBIRT)

Where the field is with SBIRTDespite recommendations, most studies show that relatively few PCPs screen, and even fewer screen according to guidelines or use standardized instruments (Denny, 2003, Center for Substance Abuse Treatment, 2000).

It is difficult to get adolescents to specialty treatment when needed (Institute of Medicine, 2006)

Special concern to clinicians

There is little coordination with Substance Use treatment by PC after treatment, (Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions,” 2006)

BIs with adolescents - efficacious and/or effective on a range of outcomes including: reducing AOD use, binge drinking, drinking and driving, smoking, AOD- related consequences, marijuana use, and ER utilization (Bernstein, 2009; Knight, 2005; Marlatt, 1998; Martin, 2005; Lawendowski, 1998, De Micheli, 2004; D'Amico, 2008; Ozer, 2003).

BIs have been shown to be as effective as more traditional therapies for AOD use for those with lower-severity problems (Tevyaw, 2004).

Pediatric Primary Care Providers may be especially effective agents of SBI (Levy, 2002) – teachable moments, health risk context rather than moral or legal issue.

High receptivity to screening and intervention by PCPs (Yoast, 2007; Steiner, 1996; Stern, 2007; Stern, 2006).

Teens have more positive perceptions of care when their PCP discussed AOD use (Brown, 2009).

Developmentally, young people are likely to be receptive to self-guided behavior change strategies, a cornerstone of brief interventions (Miller & Sanchez, 1993).

Brief Intervention and Adolescents

BIs with adolescents have often been conducted in non-medical settings, and by non-MDs, and have shown promising results on a range of outcomes: AOD use, binge drinking, tobacco use, AOD-related consequences (Burke, 2005; Gil, 2004; Grenard, 2007; Martin, 2005; Winters, 2007; McCambridge, 2004).

Non-Physician Interventions in adult PC had better adoption than (and similar effectiveness to) physician-delivered SBI. (Babor, 2005), but such comparisons have not yet been studied in pediatrics.

Brief Intervention by Non-Physicians

AAFP AAP AMA BF USPSTF

Screening/counseling

Obesity Yes Yes Yes Yes Yes

Contraception Yes Yes Yes Yes Yes

Substance use Yes Yes Yes Yes Yes

Alcohol use Yes Yes Yes Yes Yes

Tobacco use Yes Yes Yes Yes Yes

Hypertension Yes Yes Yes Yes Yes

Depression/suicide No Yes Yes Yes No

Eating disorders No Yes Yes Yes No

School problems No Yes Yes Yes No

Abuse No Yes Yes Yes No

Hearing Yes Yes No Yes No

Vision No Yes No Yes No

Periodicity of visits Tailored Annual Annual Annual Tailored

Target age, range, y** 13-18 11-21 11-21 11-21 11-24

American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Association (AMA), Bright Futures (BF), US Preventive Services Task Force (USPSTF)

GuidelinesComparisons Among Recommendations for Adolescent Preventive Services Developed

by National Organizations *

Provider and Organizational FactorsProviders do not screen according to recommendations (Denny, 2003; Bethell, 2001)

AAP survey (AAP, 2002) found that:

< 50% of fellows routinely screen all adolescents for substance use;

only 16% reported using standardized screening instruments

Provider factors which may affect screening practices:Inadequate training and education (Emans, 1998; Gassman, 2003),

Knowledge and competence in AOD area (Friedmann, 2000)

Self-efficacy about sensitive health issues (Ozer, 2004; Gottlieb, 1987)

Attitudes toward patients with AOD problems (Ogborne, 1986; Westermeyer, 1978; Roche, 1991; Miller, 2001)

Specialization in adolescent medicine (Ellen, 1998)

Confidentiality

Managed care organizations may have higher AOD screening rates than other health systems (Halpern-Felsher, 2000), but few health plans require AOD screening (Garnick, 2002).

Setting: Northern California Kaiser Permanente

Staff-model integrated health care delivery system

Serves 4 million members (about 40% of insured

population in the region)

~ 400,000 members 12-18

18 hospitals, 27 outpatient clinics

Integrated health care system (medical, psychiatry, AOD

services)

KPNC Teens entering AOD Treatment and 3, 5, 7 & 9-year follow-ups KPNC Teens with Depression and Suicide Behavior “Dually-Diagnosed” KPNC Teens

Teens typically arrive at AOD treatment with a clustering of problems: alcohol and drug use, psychiatric and medical problems, risky sexual behavior, school and legal problems, childhood trauma (Mertens, 2007; Sterling, 2004; Sterling 2005; Ammon, 2005).

Integrated treatment (Co-location, concomitant AOD and Mental Health Tx, etc.) is beneficial (Sterling 2005; Chi, 2006).

They have had frequent contacts with the health plan, often in Primary Care, yet few were identified as having problems and referred to specialty treatment before their problems became severe.

DART Adolescent Studies (NIDA, NIAAA, CSAT & RWJF):

Utilization Patterns during 24 Months prior to Treatment Intake

24 months prior to intake (%)

12 months prior to intake (%)

3 months prior to intake (%)

Primary Care* 89.5 79.2 48.7

Psychiatry 50.1 42.0 30.8

ER 26.3 17.9 11.7

*Includes visits to the following departments: Family Practice, General Medicine, GYN, Medicine, Pediatrics, Physical Medicine and Urgent Care.

•Only 49% of those who had a visit in Psychiatry in the year prior to their AOD Tx. intake had received a diagnosis in Psychiatry related to alcohol or drug problems.

Referral Sources

Parents - 83%Health care provider - 18%Legal system - 33% (20% Court Mandated)Friends - 19%Mental health providers - 35%Schools - 13%

Results: Study Participants versus Controls

Study participants had higher ER utilization and cost in the one year pre- and one year post-intake

(p < .01).

There was no decrease in ER utilization or cost over time.

Study of Pediatric Primary Care Providers and Behavioral Health Screening

Practices and Beliefs (NIAAA)

Survey of Pediatricians Conceptual Model

(Data from Administrators, Providers, Health Plan Databases)

NIAAA Study of KPNC Pediatric Primary Care Providers and Alcohol and Drug Screening Practices

Web-based survey, sent to all KPNC pediatric primary care providers with >50 adolescent patients in panel (80% response rate, N=437).

14% reported any recent (≤ 5 years) continuing education about AOD screening, assessment, treatment or referral.

11% reported receiving any AOD training in medical school.

48% were satisfied they were staying current on AOD problems and treatment.

Fewer than 10% reported using a standardized or evidence-based screening instrument.

Sterling S, Kline-Simon AH, Wibbelsman C. (2011). SBIRT for youth alcohol and drug use in primary care: Predictors and implications for practice and policy. INEBRIA, Boston, MA, Sep 21-23.

Time/resources

Clustering of problems

Linkages with specialty care

Discomfort with addressing alcohol and drug problems, particularly compared to other behavioral problems (e.g., risky sexual behavior, depression).

They rated alcohol use as more difficult to discuss, or diagnose, than depression (19% v s 15% and 70% vs. 56%, respectively), and

were more comfortable talking about risky sex than alcohol (32% vs. 22%).

Sterling S, Kline-Simon AH, Wibbelsman C. (2011). SBIRT for youth alcohol and drug use in primary care: Predictors and implications for practice and policy. INEBRIA, Boston, MA, Sep 21-23.

NIAAA Study of KPNC Pediatric Primary Care Providers and Alcohol and Drug Screening Practices

Differential screening? 13% reported being more likely to screen boys than girls; Male PCPs were even more likely to screen more boys than girls (23% vs. 6%; (p<.0001).

94% said that evidence of depression would trigger them to screen for AOD.

What would it take to consistently screen every teen?

More time – 77%

Have MA screen and another clinician receive results for discussion with teen – 57%

NIAAA Study of KPNC Pediatric Primary Care Providers and Alcohol and Drug Screening Practices

Self-reported likelihood of referring patients to AOD treatmentLogistic Regression Models

≥ 10 years of experience being an adolescent medicine specialist having had recent AOD training (all

p<.05).

Self-reported vs. Actual (From EMR) Screening

Self-report 6-mo pre-survey

(%)

Actual 6-mo pre-survey

(%)

Actual 6-mo post-survey

(%)

Alcohol 92 65 66

Other drugs 88 65 66

Tobacco 92 66 64

Friends’ AOD use 76 66 64

AOD use while driving 47 66 64

We examined by: experience, self-efficacy with AOD Dx, comfort level with AOD, attitudes about AOD Tx, confidentiality as a barrier, linkage with AOD program, awareness of AOD Svcs, training, specialization –> No differences

These findings informed an intervention:

Purpose1)Identify adolescents before their problems become severe

2)Provide brief interventions for those whose problems are not severe

3)Improve referral and engagement with specialty care if needed

Better integrate care between Pediatrics, Substance Use treatment, and Child and Family Psychiatry for those needing referral

“Medical Home” Model for Adolescent Substance Use Problems

Specialty Care(CD and Psychiatry)

Pediatrics

Lower severity problems

and ongoing disease

management

Higher severity

problems, acute care

Basic principles in developing SBIRT intervention: Critical for adoption

Evidence-based screener and intervention

Resources (skilled helper/time)

Fit into the existing workflowUsing electronic medical record

Time-efficient

Generalizable to other health systems (FQHCs)

Pilot study of a Brief Intervention Model of Care for Adolescents in a General Pediatrics Clinic – Internal Kaiser Funding

Does an SBIRT model of care in Pediatrics increase identification of behavioral health problems compared to usual care?

Is this model of care more effective than usual care at promoting behavioral health treatment utilization?

What factors affect the implementation of an SBIRT model in Pediatrics?

Behavioral Clinician in General Pediatrics clinic, trained in Brief Intervention and Motivational Interviewing techniques.

PCPs Screened teens and referred those identified with behavioral health problems to the Clinician.

Clinician assessed patients further, and either:

provided BI for lower-severity substance problems.

facilitated Referral to specialty Treatment (CD or Psych) for higher-severity substance use or mental health problems.

77 teens referred (55 girls, 22 boys)

Adolescent SBIRT Pilot Protocol

Depression, Anxiety, school and family problems, and stress much more common than AOD as presenting problems.

After further screening however, AOD use was frequently present and problematic.

Very well-received by PCPs and patients and parents

de-stigmatized: “Teen Healthy Lifestyle Check-Up”.

Warm hand-off was very important.

Providers reported that the model improved care.

Adolescent SBIRT Pilot Findings

Behavioral Health Treatment InitiationPC Adolescent Well Visits

2008 – 2009(N=2,611)

2009 – 2010(N=2,708)

p-value

Total Behavioral Health Visits (BI & Specialty AOD, MH)

N / %228 / 8.7% 325 / 12.0% <0.0001

Specialty AOD and MH onlyN / %

228 / 8.7% 269 / 9.9% 0.0660

Behavioral Health treatment utilization (overall, and specialty AOD and Mental Health treatment alone) increased during the pilot.

Adolescent SBIRT Pilot Findings

Sterling S, Kline-Simon AH, Wibbelsman C, Wong A, Weisner C. (under review). Screening for adolescent alcohol and drug use in Pediatrics: Predictors and implications for practice and policy. Addiction Science & Clinical Practice.

NIAAA Teen SBIRT Comparative Effectiveness Trial

Randomizes PCPs to different modalities of delivering SBIRT for adolescent behavioral health (PCP-delivered vs. BMS model of care).

No studies have examined the effectiveness and cost-effectiveness of physician vs. non-physician delivery of SBIRT for adolescents.

Little research on implementation of SBIRT in Pediatrics.

Non-Physician Interventions in adult PC had better implementation rates than (and similar effectiveness to) physician-delivered SBI (Babor, 2005).

Takes advantage of the health plan’s EMR: an important facilitator of screening and generalizable to the future of U.S. health care (Saitz, 2006; IOM, 2006; IOM, 2001).

Addresses clinician (and research) concerns:

Evidence-based

Skilled help (BMS)

Integrated into clinic flow

Time efficient (smooth hand-off and easy script)

Got in Electronic Medical Record!!!!!

Based on pilot, advocacy by clinicians, business case of previous studies, and improvement in successful referrals

Population-based

Study design integrated with EMR, uses regular practice

Current Study - NIAAA Teen SBIRT Comparative Effectiveness Trial

Treatment as usualBMSs are trained to conduct SBIRT

PCPs refer to BMSs

PCPs are trained to deliver SBIRT

CMEs

Research Questions

1. Effectiveness:

Provider outcomes:

Which model of SBIRT produces the best screening, brief intervention and referral rates?

Patient Outcomes:

Which model of SBIRT produces better patient outcomes (AOD use and AOD-related-school, legal & family problems) at 1 year?

Which model results in better specialty treatment (CD or Psychiatry) initiation and engagement rates?

2. Cost

Which model of care is most cost-effective?

3. Process of/Barriers to Implementation

Full CRAFFT Questionnaire added to EMR

C

R

A

F

F

T

Patient Outcomes Questions in EMR

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Patient Outcomes Questions in EMR

What we’ve learned and next steps:

Adapt based on findings and other learnings from the study (quantitative and qualitative)

Work with clinicians, health plan administrators, consult with FQHCs and other health systems and other new research

Roll-out or larger implementation study as with adult SBIRT

Challenges

Training timeConfidentiality

DART Research GroupInvestigators/Staff ScientistsConnie Weisner, DrPH, LCSWJennifer Mertens, PhDCynthia Campbell, PhD

Health EconomistSujaya Parthasarathy, PhD

AnalystsFelicia Chi, MPHAndrea Kline Simon, MSWendy Lu, MPHTom Ray, MBA

Project CoordinatorsTina Valkanoff, MPH, MSWAgatha Hinman, BAAliza Silver, MA

Adjunct InvestigatorDerek Satre, PhD

Interview SupervisorGina Smith Anderson

Research Associates Georgina BerriosVirginia BrowningJessica DuheDiane Lott-GarciaMelanie JacksonCynthia Perry-BakerBarbara PichottoMartha PrebleLynda TishSabrina Wood

Research CliniciansThekla Brumder, PsyDSarah Ferraro, PsyDAmy Leibowitz, PsyDAshley Jones, PsyD

Clinical PartnersAnna Wong, PhDCharles Wibbelsman, MD

KPNC Chemical Dependency Quality Improvement CommitteeKPNC Adolescent Medicine Specialists CommitteeKPNC Adolescent Chemical Dependency Coordinating Committee

In-person group trainingsWEBEXesE-mailed Power PointsBoostersQualitative conversationsFeedback reportsOne-on-one training

PCP-arm trainings – three, 1 hour trainingsDay 1Overview of problem & rationale for screening - Prevalence of problems, Recommendations (AAP, AMA, etc.)Study overview – research questions, randomization schemeHow-to:

Screening and assessment tools in EMRWorkflowReview of resourcesDocumentation

Day 2How to - Motivational Interviewing & Brief Intervention techniques

Day 3Skills practice using cases from pilotHow to make a referral to specialty (CD and Psychiatry) treatment

BMS-arm trainings – one, 1 hour training

Overview of problem & rationale for screeningPrevalence of problemRecommendations (AAP, AMA, etc.)

Study overview – research questions, randomization

How-to – Day 1Screening tool and “trigger” questions in EMRWorkflow

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Ask CRAFFT Questions and enter into Health Connect

CRAFFT score? Each yes=1

Counsel patient to stop using substances. Provide brief advice linking substance use to

undesirable health, academic & social consequences. F/U at next visit. (1 - 2 min)

Are there no major problems & patient believes he/she will be successful in making a change?

At follow up visit, confirm whether patient stopped using

Brief Intervention. Refer to CDRP for assessment

Give praise and encouragement.

During the past year: 1. Did you drink any alcohol? 2. Did you smoke any marijuana or hashish?3. Have you used any other drug to get high (such as prescription drugs, meth, ecstasy, glue of cocaine)?

OR1. During the past few weeks, have you OFTEN felt sad, down or hopeless?2. Have you seriously thought about killing yourself, made a plan, or tried to kill yourself?

OR In your clinical judgment, teen has risk for AOD or other behavioral health problems

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Accessing the CRAFFT Questionnaire in Health Connect

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Use this V Code (V65.42D) to document that a Brief Intervention for alcohol or drug problem was performed –

this is how we will measure intervention rates

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Patients’ progress over time can be viewed in this CRAFFT flowsheet