Promote Practice Change: Take Manageable Steps Toward Better Care

The prospect of developing a comprehensive menu of services for your patients with alcohol-related problems may seem daunting. But you don’t need to overhaul your clinical workflow, or make changes all at once, to start to improve care for patients with alcohol-related issues. You and your practice can start slowly and incrementally, taking small, manageable steps, to better equip you to prevent and address the spectrum of alcohol-related problems, from mild to severe, in your patients. Here, we describe eight basic steps to building and supporting a strong system of evidence-based alcohol screening and follow-up care for your practice.

What practices can improve care for patients with alcohol problems?

A number of evidence-based practices have been found to improve care for patients with alcohol problems, including alcohol use disorder (AUD):

• Reducing the stigma around alcohol problems can increase clinician comfort levels for discussing alcohol matters with patients,¹ which may facilitate frank discussions and increase the patient’s openness to accepting treatment if needed. (See Core article on stigma.)
• Screening and conducting brief interventions for heavy alcohol use can help patients with drinking problems to reduce their alcohol intake and improve their health.^2,3 (See Core articles on screening and brief intervention.)
• Prescribing FDA-approved medications for AUD—naltrexone, acamprosate, or disulfiram—can help many patients reduce or quit drinking.⁴ You can prescribe these non-addicting medications in primary care without specialized training, or you can involve a specialty prescriber (see next bullet). (See the AUD medication guides in Resources below, and the Core article on treatment.)
• Offering supportive referrals to specialty care can connect patients to effective addiction treatment when needed.⁵ Treatment could include behavioral care offered by specialty therapists; the AUD medications noted above, but prescribed by board-certified addiction physicians; or both. Set reminders to check with patients about follow-through on the referrals. (See Core article on referrals and the NIAAA Treatment Navigator.)

With these practices in mind, taking any of the following eight basic steps can help you begin to improve care for your patients struggling with alcohol-related problems. The first four steps can help you build a better system of care while the second four can help support the success of your new system.

Four Basic Steps to Build a Better System of Care

1. Adopt evidence-based screening and assessment tools and clinical protocols
   • Choose evidence-based tools. Pick a set of brief, user-friendly, and evidence-based standardized alcohol screening and assessment measures, suitable for use in primary care. (See Core article on screening and assessment.)
   • Screen universally. If clinicians are left to decide when and whom to screen, then time pressures, competing priorities, and assumptions about individual risk levels can leave some patients behind.⁶ Without a comprehensive, systematic strategy, for example, men may be screened more often than women, who are especially vulnerable to the health effects of hazardous alcohol use.⁷ (See Core article on risk factors.)
2. Formalize an alcohol problem response plan and infrastructure
   • Establish a clinical workflow for responding to patient alcohol screening responses, that is, determine who in the care team does what, when, and how.
   • Appoint a practice-facing “alcohol care champion” if feasible. This person would receive training to improve alcohol care in the practice and would guide a care team. This can improve patient outcomes.⁸
   • Create administrative time for regular information sharing between the alcohol care champion and the rest of the team.
3. Develop a collaborative care team of primary care and addiction specialists
   • Establish relationships with specialty clinicians, both therapists and board-certified addiction physicians, whether internal or external to your practice. Learn about their services. These relationships will be invaluable when you need to make a referral, so that you and your patients know what to expect. For help finding these specialists, see the Resource section below.
   • Consider integrating behavioral health care into your practice, to help you to deliver the full spectrum of primary care-based services for your patients with alcohol problems and other mental health disorders. Embedding such clinicians and adopting an integrated approach, which may include telehealth and other online resources, is a reimbursable service (see Resources) that has been shown to improve patient care related to alcohol problems. ^9–11
   • In large organizations, facilitate relationships between alcohol care champions or other key personnel across facilities, departments, and disciplines, to include primary care, addiction medicine, psychiatry, and other relevant specialties.
   • Encourage the free flow of information between your practice and specialists by setting a standard procedure of obtaining consent-to-release documentation or memoranda of understanding. Establish a follow-up workflow protocol so that information from specialty care reliably comes back to you.
4. “Make it automatic” with your electronic health record system

   Work with your information technology specialist or team, or electronic health record (EHR) vendor, to have evidence-based screening, assessment, and clinical decision support tools incorporated into your EHR system.^12,13 Your vendor may already have a basic alcohol-related workflow that you can customize. (See Resources for a guide to implementing alcohol screening and follow-up using Epic-based EHR systems.) Components could include:

   • Evidence-based tools for alcohol screening and assessment
   • Best practice alerts that prompt your follow-ups based on patient responses
   • Cues and guidelines for delivering a brief intervention
   • Local referral resources for specialty addiction treatment
   • A documentation mechanism for performance measurement and quality improvement purposes, which may include billing and administrative ICD codes. ^14,15

   Alcohol screening questions should be incorporated into standard screening tools alongside questions about smoking, exercise, and nutrition, rather than as a “stand-alone” instrument. This way, they may be more likely to be completed.

Four Basic Steps to Support the Success of Your New System

1. Engage leadership support

   Leadership support, whether active or tacit, can help ensure the success of primary care-based alcohol care efforts.

   • Inform leaders concisely about the extensive, costly, and well-documented negative health effects of heavy alcohol use, ^16–34 and the cost-effectiveness of primary care-based alcohol services.³⁵ This information can be compelling to leaders who must balance population health and fiduciary concerns.
   • Consider showing leaders a visual of the high ranking of alcohol screening and brief intervention among effective preventive services (see table below).

2. Train all staff on your alcohol care team

   Make sure all care team members who are involved in alcohol-related activities have access to education, training, and technical assistance. Alcohol-related activities include screening, assessment, brief interventions, treatments, and linking patients to outside care. If your practice has an alcohol care champion, this person can coordinate training and lead debriefing discussions as you implement changes in your practice. Here are a few tips:

   • Take stock of training possibilities. Take advantage of the many free, excellent clinician training materials on alcohol screening, assessment, brief intervention, pharmacotherapy, and referral. If resources allow, consider investing in training tools that allow for skills-based practice. (See Resources.)
   • Practice. Prepare yourself and team members for potentially sensitive discussions with patients by reviewing and practicing sample interactions ahead of time. Here are two ideas for staff meetings:
     • View and discuss readily available videos. Observe sample clinician-patient conversations as a starting point for discussions. Or ask the clinicians in your practice to view them at their convenience. (See Resources.)
     • Role play. It may seem awkward at first, but role-playing with colleagues can help prepare you to respond to patients in a direct, non-judgmental manner, which can facilitate frank and open discussion.
   • Consider dedicating time for debriefing as you make these changes to facilitate ongoing learning and continuous quality improvement. Check in regularly with your staff, ask for success stories and challenges, and work together to address barriers and improve care for your patients.
3. Frame heavy alcohol use as a health problem to reduce stigma and engage patients’ interest and openness
   • Consider posting “We ask everyone” or similar signs. Some health systems have adopted messaging and signage emphasizing that they screen everyone, which helps to normalize the process and reduce patient perceptions of being singled out for alcohol screening. You may also wish to have visuals to help explain standard drink sizes and the U.S. Dietary Guidelines. See the “Resources to Share with Patients” below for sample mini posters and a handout.
   • Connect alcohol use to presenting problems. Many patients are not aware of the relationship between alcohol use and consequences, including physical ^16–28 and mental health problems.^29–34 (See Core articles on medical complications and mental health issues.) Tying their alcohol use to their conditions such as hypertension, liver and other gastrointestinal problems, trouble sleeping, anxiety, depression, or obesity can help reframe reducing or quitting drinking as a strategy to address an issue that is salient to them, rather than a loss. (See Core article on brief intervention.)
   • Avoid moralistic, punitive, or judgmental language. Excessive alcohol use is not a moral failure, and such language can be counter-productive and can increase resistance to change. Instead, use person-first terms such as “people with AUD” rather than “alcoholics” or other slang or idioms. (See Core article on stigma.)
4. Add alcohol care metrics to your practice’s performance feedback system to spur clinical quality improvement
   • Identify your target audiences and establish schedules for performance feedback reports. Determine whether the audience would be chiefs-of-service, physicians, nurses, medical assistants, behavioral health clinicians, administrators, leaders, or any combination. Establish a process and schedule for dissemination of the performance feedback data.
   • Ensure that your performance metrics monitor the alcohol interventions that your improvement plan recommends. Monitoring screening is critical—but the most common care gaps are whether patients who screen positive for heavy drinking are counseled to reduce their drinking³⁶ and whether they go on to receive the recommended follow-up care.^37,38
   • Create templates for performance feedback reports for providers and staff, along the lines of “In March, x% of Dr. A’s patients were screened, and y% of those screening positive for heavy drinking received a brief intervention; z% of Dr. B’s patients with an alcohol use disorder diagnosis received a prescription for AUD pharmacotherapy.”
   • Encourage use of feedback reports for performance improvement efforts, through a combination of encouragement and incentives, using un-blinded performance reporting once practices are established.
   • Use practice facilitation methods, and possibly an expert facilitator, to support local care teams in reviewing feedback, working through barriers, and improving performance and care quality.¹² (See Resources below for practice guides.)

   If you’re part of a health plan, you can also encourage the organization to adopt alcohol screening and follow-up as part of their quality improvement plan.^13,39,40 (See Resources below for a “change package” from the National Committee for Quality Assurance.)

In closing, do what you can. Different practices will have varied levels of flexibility and support in making changes toward better care for patients regarding alcohol. Each step you take will be a move in a good direction to better support your patients who would benefit from drinking less or not at all.