Promote Practice Change: Take Manageable Steps Toward Better Care

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    Takeaways

    • With small, incremental steps, you can create and support a better system of care for your patients with alcohol-related problems.
    • Steps to create a strong system of care include adopting evidence-based practices, developing a problem response plan, creating a multidisciplinary collaborative care team, and leveraging your electronic health record system to make processes automatic.
    • Steps to support the success of your new system include engaging leadership support, training all staff involved in the care of alcohol-related problems, framing alcohol problems as a health issue, and adding alcohol care metrics to your performance review system.

    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.

    A note on drinking level terms in this Core article: The 2020-2025 U.S. Dietary Guidelines states that for adults who choose to drink alcohol, women should have 1 drink or less in a day and men should have 2 drinks or less in a day. These amounts are not intended as an average but rather a daily limit. Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    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. Screen patients of all ages, genders, racial groups, and ethnicities. (See Resources for guidance on adapting alcohol screening and follow up for culturally diverse populations.) If clinicians are left to decide when and whom to screen, then time pressures and competing priorities can get in the way.6 Without a 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. 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.12,13

    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,14–32 and the cost-effectiveness of primary care-based alcohol services.33 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).
      Top evidence-based clinical preventive services in terms of health impact and cost effectiveness
      This chart can help leaders decide how to allocate resources to achieve greater improvements in the health of their patient population.
        Clinical Preventive Service Clinically Preventable Burden Score Cost Effectiveness Score Total
      1a Childhood immunization series 5 5 10
      2 a Tobacco use, brief prevention counseling, youth 5 5 10
      3 a Tobacco use screening and brief counseling, adults 5 5 10
      4 b Alcohol misuse screening and brief intervention 3 5 8
      5b Aspirin chemoprevention for those at higher risk of cardiovascular diseased 3 5 8
      6b Cervical cancer screening 4 4 8
      7b Colorectal cancer screening 4 4 8
      8c Chlamydia and gonorrhea screening 3 4 7
      9c Cholesterol screening 4 3 7
      10c Hypertension screening 4 3 7

      Methods: Each service received 1 to 5 points on each of the two measures—clinically preventable burden and cost-effectiveness—for a total score ranging from 2 to 10, with 10 representing the highest impact and most cost-effective services.
      Tied Scores (a,b,c): Services with the same total score tied in the rankings
      Clinically preventable burden: Disease, injury, and premature death prevented if the clinical preventive service were delivered at recommended intervals to the full target population
      Cost effectiveness: A standard measure for comparing services’ return on investment
      Updated (d): On April 26, 2022, the U.S. Preventive Services Task Force updated this recommendation.
      Source: Maciosek, MV et al., Updated Priorities Among Effective Clinical Preventive Services, 201733


    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 “We Ask Everyone” to normalize alcohol screening and discussions and reduce patient perceptions of being singled out for alcohol screening. (See examples.) You may wish to also have visuals to help explain standard drink sizes and the U.S. Dietary Guidelines (see PDF handout [PDF – 184 KB]). Make sure patient-facing materials reflect your population’s linguistic preferences.
      • Connect alcohol use to presenting problems. Many patients are not aware of the relationship between alcohol use and consequences, including physical14–26 and mental health problems.27–32 (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 drinking34 and whether they go on to receive the recommended follow-up care.35,36
      • 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.

    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 (see resources 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.

    Resources

    Further Reading in the NIAAA Journal, Alcohol Research Current Reviews

    Implementation and Quality Improvement Guides for Health Care Systems

    Alcohol SBIRT Resources Related to this Article

    Alcohol Use Disorder Medication Guides

    Adapting alcohol SBIRT to culturally diverse populations

    Referral Resources

    SBIRT Training Videos

    Resources to Share with Patients Related to this Article

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

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    10. Sterling S, Kline-Simon AH, Jones A, Satre DD, Parthasarathy S, Weisner C. Specialty addiction and psychiatry treatment initiation and engagement: Results from an SBIRT randomized trial in pediatrics. J Subst Abuse Treat. 2017;82:48-54. doi:10.1016/j.jsat.2017.09.005
    11. Crowley RA, Kirschner N, Health and Public Policy Committee of the American College of Physicians. The Integration of Care for Mental Health, Substance Abuse, and Other Behavioral Health Conditions into Primary Care: Executive Summary of an American College of Physicians Position Paper. Ann Intern Med. 2015;163(4):298-299. doi:10.7326/M15-0510
    12. Coding for Screening and Brief Intervention Reimbursement. Accessed May 13, 2021. https://www.samhsa.gov/sbirt/coding-reimbursement
    13. Screening, Brief Intervention, & Referral to Treatment (SBIRT) Services. Published online February 2021.
    14. Peng Q, Chen H, Huo JR. Alcohol consumption and corresponding factors: A novel perspective on the risk factors of esophageal cancer. Oncol Lett. 2016;11(5):3231-3239. doi:10.3892/ol.2016.4401
    15. Ekwueme DU, Allaire BT, Parish WJ, et al. Estimation of Breast Cancer Incident Cases and Medical Care Costs Attributable to Alcohol Consumption Among Insured Women Aged <45 Years in the U.S. Am J Prev Med. 2017;53(3 Suppl 1):S47-S54. doi:10.1016/j.amepre.2017.05.023
    16. Praud D, Rota M, Rehm J, et al. Cancer incidence and mortality attributable to alcohol consumption. Int J Cancer. 2016;138(6):1380-1387. doi:10.1002/ijc.29890
    17. Shield KD, Soerjomataram I, Rehm J. Alcohol Use and Breast Cancer: A Critical Review. Alcohol Clin Exp Res. 2016;40(6):1166-1181. doi:10.1111/acer.13071
    18. Ben Q, Wang L, Liu J, Qian A, Wang Q, Yuan Y. Alcohol drinking and the risk of colorectal adenoma: a dose-response meta-analysis. Eur J Cancer Prev Off J Eur Cancer Prev Organ ECP. 2015;24(4):286-295. doi:10.1097/CEJ.0000000000000077
    19. Liu Y, Nguyen N, Colditz GA. Links between alcohol consumption and breast cancer: a look at the evidence. Womens Health Lond Engl. 2015;11(1):65-77. doi:10.2217/whe.14.62
    20. Mahajan H, Choo J, Masaki K, et al. Association of alcohol consumption and aortic calcification in healthy men aged 40–49 years for the ERA JUMP Study. Atherosclerosis. 2018;268:84-91. doi:10.1016/j.atherosclerosis.2017.11.017
    21. Ricci C, Wood A, Muller D, et al. Alcohol intake in relation to non-fatal and fatal coronary heart disease and stroke: EPIC-CVD case-cohort study. BMJ. 2018;361:k934. doi:10.1136/bmj.k934
    22. Wood AM, Kaptoge S, Butterworth AS, et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies. The Lancet. 2018;391(10129):1513-1523. doi:10.1016/S0140-6736(18)30134-X
    23. Samokhvalov AV, Rehm J, Roerecke M. Alcohol Consumption as a Risk Factor for Acute and Chronic Pancreatitis: A Systematic Review and a Series of Meta-analyses. EBioMedicine. 2015;2(12):1996-2002. doi:10.1016/j.ebiom.2015.11.023
    24. Hadland SE. Alcohol Policies and Alcoholic Cirrhosis Mortality in the United States. Prev Chronic Dis. 2015;12. doi:10.5888/pcd12.150200
    25. Otete HE, Orton E, Fleming KM, West J. Alcohol-attributable healthcare attendances up to 10 years prior to diagnosis of alcoholic cirrhosis: a population based case-control study. Liver Int Off J Int Assoc Study Liver. 2016;36(4):538-546. doi:10.1111/liv.13002
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    27. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766. doi:10.1001/jamapsychiatry.2015.0584
    28. Frye MA, Salloum IM. Bipolar disorder and comorbid alcoholism: prevalence rate and treatment considerations. Bipolar Disord. 2006;8(6):677-685. doi:10.1111/j.1399-5618.2006.00370.x
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    31. Sullivan LE, Fiellin DA, O’Connor PG. The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med. 2005;118(4):330-341. doi:10.1016/j.amjmed.2005.01.007
    32. Worthington J, Fava M, Agustin C, et al. Consumption of alcohol, nicotine, and caffeine among depressed outpatients. Relationship with response to treatment. Psychosomatics. 1996;37(6):518-522. doi:10.1016/S0033-3182(96)71515-3
    33. Maciosek MV, LaFrance AB, Dehmer SP, et al. Updated Priorities Among Effective Clinical Preventive Services. Ann Fam Med. 2017;15(1):14-22. doi:10.1370/afm.2017
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    35. Glass JE, Hamilton AM, Powell BJ, Perron BE, Brown RT, Ilgen MA. Specialty substance use disorder services following brief alcohol intervention: A meta-analysis of randomized controlled trials. Addict Abingdon Engl. 2015;110(9):1404-1415. doi:10.1111/add.12950
    36. Glass JE, Bohnert KM, Brown RL. Alcohol Screening and Intervention Among United States Adults who Attend Ambulatory Healthcare. J Gen Intern Med. 2016;31(7):739-745. doi:10.1007/s11606-016-3614-5
    Earn CME/CE Credit

    We invite healthcare professionals including primary care physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

    CME/CE Activity — Promote Practice Change: Take Manageable Steps Toward Better Care

    Released on 5/6/2022
    Expires on 5/10/2023

    Complete CME/CE Post-Test

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    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Identify evidence-based practices to improve care for patients with AUD.
    • Summarize system-wide practices to establish a better system of care for patients with AUD.
    • Establish quality processes to ensure success in new practice strategies for patients with AUD.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    External Writers

    Stacy A. Sterling, DrPH, MSW, MPH
    Co-Director, Center for Addiction and Mental
    Health Research, Kaiser Permanente Division
    of Research, Oakland, CA

    Constance M. Weisner, DrPH, MSW
    Research Scientist, Kaiser Permanente
    Division of Research, Oakland, CA;
    Professor emeritus at the Department of
    Psychiatry, University of California San
    Francisco

    NIAAA Content Contributors

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    Randall Brown MD, PhD
    Professor, School of Medicine
    & Public Health,
    University of Wisconsin, Madison, WI

    Hector Colon-Rivera MD, MRO
    Medical Director of Asociacion
    Puertorriquenos En Marcha, Inc;
    Attending at University of Pittsburgh Medical
    Center, Philadelphia, PA

    Joseph Edwin Glass, PhD, MSW
    Associate Investigator Kaiser Permanente,
    Washington Health Research Institute,
    Seattle, WA

    Lewei (Allison) Lin MD, MS
    Assistant Professor, Department of
    Psychiatry, University of Michigan,
    Ann Arbor, MI

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Falk W. Lohoff, MD
    Lasker Clinical Research Scholar;
    Chief, Section on Clinical Genomics and Experimental Therapeutics, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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