can you really do this in primary care? – the da vinci project · da vinci: the medical visit •...

Can you really do this in primary care? – The DA VINCI Project Dr. Nadeem Akhtar Brad LaForme MBBS (Lond),MA (Cantab), MRCPsych(UK) MSW RSW Dr. Jehaan Illyas Katie Davidman MD, F.R.C.P.C. MSW RSW

PRESENTER DISCLOSURE

• Presenter: Nadeem Akhtar MA (Cantab), MBBS (Lond), MRCPsych (UK) Assistant Professor, Department of Psychiatry, McMaster University Staff Psychiatrist, Hamilton Family Health Team

• Relationships with commercial interests: – Grants/Research Support: none – Speakers Bureau/Honoraria: none – Consulting Fees: none – Other: none

Department of Family Medicine

Department of Psychiatry




• Presenter: Dr. A. Jehaan Illyas M.D., F.R.C.P.C.

• Relationships with commercial interests:

– Grants/Research Support: None – Speakers Bureau/Honoraria: Sunovion, Allergan – Consulting Fees: Sunovion, Allergan, Lundbeck – Other: None


• Presenters: Brad LaForme MSW RSW

Katie Davidman MSW RSW

• Relationships with commercial interests:

– Grants/Research Support: None

– Speakers Bureau/Honoraria: None

– Consulting Fees: None

– Other: None



LEARNING OBJECTIVES



1) Describe an Integrated Care Pathway (ICP) for treating major depression and alcohol use disorders concurrently, and how to make it fit for primary care.

2) Describe how collaboration between all clinical parties, (Family Physician, Psychiatry,

Mental Health, Pharmacy, and Nutrition) were developed, refined, and organized for improved patient care.

3) Describe how technology was utilized for ongoing patient screening/assessment and

how this data informed medication changes when indicated by the algorithm.

“Can you really do this in

primary care?”

The core elements of the pathway include: measurement-based care, pharmacological and psychotherapeutic interventions, and a clinical workflow that incorporates an

inter-professional team.

PART ONE: The Group

“We took a 16-session out-patient hospital-based program and transformed it into a 17-week primary care

psychotherapy group.”

Program Structure

o Concurrent Treatment of Major Depressive Disorder and Alcohol Use Disorder as defined by DSM V

o 17 – 2-hour weekly group psychotherapy sessions. o Pharmacological intervention via anti-depressant and anti-craving

medication. o Pre and Post group assessment tools, as well as…. o Bi-weekly screens for depression symptoms, alcohol cravings scales,

and weekly drinking results. o Bi- weekly medical visits with team psychiatrist to review screening

tools scores and adjust medication as informed by the DA VINCI anti-depressant and anti-craving medication algorithm.

DA VINCI: Psychosocial Therapy Overview

Session: 0-2

Introduction &

Motivational Enhancement

Session: 3-6

Behavioural Focus:

Behavioural Activation

Skills Building for High-Risk

Situations

Session: 7-11

Cognitive Focus:

Cognitive

Restructuring,

Maladaptive Assumptions,

Problem Solving,

Action Planning

Session: 12-13

Relapse Prevention

Lapse

Management

Session: 14-16

Comprehensive Review

Building Social

Supports

Aftercare Planning

Assessment Tools

Measures

Alcohol Use Disorders Identification Test

(AUDIT)

Enter the Pathway

Exit the Pathway

Penn Alcohol Craving Scale

(PACS)

Enter the Pathway

Biweekly

Exit the Pathway

Quick Inventory of Depressive

Symptomatology (QIDS)

Enter the Pathway

Biweekly

Exit the Pathway

Suicide Risk Assessment

Enter the Pathway

If required

Exit the Pathway

Quality of Life Scale (EQ-5D-5L)

World Health Organization Disability

Assessment Schedule (WHODAS 2.0)

Enter the Pathway

Exit the Pathway

Standardized Assessments

Ocean Tablet

Weekly Drinking Record

Session Number: 14

Date: April 19, 2017

Name: ___________________

This past week…

SDDD (Standard Drinks per Drinking Day) When you drank, how many drinks did you have on average? _____ DDW (Drinking Days per Week) How many days did you drink? _____ SSW (Standard Drinks per Week) How many drinks did you have in total? _____ HDDW (Heavy Drinking Days per Week) How many days did you have (Men: 5 or more; Women: 4 or more) _____

Patient

Group Materials

Therapeutic Modalities Cognitive Behavioural Therapy (CBT) Motivational Interviewing (MI) Structured Relapse Prevention (SRP) Dialectic Behaviour Therapy (DBT)

Referral/Screening

Role of Multidisciplinary Team

Clinical Family Doctor Psychiatrist

Dr. Nadeem Akhtar Dr. Jehaan Illyas Pharmacist

Dr. Antony Gagnon Group Therapists

Brad LaForme MSW RSW Katie Davidman MSW RSW Cynthia Forrest RN BScN CPMHN(C) Registered Dietitian

Susan Smith RD CDE

Non-Clinical Sari Ackerman Coordinator/Administrator

Jesse Lamothe Quality Improvement Decision Support Specialist

Kathy & Emily Admin/Reception

Organization Leadership Catherine McPherson-Doe Manager, Mental Health and Nutrition Programs

Dr. Lindsey George Clinical Director and Lead Psychiatrist

0

10

20

30

40

50

60

Group 1 Group 2 Combined

Pre and Post SDW

Mean pre score

Mean post score

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Wk 0 Wk 2 Wk 4 Wk 6 Wk 8 Wk 10 Wk 12 Wk 14 Wk 16

SDW Bi-Weekly Scores

Group 1

Group 2

Combined

Group 1 (n=13) Group 2 (n=7) Combined (n=20)

Mean SDWs at orientation 50.2 17.1 38.6

Mean SDWs at end of treatment 30.8 1.7 20.7

Percent decrease from pre- to post-group 38.6% 90.0% 46.4%

Pre and Post Group Measures

Standard Drinks Per Week (SDW) SDW were self-reported by participants every 2 weeks from week 0 (orientation)

to week 16 (end of treatment).


Standard Drinks Per Drinking Day (SDDD) SDDD were self-reported by participants every 2 weeks from week 0 (orientation)

to week 16 (end of treatment).


Mean SDDDs at orientation 8.7 7.1 8.2

Mean SDDDs at end of treatment 5.0 1.3 3.7


0

1

2

3

4

5

6

7

8

9

10


Pre and Post SDDD

Mean pre score

Mean post score

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0


SDDD Bi-Weekly Scores

Group 1

Group 2

Combined

0.0

5.0

10.0

15.0

20.0

25.0


PACS Bi-Weekly Scores

Group 1

Group 2

Combined

0

5

10

15

20

25


PACS Pre and Post Scores

Mean pre score

Mean post score


Penn Anti-Craving Scale (PACS) (min=0, max=30) The PACS was administered every 2 weeks from week 0 (orientation) to week 16 (end of treatment).


Mean score at orientation 22.9 21.4 22.4

Mean score at end of treatment 19.1 14.4 17.4



Quick Inventory of Depressive Symptomology (QIDS) (min=1, max=27) The QIDS was administered every 2 weeks from week 0 (orientation) to week 16 (end of treatment).

0

2

4

6

8

10

12

14

16

18

20


QIDS Pre and Post Scores

Mean pre score

Mean post score

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Wk 0 Wk 2 Wk 4 Wk 6 Wk 8 Wk10

Wk12

Wk14

Wk16

QIDS Bi-Weekly Scores

Group 1

Group 2

Combined


Mean score at orientation 16.0 17.4 16.5

Mean score at end of treatment 11.3 14.7 12.5


But the numbers don`t tell the whole story

More than just alcohol and depression

Other substance use Other mental health issues (anxiety)

Personality issues (BPD) Relationship issues

Trauma Physical health

Chronic pain Employment

Group Personality

Like opening Pandora's box

What does success look like?

Group Personality

DA VINCI Duckpins

“Initiating friendships with other group members outside of group is not recommended. If conflict or disagreement between group members occurs this can interfere with your comfort

level and attendance at treatment.”

DAVINCI Psychotherapy Group Workbook: Guidelines and Expectations for Group Members

Support beyond the confines of the group – a pleasant discovery!

A Patient's Story

0

20

40

60

80

100

120

14-Sep-

16

21-Sep-

16

5-Oct-16

19-Oct-

16

2-Nov-

16

16-Nov-

16

30-Nov-

16

28-Dec-

16

# Drinks per DrinkingDay

14 14 13 12 9 8 8 5

Drinking Days perWeek

7 7 7 7 7 7 7 7

Standard Drinks perWeek

98 93 87 86 66 57 61 27

0

5

10

15

20

25

30

35

7-Sep-16 21-Sep-16 5-Oct-16 19-Oct-16 16-Nov-16 28-Dec-16

PACS 17 15 12 21 19 16

QIDS 30 25 29 30 30 23

Depression & Craving Scales Drinking Scales

0

10

20

30

40

50

60

70

80

90

14-Sep-

16

5-Oct-16

19-Oct-

16

2-Nov-

16

16-Nov-

16

30-Nov-

16

14-Dec-

16

28-Dec-

16

# Drinks per DrinkingDay

12 10 10 10 8 9 10 7

Drinking Days perWeek

7 7 7 7 7 7 7 7

Standard Drinks perWeek

79 83 70 68 62 60 63 51

0

5

10

15

20

25

30

7-Sep-16

21-Sep-16

5-Oct-16

19-Oct-16

2-Nov-16

16-Nov-16

30-Nov-16

14-Dec-16

28-Dec-16

PACS 21 19 25 16 17 12 19 20 17

QIDS 7 11 10 4 10 8 8 9 9

Depression & Craving Scales Drinking Scales

A Patient's Story

Therapist and system that suits the client population Going beyond the Manual

Adapting to meet the evolving need for support

Therapist Experience

It can be exhausting!!

Before Starting – Preparation

– Psychiatric History – Medication Reconciliation

PART TWO: The Medical Visit

Before Starting – Preparation – Genetic Testing – PRIME, Pillcheck

• Done by A. Gagnon (Pharmacy) – Medical History – Laboratory Testing

DA VINCI: The Medical Visit

Before Starting – Preparation – Medical History – Laboratory Testing

• Liver function testing, CBC, Kidney Function, Urine DS • Other labs as necessary eg. TSH, Ferritin, Vitamin B12

– Other Substance History • Cannabis • Opioid Use – exclusion for Naltrexone


• Week 0 Visit – Explanation of medical role to group – Questions/ Clarifications – Brief Discussion on Agents Used

• Antidepressants • Anti-Craving Drugs



• Weeks 2, 4, 6, 8, 10, 12, 14, 16 – Brief Medical Interview – Charting – Medication Titration – Psychosocial Stressors – Management of Comorbidities

DA VINCI: The Medical

Visit

Weeks 2, 4, 6, 8, 10, 12, 14, 16

– Algorithm: • Antidepressants

– Sertraline – Fluoxetine – Venlafaxine XR – Mirtazapine


• Weeks 2, 4, 6, 8, 10, 12, 14, 16 – Algorithm:

• Anticraving – Naltrexone; Acamprosate; Topiramate


• Weeks 2, 4, 6, 8, 10, 12, 14, 16 – Scales Used

• QIDS – Quick Inventory of Depressive Symptomatology Scale

• PACS – Penn Alcohol Craving Scale – Guide for Pharmacotherapy


• Discharge Planning – Charting completed and sent to Primary Practice – Follow-up Planning – Aftercare:

• Community Resources • Within Family Health Team • Complex Care Referral

– Concurrent Disorders Treatment • Residential Treatment planning

– Indirect Support of Primary Practice

The HFHT DAVINCI Pilot Group Lessons Learnt

The First Session:

ORIGINAL ISSUE LESSON, CHANGES

Group medical visit vs individual review Group medical not billable. Complex cases need individualized care. Opted for brief individual review every 2 weeks.

Time Constraints. One hour for 20 patients’ psychiatric review. Two psychiatrists

Group size limited to 10 total. Review time increased to 1.5 hrs. 1 hr. paperwork prep before review.

Medical co-morbidity-impacting treatment choice

History unclear. Often complex array of diagnoses. Now opting for psych consultation at the point of acceptance of the group.

The First Session:


Patient history, narrative, diagnosis History unclear. Often complex array of diagnoses. Now opting for psych consultation at the point of acceptance of the group.

Physical health/medication reconciliation

Records from family doctor, pharmacist led medication reconciliation prior to first week

Clarify opiate prescribing-impact on Naltrexone prescription

Practical issues:


Not sure if coverage for medication

Acamprosate and Naltrexone cost

No clear structure for reporting to family doctor

Pharmacist reconciliation and interview Prior to first session. Compassionate access Support in linking to this

Template for initiation and discharge. Family physician to be updated at any critical change

During the Programme:


Appointment expectations Issues between psychiatric review

Titration schedule

Scale scores not aligned with progress

Coverage if one psychiatrist away

Flow of information within the team

Clarify psychiatrist role from outset Delineate time limitations Facilitators go-between outside of Scheduled reviews

Individualise as per standard practice

Clinical perspective given greater weight Discuss discrepancy with pt. and facilitators

Facilitators go-between outside of Scheduled reviews. Cross coverage review In unscheduled week for urgent issues

Check in at end of group every other week, updates as they may arise

The End of the Group:


For higher risk patients connect to Concurrent Disorders counselling and psychiatric review within the HFHT until care assumed by a secondary care service.

AFTERCARE

Link to Drinkwise, other HFHT groups, community resources Drop-in after-care group/?peer support group

Encourage follow-up with family physician and practice mental health counsellor

Quite the Journey… BUT it could

HAVE BEEN worse!!

Contact

Can you really do this in primary care? The DA VINCI Project

Dr. Nadeem Akhtar MBBS(Lond), MA(Cantab), MRCPsych(UK) Psychiatrist

Hamilton Family Health Team [email protected]

Brad LaForme MSW RSW

Substance Use Program Coordinator Hamilton Family Health Team

905-667-4848 ext. 146 [email protected]

mailto:[email protected]



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