Referral Shared Care What is an AOD Referral

Referral & Shared Care

What is an AOD ‘Referral’? • ‘Usual’ referral practice tends to result in relinquishing principal care of a patient to another service. However, for people with AOD problems this frequently results in: – a high attrition rate following 1 st appointment – a high rate of ‘no shows’ – no guarantee of a good match between patient and the service – reluctance of the patient to return to place of initial contact. • The concept of ‘shared care’ has arisen in response to referral problems, and achieves more comprehensive, collaborative care for the patient. Referral & Shared Care

Who to Refer? • Refer any patient who may gain from treatments or services GPs may not be able or willing to provide • Key referrals may include patients with: – severe dependence and long history of psychoactive drug use – polydrug use – chaotic lifestyle with multiple problems – social isolation – legal problems – poor general life/coping skills – poor / lack of social supports. For the client, referral is a voluntary process – it should always involve the client Referral & Shared Care

Typical AOD Referral Options • • Sobering-up services / non-medical withdrawal Out-patient services for cognitive behavioural therapy In-patient withdrawal Pharmacotherapy services Specialist mental health services Residential care / therapeutic community Community-based services – self-help groups (as an adjunct to other treatments) – home-based withdrawal – counselling – youth / welfare / legal services. Referral & Shared Care

Refer When. . . • The patient requests referral • Ongoing contact is not conducive to the GP– patient relationship (and where it seems unlikely to improve) • When the GP is uncomfortable / unable to respond to the needs of the client • When the GP is unable to provide adequate time to ensure benefit from the interaction. Referral & Shared Care

Good Referral Practice (1) Identify and liaise with relevant AOD and welfare services in your area • What is their treatment philosophy? – abstinence, harm minimisation, eclectic approach • What generic or specialist services / treatments do they offer? – 12 -step, harm minimisation, pharmacotherapies, CBT • Do they have a specific orientation? – youth, Indigenous • What are their admission / entry criteria? Referral & Shared Care

Good Referral Practice (2) • Where possible (and with patient consent) provide comprehensive assessment (referral letter) to the new provider • High involvement in referral is associated with higher uptake and retention in treatment – arrange appointments for the patient, give instructions on how to get there – provide information to the patient about the service he or she has been referred to – build expectations of good outcomes – ask permission to call patient to ascertain outcome of referral. Referral & Shared Care

Good Referral Practice (3) • Follow-up to ensure connection occurred • Ensure referral is coordinated: – to prevent polypharmacy – to link other services into care • Establish ‘priority of need’ with patient to ensure success e. g. , ‘non-medical’ needs (e. g. , childcare, housing, food) may be a higher priority for referral than the immediate medical problem / AOD issue • Research suggests that practice nurses who are involved in AOD intervention and referral processes increase the likelihood of good outcomes. Referral & Shared Care

What is ‘Shared Care’? Shared care is: • multidisciplinary and multi-agency • includes prevention and treatment • fundamental to effective harm minimisation Respective roles have to be clearly defined, guidelines and protocols established and structures developed to sustain quality of delivery. Referral & Shared Care

‘Shared Care’ is About • Systemic Cooperation – how systems agree to work together • Operational Cooperation – cooperation at local levels between different groups of clinicians. Referral & Shared Care

“Shared care ensures that people who need ongoing services from GPs and other service providers receive the most effective combination of care. ” The concept of shared care extends beyond simple collaboration to: “… how the team, and functions of the team, are organised and sustained. ” Penrose-Wall et al. (2000, p. 6) Referral & Shared Care

The GP’s Role in Shared Care • Although AOD problems may be the primary presenting problem, they are more commonly detected when the patient presents for another issue • The role of the GP in shared care arrangements will depend on: – the GP’s specific skills, knowledge and abilities to intervene with AOD issues – the amount of time GPs are prepared to invest in responding to these issues – their decision to engage in a shared care relationship with other service providers – relationship and willingness to continue care with the patient. Referral & Shared Care

Treatment Roles for GPs Along a Harm Reduction Continuum Treatment intensity increases with intensity of drug dependence and related harms Referral & Shared Care

Illicit Drug Use Shared Care May Include: • Harm reduction and prevention of infectious diseases • Long-term, GP-centred, pharmacotherapy programs • Sharing pharmacotherapy management (e. g. , with specialist service) • Ambulatory withdrawal • Supporting user-led and peer outreach programs • Supporting Indigenous primary care agencies • Comorbidity shared management. Referral & Shared Care

Barriers to GP Involvement in Shared Care Evidence suggests that many GPs: • lack knowledge of illicit drug management • lack confidence to become involved • are concerned they will not receive adequate support from peers, colleagues or community • prefer not to be involved (e. g. , few GPs are involved in pharmacotherapy treatments) • accept they have a role in detection and referral of AOD problems but not treatment. Referral & Shared Care

Current GP Responses to Shared Care • A generational shift is apparent • Medical students are increasingly trained in AOD issues, so their knowledge and confidence to respond is increasing • AOD issues are increasingly accepted as a legitimate part of everyday general practice. Referral & Shared Care

How to Increase GP Involvement • Shared treatment roles increase with: – an increase in knowledge – attitudinal shift – higher confidence – skill attainment – belief in treatment efficacy – appropriate role fit for the GP’s practice • To ensure shared care works, develop protocols and arrange for back-up support. Referral & Shared Care

Successful Shared Care Programs Occur when: • GPs are involved from the outset in designing shared care programs & protocols • barriers to GP involvement are actively removed • GPs have broad preventive-treatment roles (but involvement is optional). Referral & Shared Care

Success Requires • Resources / training for GPs • Patient access to broader services direct from the surgery • A specialist drug unit to coordinate at the macro level – GP initiated programs can be innovative but are not easily sustained without this coordination. Referral & Shared Care

Australian Examples of Shared Care (1) • Mental health workers, specialist AOD services and pharmacists • Private psychiatrists and NGO support services (usually for comorbidity issues) • Primary prevention – attachment to schools, youth centres • GP-run youth health clinics addressing AOD issues within a broad health context. Referral & Shared Care

Australian Examples of Shared Care (2) • Prescribing methadone / pharmacotherapies • After-care services • Special populations (e. g. , prisoners) • Hep C screening and counselling. Referral & Shared Care