Address comorbid problems collaboratively

We know that addiction to alcohol and/or drugs carries the risk of multiple medical, psychiatric, and behavioral comorbidities that are often neglected, undertreated, or overtreated. The presence of toxins in the body alters physiological functions that have an impact on such factors as blood pressure, pain control, memory, emotional state, liver function, and immunity. The transition from an intoxicated state to a drug- and alcohol-free state is a time of stress, both physically and emotionally. In early recovery, there is the potential for calamity—either medical, emotional, social, or all combined. A team approach to treatment that marries the talents and input of medical, clinical, spiritual, and programmatic professionals, relying on collaboration at every level, can be a major contributor to success.

At Father Martin's Ashley, we have worked diligently to create and grow a pa-tient model of care that has collaboration at its core. Long-term staff have honed their communication skills and refined their approaches to include consultation with other disciplines, ensuring 360-degree patient observation and documentation and creating a culture of shared responsibility for patient success. New employees are trained in the collaborative processes, and all are encouraged to provide suggestions so processes may improve over time because of better ideas, the introduction of technology, modifications in work space, changes in regulations, or responses to patient, family, and referring partner input.

All departments involved in patient care are required to communicate with one another. This communication starts before admission with the initial information-gathering process and continues throughout the patient's stay and on to aftercare. All relevant patient information is captured and shared through a variety of mechanisms.

As staff members observe patients in different settings and interactions, these observations are shared in the confidential patient electronic file, at daily team meetings, or both. We have found it critical for these multiple observations to be shared, especially if a patient is struggling.

First contact

We believe that matching potential patients with the programs that best suit their needs is the key goal in the admissions process. A thorough assessment of the potential patient's medical and psychological status is imperative. We often ask referring professionals to help provide a complete medical/psychological history so we can structure a treatment program tailored to the patient's specific needs. In some cases, we recommend that the patient seek treatment in a different program, such as a psychiatric facility, if his/her condition warrants.

Since medical or emotional problems can interfere with a patient's participation in some treatment programs, the information gathered in this critical first assessment becomes the backbone of the shared patient treatment data file. Our admissions staff often consults with me, our other full-time physician (Howard Williams, MD), or our director of nursing (Charlotte Meck, RN) to ensure that any co-occurring issues are within our scope of service. This pre-admission collaboration minimizes situations in which arriving patients are too sick to participate successfully in programs.

For the admissions staff to be able to conduct effective screenings, they are trained to ask about medical and psychiatric problems and medications. Our physician and nursing staffs regularly update our admissions counselors and are available for immediate consultation. Admissions staff members work with a comprehensive list of questions and follow-up inquiries to gain a complete understanding of the prospective patient's health and family situation. For example, if an individual inquiring about treatment reports that he/she has been treated for bipolar disorder, a series of follow-up questions assesses current status. If an individual, family member, or referring professional reports that the patient is experiencing weakness or falls, the admissions staff knows what questions to ask about ambulation and ability to engage in activities of daily living.

We have found that it is critical for admissions staff to be aware of the drugs of abuse and their common names, as well as the names of medications. Staff members have been instructed by the physician staff about certain medications or multiple medications that raise red flags for further assessment or consultations from medical staff in the assessment process.

Individuals who are in the hospital or who have complicated medical or psychiatric histories may require a more thorough screening. It is not unusual for the admissions staff to request hospital records for the staff physician to review, or to ask the potential patient's physician to contact our physician so that a decision about the patient's ability to participate in the treatment program can be assessed. There are times when our nursing staff will contact the nurses caring for a hospitalized patient to get a nursing report so that we can accurately assess the individual's functioning, or the nurse may speak with the patient directly.

Case examples

A case overview for “Frank” presents a good example of how early collaborative assessment can lead to appropriate timing for addiction inpatient admission, as well as define the important continuum of care for co-occurring issues.

Frank is 72 years old with a history of opioid dependence and a remote history of alcohol dependence. He was referred from the hospital where he had been admitted for treatment of pneumonia and respiratory failure. In preparation for discharge he was referred for addiction treatment, but on our review of the medical records the patient was noted to be too weak to endure our program, but not sick enough for a temporary admission to a physical rehab program. He decided to return home, and within several days of his hospital discharge one of our nurses made telephone contact with him to speak with him and his wife about his recuperation. She was able to assess his functioning by their reports and within two more days it was determined that he had the strength and endurance to participate. In addition, his personal physician was contacted and current medical needs were reviewed. He was admitted and had an uneventful treatment course.

Although the admissions screening might seem time-consuming and require a higher level of training for staff, it reflects our attempt to look for every reason why we can manage an individual, rather than look for reasons why we can't accept a person who may have multiple problems. The questions “Who admitted this person?” and “Why did we admit this person?” are not asked as a result of this kind of cross-functional collaboration.

Timothy is a 35-year-old male who was referred from a local psychiatric hospital. He had a rather long psychiatric history and carried a diagnosis of bipolar disorder as well as having Cluster B pathology on Axis II. He had a history of multiple suicide attempts and many psychiatric hospitalizations along with alcohol, cocaine, and cannabis dependence. When he was initially referred for treatment, his medical record was reviewed and it was determined that he had too many psychiatric problems to manage successfully in our program. He remained hospitalized for a month. We were then contacted again by the hospital staff and asked to reassess Timothy's status for admission. Updated medical records were obtained and our staff psychiatrist spoke with his attending psychiatrist, while an admissions staff member spoke directly with Timothy. He was on an antidepressant, a mood stabilizer, and an antipsychotic. It appeared that he had made good progress in his hospitalization and had stabilized sufficiently to be accepted on transfer to our program. Timothy had slight difficulty adjusting to the new setting, but our counselor and psychiatrist worked together to manage his care. He was able to participate in the program in a meaningful way, had no deterioration in his psychiatric status, and completed the program to go on to continuing care.

Shift-to-shift communication

In a 24-hour-a-day operation, activity does not end when the day shift leaves. Nurses in other settings have traditionally written or dictated a Change of Shift Report, passing on to the next shift important information about their patients. Resident hospital physicians have a similar process, sometimes called “signing out.” The goal is to inform the next shift of caregivers about their patients, what problems occurred, what is being observed, and what problems might occur.

At Ashley, we have formalized this process for our treatment team and we use technology to assist it. Our Change of Shift Report is electronic and on an internal, secure shared network drive so that nurses, counselors, physicians, and program service assistants or PSAs (non-medical staff who monitor and observe the patient community 24 hours a day) all have access to it.

With this electronic vehicle, if a counselor anticipates a problem during a later shift, he/she can type it into the report. The scenario below offers an example of the benefits of this kind of record sharing.

When patient Roger was informed that his father had died, the counselor put this information on the Change of Shift Report so that the evening staff knew that Roger might need extra support.

The Change of Shift Report allows staff members to report any actions that have been taken on identified problems. For example, if it has already been identified that a patient is spending too much time with community members of the opposite sex, the counselor can include in the report how this has been addressed so that the other shifts know what behaviors to reinforce or discourage.

In addition to the written report, our treatment staff has a morning meeting that includes the counselors, a member of the nursing staff, a representative from the admissions staff, the utilization review staff person, and the medical director. At this meeting the Change of Shift Report is briefly reviewed, other issues from the night are reported, incoming patient intake information is reviewed, and patients who are being discharged are mentioned.

Inpatient management

Depending on the problems that the patient presents, multiple team members will need to be involved. Nurses and physicians of course work closely, but in a residential setting other staff members are involved with the patients as well.

Brad is a 49-year-old male with chronic alcoholism who ran his own business. He presented for treatment and required medically supervised detoxification. In addition to the alcoholism, he had hypertension and arthritis. He was cognitively clear on admission, but he became slightly confused and very slowed. He was often falling asleep even in the middle of a conversation, and complained of arthritic pain. To successfully treat Brad, nurses, physicians, counselors, and PSAs needed to collaborate, coordinate, and regularly consult. Nurses provided ongoing monitoring of vital signs and functioning. In the work-up for the confusion, his ammonia level was checked and it was found to be elevated, so it was treated. Until his mental status cleared, he needed more direction and the PSA staff was helpful in keeping the patient oriented to program activities while the counselor worked with him to participate in groups and start assignments.

Our staff psychiatrist was called on to assess the mental status changes, but other medical interventions were needed. Medications for hypertension had to be adjusted. In addition to the laboratory abnormalities in liver functions, he was noted to have an elevated glucose level that persisted on rechecking. He was started on an oral hypoglycemic agent. Arthritic pain interfered with his ambulation and this was managed pharmacologically to his satisfaction.

As his mental status cleared he was still observed to fall asleep very easily. He reported a history of snoring, his roommates complained of his loud snoring, and the night nursing staff witnessed excessive snoring and episodes of apnea while sleeping. It was likely that he had an obstructive sleep apnea, but since a sleep study could not be conducted while he was in treatment, the excessive daytime sleepiness was managed pharmacologically until the appropriate work-up could be done.

By the time of discharge, Brad was alert, attentive, oriented, and ambulating well. His blood pressure and glucose were in the normal range and he was making significant contributions to the patient community. For continuity, the counselor arranged for family involvement and continuing care. The staff physician contacted his personal physician to advise him of the problem list and current treatments; an appointment was made with him for follow-up on discharge.

Sometimes it is not the formal treatment team that gets involved with helping a patient who is struggling.

Andrew is an 18-year-old addicted to opiates. He also had significant symptoms of agoraphobia that had been impairing. The agoraphobia became very apparent one evening when the patient was taken off the grounds to attend a community NA meeting. He became extremely anxious while making the short trip to the meeting site and was unable to participate because of his high level of anxiety. The psychiatrist arranged with one of the staff drivers to drive the patient to the limits of the facility grounds and return to desensitize the patient. The patient tolerated this with a high level of anxiety, but progressed sufficiently to tolerate trips to physical therapy during which he had the support of the driver.

This example illustrates that there are opportunities for patient care collaboration with every staff position. At Ashley, staff drivers often are the first and last people to see patients as they are picked up from the airport or train station and returned there on discharge. Drivers frequently provide important observations to the intake staff and also relay important feedback from discharged patients that can improve future care and continuing care planning.

Finally, critical parts of our collaborative team are the addiction treatment professionals who refer to our center and who often receive patients for continuing care after discharge. We encourage a thorough sharing of patient information between the referring addiction professional, Ashley, and the continuing care professionals. This continuum of care, coupled with strong family collaboration, delivers the important network that addicts need to support their sobriety. By combining our talents and knowledge, we as addiction professionals should and can strengthen our collaboration to continue to improve the quality of our intertwined treatment plans and, ultimately, improve outcomes.