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|  Quality IMPACTImproving the Assessment and Integration of Physical Health Needs with Adults Participating in Drug and Alcohol Treatment ProgramsProject BackgroundRationale Individuals with substance use disorders often do not access routine medical care. As a result, the medical needs of this population are too often overlooked or addressed during crisis visits to the emergency room. Many of the medical conditions that afflict those in the mental hygiene system are caused by modifiable risk factors, including smoking, alcohol consumption, drug use, poor nutrition, lack of exercise, and risky sexual practices (Parks et al., 2006). Drug users are at increased risk of contracting infectious diseases, in particular tuberculosis (TB), the human immunodeficiency virus (HIV), and the Hepatitis C virus (HCV). As of 2006, 21.2% of all reported cases of HIV/AIDS in NYC were associated with a history of injection drug use (IDU) when the risk factor was indicated. Of the 248 new cases reported in 2006 connected to IDU risk, 31 percent had developed AIDS by the time of the report, indicating that they may have been infected for many years before knowing their HIV status (NYC Department of Health and Mental Hygiene, HIV Epidemiology & Field Services Semiannual Report, October 2007). Knowledge of HIV status is the first step in accessing lifesaving medical care and encouraging preventive practices to stop the spread of infection to others. Both the CDC and NYC Department of Health and Mental Hygiene recommend that HIV testing be made a routine part of medical care. As substance users often do not access routine medical care, an important point of intervention is lost for this population. Providers in this project will ask clients about their HIV status and facilitate testing and access to care as needed. According to established clinical guidelines, individuals with HIV infection should be seen by their primary care provider every six months (HSRA HIV/AIDS Bureau). Drug users constitute the largest group at high risk for acquiring HCV. This is due to a number of risk factors associated with drug use, such as injecting (sharing syringes and other paraphernalia), crack-cocaine smoking (sharing pipe/stems), and sniffing drugs (sharing equipment). The prevalence of HCV infection for IDUs in New York City is estimated at 63% (Des Jarlais et al., 2005). Chronic alcohol users have a prevalence rate of HCV between 14% and 36% and for reasons that are still unclear, this group has an increased prevalence of HCV even in the absence of risk factors (Singal & Anand, 2007). Serious negative health outcomes are associated with unmanaged HCV infection. Approximately 80% of individuals with HCV develop chronic infection, 25% of whom develop serious health conditions, such as cirrhosis and liver cancer. Despite the high prevalence of HCV among drug users, many are unaware of their HCV status and lack education about the disease and their risks. Recent research suggests that intake medical exams at drug and alcohol treatment programs provide important opportunities for HCV screening and treatment initiation (Hagan 2005). However, research has also indicated that while HCV education is frequently offered at drug treatment programs, these efforts do not reach all clients. One national study that included a sample from New York City found that only 60% of program participants used any of the programs' HCV educational opportunities (Strauss, et al. 2007). Studies have shown that chronic HCV infection progresses more rapidly to cirrhosis and liver disease in those co-infected with HCV and HIV. Seroprevalence for HIV with HCV is currently estimated at 25% among injection drug users who are HIV positive (Des Jarlais et al., 2003). Aim Research suggests that closer integration between drug treatment and traditional medical care systems could improve access to and utilization of medical care among drug users (Chitwood, 2001). Best practice models have been developed that provide knowledge and tools to assist people in making informed decisions about healthier lifestyle behaviors including addressing tobacco use and excess weight gain (Vreeland, 2007). The evidence overwhelmingly points to a critical need to focus on the overall physical health care needs of those in drug and alcohol treatment programs and to assist in addressing critical health risks endemic to the population. The primary goal of this CQI project is to assist clients in accessing routine medical care, and to assess, educate and provide support around the treatment and management of chronic conditions prevalent in drug and alcohol using populations, including infectious diseases such as HIV and HCV. Development This CQI project was developed through a consensus-building process initiated in 2007. An extensive literature review was conducted and a workgroup of local stakeholders (community providers, clients of services, advocates, family members and NYC DOHMH staff) met regularly to help design this project. Implementation Participating programs will measure and monitor their progress in this quality improvement project by collecting data on: completion or update of a health screen for each treatment planning period; identification of all outstanding or unmet physical health needs; the integration of these needs into treatment planning; and follow up. Programs will also track data on HCV testing, access to treatment and prevention. CitationsChitwood, D.D., Sanchez, J., Comerford, M., McCoy, C.B. (2001). Primary preventive health care among injection drug users, other sustained drug users, and non-users. Substance Use and Misuse, 36(6&7): 807-824. Desai, M.M., Rosenheck, R.A., Druss, B.G., & Perlin, J.B. (2002). Mental disorders and quality of diabetes care in the Veterans Health Administration. American Journal of Psychiatry, 159(9), 1584-1590. Des Jarlais, D.C., Diaz, T., Perlis, T., Vlahov, D., Maslow, C., Latka, M, et al. (2003). Variability in the incidence of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection among young injecting drug users in New York City. American Journal of Epidemiology, 157(5), 467-471. Des Jarlais, D.C., Perlis, T., Arasteh, K., Torian, L.V., Hagan, H., Beatrice, S., et al. (2005). Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990-2001. AIDS, 19 (Supplement 3): S20-25. Druss, B.G., Rosenheck, R.A., Desai, M.M., & Perlin, J.B. (2002) Quality of preventive medical care for patients with mental disorders. Medical Care, 40(2), 129-136. Druss, B.G., & VonEsenwein, S.A. (2006). Improving general medical care for persons with mental and addictive disorders: systematic review. General Hospital Psychiatry, 28(2), 145-153. Frayne, S.M., Halanych, J.H., Miller, D.R., Wang, F., Lin, H., Pogach, L., et al. (2005). Disparities in diabetes care: impact of mental illness. Archives of Internal Medicine, 65(22), 2631-2638. Hagan, H., Strauss, S.M., Astone, J.M., Des Jarlais, D.C. (2005). Medical examinations at entry to treatment for drug abuse as an opportunity to initiate care for hepatitis C virus infection. Clinical Infectious Diseases, 40 (Supplement 5): S297-303. Parks, J., Svendsen, D., Singer, P., Foti, M., & Mauer, B. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: National Association of State Mental HealthProgram Directors (NASMHPD) Medical Directors Council. Singal, A.K., Anand, B.S. (2007). Mechanisms of Synergy Between Alcohol and Hepatitis C Virus. Journal of Clinical Gastroenterology, 41: 761-772. Strauss, S.M., Astone-Twerell, J., Munoz-Plaza, C.E., Des Jarlais, D.C., Gwadz, M., Hagan, H., et al. (2007). Drug treatment program patients' hepatitis C virus (HCV) education needs and their use of available HCV education services. BMC Health Services Research, 7:39. Vreeland, B. (2007). Bridging the gap between mental and physical health: a multidisciplinary approach. Journal of Clinical Psychiatry, 68(Supplement 4), 26-33. WorkbookMental Health Providers Drug and Alcohol Treatment & Mental Health Providers Data SheetsIndividual Tracking Sheets (ITS) These optional paper and pencil forms can be used in conjunction with the electronic Data Sheets. These forms collect information on individual consumers. Mental Health Providers
Drug and Alcohol Treatment Providers
Electronic Data Sheets Each electronic Data Sheet assists with the collection of information on the Health Project's Core Indicator set and an Additional Indicator set chosen by each program. The Additional Indicator sets include HCV Prevention, Assessment, Testing and Follow-up, Metabolic Abnormalities, Weight Management, Dental Care and Smoking Cessation. Mental Health Providers
Drug and Alcohol Treatment Providers Participating Providers
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