So Jeremy had a really good idea, which is what, you know, my name is, so my name is Lauren Scherr. I'm one of the, I'm a psychiatry faculty member at UC Davis, and I direct integrated behavioral health services across our 14 network primary care network operation at UC Davis. And so I'll give the group a chance to introduce themselves, but after we do that, we actually want to, I mean, there's, it's a small enough group that we knew it was going to be relatively small on a Wednesday at the end of the day, but we're kind of interested to know who's in the room. So if that's okay with you guys, would you mind sharing sort of who you are and where you work so we can help tailor the discussion? Yeah, either way is fine, I think, it's up, yeah, that's, does this work, is this on? Okay. Yeah. I'm Adam Ketron. I'm a psychiatry resident, third year at University of Washington, interested in going into addiction psychiatry, and we do a lot of collaborative care, and we call it IBH, integrated behavioral health care, there in the Montana program, which I'm a part of, so, yeah. Oh, wonderful. That's great. I have very close colleagues at the University of Washington, many of us do, especially with integrated care. Hi there. Hi, I'm Bob Kieselham, psychiatrist from Washington, D.C., and I spent about eight years in a federally qualified health center doing psychiatry and primary care, so, had a lot of experience with integrating mental health and primary care. Wonderful. Well, thank you. Thank you for being here. Hi. I'm Brianna, I am a third year medical student, interested in learning more about psychiatry, and one of my interests is addiction medicine, so just learning more about that, and that's why I'm here. Wonderful. Thank you for coming. Hi. Colin Chalice. We met the other night. We do know each other. Yes. Met the other very late night. I'm a medical science liaison for Alkermes, we make Vivitrol, and, you know, as part of a product that's been out on the market for a while, and being in the medical affairs department of a pharma company, we are tasked with designing phase four studies, coming up with evidence that we can then talk to you guys all about and improve patient care. So, yeah, just, you know, here to learn, really. Thank you for being here. So, Dr. DeMartini, would you like to introduce yourself? Yes. So, I'm Jeremy DeMartini. I am the training director for one of our three residency programs at UC Davis, and it's combined internal medicine and psychiatry. It's a five-year program where residents are actually eligible for both sets of boards. I practice primarily in integrated care and what some people call reverse integrated care, so I work in a primary care clinic doing a bit of collaborative care as well as kind of like consultations for really complex medical psychiatric clinics in our main academic center, and now actually spend slightly more time in a psychiatric hospital doing general medical consults and preventative and urgent care for the patients with serious mental illness, predominantly patients who are conserved, mostly schizoaffective disorder, bipolar disorder, and so it's kind of just really interesting to kind of see the two sides of the coin and some of these problems like substance use disorders that really impact all patients at all levels. And Annabelle. Can everybody hear my voice? Yes. Okay. I'm Annabelle Lestranger. I'm a population health specialist at UC Davis, project manager is another title I use sometimes, and I have worked with everyone in this room on the project we're going to talk about today. It's been a great partnership. Yes, we have a partnership between psychiatry, primary care, and population health, and we're going to talk a fair amount about how we've accomplished, what we've accomplished through that partnership. And Alvaro. Hi. My name is Alvaro Gonzalez. I'm an associate American family therapist at UC Davis. So I work with patients who are having substance use on the substance use navigator within the primary care network. I'm also a therapist with the clouded care program at UC Davis for patients for short-term therapy. And in addition, I'm also part of the early psychosis team with the Department of Psychiatry. Excellent. So it's been a real pleasure to work with this group. And so what we're going to talk about today really relates to how we have integrated equitable screening and treatment of substance use disorders into primary care. And so we're really focusing on equity here, right? Because as, you know, we have a diverse group. We have medical students, we've got someone from industry, we have a resident, and then someone who's been in practice at an FQHC, thinking about how we systematically integrate mental health services into primary care is not easy. It takes a system, a coordinated effort to do that. So that is really the goal of what we are going to talk about today. So real fast, we did get a grant from the California Healthcare Foundation. And so I mentioned before that we have integrated behavioral health services at UC Davis. We operate 14 primary care sites in the Sacramento area, which is where UC Davis Health System is based. We have three hospital-based clinics where we train residents and medical students who work with, you know, psychiatrists and primary care doctors like Dr. DeMartini. And then we have 11 community-based clinics. We're doing the evidence-based collaborative care model, which was developed at the University of Washington, and all of those sites. And we continue to have other types of services like electronic consultations, integrated case management services, I mentioned the collaborative care model, and psychiatric consultations. And we distinguish that it's all consultation-based as opposed to sort of what we describe as continuity care within the Department of Psychiatry. Because the goal, of course, is to improve access to care for our patients in need. And so within this program, we got this grant to develop, to really think about how we're addressing substance misuse and substance use disorders. And so I think everyone in the room knows this, right? But the prevalence of substance use disorders is very significant, right? If you look at California data in particular, 8.8% of Californians, that's almost 3 million Californians meet criteria for a substance use disorder. Alcohol use, right, 2 million Californians, 6.3% of the population. Illicit drugs, 3.6% of the population. And of course, pain medications are in there as well. If you look at alcohol use in the past month, if you can see that, what you're looking at is sort of an age distribution. And alcohol use and alcohol, binge alcohol use is very common even for adolescents ages 12 and above, right? And so very significant prevalence of substance misuse and substance use disorders. So substance use was also exacerbated by the pandemic. There's been a number of population health studies and surveys which have demonstrated this in many different states, including California. Drug overdose deaths increased by approximately 30% in the United States in 2019 and 2020. And in California, we've seen a market increase in both opioid and stimulant related deaths. I served as the director of emergency psychiatry services for about 10 years as I've gradually sort of moved into integrated behavioral health within primary care. And so we see quite a bit of opioid and stimulant related presentations to the emergency department, which should not be a surprise to those in this room. And then from a health equity standpoint, there's a disproportionate increase in overdose mortality observed in black and American Indian and Alaskan Native individuals as compared to white individuals. And that's something that we thought about as part of this mental health equity project that we worked on. So again, this is not a surprise to you. This is sort of what we call our soapbox slides, but still important to help set the frame. Alcohol misuse and alcohol use disorders, they are a significant health and economic issue and have significant economic burden and health burden in this country right across multiple organ systems. You're learning about that in medical school. We continue to teach that in residency and we certainly see it when we're out in practice. So excessive alcohol consumption is linked to greater risk of liver cirrhosis, cardiovascular disease, infections, accidental deaths, neurocognitive disorders, and cancer. And almost 100,000 deaths in the United States annually are attributed to alcohol use. And the economic impact of excessive use of alcohol is upwards of $250 billion annually. So thinking about how important screening is for any population health effort is that screening practices remain very uncommon in primary care. I'm interested for our colleague who's working in Washington, D.C., how long you guys have been screening for depression, right? So that in itself was a big hurdle to start to screen for depression and anxiety disorders and other common mental health conditions within primary care. But there's even more stigma around substance use disorders and substance misuse. And so we'll talk about that. There's a study done by a number of our family medicine and internal medicine colleagues at UC Davis, Dr. Chatterton, Dr. Agnoli, and Dr. Fenton, who looked at alcohol screening with a validated questionnaire documented during less than, was really documented during less than 3% of primary care visits. So that's a real small amount when you think about the prevalence rates that we had talked about earlier. And so, and also there's a higher risk of being missed by appropriate screening based on race and ethnicity and insurance class, which is an equity issue, which impacts access to care and addresses structural issues of inequity in our system. So there are barriers to screening and treatment in primary care, right? Time and resources are a big one. Anytime I go into one of our primary care sites with a plan to help them, even the U.S. Preventative Services Task Force does not recommend that we do any screening for most things unless we have a system in place to respond to those screens. A big reason for that is short primary care visits. There's too much to do in terms of chronic illness, right? And so, as you know, Dr. Martini, half of his work is being a primary care doctor. And, you know, but if you're managing so many chronic illnesses like diabetes and high blood pressure and heart disease, when a patient comes in with an acute issue like pain or an infection, chronic disease management goes out the door for that visit because you have to address what's causing challenges for the patient and person in front of you. And PCPs aren't, you know, we'll tell you, they don't feel trained often to manage behavioral health conditions within primary care, too. So that's our job, not just as integrators of mental health into primary care, to partner with our primary care colleagues for appropriate training. So, and also the insurance system and many other reasons have caused us, caused a lack of integration over the years, which is, you know, you know, primary care services and specialty mental health services have been separated in both the sort of insured patient populations and also in the public, you know, insurance system for a long time. And that is a barrier to doing effective integration, especially now that we have more, you know, even now that we have more evidence base for that. It's really important that we acknowledge what those barriers are and a history, a structural history of lack of integration is a big part of that. And then stigma is a huge one, right? We're going to talk about substance use disorders where there's even more stigma than other psychiatric conditions, but there's stigma on the patient side. There's stigma from members of the healthcare team, right? There's quite a bit of stigma related to patients with psychiatric conditions and substance use disorders. And then also stigma within the health system and how things were created. So, you know, when you think about stigma around substance use disorders, I made a few comments. We'd love to hear your perspectives on that from what you've seen in your clinical work. And some of us are going to talk about that a little bit more. But, you know, on the public side, you know, we, you know, there's discrimination and, you know, feeling devalued by others and in terms of, you know, when patients have comorbid substance use disorders, especially when they come in to non-mental health and non-psychiatric settings. You know, patients have reduced access to care and there's, you know, limited resources due to policy, right? You know, we don't, it's much faster to get into a pulmonologist or a cardiologist than it is to get in to see a psychiatrist or certainly an addiction psychiatrist or an addiction medicine provider. And then what sort of stigma do we have, you know, for our patients and ourselves who struggle with substance use disorders, internalizing those negative stereotypes is something that we have to work against too, especially when we're working on which psychotherapies work as we are engaging our patients with substance use disorders. So, again, we know we are by definition a small group. So I think what we can do is keep this informal. But I guess our question for you and anyone can answer and we can even have a discussion amongst ourselves up here is that, you know, we ask you to sort of pose this question to yourself. What barriers, including stigma, to substance use disorder screening and treatment have you faced in your practice? Please. And we did get an ask if you could speak in the microphone for those that are listening remotely. Oh, thank you. Great. Okay. I go to school in Kansas City. So I'm born and raised in Los Angeles, but I'm at Kansas City University for medical school. And my very first rotation of my third year, it was family medicine, but it was called community health because it took place in Smithville, Missouri, which has a population of 12,000 or less people. So that kind of qualifies as rural. And I did not know this, but my preceptor is the only primary care physician who takes on a panel of patients who have substance use disorder. And not just that Smithville region, and what I mean by primary care provider, I mean non-psychiatrist, but like the entire Kansas City region, including surrounding large areas like Independence, Missouri, and places like that. And I was astonished to hear that, but also really excited to see how he did things. He had one other physician in his small practice, and I kind of asked her, I was like, hey, so like, are you going to get buprenorphine waived? Like, are you going to, you know, do what it takes to also do this? And she was like, no, period. Like, end of discussion. And, you know, me wanting to not be disrespectful. I didn't ask more about that. And then I would ask, whenever I had another primary care rotation, I would ask the provider, like, hey, are you trained to do this? Are you looking to get trained to do this? Would you do this? And the answer was always the same. No, period. Not my problem. Not going to deal with it. So that's something I've seen. I've seen providers, for whatever reasons, not want to get involved. And I've seen one provider who did want to get involved and took on a panel of patients himself. So, yeah. Thank you. I'd like to make a follow-up comment on that one. Thank you for sharing. I definitely have seen those barriers, and the X waiver in particular, which is why I'm so glad now that we have finally done away with the X waiver. That was a huge barrier. And I think, you know, some people maybe was too onerous to take an eight-hour course. Other people, I think, might have used it as an excuse due to stigma or time, right? In primary care, you often have to deal with 10 or 15 problems at once. And so it's much easier when something like substance use comes up that could take your entire visit, right, to say, okay, I'm going to defer that issue to a psychiatrist, an addictionologist, somebody else that's not me. I don't have time to put in that person's, you know, suboxone refills, they could be saying, right? And I'll admit, even though I was, you know, always felt strongly about treating substance use disorders, initially when I started practicing, I did not have a big panel of suboxone. I was not commonly prescribing it because I didn't want to be that one person, like you said, that brought in all the patients on suboxone coming to me. And so there's always been this thought of, like, when are we going to get a critical mass where it's just normalized where we can all prescribe this? And so now, legally, hopefully that will happen. And, you know, now everyone's going to be mandated when they renew their DEA to get eight hours of training if they hadn't had it yet, which is kind of equivalent to the X waiver. So hopefully we'll see at least the education level barrier will be decreasing from the physician standpoint. And that's for all doctors? For all doctors that want to renew their DEA. How often do doctors have to renew their DEA? Two years? Three years. Oh, three years. Thank you. So I started using buprenorphine in 2003. It was pretty much as soon as it came out because I got tired of referring these people somewhere else and seeing them bounce back in my face. And so I worked in this system. It served 50,000 people a year. We had a dozen or so primary care clinics, plus we also did the health care for the homeless program in D.C. We had all these clinics and homeless shelters and drop-in centers and whatnot. But you were limited to 30 patients when it first came out, and D.C. Medicaid had a prior authorization program where you had to call every 90 days to get a prior authorization for Suboxone, which made no sense whatsoever because most of these guys are going to be on it for years. Most of the guys I was seeing had been in jail, prison, 20-year histories of heroin abuse. I mean, it's ridiculous. So there were so many barriers in terms of treating these folks, and I was the only guy certified to prescribe buprenorphine at that time. We had maybe 100 providers, physicians and nurse practitioners, et cetera. And so that's how we got started. And what I found over the years is why did we have all these restrictions on buprenorphine? We don't have restrictions on benzos, and a lot more people overdose on benzos than overdose on buprenorphine. And so it's easy to use. People respond great to it. And, you know, it remains to be seen if there's going to be this big uptake in people prescribing, even now that we don't have the X waiver. But we'll see if more and more people get into it. But a lot of people don't like to work with addicts. They're problem people, they lie to you. But my experience is these guys keep their appointments, they take their meds, some of them are on probation, parole, getting urine and drug screens, they don't want to go back to jail. But they're some of the most reliable patients and compliant patients that I have in practice. Can I ask a question? So I asked this question to the future APA president, we were at a dinner actually about a month ago. Do you think that general psychiatrists, it's ethically, you know, should be within their purview to prescribe their patients MAT, including buprenorphine? Absolutely. I think primary care docs should do it, too, because there's not enough psychiatrists to go around and treat all these folks. Yes. And that's one common thing I always see from both sides is it's hard for anyone to take ownership of this issue. Primary care docs, a lot of them, and psychiatrists. And each side kind of puts it on the other side. So I think it's something we all should do, definitely. And I have started doing it, finally, and it's been very rewarding. And it's not that hard. It's pretty easy. Yeah, thank you for both of your comments, because you're highlighting, you know, there are barriers in our, you know, it's a politically fraught issue, so there are barriers in our political system, there's biases there, in our payment system around how medical and psychiatric care, because they've been separated for so long, and social barriers that have also contributed to this challenge. But yes, I'm glad. Thank you for bringing up Dr. Lavounas, because yes, he visited UC Davis last year, last month as a visiting professor, and so I think it's a, the timing is very important to have an addiction psychiatrist as the incoming president or the now president of the APA. And so we did have a nice discussion about that. So thank you for your comments. And I think what we're going to do is skip ahead to Dr. DeMartini's part of the presentation, and then we'll continue to have a discussion throughout. Thank you for your comments, and again, because this is a small group, I hope the whole thing can remain a small group activity. I may try to engage you a few times here and there, but if you can, please speak into the microphone for those that it's being recorded. Now we're going to switch gears a little bit to, from kind of the background soapbox talk to why we were doing this, into what specifically we decided to do. And one of the barriers that we were faced here at UC Davis is we are not an FQHC, and so we don't have sort of like one payer model. We have a very complex Medicare, Medicaid, commercial-based insurance population that spans a really large region in Northern California. And so what we wanted to do is take a small clinic and try to apply some of the concepts for best practices in deciding how to expand that out, hopefully, to our larger network of all of our clinics. And we decided to pick, actually, the most complex clinics. They're the most FQHC-like in terms of they do have the largest Medicaid population. We have a lot of MediMedi patients who are dual-eligible for Medicare, but there's also a decent number of commercial insurance. This is in our academic internal medicine clinic and academic family medicine clinic. And they're doubly complex because they have so many different faculty that are there for one half day a week and so many different residents that are there one half day a week or one half day every other week or something. And so you end up having, you know, a couple hundred physicians that are all in and out. So it's really challenging to implement something at like a physician education level because how do you capture all these people and ensure they're doing everything? So you really have to kind of think of things at a systems-wide population level and really simplify things systematically and electronically so that everyone gets equitable care. So Dr. Sher already mentioned the U.S. Preventative Task Force, which you may already know is kind of like a volunteer council of people that's supported by the Agency of Healthcare Quality and Research. And they make various different recommendations or practices that are implemented into primary care. And they take a lot of thought into different screening metrics, whether or not these practices should be applied broadly to all patients, whether they should be applied in certain circumstances or whether they should not be applied because they could either be harmful or there just really isn't enough support in primary care to implement these. When we have all these different best practices at UC Davis, I think there's like 20, 26 different ones now that our PCPs have to do, and when you throw that all on the physician level, the provider level, it gets very onerous. And so now we're starting to think more and more of like team-based care, systems-based care. And we need to think about the other people that can help us implement these changes. So directly applicable to our talk, the USPTF recommends alcohol use disorder, alcohol unhealthy screening is done for all patients in primary care. And they also implement some sort of a brief intervention with patients who screen positive for unhealthy alcohol use. On the other hand, for drug use, they do kind of add that caveat in there that screening should be implemented if there is appropriate treatment available for the patients. I think kind of like going back to the things like the X waiver and such, if you start screening for an opioid use disorder but you can't treat for it, are you creating more problems? Hopefully maybe they'll change that recommendation in the near future now with some of the changes politically. And also they do make the caveat in there that screening is not giving a drug screen to all of your patients, it's asking them about their drug use because that's opening up a conversation that's going to open up more different psychosocial aspects that are really important to the care. So we kind of did a multi-pronged, a multi-step approach into integrating to expand access to treatment and screening of substance use disorders and help reduce stigma. And the reason that we're doing this is because patients in primary care actually may be more likely to enter into treatment than patients getting subspecialty care. And access to subspecialty care is very challenging, can take months or sometimes never. The majority of patients with substance use disorders will probably never see an addiction psychiatrist. Also primary care teams are a key foundation to population-based services. The population of people seeing addiction psychiatrists is going to be very small and it's going to be patients kind of at the later stages of their disease. So when we're thinking of prevention, if we're really trying to have the biggest impact in terms of morbidity, mortality, and cost, we want to catch people early in the disease. So right when they're at the kind of point of unhealthy use rather than a severe alcohol use disorder or substance use disorder. Primary care providers do have established relationships. They may have trust with their patients. There's a lot of stigma on multiple different fronts that can be a big barrier to patients seeking those kind of subspecialty services. They already know the patient's past history. And with that question that I asked, MAT might actually be at the psych level or the primary care level. But traditionally, a lot of MAT has been offered in primary care. But maybe we can all offer MAT. So you may already be familiar with the term SBIRT. So SBIRT is basically a model that implements screening, brief intervention, which is usually brief counseling done by the primary care physician or a counselor in the clinic, and then if needed, referral to other advanced addiction services or psychosocial services. And the whole purpose of SBIRT, again, is trying to catch that patient population early in the disease before they have the worst outcomes. So with any quality improvement type project, we like to make a SMART goal, so something that's specific, measurable, achievable, realistic, and timely. And so for our project, what we decided was by May of 2023, so by this month, we wanted to have 30% of patients screened in the past year in both our family medicine clinic and our internal medicine clinic. And then what we were going to do is we were going to integrate a substance use navigator into our primary care clinic. And then they were going to use this data to outreach and try to understand a bit more about any disparities that might exist in the screening and treatment processes at UC Davis. And so you can see here in the table we have our baseline screening rates. Our family medicine clinic had less than 1%. This doesn't mean that the PCPs were never talking about substance use disorders or alcohol use disorders or any unhealthy use in clinic. It means that they weren't necessarily using a validated screening questionnaire that we could capture, however, much, much less than our goal here. Our internal medicine clinic had slightly higher numbers. And I'm an internist, and I was in that clinic, so a little proud to say that, that we were doing a little better in the beginning. But I'll show you later. Maybe family medicine beat us. And part of that is because we actually had a resident who graduated a couple years ago who had implemented a quality improvement project trying to implement substance use screening. I think our numbers were actually higher a couple years before, and they kind of petered off after the resident graduated, which is one of the challenges with a resident quality improvement project is how do you make it sustainable, right? And then when we look at all of UC Davis primary care network, it's about 1% of patients. And so that's where maybe we would implement this pilot too with some modifications. So first what we wanted to do is implement our standardized substance use screening into our workflows. We didn't want to make it something that was at the individual provider level where they're going to have to remember to do everything. We wanted to make it a standardized thing within our clinic with multiple different team members that are going to be assisting with this. We wanted to have electronic health record best practice advisories, basically screens that pop up recommending what should be done if it hasn't been done in the past year, including drug and alcohol use screening. And we wanted these advisories to be functional and not be onerous on top of all of the other advisories that primary care physicians are already getting. And then we also wanted to provide scripting to the staff and the providers, which I'll talk a little bit more about in a minute, especially due to the stigma in these areas. We were very fortunate to, it took us some time actually to do this, but we're really fortunate to have our substance use navigator here with us all throughout today. It took us quite a while to find somebody who could work as a substance use navigator in our clinic. And I think that kind of also reflects back to your statement about finding that primary care physician who was the one physician who was taking care of all the addiction in that area. And I think substance use navigators are also far and few between. And so these are people who can function as counselors, providing a bit of motivational interviewing, supportive kind of counseling around the substance or alcohol use, as well as link patients to more advanced resources, whether it's kind of like a recovery treatment center, detox, whatever it is that they need that we can't already provide in primary care. And one of the complexities to this person's role, which we had to have several meetings about, we actually had to have a whole separate committee, it was like six meetings or eight meetings or something, was just to take a repository of all the different substance use resources for all the different insurance providers. Because every insurance payer has a different system that they like to use for mental and health and substance use that's totally separate from primary care. And so we had to kind of put all this stuff together in terms of intensive outpatient versus hospitalization for patients with substance use disorders. And then we had to find a way for that substance use navigator to interface with our advanced addiction psychiatry team, which was all we had prior to this pilot. And they provide great services, but it's a very small subset of our population in primary care. They cannot see the majority of patients that actually have a substance use disorder in primary care just due to capacity. And then finally, what we would like to do is take this to the population level and look at where we are with the pilot in terms of are there any disparities, are there certain populations that aren't getting the screening or aren't getting the treatment, and do we have patients that aren't getting enough of the substance use navigation and how do we improve upon that. And so we decided to break that down by race, ethnicity, language, sexual orientation, gender identity. So as we mentioned several times already in this talk, stigma is a huge issue. There's still a lot of people out there that believe addiction is a choice and not a disease. And a lot of the wording that we use around addiction, even the term addiction itself, even the term substance use itself, it feels like we just don't have a perfect term to kind of talk about that isn't stigmatizing. So I think part of it is really just trying to normalize that people do use substances, people do drink alcohol, and how do we normalize it and differentiate what is unhealthy and how do we intervene early in those stages so that people don't have to feel a lot of shame about that. And so we had work groups formed of multidisciplinary, multi-professional staff, including LCSWs, LMFTs, physicians, and nurses, and we got together and talked about what is some of the language that we should be using amongst ourselves as well as with patients. For example, the term substance use navigator, we're still not even sure that's really the best term. Just the fact that it has substance use in there might kind of scare away some patients just because of all the stigma associated with it, but yet we're also trying to normalize it so that we're not chasing patients away from using these terms. So it's challenging. We did together decide on what were some of the kind of standardized scripts that we would recommend everyone at every level to use from the appointment schedulers to the medical assistants to the physicians when they did identify there might be a substance use or when a patient might benefit from these counseling resources. So these are the screening forms that we use, and I said I was going to do some audience participation, so I'll do some now. Who remembers being taught, and this will be interesting since we have so many different levels of training in medical school, that the CAGE questionnaire is what we should use to screen for alcohol use disorder? Okay. So the CAGE questionnaire was developed in about 1968 or so, and now it is not the preferred method. Does anyone know why it is not the preferred method? Or does anyone remember what the CAGE questionnaire stands for? That might be a little easier starting point. Yeah. So ever felt the need to cut back on your alcohol? Ever been annoyed by anyone telling you you need to cut down, feel guilty about that? You ever need to have an eye opener in the morning to keep yourself from getting the shakes, right? So this questionnaire was found to be pretty valid and sensitive for detecting chronic alcohol dependence, however it misses a large population of patients who don't have chronic alcohol use but still have unhealthy more recent use, and so what happens is if you focus only on that population, you're actually going to miss the population that we want to intervene on early with SBIRT. And so it's also been found that the CAGE questionnaire was not as sensitive for detecting alcohol use disorders in women as well. And so they developed as part of these findings the audit questionnaire I think in 1989, so about 20 years later. And the audit questionnaire kind of looks at different parts of alcohol use disorders, so not only kind of the frequency of use, also kind of elements of physiologic dependence, but then also the psychosocial kind of consequences from alcohol use. And kind of from those three domains they developed even a shorter three-item audit questionnaire, the Audit C. So in our project what we did first is we just asked everybody a one-item screening for alcohol when we asked if they have four or more drinks in a day for women or five or more drinks in a day for men in the past year, and if they responded to one or more then that meant they were going to get the Audit C. And then likewise we had a one-item screening questionnaire for any drug use, and that was just how many times in the past year have you used a recreational drug or used a prescription medication for non-medical reasons. I'm not sure I even love the wording of this question, but it has been found to be very well validated, actually very high sensitivity and specificity for drug use, but maybe over time we'll find some better wording for this one. But anyway, so in that one if patients responded one or more days that they've used that, then we would give them the drug screening questionnaire, the DAST, and we used the 10-item version of that one to kind of match along with the Audit's 10-item. There is a 20-item version, but it's not really any more specific or sensitive. And the reason that we kind of like to use these slightly longer kind of medium-sized questionnaires is sometimes you can also track people's progress over time with using those rather than just using like the Audit C, which only has three questions. It's a little harder to do that. All right, so now I'm going to be handing off to Alvaro, who is our Substance Use Navigator for our project. All right. Thank you, everyone. So we discussed this new program that we implemented, this pilot program, but the question is how do we get patients into, you know, to meet with the Substance Use Navigator? So previously, you know, traditional, you know, primary care physician roles would be to address whatever the primary issue that the client has, the patient has at the time. And many times we don't have time to discuss alcohol use, drug use, and so many times this is only brought up if the client brings it up or if the primary care physician has time to research and look through the electronic medical record to see if there's a past use. So what we're doing now is, again, with the annual screenings is we're actually able to check right at the beginning of their check-in. So at the front desk, you know, they're able to see whether we have an updated annual screener. And if they do not, then we actually provide it for them so they're actually filling it out while they're in the waiting room, aside from other paperwork that we normally have for annual screening and checkups. So the medical assistants from there check in the patients, they confirm that all the forms are completed, and then they manually enter them into the electronic medical record. You know, we would then inform the primary care physician that this information has been included. And so, like we discussed, we have the best practice advisory, which actually fires off a notification if any of the patients have a four or higher score on the audit or three or higher on the DOST. And so that lets the primary care physician know, okay, this patient scored positive for alcohol or drug use. And during this time, if possible, the primary care physician would discuss what the SUD navigator services are, kind of give a little bit of information in terms of what's entailed and so forth. And they can have a discussion whether they're interested or not. The great thing about this, too, is that also if the primary care physician doesn't have time to discuss it, the BPA will still fire even after the visit. So that way the primary care physician will still get the notification that, hey, this patient might benefit from the substance use navigator, do you want to refer? And so at that point, you know, we can go ahead and place the referral. And what's great about it is the BPA automatically pre-selects the substance use navigator for this advisory. So that way there's no additional stuff that they have to fill out. And they just do a simple dot phrase to kind of do the documentation, and then that's sent off to the substance use navigator, which is myself. And so from there, there it goes. There we go. So from there I received the referral through our coordinators, and I received the phone numbers and information, and kind of am able to look through the medical history, look at the actual encounter that the primary care physician provided, and I'm able to get an understanding in terms of what is going on with the patient. I would then make the initial appointment or initial phone call explaining what the services are. They're generally one, the first visit is one 45 to 50 minute intake appointment that would kind of gather information. And if they're interested, we go ahead and schedule, and like we discussed earlier, we do SBIRT. So we do the screening, the briefs, intervention, and then referral to resources. And so from here, we can determine whether they would benefit from, you know, external community resources, or if they actually would benefit or actually qualify for the addiction medicine within UC Davis. And then after that initial appointment, I tend to do a follow-up, either a phone screen or a video visit, just because it's easier for the patients to come in, where we just kind of check in. How was that resource? Were you able to get connected? What were the barriers that prevented you from getting connected? And then we can kind of follow up with that. And then from there, we do all the documentation, so that way the primary care physician can see what was done, what interventions were done, what resources were provided, and so forth. So the approach that I typically use with each patient is first, you know, we do a lot of motivational interviewing, but one of the main things I like to do is just educate. A lot of these individuals don't know what's going on. They don't understand. They know how certain substances affect them physically, but how it affects them emotionally, physically, and how that can affect everything else. I am very client-centered in terms of we try to see where this patient is in terms of their stages of change, right? Whether they're in the pre-contemplative, like they're not really sure of something going on, so we're just kind of, they don't really believe that there needs to be change to the patients that actually are contemplating change, versus those are actually in the preparation stage. So I kind of meet with them to see where they are. We also like to discuss what are their goals. Some would prefer to do moderation management. Some would prefer abstinence, but it also depends on the level of severity of their usage, and so we kind of work to see what are their goals. What do they want to accomplish? Do they want to accomplish from drinking so much or using a certain amount, you know, a week to cutting down to half? Understanding what their wants and needs are, and also just understanding what their views of substance use are. How does it affect them? What is their relationship with the substance? And then we provide very short-term interventions, techniques, strategies, so like for alcohol use, like we'll do like the drink tracker, like drinking analysis, so like identifying stressors and situations that lead to usage. Also creating a list of coping strategies and skills, creating schedule, structure, and routine to help with those times. So if the patient notices, I really get that craving when it's late night, two in the morning, trying to figure out some other coping strategy, some other, trying to alternate their routine to kind of prevent them from having that time. And then the final, one of the final things that we do is provide them the resources. So it can vary from inpatient, outpatient, and from outpatient we can do partial hospitalization, intensive outpatient programs, even moderation management programs. And again, follow-up to see how they're doing. Like everybody was saying before, insurance is a major factor with this, so we're looking at what their insurance is. If they're Medi-Cal, what are some, what are certain Medi-Cal programs that they can use? If they're private insurance, we look through their actual private insurance provider list and try to see, okay, what specialists do we have that are at your disposal? And so the substance use navigator position can be used in kind of one or two ways. One, as the bridge to these resources by helping the patient identify what is available to them. But at the same time, using brief interventions and coping and brief techniques in the moment, in session, to kind of help them take these new techniques and strategies home with them, right? Creating a list of supportive person, people that can help them out. Creating a list of coping strategies that have worked for them. You know, I use a lot of solution-focused problem solving therapy, as well as some CBT. So cognitive behavioral therapy, where we do structured routine and a lot of that. So I just kind of want to give a couple of patient stories to kind of highlight how the substance use navigator can be used in both ways. So Bruce was a 76-year-old male with mild alcohol use disorder and was currently drinking about two to three 32-ounce beers a day. And this typically started as early as 9 a.m. and would continue on throughout the day. But sometimes he would binge drink these drinks within a couple of hours. He was a Vietnam veteran and started drinking overseas to actually help relieve stress and anxiety and what he was experiencing back then. He also has PTSD, which included night terrors. And he also has been suffering from severe dementia, where at times he believes that he's still in active duty, which has caused immense distress, not only for himself, but for his wife. And so we kind of identified what were some of the needs that he required. And one of the things that we noticed is that he had actually been in contact with the VA. So one of the goals for us was, okay, what can we do to get him with the VA to get him with the substance use programs there? On top of that, trying to get him into the UC Davis Addiction Medicine Clinic. And one of the cool things about this is we were also able to collaborate and get his wife connected with our collaborative care program to kind of help deal with the stress and anxiety surrounding his dementia and his alcohol use. So that was kind of how we were able to locate the resources for this patient in this in the session. Wife was actually there as collateral to kind of help gather this information. And so that was a great way of how we were able to navigate. Now, John on the other hand, was a 70-year-old, 74-year-old male with mild alcohol use disorder and an extensive family, extensive family history of alcohol use disorder. And he was drinking about five to six drinks a night to help him sleep and relax. Same thing, another Vietnam veteran who began drinking heavily overseas and just had this pattern of, between certain times, he was just kind of relaxing, bored, and didn't know what to do with himself. So what we did is we actually discussed specific strategies, how to create structure at home, how to create techniques and things to kind of help keep his mind off of those urges, identified triggers. And for him, it was he's just bored. He stays up until a certain amount of time just because he has nothing else to do. So adjusting his sleeping routine to kind of help cut down that time that he'd be more likely to drink. The other thing we also noticed is when were the times that he did not drink. And those were the times, the nights that he did not drink as much were the nights that he were, the following morning is when he had things to do. He had appointments, he had to visit with, he had to take his grandchildren to school. So we found that, hey, if you have things to do in the morning, what can we do to, let's try to see if we can structure your morning in such a way that you have responsibilities. So do your responsibilities in this. So just with that one session and providing just very brief techniques and coping strategies, he was actually able to cut down his drinking to, you know, five to six, five to six drinks only half the week. And the other days were only three to four. So there's still, there's still alcohol usage, but he was able to decrease it somewhat. So again, this is just to highlight that aside from providing the resources to these patients, we could also provide brief, you know, strategies, brief interventions, brief therapy, you know, whether it's solution-focused, cognitive behavioral therapy, and also just an expert in general. So that's just how we want to highlight what the substance use navigator role is. And then I will pass it on to Emily. I am going to talk about some of our initial pilot data. So we started this pilot in November of last year of 2022, and it's been running for about six months. And as Jeremy introduced, one of our clinics started just under 1% screening, and the other started around 13%. And we were very excited and pleased to see that every single month the screening rates just continued to go up. So both clinics actually exceeded the, their, the screening goal of 30% by April of 2023. Family medicine is up to 40, almost 43%, and internal medicine at 31%. So Jeremy, there's still time in our pilot. It's not over yet to surpass family medicine. But we've just been really encouraged to see this data just suggests that the screening workflows are kind of baked into the primary care practice, and so we're excited to see that continue to rise. So in the six months, we've screened over 5,000 patients. This is a measure of our annual brief screening questionnaire. Of those patients, we've found that about 11% have been flagged for alcohol use, meaning that their audit score, if they were prompted to take the audit, was four or higher. So that's a relatively low audit cutoff that we've set. So we've kind of heard some feedback internally that 11% might feel a little bit high, and we think one of the reasons might be that we've set a relatively low cutoff. Also, I just wanted to note we did have an EMR scoring issue during our pilot, and so our percentage that might be a little elevated because of that as well. So we're looking forward to seeing how that changes over time. And we are seeing a little under 1% of patients who are being flagged for drug use. We've set our DAST cutoff at a score of three or higher, and I think that's consistent with what we had anticipated going into this pilot, that we would likely identify more alcohol use compared to drug use. Of the patients flagged, we've had 35 referrals sent from primary care doctors to Alvaro, our son. We have had, I think, in the ballpark of 15 additional referrals that have gone directly to our addiction medicine clinic. The average, so some patient information around our referrals, the average age of patients being referred is around 51 years, with a max of 78 years old and a minimum age of 26. Most of the referrals have been for male patients, so 26 referrals for male patients, nine for female patients. And looking at race and ethnicity, 19 referrals have been for white patients, 10 for African-American or black patients, two for Latinx, Hispanic patients, one for a Native Hawaiian or other Pacific Islander, and three in an other category. And we'll talk a little bit about some of our race, ethnicity data we're looking at later as well. And 12 patients, so of the 35, not all have ultimately been interested in meeting with Alvaro, but Alvaro has been working with 12 patients. And so I'll talk on our next slide a little bit about kind of where we're focusing our efforts as we continue the pilot to hopefully increase referrals and patients who are engaged with our son. So I think this will wrap up the pilot overview, but we just wanted to call out some of the successes that we've seen in this pilot, where we think we have opportunities, and where our next steps are. So in terms of successes, again, our screening data suggests that the screening workflows in primary care are working and being followed, and that's really encouraging. We've had really positive clinic engagement from the physician, clinic management, and staff levels. We've just had exceptional partners, thank you Jeremy and Kate, who's not here as partners in the clinics as well. So we've just been really encouraged by the partnerships in this project. And then we've we successfully did embed a substance use navigator in primary care, so our kind of continued pilot focus will be to look at how we can increase referrals. But in terms of just the logistics of finding the right fit, finding clinic space for our navigator, schedules, things like that, we're just excited that we sort of have figured out and found a model that's working. So in terms of opportunities, going back to the data on the last slide, I think we're really focused on how we can increase referrals to our navigator. With 11% of the 5,000 patients screened being flagged for alcohol use, there's opportunity there for more patients to be referred. And so one of the key things we're working on right now is an outreach process, so identifying patients who have been flagged in screening and didn't get a referral, and then a workflow to contact them and invite them into this program if they're interested. So for next steps, we would like to complete the pilot. I think we're planning to run the pilot for a few more months to kind of focus in on those opportunity areas. We'd also like to complete a disparities analysis, so we'll show some really early data on kind of how we're thinking about this right now. But we want to make sure that our processes are equitable, and if we are missing certain subpopulations in our screening or referral processes, we want to know that so that we can think about ways to close those gaps. And then ultimately, we would like to expand this out to our other primary care sites at UC Davis. So I think we have 15 other primary care locations that are not participating in this pilot that we would like to, likely with a few modifications to the workflow, expand this to. So like I said, we'll look at some early kind of data. I think this is within the last couple of weeks that we've started looking at this data around disparities. But before we get into that, I just wanted to show this framework that we've used to sort of think about how we're addressing influences on disparities at multiple levels. So this is adapted from some work that was done around reducing disparities in hypertension patients that really is meant to look at what are the influences on disparities at every level. And so what we've done, we have an internal inequities group that shared this with us at UC Davis. And so we've kind of taken our project and looked again at every level to think how are we addressing each piece. So from the individual patient level, you know, we're really focused on the universal screening. So every patient gets screened, providing brief intervention to every patient who's flagged, and having a mechanism to navigate folks to resources if they need them. At the family and social support level, the comprehensive resource list that Jeremy talked about earlier includes family resources. And Alvar, you had a great example as well of connecting a family member into resources. At our organization level, you know, we're really trying to take a population health approach to this project, to making sure that we have equitable screening and referral practices, and that we're using data to identify disparities and again try to close the gap with workflow adjustments. At our provider and our clinical team level, we really wanted to take time to think about scripting and minimizing the stigmatizing language that can be used when talking about substance use and use disorder. So we were trying to be very thoughtful there. At the local community level, again our resource list includes, we think, almost a good majority of community resources that are available to patients in the Sacramento area. At the state level, this project was made possible through a grant that we participated in through the California Healthcare Foundation that Dr. Scher mentioned earlier. And then at the national level, we are of course trying to be consistent with the recommendation for alcohol use and drug use screening in primary care. So just a sort of a framework that we use to sort of think about our project at multiple levels. So this again is some really initial data on our substance use screening practices by or rates by race and ethnicity. And we'll also look at this data by pair class. We plan to also look at this data by sexual orientation, gender identity, age, and language. But just share these, we'll share these two today. So what we're looking at, we took the patient population of both pilot clinics and stratified them by race and ethnicity. And so what we're looking at here is the percentage of each sub population, the percentage of that subpopulation that's been screened. So 23% of the American Indian or Alaska Native population in both of the clinics has been screened in this process. 22% of the Asian subpopulation has been screened in this process. And you can see the corresponding rates for each additional race and ethnicity. So we will, I think we'll be taking some time to sort of reflect on this and think about some follow-up questions and explore where, you know, where we might want to address some of our process. But this is kind of the initial breakdown of that data and the framework that we're using to understand where we have disparities. So similarly, and I think this is, there's more of a visual disparity here that we will be talking about, but this is screening rates by primary financial class or payer. So we can see that 31% of Medicare patients in our two clinics have been screened through this process. And the lower end, 15% of our Medicaid patients have been screened in this process. And so, you know, I think we'll be again reflecting on that and thinking about factors that maybe have got go into this disparity and brainstorming how we might be able to adjust to close that gap a little further. So I think I've mentioned a few of these, but what are our next steps in terms of disparities analysis? We'd like to look at this data at the clinic level as well. We'd like to review the additional subpopulations, sexual orientation, gender identity, etc. And then I think we'd really like to consider intersectionality of certain subpopulations as well and what that might look like. And then of course, ultimately this is so that we can consider adjustments to our process to address disparities that we potentially identify. So that concludes the presentation, but we'd love to open it up for for Q&A. Thank you. I have a question. So when I think about the percentage of patients who were screened but not referred, was that the provider who decided, OK, I screened them, but I'm not referring them to the sun? Is that right? Potentially. Yeah, so sometimes it's sort of a conscious decision, maybe. But that was why we thought, hey, let's automate it so it automatically selects the sun when the alert pops up. However, there's some complexities here. So a lot of times, this is a resident clinic where residents are only there one half day every other week or something, and they're on inpatient rotations in between. And so a lot of times, it's someone who's not the primary care physician of the patient seeing them. And they're seeing them for 10 other issues on that day. And so I just don't have time to address this or even think about this. And so they're kind of dismissing the alert. And so then we've changed it so the alert will then pop up again later for the PCP. So maybe over time, some of those will improve. But yeah, I think we still need to explore exactly why those numbers seem so low. How much of that is on the patient end? Is there a better way that we could engage with the substance use navigator? One thought I was just having recently was, can we use technology to, if we're going to implement this across multiple clinics, can we zoom in the substance use navigator right at that moment as soon as the patient says maybe they're interested so that they can at least just say hi and put a face to the name? And maybe that'll be more likely to want to engage with that person rather than just saying, I'm not interested this time. Right, just hook them in. Yeah, because I was wondering maybe if a provider was like, oh, this patient is pre-contemplative, I'm not going to refer them. Maybe that's one of the reasons why. But I think what I'm hearing is regardless of where the provider thinks that the patient is, if they scored four or more on audit, three or more on the other one, they should be getting a referral. Well, the system is kind of recommending that they do and automatically selecting it. But they can choose not to sign it. And so maybe some of them, like you said, are saying, oh, this person's not, they're pre-contemplative, so they don't need this. But that doesn't mean Alvaro can't work with them at their pre-contemplative stage. And so maybe there's a way they could at least introduce them to that resource so they know that it's there. That's what I'm thinking. Thank you. Hello. So my question is mostly on the screening part. So how did you go about selecting that particular screening, like one for alcohol and then, I assume, the full DASH? I know, for example, the logistics that we had with the cage, that wasn't very sensitive. And now they also have the cage aid, which combines alcohol and drugs. And then there's also the TAPS 1 and 2 that combines alcohol and drug use together. Is there time being, obviously, an issue in a lot of clinical encounters? Is it just trying to find a balance between a good screening tool that applies to everything or just going more in-depth on the alcohol one? Thank you for your question. And we actually did intros with everyone else in the room because it's a small group. Where do you work, just out of curiosity? Montreal, Canada. Oh, wonderful. Thank you for coming. So yeah, we had just about seven years or eight years earlier, we had gone through this with depression screening when thinking about which tools to use. So we used the PHQ-2 for depression, which, of course, is only two questions. And only if it triggers positive, then do we ask the full nine questions of the PHQ. So we wanted to use a similar approach in terms of time, which is really the two questions, one for alcohol use and one for substance. And if that triggered, then we would use the longer tools. And if you look at some of the national data, more and more there's more recommendations to use the audit and the DAST for population health level screening. And so we did get our group together. We even consulted with our addiction psychiatrists who work in the addiction psychiatry clinic to see what they recommended. And interestingly, if you look at the data for audit, you're more likely to pick up patients with alcohol misuse than even find use disorders. And so we had to really think about wanting to come up with a sensitive enough instrument that was going to pick up misuse as well. And so that was also part of the discussion. Interested to see if there are other comments here. Part of it, too, was just speeds. We were trying to get the pilot off the tracks really quickly. And the audit was already available as a build in Epic. Rather than having to pick a different one, and then we have to wait for someone to build it, which could take years sometimes. And do either of you have any experience with the TAPS1 and TAPS2 in comparison to, let's say, audit and DASH? I do not, but it sounds like you might. And I'd love to hear. No, it's a question because we're building an EAP-type program, which is looking specifically at screening for substance misuse and substance use disorder. And the clinical team that's responsible in our group keeps wanting to go with the CAGE and the CAGE-AID as a simple tool. But I was just looking for better alternatives because, again, the audit C is the other one they were looking at. It was just too long. And I found the TAPS, but I don't really have any. It was part of the, I think there's a US website that's specific for, like, it lists, OK, well, is this a good screening tool and then a good stratification tool that you can use to monitor? And it's kind of like a four-question for TAPS 1. And then if anything screens positive, I think it's like one question on alcohol, one question on opioids, one question on marijuana, and tobacco. And then if any screens positive, you get the full questionnaire. But I haven't actually seen it. I don't know who uses it or if it'd be a good tool. Yeah, I saw it listed as well in the same website that you saw, but I practically don't know anyone that's using it. And a lot of research studies, I don't know, aren't using it as far as I can tell. And then any experience on CAGE-AID versus the CAGE? Or is this still the same problems? Aside from knowing about it, I have not used it. So no. I don't know if anyone else has. Yeah, I can't say that I'm an expert on this area. I mean, a lot of this, we're kind of mixing best practices and also some parts of being practical, the pilot. And maybe that's the next stage as we have to think about are we using these in the best way? Are these taking too long, the 10 items? Do we need to be doing a shorter one for a follow-up? Can we only do the Audit C? I don't know. We might find those kind of things when we implement this across all the clinics. Do you do sort of monitoring? Like once you've done the initial set of questionnaires, do you use them then again? Like the PHQ-9 and the GAT-7, like to track improvement over time, do you do that with those questionnaires as well? So that's one advantage to the 10 question as opposed to the Audit C is you could potentially do that. I don't think we quite have a workflow of that with the Substance Use Navigator because we've just started that. But that is something that we could do over time. We could track those to see where people are in their stage. And last question is how long in like your current process, how long does that screening take? I mean, it's supposed to take together less than five minutes. Practically speaking, we should actually time it with the stopwatch and see. I mean, it all depends on the patient, right? And so if it's a non-English speaking elderly patient with dementia or something, you know, it's going to be a little bit more complex. And the screens we have right now are just in English. That's another thing we have to think about too is, you know, implementing these for other languages, so. I'm glad you asked that question because we didn't think about that. I mean, we thought about time, but we didn't actually think about tracking the time because a big part of this work was actually to get, you know, meet with all the residents and faculty at each of these clinics and actually talk about the screening. But then there was also the meetings with the back office staff and the medical assistants explaining to them why we were doing this, welcoming them to the team, you know, just like we had done for, you know, other behavioral health screenings like depression care. But we probably should track how much time it takes. So that's a, I'm going to remember that. We're going to add that to our list. Thanks. I wanted to come back to one thing you had asked too about. Oh, there was a quick, now it just escaped me. Tell me your question again because then it. My question? Before. Yeah. I think I was asking about what folks do if they're pre-contemplating. Oh, yes. Does the provider change? Like, I'm just not referring to this on my own. Yes, that, no, thank you. That cued my memory. So I'm glad you brought up the stages of change because, you know, a number of the patients have been screened once, right, through this program. But if we're not asking, you know, we don't actually know that a patient's going to be more receptive the first time they're asked. But you know what, if we identify an issue, they're not interested in a referral at that time, maybe at their pre-contemplative stage, but maybe a year later, right, if they hit rock bottom or they lose their job due to substances or some other adverse experience happens in their life, they will remember that they were asked by their doctor the first time, right, because we're normalizing it by bringing it into the healthcare space. And by not asking it, really, the meta-message is that we're not interested. And so it does take some time for us to really know how many patients over time will want to engage. And I think of that often as a longitudinal process. And it's also something we talk to our residents and medical students about a lot, is that when you're in a medical or surgical setting and a patient is struggling from a mental health or substance use condition, if they see a psychiatrist or an SUD counselor or an LCSW or an MFT in collaborative care, that may be the first time they've ever seen a mental health professional. And so that's an important, it has to go well, right? And so we have to think, so this is actually really hard work to bring in mental health and substance use treatment into primary care. And so it's one of the reasons we were excited to bring SUD screening and implementation work because by definition, that is an inequity. So thank you for your question. And you have another one. I do. But just building off of what you're saying, that kind of reminds me about intimate partner violence screening and OB-GYN clinics and things. Like you just always ask, always screen because you just never know when someone's going to feel comfortable enough to be like, okay, you've asked for the 20th time. I guess I'll tell you. But I was wondering if you guys had examples of some of the scripts that you shared with the team, like what would the script be like for the person who's maybe like answering the phones or greeting them versus the scripts that are for the providers to say and things like that. We don't have them with us, but I can tell you that so the script given to the front office who's offering the screener is very short. And this is a standard screener we're asking everyone to complete. The information will only be shared with your primary care doctor. So it's pretty short and then just kind of gives them something to say that helps them feel comfortable. Bringing it up, the medical assistant one is along the same lines with a little bit more meat, I guess, as they're, because they're also checking to make sure that the patient completed the screener correctly and if they were positive on the initial question that they go on and complete the full screener. And then the physician scripting was much longer and talked, I think we provided some guidance on how to talk about the navigator role with the patient and sort of encourage them to consider meeting with Alvaro. And so it was a much sort of longer, more comprehensive script than what the staff got. Yeah. I think one of the biggest challenges with the physician piece, the last piece, just like I said, there's just so many different physicians in and out because this is a resident clinic. So any sort of improvement project when you're trying to do something at the education level, it's much harder. So ideally there'd be some way to harness technology or something to kind of do that and improve that gap like we keep talking about between the number of patients identified and the number actually referred to the substance navigator. Maybe, I don't know. I'll just grab the mic so I don't have to keep getting up. So I remember from my time in undergrad learning about the importance of making sure that like any kind of community project language should be kept at a fifth grade level. Or is that taken into consideration when you guys were forming the scripts? Sure. I don't remember us talking about that specifically. So I don't, yeah, we might wanna go back to just reread it and make sure that it kind of meets that criteria. I don't think, I think we've also talked about, we haven't done it yet, but creating some sort of patient materials. And so if we do that especially, then I know we would wanna keep it at that level. Yeah, that's a really good point. We use like fourth to sixth grade reading level. And I found actually, it's one of the fun uses of ChatGPT is like I've programmed it and I said, please rephrase this in a fourth to sixth grade reading level. And it is really good at generating like patient materials and just formulating stuff. It's made to be a language. That's its number one strength is not coming up with facts, but rephrasing things is really interesting. I love the ChatGPT reference, which is like all over the news right now. So that is something, I guess we have talked, I mean, one of the coolest things about this partnership is that there's like three departments represented, right? We've got psychiatry, we've got population health, we have primary care. And the population health team is working very closely with lots of different departments to address social determinants of health, health literacy being one of them. So we're gonna also keep that in mind. We love coming to present our data in different forums because we always get ideas about process improvement. So thank you both for your questions and your comments. So you gotta be careful about how much information you're gonna give because I see these patients discharged from hospitals and they've got hospital discharge instructions that are 17 pages long, written by lawyers. They never read them. They throw them in the trash as soon as they walk out the door. So it's basically a total waste of time. And I think giving them a one page poop sheet is fine, but somebody came up with this idea, you gotta tell them everything or we're gonna get sued. And so then I send these 17 pages and they don't read it. They don't even read the meds that they're on or the diagnosis or anything because this is too complicated. I'm not gonna read this and they throw it away. So that's what the average patient is doing. I see a lot of patients with somatic symptom disorders too. And so some of them will do the opposite. They'll read every single detail and they'll freak out about every less than 1% risk of every possible treatment that they've ever been given. And I have to like go back and explain to them, what about, have you ever read vitamin C? Like what are all the possible risks of that one or aspirin? But yeah, it's really challenging to like how do we direct information to the patient in a patient centered way and individualize that. Well, they actually did a study a lot of years ago where they gave patients this information that a doctor would like to try you on this medication. Here are a list of all the possible side effects and half of them wouldn't sign it. It was for aspirin. It's the same reason why we have a lot of challenges sometimes consenting patients for studies, right? Because we're by, you know, sort of required by IRBs to have these, you know, sometimes three to five page or even longer consent forms. So, you know, so it is a real issue. I'm also a CL psychiatrist, right? So I do a lot of, you know, Jeremy and I are sort of cousins because he's a combined psychiatrist in internal medicine and psychiatry. But, you know, it reminds me of the literature around, you know, patients at higher highest risk for readmission within 30 days after discharge from a medical or surgical facility on the behavioral health side. If they, I mean, from a med surge facility, if they are admitted to the hospital with a depressive episode, or have delirium at some point during their admission, they have a much higher rates of readmission. And often that's because they're not gonna remember the discharge instructions from the surgeon or from the internist or the nurse practitioner or whoever's providing care on the day of discharge or the day before. And so that is something we think about, right? Patient communication and then the guidance from based on hospital policy and medical legal risks are often at odds with each other. So I agree with you. This isn't a question, this is a compliment. I wanted to just kind of commend you guys for the concept of trying to find people who are in that misuse category. I think that's a really smart design because like before it gets to the point of like, I don't know, people on euphoria, right? Versus, yeah, I think that's a smart design because like out of wherever anybody is in their journey with addiction or substance use, if you can catch them earlier versus them later, then that means the best chances. So it'll be really cool to see the outcomes of, I don't know, we'll never know if, you know, an alternate reality, if this intervention didn't exist, like what would have happened to those patients. But it is really cool and I don't know if you guys mentioned that, do the, I know that you mentioned that as the son you do follow up with the patients that you did interact with, but do they get like a follow up screening at the end of, I don't know, like do we get to see how far they've grown from just like the first screening to the last screening? So it's a great question. We're not at that point yet, but you know, if you look at the collaborative care literature for depression and anxiety, there is, you know, there's screening and then there's treatment monitoring and those are two different but related things. In the SUD literature, there's not as much there on treatment monitoring yet. However, you know, that's one of the things that I personally like about the audit and the DAS for reasons that were talked about is that there can be sort of a treatment monitoring approach. That part isn't as evidence-based. That being said, the collaborative care model does work for many substance use disorders too when you have, you know, a consultant psychiatrist and a behavioral health clinician or case manager working, you know, in partnership in a patient-centered way with our patients. But we are gonna talk about that as we advance this project and scale it up to the rest of the primary care clinics. So thank you for your comment. Sure. Yeah. Also, the TAPS is really good. I was just looking at it. Like it asks about like Klonopin and like all this other stuff and. Yeah, it's like a really good screening question. It seems like a great screening questionnaire, the TAPS too. Keep going with it. Any other comments from the panel or questions from the group? If not, we appreciate you coming to one of the last sessions of the APA. And we appreciate your discussion, your questions. And also, it's been such a wonderful thing working with this group. There's a number of people who are not represented in this room on the panel who've also been part of that project. But have a good rest of your evening. Thank you, everyone. Thank you. Let me show you the picture.

substance use disorder

primary care

screening

intervention

UC Davis

Audit-C

DAST

stigma

health equity

integrated care

motivational interviewing

cognitive behavioral therapy