Healthcare Access Flowchart for Alcohol Withdrawal: The community feedback period for this idea began on 8/13/2019 and will end on 10/12/2019

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Alcohol withdrawal is a well-understood phenomenon, but where to go for alcohol withdrawal is always an open question. Although alcohol withdrawal can be fatal, such a situation is always “treatable” by drinking more alcohol. Facing this choice, a healthcare referral network may not see a value in treating alcohol withdrawal when a person can keep drinking and this can be offered as a choice in combination with discharge instructions to “seek a treatment program” that doesn’t exist in the current healthcare setting. Thus we are off to the races for a not-so-fun scavenger hunt for a person experiencing substance use disorder and possibly an underlying mental illness. The scavenger hunts tend to worsen psychiatric symptoms and be not well tolerated. Such a system also provides Operant Conditioning encouraging the keep drinking behavior.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Orange County and others can learn what their health systems value when it comes to treating alcohol withdrawal. Maybe Orange County is Sunshine and Roses when it comes to Alcohol Withdrawal and we all can move on to something else.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
What is currently being done depends upon your payer. In general, the following is observed: If you have the Veterans’ Administration as your payer then you probably get a long half-life oral benzodiazepine and are sent on your way after a few days. If you have liver issues then you’re given a shorter half-life benzodiazepine and sent on your way after a longer stay. SARRTP may be offered. If you have cash money then you can choose from a wide variety of alcohol treatments that include withdrawal treatment, rehydration treatment, continued alcohol abuse, or choose from the menu of any drug you want. If you have private health insurance then you can likely get into a private alcohol treatment program in a Medi-Spa setting. If you have Medi-Cal/Medicaid then the path to treatment is unknown as most drug treatment programs prefer private payer. Unless an underlying medical/surgical issue needs immediate inpatient treatment it is unlikely that a provider will be conducting an alcohol withdrawal protocol with Medicaid/Medi-Cal reimbursement. If you do get into this setting then some kind of Alcohol Withdrawal treatment flowchart/checklist that bases doses of medium half-life benzodiazepines to symptoms is used. I don’t have any context for what happens if you have Medicare or Medi-Medi as a payer. However, Medi-Medi probably has the least access to alcohol withdrawal treatment of any payer. If you are at some healthcare settings at Stanford University then you get a benzodiazepine sparing alcohol withdrawal protocol.

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
There is nothing new about alcohol withdrawal. There is nothing new about anticipatory guidance. There is nothing new about differences in healthcare access depending upon your payer. Combine alcohol withdrawal, anticipatory guidance and understanding the difference in healthcare payers and you get something new.

What is the project idea? Please describe how this project will operate.
The project idea is divided into two phases: 1) Pre-funding, and 2) Post-Funding. In the pre-funding stage, the curious public health official would look at treatment rates for alcohol withdrawal at various healthcare facilities. After that observation, asking “Why are there such dramatic differences between these facilities?” Also asking, “Why do certain payers not show up in certain facilities?” would be interesting. If this project gets to funding then, at a minimum, establishing a payer-based flowchart for how to get alcohol withdrawal treatment would be required. A maximum would be a Veteran’s Administration level of service (or better without the waitlists) for an any-payer patient to receive alcohol withdrawal treatment. This entire submission is an educated guess, but likely occurring based upon anecdotal observations.

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July 25, 2019

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Thank you for your submission. The Innovation team will review this idea and post comments and updates when available.

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