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Health Services Research & Development

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FORUM - Translating research into quality health care for Veterans

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Research Highlight

Substance misuse is a common health condition among Veterans receiving care from VHA. The harmful health effects of substance misuse are well documented and include loss of relationships and employment, legal problems, medical and mental health comorbidities, and premature death. The term "substance misuse" refers to a range of behaviors, from the hazardous use of a substance to meeting diagnostic criteria for a substance use disorder (SUD).

Veterans who misuse substances obtain care in a range of settings including primary care and SUD specialty care (involving inpatient, residential, and outpatient settings). Substance misuse is common among primary care patients; almost one-quarter of male, and one-fifth of female OEF/OIF Veterans in VA outpatient care screen positive for alcohol misuse. Patients with SUDs frequently require varying intensities of care throughout the course of the disorder. Often, more intensive intervention is needed upon initial identification of SUDs, whereas less intensive care, such as monitoring, is needed post-treatment to support continued abstinence. Due to the chronic nature of addiction, this stepping up and stepping down of care may occur repeatedly over a number of years. Existing treatment guidelines emphasize coordination between care settings based on the core assumption that SUD patients have better clinical outcomes, and require fewer health care resources, when they are able to successfully transition between different levels of care.

Despite the availability of evidence-based interventions, providers face considerable challenges in facilitating care transitions of patients with SUDs. Accordingly, we have presented a conceptual model of SUD care transitions that takes into account patient, provider, and system-level facilitators and barriers that may impact the transition process. This model also offers intervention strategies that providers can utilize to improve care transitions. 1 A potentially useful intervention strategy to support this process is telephone monitoring.

Telephone monitoring is designed to increase participation in continuing care and improve outcomes for SUD patients who have achieved abstinence in intensive treatment. Much of the early work on telephone monitoring with SUD patients was conducted at the Philadelphia VA by James McKay, Ph.D., and colleagues. Telephone monitoring generally consists of one face-to-face session to orient patients to the protocol, followed by regular, brief telephone contact, with provisions to step up the level of care when a patient's status or symptoms indicate increased risk of deterioration. Research with SUD patients completing intensive treatment has demonstrated that telephone monitoring facilitates access to, and engagement with, SUD continuing care and 12-step mutual-help groups, and improves SUD outcomes. However, this prior work has focused on care transitions within the SUD specialty system. It is likely that opportunities exist to identify SUD patients in other settings and link them to SUD services prior to discharge. For example, a VA study found that, among Veterans in inpatient psychiatry diagnosed with both SUD and another mental health disorder, only 31 percent received continuing SUD care, even though such care was associated with a significantly reduced likelihood of rehospitalization. 2

To facilitate the transition from inpatient psychiatry to continuing SUD care among dually diagnosed patients, we are conducting a randomized trial comparing telephone monitoring to usual care (HSR&D IAC 09-055; Timko & Ilgen, Multiple PIs). The trial tailors the telephone monitoring protocol developed by Dr. McKay for SUD patients, to help dually-diagnosed Veterans at the Palo Alto and Ann Arbor VAs to utilize outpatient continuing care and mutual-help groups following discharge from inpatient psychiatry. Our experience conducting this project indicates that telephone monitoring can be integrated into inpatient psychiatry settings and delivered post-discharge. Based on this successful experience, we will use enhanced telephone monitoring in a project to help Veterans completing inpatient detoxification to access and engage with SUD treatment (VA HSR&D CRE 12-010). The latter project enhances telephone monitoring by incorporating Contracts-Prompts-Reinforcements (CPR), a method developed in VA to facilitate SUD patients' care transitions. 3

As SUD or dually-diagnosed inpatients step down to and complete continuing care, it is important that they also obtain regular primary care services. Making this transition is associated with many important health benefits for SUD patients: reduction in addiction severity, higher abstinence rates, and fewer emergency department visits and hospitalizations. Historically, SUD care has been poorly integrated into the rest of the health care system, so concerted efforts are needed to enhance the ways in which SUD patients receive needed medical, psychiatry, and SUD-related care.

  1. Cucciare, M.A., Coleman, E., and Timko, C. "A Conceptual Model to Facilitate Transitions from Primary Care to Specialty Substance Use Disorder Care: A Review of the Literature," Primary Care Health Research & Development (in press).
  2. Ilgen, M.A. et al. "Continuing Care after Inpatient Psychiatric Treatment for Patients with Psychiatric and Substance Use Disorders," Psychiatric Services 2008; 59(9):982-8.
  3. Lash, S.J. et al. "Contracting, Prompting and Reinforcing Substance Use Disorder Continuing Care," Journal of Substance Abuse Treatment 2013, 44(4):449-56.

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