Every year, approximately 30,000 Veterans receive inpatient detoxification (detox) for substance use disorders (SUDs). Detoxification is not SUD treatment; it is the medical management of withdrawal to prevent complications, which may be fatal. Detoxification inpatients who enter SUD treatment and peer-based mutual-help groups (e.g., Alcoholics Anonymous) have much better outcomes (less substance use, HIV/HCV risk behaviors, homelessness, rehospitalizations, Emergency Department visits) than those who do not. However, because of their unique characteristics (severe and chronic addictions, co-morbidities, lack of resources, self- and provider-perceptions as unsuitable for treatment), most Veterans discharged from inpatient detoxification do not enter SUD treatment. For many Veterans, a pattern of repeated inpatient detoxification, with each episode incurring higher risk of overdose, occurs. Therefore, in its Uniform Services Handbook, Mental Health Operations places major emphasis on increasing the rate of SUD treatment initiation and engagement following detoxification, to benefit Veterans' outcomes and prevent more use of costly health care.
The project's primary objective was to implement and evaluate Enhanced Telephone Monitoring (ETM) as a new and innovative telehealth intervention to facilitate the transition from inpatient detoxification to SUD specialty treatment (residential, outpatient, pharmacotherapy), thereby improving Veterans' outcomes and decreasing VA health care costs. In a randomized trial at two sites (VA Palo Alto and Boston), we hypothesized that patients receiving ETM, compared to patients in usual care (UC), would be more likely to enter and engage in SUD treatment and mutual-help, have better SUD and related outcomes, and have fewer and delayed acute care episodes. This project also conducted a process evaluation of how to implement ETM VA-wide, focusing on diverse subgroups of Veterans. Further, it is conducting a Budget Impact Analysis (BIA) to determine the impact of ETM on total costs of VA care. We hypothesize that the higher costs associated with ETM (because patients will engage in SUD treatment) will be more than offset by its lower costs of acute care.
Patients in the ETM condition received an in-person session while in the detoxification program, followed by coaching over the telephone for 3 months after discharge. The intervention incorporated Motivational Interviewing, and Contracting, Prompting, and Reinforcing, to provide support while waiting for treatment, and facilitate entry into treatment and mutual-help, and improve responses to crises. Patients were assessed at baseline and 3 and 6 months post-discharge for outcomes and non-VA health care. Analyses of covariance were conducted to compare the UC and ETM groups on outcomes at follow-ups. The process evaluation to inform the implementation of ETM used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Semi-structured interviews were conducted with inpatient detoxification staff and patients to yield facilitators of ETM implementation and modifiable barriers with associated action plans. For the BIA, costs of ETM are being measured through microcosting methods. For patients in both the ETM and UC groups, all inpatient, residential, outpatient, and pharmacy care are being measured from VA utilization and cost files.
Baseline demographic and clinical characteristics did not differ between Veterans randomly assigned to usual care (UC; n=150) or the intervention, Enhanced Telephone Monitoring (ETM; n=148). At the 3-month follow-up (i.e., at the end of the ETM intervention), compared to UC patients, ETM patients were significantly less likely to have received additional inpatient detoxification, but no more likely to have participated in 12-step groups or received outpatient addiction treatment. Even so, ETM patients had better alcohol, drug, and mental health outcomes. In contrast, at the 6-month follow-up, patients in ETM and UC generally did not differ on primary or secondary outcomes. Findings suggest that ETM deters additional detoxification episodes while the intervention is ongoing, but not after the intervention ends. Because telephone monitoring is low-intensity and low-cost, its extension over time may help reduce repeated detoxifications. In addition, qualitative analyses of detoxification and addiction treatment provider interviews found providers viewed the intervention as compatible with ongoing clinical practices.
VHA's Office of Mental Health and Suicide Prevention (OMHSP) is strongly committed to eradicating the dangerous, costly pattern of Veterans obtaining inpatient detoxification services but not receiving the substance use disorder (SUD) treatment they need. Telehealth interventions, a promising way to improve treatment access and outcomes by SUD patients, have not been utilized with the challenging population of detoxification inpatients before. In accordance with others in this CREATE, this project is helping to accomplish OMHSP's goal of implementing the Uniform Handbook by increasing Veterans' access to, engagement in, and benefit from, SUD treatment services, particularly among Veterans who are using VA medical services and need SUD services but are not receiving them.
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Grant Number: I01HX000895-01
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