Substance use disorders (SUDs) are among the most common and costly of medical conditions and are associated with significant morbidity and mortality. Typically SUDs have been managed with time-limited interventions, but there is growing evidence that for a subset of treated patients, substance-use problems are recurrent with severe symptomatology and high healthcare utilization. Although there is agreement that new models are needed for patients with complex SUDs, little research has evaluated the acceptability or use of such approaches. This pilot study evaluates patients' acceptance and use of a Collaborative Care Management Model (CCMM). The model is informed from chronic care models, but adapted for patients with complex and recurrent SUDs and high intensive service utilization.
The aims of this project were to: 1) estimate rates of registry-based recruitment among eligible patients seeking VA services via 4 clinical pathways during the initial 6 months of the study, 2) describe patients' use of CCMM services and compliance with monthly monitoring, and 3) describe patient-identified barriers and facilitators to engagement with CCMM services and examine patients' satisfaction with services. A secondary aim of the project was to evaluate pre-post change on substance use, psychological distress and health-related quality of life outcomes.
This mixed methods study recruited patients with SUDs and high utilization at the VA Puget Sound Health Care System. Data sources included questionnaires, chart reviews, semi-structured interviews and utilization data from the VA Corporate Data Warehouse (CDW). Utilizing the CDW, we developed a registry of eligible patients who met high utilization criteria. Patients on the registry were monitored for activity via clinical pathways [emergency department (ED), inpatient mental health, primary care, SUD specialty-care] and invited to participate in the study. High utilization was defined as 1) > 2 episodes of SUD specialty-care in prior two years, and 2) >1 inpatient SUD and/or mental health admission in two of three prior consecutive years, or >2 ED visits in each of the prior two consecutive years. Eligible patients completed assessments at baseline and 3- and 6-month follow-up, participated in monthly monitoring, and received CCMM services from a social worker and psychiatrist for 12 months. Recruitment rate was defined as the total number of patients who enrolled in the study divided by the total number of eligible patients who were invited to participate (Aim 1). Mean number of contacts were tabulated from chart reviews to estimate patients' use of on-demand, planned, and proactive services, and successful participation in monthly monitoring (at least 6 of 12 contacts completed) was estimated using proportions and 95% confidence intervals (CI) (Aim 2). Participants completed semi-structured interviews at 1- and 3-months after baseline assessment to identify barriers and facilitators to patient engagement and retention and patients' satisfaction with services (Aim 3). Secondary analyses assessed pre-post change on substance use, psychological distress and quality life.
Over 16 months, 419 patients met high utilization criteria. However, 43 (10%) patients had a current opioid use disorder with a history of methadone treatment, which could not be offered as part of CCMM services due to federal regulations. Furthermore, logistical and system barriers made it difficult to recruit in the emergency department and primary care clinical pathways. Overall, 33 patients were approached about CCMM services and 22 enrolled in the study (67% recruitment rate). On average, it required 22 days to enroll one participant. Participants' mean age was 55.2 (SD=10.0). All participants were male and the majority was Caucasian (59.1%). Eighty-two percent of participants had an alcohol use disorder, 40.9% had a psychotic disorder and 45.4% were homeless/unstably housed.
Over 12 months, the CCMM interdisciplinary team completed 485 planned, on-demand and proactive contacts, with 81.6% of contacts occurring in person and 18.4% by telephone. The mean number of contacts per patient was 24 (range: 3-73). On average, patients completed 18 (SD=16.2) planned visits and 6 (SD=6.0) on-demand visits over 12 months. The most common interventions with social workers included: supportive counseling (27.2%), motivational interviewing (25.2%) and case management (15.8%). The most common interventions with psychiatrists included: medication assessment (43.6%) and supportive counseling (28.9%). Approximately 68% (CI: 48.5-87.5%) of participants attended visits during at least 6 of the 12 months. On average, participants completed 45% of all monthly monitoring assessments.
Several barriers and facilitators to engagement and retention in CCMM services emerged from qualitative analyses of 1-month (n=15) and 3-month (n=14) interviews. Participants reported that individual appointments, team-based approaches and coordination of their care were all facilitators to engagement and retention in CCMM services. Participants also preferred elements of CCMM services that are less standard in conventional SUD specialty-care such as services that are delivered in individual appointments, personalized, responsive to their needs, flexible and focused on measured improvement versus abstinence. Several key themes related to the patient-provider relationship emerged as important to facilitating engagement in CCMM services, including familiarity with the providers, providers caring/taking an interest in them and feeling comfortable with the providers. Barriers to patient engagement included a need for more outreach and help with housing and transportation.
On a measure of heavy drinking days (5 or more drinks per day), 2 (9.1%) patients increased, 9 (40.9%) decreased and 4 (18.2%) had no change in their drinking. No data was available for 7 (31.8%) participants. Psychological distress was measured with the Kessler-10 and participants' outcomes were categorized by reliable change on the measure. Outcomes were as follows: 1 (4.6%) reliably worsened, 7 (31.8%) reliably improved, 7 (31.8%) had no change and 7 (31.8%) had no data. Minimal change in mean scores was observed on the physical health, environment and social relationship scales of the brief World Health Organization Quality of Life measure. Pre-post changes on these measures should be interpreted with caution due to the small sample size and low follow-up rate at 6-months.
Results suggest patients with complex substance use problems and high utilization of resource intensive services may prefer CCMM services over conventional substance use treatment approaches, which may improve clinical outcomes and reduce utilization of resource intensive services.
- Hawkins EJ, Danner AN, Malte CA, Painter JM, Lott AMK, Baer JS. Feasibility of a care management approach for complex substance use disorders and high acute services utilization. Journal of substance abuse treatment. 2018 Sep 1; 92:100-108.
- Bradley KA, Ludman EJ, Chavez LJ, Bobb JF, Ruedebusch SJ, Achtmeyer CE, Merrill JO, Saxon AJ, Caldeiro RM, Greenberg DM, Lee AK, Richards JE, Thomas RM, Matson TE, Williams EC, Hawkins E, Lapham G, Kivlahan DR. Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial. Addiction science & clinical practice. 2017 May 17; 12(1):15.
- Hawkins EJ, Lott AMK, Malte CA, Frank AN, Hamilton B, Sayre GG, Painter JM, Baer JS. Patients' perspectives on care management services for complex substance use disorders. Journal of addictive diseases. 2017 Jul 1; 36(3):193-206.
- Bradley KA, Rubinsky AD, Lapham GT, Berger D, Bryson C, Achtmeyer C, Hawkins EJ, Chavez LJ, Williams EC, Kivlahan DR. Predictive validity of clinical AUDIT-C alcohol screening scores and changes in scores for three objective alcohol-related outcomes in a Veterans Affairs population. Addiction (Abingdon, England). 2016 Nov 1; 111(11):1975-1984.
- Grossbard J, Malte CA, Lapham G, Pagulayan K, Turner AP, Rubinsky AD, Bradley KA, Saxon AJ, Hawkins EJ. Prevalence of Alcohol Misuse and Follow-Up Care in a National Sample of OEF/OIF VA Patients With and Without TBI. Psychiatric services (Washington, D.C.). 2017 Jan 1; 68(1):48-55.
- Hawkins EJ, Malte CA. Prioritizing the reach and patient-centeredness of substance use-related care. The American journal of drug and alcohol abuse. 2016 May 1; 42(3):245-9.
Mental, Cognitive and Behavioral Disorders
Treatment - Observational
Implementation, Substance Use and Abuse