building an collaborative care infrastructure for opioid-addicted patients in primary care

Building an Collaborative Care

Infrastructure for Opioid-Addicted

Patients in Primary Care

Christopher Shanahan MD, MPH, FACP

Assistant Professor of MedicineDept. of Medicine, Section of General Internal Medicine

Director, Community Medicine UnitBoston University School of Medicine

Board Certified: Internal Medicine (ABIM)

Addiction Medicine (ABAM)

Conflicts of Interest - None

1

Outline

The Need

An Approach

◦ Integration

◦Coordination & Collaboration

To Implement

◦ System & Workflow

◦ Electronic Health Record

2

THE NEED

3THE NEED AN APPROACH TO IMPLEMENT

High Burden of Chronic Medical

Disease in Substance Users

45% dx’d w/a chronic illness

80% prior medical hospitalizations

SU have a lower Mean SF-36

Physical Component Summary (44)

vs. General US population (50) p<0.001

Heroin & other opiates a/w worse

health.

De Alba, 2004THE NEED AN APPROACH TO IMPLEMENT4

Substance Users have Higher

Healthcare Utilization & Costs

In Patients (PT) w/ Chronic Medical

illness….

◦ PTs w/ Substance Use Disorders (SUD)

vs. PTs w/o SUD have….

utilization & costs

PTs in treatment (alcohol, drugs, both)

◦ (often) higher average healthcare charges

vs. PTs w/ other chronic medical

conditions Garnick, 1997

THE NEED AN APPROACH TO IMPLEMENT5

Linkage of Addiction & Primary Care

for Substance Users Advocated


Linking Primary Care & Substance Abuse (SA) Care Services

Samet, et.al. 2001

Patients Care convenience Patient satisfaction

Primary care / Mental health care providerPromotes screening for alcoholism in patients

Alcohol & drug abuse more likely in differential

diagnosis

Substance abuse provider SA Treatment outcomes

Develops Quality Improvement in SA programs

Societal health care costs & overall long-term costs

duplication of services & administrative costs

Examples of Potential Benefits by Perspective


The Case for IntegrationEvidence-based SU Treatment Essential for Quality & Safe Care

USPSTF supports SBIRT for alcohol use:

…A high priority & cost effective intervention…

Meds & counseling methods now available:

◦ alcohol use & treat opiate addiction

◦ Help avoid relapse & support abstinence

◦ Proven feasible & cost effective in Primary care

Treating PTs w/ SUD in Primary Care:

◦ PT treatment choices in comfortable setting

◦ Risk of stigma

Drug use SBIRT effectiveness?

◦ Evidence forthcoming (Saitz, ASSIST Trial) Workforce Issues Related to: Physical and Behavioral Healthcare

Integration Specifically Substance Use Disorders and Primary

Care A Framework Dilonardo, 2011THE NEED AN APPROACH TO IMPLEMENT8

AN APPROACH


Rationale for Integrating SA

Treatment into Primary Care

SU disorders:

◦ a/w risks for primary mental & physical

conditions

◦ complicate comorbid conditions

◦ are costly - Treatment ’s Overall costs.

Persons w/ or at risk for SUD can be

identified & treated in primary care

settings

Dilonardo, 2011THE NEED AN APPROACH TO IMPLEMENT10

Physical Health Needs

Low High

Su

bst

an

ce U

se N

eed H

igh

Quadrant II• Out-stationed medical nurse practitioner/physician

w/ standard screening tools and guidelines or

• Community PCP

• SU clinician/case manager w/ responsibility for

• Coordination w/PCP

• Specialty outpatient SU treatment including

medication assisted therapy

• Residential SU treatment

• Crisis/ED based SU interventions

• Detox/sobering

• Wellness programming

• Other community supports

Quadrant IV• Out-stationed medical nurse practitioner/physician

w/ standard screening tools and guidelines or

Community PCP

• Nurse care manager at SU site

• SU clinician case manager

• External care manager

• Specialty medical surgical

• Specialty outpatient SU treatment including

medication assisted therapy

• Residential SU treatment


• Detox/sobering

• Medical/surgical inpatient

• Nursing home/home based care



Lo

w

Quadrant I• PCP w/ standard screening tools and MH/Su practice

guidelines for medications & medication assisted

therapy.

• PCP based BH/Care manager competence in both

MH/SU

• Specialty prescribing consultation




Quadrant III• PCP w/ standard screening tools and MH/Su practice


therapy.


MH/SU

• Specialty medical-surgical based BHC/care manager

competent in both MH/SU







4 Quadrant Clinical Integration Model for SU Disorders

Mauer, B. 2006.

Quadrants I & III• PCP w/ standard screening tools and MH/Su practice


therapy.


MH/SU

• Specialty medical-surgical based BHC/care manager

competent in both MH/SU








Core Components for

Successful Integration


Coordination & Collaboration

Coordinating Care

After assessment,… Care coordination ensures key PT needs

are addressed:

Important Clinical / Social States◦ Adolescent, Pregnancy, Homelessness

Co-morbid conditions◦ Acute & Chronic Pain

◦ HIV Disease, Pulmonary Disease

◦ Hepatitis & Other Liver Disorders

◦ Co-existing Psychiatric Disorders

◦ Chronic Illness (Diabetes, Hypertension, etc.)


Collaboration

Establish clear Staff roles & relationships

Functional relationship of Nurse Case

Manager (NCM) to prescribing physician

Personal characteristics of clinical staff

Organizational infrastructure must

support program.

Supportive relationships w/ other local

SA treatment providers as resources to

Primary Care treatment providers


TO IMPLEMENT


Office-Based Opioid Treatment

(OBOT) in 2 Primary Care Clinics

Large Scale

Program

Small CHC

Practice

# of Patients 382 8

MD FTE (n) .9 (9) .1 (1)

# of Patients / MD 51 (21-94) 7 (2-10)

NCM FTE / (n) 2.2 (3) .1 (1)

Program Coordinator FTE / (n) 1.0 (1) -

Nurse Program Director 0.4 (1) -

Primary Care Clinic Sessions / week 22 1

Screening / TriageProgram

CoordinatorNCM

Intake Evaluation NCM NCM


OBOT– A Scalable Model

All Primary Care-Based Programs

Stage

Components

1. NCM & MD assessment

2. NCM-supervised induction / stabilization

3. Maintenance (Tx w/ illicit drug use

monitoring, wkly counseling) or d/c

OBOT

physician

intake

• Review/supplement NCM assessment &

treatment plan

• Physical Exam

• Evaluate other medical issues

Co-

Management

• PTs w/ active psychiatric diagnoses co-

managed w/ a psychiatrist

• Communication releases signed


Treatment Phases

Establish Clear Phases including:

1. Assessment / Induction

2. Stabilization

3. Detoxification / Supervised Withdrawal

4. Maintenance / Relapse Prevention

Create & implement standardized

policies & protocols for each phase

◦ Train staff

◦ Educate patients to goals & expectations


Assessment Workflow

Scripted screening

Triage to intake or

other treatment options

INTAKE

if co-occurring SU disorders…

Triage to other treatment options

(e.g, detox)

Documentation

THE NEED AN APPROACH TO IMPLEMENT

TASKS Establish diagnosis

Current opioid use

history

Substance use history

Identify / Refer PTs

needing supervised

withdrawal from alcohol,

benzos, other sedatives.

Identify comorbid

medical conditions / &

psychiatric disorders

Screen for / address

communicable diseases

Assess PT access to

Social supports,

Employment, Housing,

Finances, Legal advise

Evaluate treatment

readiness / motivation

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Patient Selection & Preparation

Ineligible if patient: Unable / unwilling to stop all illicit drug use

No interest in OBOT-B maintenance > 6 mos.

Will not sign all consents & agreements

(weekly counseling, transfer primary care,

communication releases)

Preparation

◦ Educate PTs on scientific basis of

medically assisted maintenance

Special circumstances

◦ Transfer from methadone maintenance


Physician Role

Review & supplement

◦ NCM Assessment

◦ Treatment Plan

Physical examination

Review Initial Labs

Initiate Primary Care

◦ Screen, Diagnose, Manage, Treat, & Refer

Chronic Disease (Hepatitis, Diabetes, etc.)

◦ Initiate Preventative measures (Hepatitis vax)

Co-manage PTs w/ active psychiatric

diagnoses w/ a psychiatrist.


Assessment - Exam & Lab Testing Physical Exam

◦ Evaluate neurocognitive function

◦ Identify sequelae of addiction / severe hepatic dysfunction

Initial Labs :

◦ Hepatitis A,B & C, Syphilis, Liver function, Pregnancy

◦ Urine Drug Testing: opiates, cocaine, benzodiazepines,

barbiturates, & amphetamines, oxycodone, methadone &

buprenorphine.

◦ PTs must test negative for all non-prescribed non-opioid

substances before buprenorphine treatment.

PTs new to primary health care

◦ Perform a broad primary care evaluation

◦ Broad H&P, other labs (CBC, electrolytes, Lipids, etc.)


Buprenorphine Treatment Safety

Careful clinical evaluation of all patients required to

Identify / address treatment contraindications.

PTs dependent / abusing sedatives, alcohol, or

both generally not appropriate for OBOT-B

OBOT-B Enrollment only if:

◦ clinical indication

◦ PT willing to d/c sedative hypnotics, alcohol, or

both by undergoing medically supervised

withdrawal

◦ h/o success tapering of other alcohol/drugs

No buprenorphine if…

Liver Function Tests: 3-5 X > Normal


OBOT Implementation Challenges

Establish Urine Drug Testing system

◦ Simple, Sustainable, Accurate, Trustworthy

◦ Testing routines & policies/procedures

◦ Train staff & patients

◦ Relationship with lab important

Personnel Training

◦ Address stigma by enhancing Knowledge

of Disease in Patients & Staff

Nursing Administration Support


Treatment expectations for patients

◦ Establish goals

◦ Communicate them clearly & effectively

Patient education

◦ Curriculum

◦ Materials / Aids

◦ Review

Cost / Sustainability

THE NEED AN APPROACH TO IMPLEMENT

OBOT Implementation Challenges

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In Primary Care Workflow is King

What will be done & Who will do it?

Under what circumstances?

Pre-enrollment Evaluation

◦ Standardized Screening for SU/MH disorders

Enrollment Assessment

◦ Case-finding w/ standardized questions

Induction

Ongoing Monitoring

Referral / Detox / Termination


Clinical Documentation

Accurate & Accessible documentation

critical for care of PTs w/ SA disorders

Supports rational & informed practice

Keeps Care Team “On the same page”

PT historical information can be

contradictory a/o ever-evolving

◦ Proper documentation decreases

ambiguity & confusion


EHRs have varied capabilities to provide/develop

documentation forms

Forms should document key phases:

◦ Determine required data components

◦ Consult a medical informatics expert

◦ Should facilitate outcomes tracking & population

management

Ensure Forms reflect:

◦ Workflow (reengineering possible)

◦ Policies & procedures

Referral system should improve communication &

coordination.

Barriers to Electronic Health Record (EHR) use


Opportunities offered by the EHR

The typical advantages of an EHR

◦ Legibility, accessibility, standardized

documentation, etc.

◦ Standardized data collection

Adherence / Treatment outcomes reporting

Automated Patient Registry

◦ Supports panel management

◦ Supports Quality Improvement & Safety

◦ Facilitates DEA compliance


Documentation & Communication - Telephone Screen

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Summary

Substance users are a stigmatized population with

complex needs & a high burden of psychiatric &

medical comorbid illness.

Integration of SU Screening & Treatment into Primary

Care is timely & proven effective.

Challenge is to sustainably implement integrated

system in the new care environment.

Primary Care provides an ideal setting for a Team-

based, best practice to provide improved treatment

outcomes & enhanced safety.

EHRs can facilitate integration by supporting critical

documentation & team communication, supporting

workflow & fidelity to policies & procedures.

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Thank You

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