Implementing a Patient-Centered, Rapid-Access Substance Use Treatment Pathway in Primary Care

Abstract

Despite the effectiveness of treating substance use disorders in primary care, access to such services remains limited. In this project, quality improvement methods were used to create and evaluate a rapid-access pathway for substance use treatment services in community health clinics. A “secret shopper” test gathered information about wait times and requirements. Results informed the development of a patient-centered pathway, in which patients requesting substance use treatment services were offered an immediate telehealth appointment with a provider and then linked to ongoing care services. This treatment pathway was feasible to implement, resulted in high treatment access rates, and was minimally disruptive to clinic operations.

Substance use disorders are common psychiatric disorders that cause considerable distress, impairment, and harm (including death by overdose or accident and long-term health consequences) (1). Research has identified effective treatments for substance use disorders, including psychosocial treatments (2) and medications (3, 4). However, most people in the United States with substance use disorders never receive any treatment (1), let alone treatments with demonstrated effectiveness. For example, medications such as buprenorphine are now the first-line treatment for opioid use disorder (3), yet starting and staying on these medications in community settings remains difficult (5).

Psychosocial barriers to care for individuals with substance use disorders (e.g., marginalization, stigma, limited ability and opportunities to self-advocate) are frequently acknowledged (5–7). However, providers and system administrators may not recognize how practice cultures also create barriers for patients. Inertia against changing workflows, concerns about capacity, reluctance to allocate resources without guarantee of use, and prioritization of clinic structure over patient access all limit the patient-centeredness of care. The resulting limited access can undermine patients’ motivation to ask for and engage in treatment. Because feeling ambivalent about reducing patterns of substance use is common among people with substance use disorders, their motivation may wane if they are unable to receive help soon after they seek it. Limited access to services places people with substance use disorders at ongoing risk of low treatment engagement, relapse into substance use, and serious adverse outcomes (e.g., overdose) (5).

Adults are most likely to seek help for substance use problems in primary care settings, which tend to be more accessible and affordable, less stigmatized, and more trusted by patients, compared with specialty treatment settings (8). In areas with health care resource shortages, primary care may be the only source of substance use disorder treatment. Furthermore, many effective substance use disorder treatments can be delivered in primary care settings (2–4). Thus, primary care is an important setting for substance use disorder treatments, yet it remains underused for this purpose (8). In this project, we aimed to improve access to substance use disorder care by creating a patient-centered, rapid-access pathway.

DEVELOPMENT OF THE RAPID-ACCESS SUBSTANCE USE TREATMENT PATHWAY

Service Context

This project took place across eight federally qualified health center (FQHC) clinics that were part of a health care system in New Mexico. The mission of FQHCs is to provide affordable, accessible primary care for underserved patients, regardless of their ability to pay. The 2023 annual report on FQHCs from the National Association of Community Health Centers documented over 30 million patients served, most publicly insured or uninsured (9). Substance use disorder services are core primary care services in the FQHC model. The clinics in this project primarily offered medications for substance use disorders (mostly for opioid use disorder, but also for alcohol use disorder); counseling services were also available. Each clinic had its own process patients needed to follow to access substance use disorder services (e.g., a procedure for scheduling appointments, eligibility requirements for services). Demand for these services was high, because this health system had a long history of providing substance use disorder care and was the only community-based provider in the region offering such services.

During this project, the FQHC clinics were sites in a community-based clinical trial testing a collaborative care model for patients with co-occurring opioid use disorder and mental disorders. The trial recruitment team recognized that many FQHC patients who might benefit from enrolling could not be directly recruited through primary care because of their limited engagement in services. In particular, some patients shared informal feedback with the recruitment team about barriers to access (e.g., long wait times, restrictive requirements) that kept them from regularly seeking substance use disorder treatment at the clinics.

In response to the patient feedback received via the recruitment team, health system leadership wanted to better understand the access issues experienced by patients and make changes to solve them. Therefore, we completed a quality improvement project focused on improving patient access to substance use disorder services. Enrollment of patients in the clinical trial was a secondary priority, and we did not restrict our efforts to patients who would be eligible for the trial. Still, the quality improvement effort may have been facilitated by the strong research-practice partnership already formed for the trial.

Quality Improvement Process

Our quality improvement goal was to maximize access to substance use disorder treatment at the FQHC clinics, defined as fulfilling the unmet demand for appointments among patients with substance use disorders. To achieve that goal, we used a quality improvement methodology called plan-do-study-act (PDSA) cycles, through which barriers to changing practice can be understood and addressed by testing structural changes in practice and continually evaluating their effects until the goal is achieved (10). Application of PDSA cycles is common in health care settings and, unlike research, does not require institutional review board approval.

In the plan step of the PDSA cycle, we used a “secret shopper” test to understand barriers to accessing medication for opioid use disorder. Using results from that test, we then designed the rapid-access pathway for substance use disorder services (the do step) and monitored access over time (the study step) to decide whether to maintain, modify, or discontinue the pathway (the act step). Two physician champions (S.J. and M.C.) committed to completing the PDSA cycles and creating patient-centered solutions; they were key facilitators of pathway implementation who partnered with the remaining authors (all of whom were researchers working on the trial) throughout the process.

Secret shopper test.

For the secret shopper test (the plan step), research assistants called the FQHC clinics to request appointments and recorded information about wait times and requirements at each clinic. The research assistants followed scripts for the calls; in half of the calls, they requested medication for opioid use disorder, and in the other half, they requested a routine physical only. We focused on requests for medication for opioid use disorder because these medications are commonly requested across the FQHC clinics as a treatment for substance use disorders, specific procedures exist for prescribing these medications to patients, and the medications were highly relevant to the clinical trial. The secret shopper test is an increasingly common method for studying access to services in health care settings (11). Although we had research assistants place the calls, the procedures were simple and could be performed by anyone trained to follow a phone script.

Research assistants made 34 secret shopper phone calls in a 48-hour period (about four per clinic); some calls were to the central scheduling line for the health system, and some calls were directly to the clinics. Table S1 (see the online supplement to this article) summarizes the results. When the research assistants requested appointments to obtain medication for opioid use disorder (16 calls total), appointment wait times ranged from the next day to 4–6 weeks. Two clinics had no opioid use disorder medication appointment availability, and two others required a behavioral health counselor appointment prior to scheduling a primary care provider appointment for initiation of opioid use disorder medication. Calls requesting a routine physical (18 calls total) resulted in a much larger percentage of appointments scheduled 4–6 weeks out than did calls requesting medication for opioid use disorder (11 of 18 vs. three of 16). However, 11 of 16 calls requesting medication for opioid use disorder ended without an appointment with a prescribing primary care provider being scheduled, whereas only three of 18 calls for a routine physical resulted in no appointment.

Design and outcomes of the rapid-access pathway.

The secret shopper test results informed the physician champions’ design of a patient-centered pathway (the do step) in which patients requesting substance use disorder treatment anywhere in the health system could receive an appointment on the same day or the next day. Because the quality improvement goal was to maximize access to care for all patients with substance use disorders, the pathway was not restricted to patients with opioid use disorder.

Figure 1 provides an overview of the rapid-access pathway. A centralized intake scheduler works with participating primary care providers (licensed prescribers) to schedule the intake appointments, typically on the same day or the next day, for patients requesting substance use disorder services and to maintain provider coverage for the pathway. The providers have administrative approval to block three intake slots per day, 4 days per week, subject to those slots being used. During the intake appointment, which is typically completed via telehealth, the provider assesses the patient’s needs and can initiate treatment (e.g., prescribe medication for opioid use disorder). As appropriate, the intake appointment can be billed to insurance as an evaluation or management problem-based visit for a new or established patient. The intake provider then schedules the patient for ongoing substance use disorder care (e.g., medication, counseling) at the FQHC clinic most convenient for the patient; the rapid-access pathway does not alter the scheduling and structure of ongoing primary care services. Patients could also continue accessing substance use disorder services without the rapidaccess pathway, such as by requesting services from their established provider.

FIGURE 1. Overview of the patient-centered, rapid-access pathway for substance use treatment services^a.

^a FQHC, federally qualified health center.

A related policy change was the elimination of certain clinics’ requirement that patients complete a counseling appointment prior to scheduling an appointment with a primary care provider who could prescribe medication for opioid use disorder. This requirement does not have empirical support for improving outcomes of patients taking medication for opioid use disorder and, when present, created significant access issues (e.g., the counseling appointment could not be scheduled for 40% (N=2 of 5) of secret shopper calls in which such an appointment was required).

The rapid-access pathway was implemented in January 2022. We then monitored the pathway’s use by examining electronic health records for patterns of patient visits in the health system (the study step). Table S2 (see online supplement) provides the pathway outcomes we examined after 1 year of operation. The rapid-access pathway averaged six unique patient visits per week, using approximately half of the available intake slots. Of the patients scheduled for an appointment, an average of 92% (N=22 of 24) completed the visit (with minimal rescheduling). Taken together, these findings suggest that demand for access was largely met, because most patients completed an intake appointment without exhausting the available intake slots. Furthermore, although our PDSA cycles focused on immediate access, we also found that about half of the patients sustained engagement in treatment for at least 2 months (similar to or possibly better than engagement levels before the pathway).

Beyond these numbers, patients spontaneously expressed appreciation for the rapid-access pathway, stating that it was very helpful and made a major difference in their ability to find care. Another positive indicator was that patients who had disengaged from established substance use disorder care—for example, after being arrested—used the rapidaccess pathway to reengage.

In addition to patient benefits, the rapid-access pathway afforded provider and organizational benefits. Because provider and staff coverage has fluctuated across clinics, the centralized intake process supported more seamless access to substance use disorder treatment. Many providers voiced appreciation for the access improvements, noting that the pathway saved them time and stress. In the past, providers often made real-time adjustments (e.g., creating new appointment slots) to enable timely responses to patient requests for substance use disorder treatment, but such adjustments became less necessary when patients could be directed to the rapid-access pathway instead. The support of a rapid-access pathway, staffed by primary care providers with expertise in substance use disorders, also enabled several providers to begin offering services for substance use disorders that they had previously felt uncomfortable providing to patients.

Ultimately, the physician champions decided to continue the rapid-access pathway because of its patient benefits, provider benefits, and feasibility (the act step). Minor adjustments were made to match pathway use patterns (e.g., ensuring additional coverage for intakes on days and at times when demand was high). Pathway feasibility was determined from use of current staffing and scheduling resources, which functioned well after being allocated to the pathway, and from patient use of the pathway, which was sufficient to refute concerns about declines in productivity and revenue.

IMPLICATIONS

Our findings demonstrate how a patient-centered, low-barrier substance use treatment pathway was feasible to implement in a primary care setting. The pathway has been well received by patients, was minimally disruptive to clinic operations (even beneficial in some ways), and promoted treatment access through strategies consistent with expert recommendations for improving substance use disorder services (3, 5, 7), such as establishing low thresholds for prescribing opioid use disorder medication (12).

Informing pathway development through quality improvement processes (i.e., PDSA cycles and secret shopper testing) was especially beneficial. These procedures helped to identify root issues and rapidly assess whether proposed solutions resulted in improvements. Quality improvement methods may be useful for a variety of problems and solutions—for example, other solutions may be better suited to solving access issues in certain contexts, or these methods could help address other challenges in substance use disorder treatment (e.g., meeting demand for services, supporting long-term engagement).

Finally, our approach in this project reflected best practices in research-practice partnerships. Our use of quality improvement methods helped to strengthen the partnership and our ultimate impact with patients by rooting decision making in practice-based evidence and a shared goal.

HIGHLIGHTS.

• Quality improvement methods, such as “secret shopper” tests and plan-do-study-act cycles, can identify and address barriers to treatment access.

• Immediate telehealth appointments for substance use disorder treatment in primary care are feasible to implement and result in high treatment access rates.