A Research Agenda to Advance the Coordination of Care for General Medical and Substance Use Disorders

Abstract

The separation of addiction care from the general medical care system has a negative impact on patients’ receipt of high-quality medical care. Clinical and policy-level strategies to improve the coordination of addiction care and general medical care include identifying and engaging patients with unhealthy substance use in general medical settings, providing effective chronic disease management of substance use disorders in primary care, including patient and family perspectives in care coordination, and implementing pragmatic models to pay for the coordination of addiction and general medical care. This Open Forum discusses practice and research recommendations to advance the coordination of general medical and addiction care. The discussion is based on the proceedings of a national meeting of experts in 2014.

Introduction

Substance use is a leading cause of death and disability in the United States (1–4). Yet only 20.3% of those who needed drug use disorder treatment and 8.9% of those who needed alcohol use disorder treatment received it in 2014 (5). Given the health and social impact of substance use disorders and the low number of those receiving treatment, many potential benefits could be appreciated from the coordination of general medical, mental health, and specialty addiction care.

In its 2006 report Improving the Quality of Health Care for Mental and Substance-Use Conditions, the Institute of Medicine (IOM) emphasized the need for coordination in substance use disorder, mental health, and general health care delivery and policy in order to improve not only the quality of mental health and addiction care, but also the quality of general medical care (6). As coordination of general health care and mental health care has advanced, this trend has not occurred with addiction care. Substance use disorders were, until recently, largely overlooked by physicians due to historic economic and organizational separation of general medical and addiction treatment services (7).

Nearly 10 years after the seminal IOM report on improving the quality of behavioral health care, a national meeting was convened to reflect on the state of addiction and general medical care coordination. A pre-conference session including interdisciplinary experts, researchers, clinicians, current and former public officials, and students was held as part of the October 2014 Addiction Health Services Research (AHSR) conference in Boston, Massachusetts. The pre-conference addressed four topics selected by the authors (JS, AQ) on the basis of conversations with leaders in addictions health services research: identifying and engaging patients in general medical settings; providing effective chronic disease management; including patient and family perspectives in care coordination; and paying for coordinated care. This paper presents each topic and research recommendations from the pre-conference. The box on page XXX provides a summary of the research recommendations. Supplement A provides further information about the issues and current state of knowledge for each topic.

Identifying and Engaging Patients in General Medical Settings

Identification of substance use disorders and treatment initiation and engagement in general medical settings is an important path to effective treatment. Screening, brief intervention, and referral to treatment (SBIRT) has been promoted as a model to identify substance use among patients in general medical settings and facilitate access to specialty addiction care (8). However, evidence of the effectiveness of SBIRT across diverse settings and populations is lacking. Identification and engagement could be reframed as part of a continuum of care in need of ongoing measurement and monitoring so as to identify cracks in the system and enable enhancement of outcomes. A potential framework for this approach is the cascade model used in HIV treatment (9), which was developed to measure HIV care engagement and follow-through with effective therapy.

Implementation studies

Implementation studies are needed to provide information about the effectiveness of specific SBIRT components including screening administration (e.g., computer-facilitated vs. self-administered vs. provider-administered); repeat brief interventions (e.g., frequency, periodicity); brief intervention provider type (e.g., primary care provider, health behavior change specialists, care navigator); provider readiness to adopt; and referral strategies (e.g., type of communication between medical and specialty settings).

New approaches to identification, brief intervention, and engagement

Innovative identification tools, brief intervention components, and engagement strategies may need to be designed for different patients considering the substance(s) used, severity, and other characteristics (e.g., readiness to change, age, ethnicity, socioeconomic status, co-occurring mental health and medical conditions). Intervention delivery settings and their features also need to be considered, including general medical vs. non-medical community settings. Electronic health records (EHRs) can be used as a tool to identify substance use disorder risks and facilitate brief interventions and engagement with specialty care. Brief interventions research can examine both prevention and treatment outcomes (10). Pharmacotherapy should be explicitly considered as a component of engagement.

Health outcome measures

The primary outcomes of screening and brief intervention research are self-reported substance use, related consequences, and care utilization. Alternative outcomes, such as quality of life measures, should be considered to improve delivery and research. Biological verification of substance use merits development in order to complement self-report assessment. Finally, measures shared across research and practice could help develop an evidence base.

Future of Chronic Disease Management

Chronic care, rather than acute care, for substance use disorders could increase access to ongoing comprehensive treatment services for many patients who have not accessed or benefitted from specialty addiction treatment (7). Additional research is needed to identify how to best implement chronic disease management to bolster successful substance use disorder outcomes. Three key areas for development and research are: system redesign, provider organization and communication, and information technology.

Primary care system redesign

Moving from an acute to chronic system could include restructuring primary care teams to deliver targeted treatments for substance use disorders across a spectrum of severity. This could involve the adoption and implementation of new and existing treatments; training primary care providers in evidence-based practices, such as prescribing pharmacological treatments for substance use disorders; and adding behavioral health providers to primary care teams. Implementation studies could be conducted to determine the effectiveness of the new system components.

Provider organization and communication

Increased links between primary care, specialty care, and community resources are needed to move to a chronic care model and improve treatment engagement. One solution to the current system fragmentation is colocation of addiction and primary care services in the same or proximate physical spaces. Co-location has been shown to increase treatment utilization (11) and reduce substance use severity among participating patients (12, 13). Tools, such as shared EHRs with appropriate confidentiality protections, are needed to promote communication between specialty addiction care and primary care.

Information technology

Information systems are an essential element of chronic disease management. EHRs can be used to improve monitoring, treatment, and evaluation of substance use disorders. Even relatively modest changes, such as including patients’ substance use status along with vital signs, could be examined regarding improvement of physician awareness and monitoring of substance use disorders. EHRs could also be adapted to assist addiction care through best practice alerts, guided screenings and assessments, and decision aids for treatment. However, research is needed to develop and evaluate standardized protocols for EHRs (14). In particular, empirically guided decision aids, such as those used in diabetes care (15), could help providers make addiction treatment decisions more effectively and efficiently. Patient portals, which help patients manage their care by integrating information across numerous health care providers (16), have vast potential to improve patient care. Examining patient portals, including those supplemented with web-based and mobile health technologies to further support patient self-management, which is another essential element of the chronic care model.

Including Patient and Family Perspectives in Care Coordination

Shared decision making—the foundation of patient-centered care—actively involves patients in the consideration of available treatment options and supports them in choosing the one that is best for them. If patients with substance use disorders were presented with a menu of options based on their needs (e.g., severity, co-morbidity), goals (e.g., decreased use, abstinence, no change), and preferences (e.g., one-on-one vs. group-based treatment, medications), patient engagement in treatment may increase. Systematic research is needed to assess effectiveness and determine appropriate menus of treatment options and develop decision aids to support patient and provider uptake of this approach.

Patient-centered interventions

Research is needed to determine what types of interventions are acceptable to which patients so that shared decision making can be implemented. Patient-centered treatment approaches might be specific to demographic and clinical subgroups (e.g., formerly incarcerated, homeless). A spectrum of culturally competent treatment strategies that are acceptable to specific subgroups should be identified. Approaches should take into account issues intrinsic to patients’ experiences and needs and could capitalize on social support systems that may have a large influence on recovery (e.g. family, friends, co-workers, peer support). Implementation science, comparative effectiveness, and mixed methods studies could inform the design of research studies in this area. To promote acceptability and sustainability of interventions, patients could be involved in the design of the research.

Decision aids

Patient decision aids that support shared decision making for the management of substance use disorders can address provider as well as patient needs. These tools can serve to educate providers about evidence-based treatment options other than specialty addictions treatment and support dialogue about patient preferences, values and outcome expectations. In this way, patient decision aids can be used to help identify pertinent issues for patients and match the best treatment option to their preferences, symptoms, and symptom severity. Decision aids can be in the form of pamphlets, videos, and/or online tools and should be evidence-based.

Paying for Coordinated Addiction and General Medical Care

Care coordination is difficult to achieve and sustain without financial mechanisms designed to support the inherently collaborative effort (17). Risk adjustment models and performance measures for coordinated care are key areas of inquiry. Risk adjustment models are important to appropriately compensate providers who deliver addiction care. Measures of coordination, integration, retention, pharmacotherapy, access, health information exchange, and EHR interoperability may be critical in payment models that support coordinated addiction and general medical care.

Understanding the capabilities, culture, and values of provider organizations and the behavior of the providers within them is an important step in developing a payment model to support coordinated addiction and general medical care. In many alternative payment models, providers take on financial risk and may need to transform their care delivery processes in order to better manage their patients’ clinical risks. Addiction treatment and general medical care provider organizations are likely to have different types of staff with different licenses, certifications, and training. How to bring these different types of organizations together—both financially and culturally—and prepare them for coordinated and integrated care delivery is an important area for research.

Financing and payment mechanisms that align patients, clinicians, organizations and payers across the health care system should be developed. How these models affect cost, quality, care delivery, and system alignment needs testing, including the effect on patient utilization, care experiences, and health outcomes. Aligning incentives and values within and across systems may be critical to the success of payment models that support coordinated and integrated care.

Conclusions and Implications

The research agenda presented in this paper lays out an ambitious pathway to advance the coordination of general medical and addiction care. Fourteen recommendations presented in the box on page XXX summarize these opportunities. Questions across the four topics include what works for specific populations; what is the role of and impact on different stakeholders (e.g., patients, clinicians, provider organizations, and payers); what is the role of health information technology (HIT); and what are the optimal outcome and performance measures? These recommendations represent the perspectives of the experts and topics addressed at the meeting and may not include all the elements of coordination (e.g., workforce development).

A significant opportunity exists to utilize HIT, particularly EHRs, to facilitate coordination of care. Consideration needs to be given to the development and implementation of clinically meaningful outcome and performance measures to monitor quality and to compare results across research studies and clinical practices. These measures should be developed or selected with the input of clinicians, patients, and researchers in order to be meaningful. When possible, the data for developing and testing these measures could be collected using HIT and EHRs and reported as part of routine care to speed up the research process and reduce the burden on providers.

These recommendations have implications for research design and analytic methods. Implementation studies, effectiveness studies, hybrid implementation and effectiveness studies, comparative-effectiveness studies, and mixed methods studies will be important to assess the impact of current and new approaches. Quality improvement techniques (e.g., Plan-Do-Study-Act cycle (18)) could be used to quickly test new identification, treatment, and payment approaches. Health care systems and states are learning environments with whom researchers can partner to examine health services questions and inform optimal care delivery. State initiatives are inherently dynamic, which challenges traditional research processes. Principles of delivery system science and pragmatic clinical trials are approaches to consider given the rapid changes and innovations taking place in health care without empirical evidence driving these decisions.

As the health care system changes, the impact on the addiction treatment system is not clear. Yet the importance of identifying substance use disorders and addressing both the addiction treatment and general medical needs of people with substance use disorders is unequivocal. While effective models of coordinated care may vary for different organizations, clinicians, patients, and families, it is important to determine which models are effective, what makes them effective, and what payment policies make them possible and sustainable.

BOX 1. RESEARCH RECOMMENDATIONS TO ADVANCE THE COORDINATION OF CARE FOR GENERAL MEDICAL AND SUBSTANCE USE DISORDERS.

Research Recommendation

Identification, intervention, and engagement

Develop and test new substance use disorder identification, brief intervention (both as a preventive service and treatment), and engagement approaches for specific populations and settings, including electronic health records and substance use disorder pharmacotherapy

Conduct implementation studies of existing and new identification, brief intervention, and engagement approaches

Develop outcomes measures of overall health beyond substance use and related consequences

Chronic care management

Conduct implementation studies of new delivery models that include chronic care management

Determine provider, organization, and system readiness to implement chronic care management

Develop and test new ways to facilitate communication between addiction and medical care providers

Develop and test care management strategies that use health information technologies, including electronic health records, patient portals, and mobile health applications

Including patient and family perspectives

Identify attitudes of specific subgroups of patients to treatment approaches, goals, and outcomes

Develop and test patient engagement strategies, including the role of social support systems

Develop and test strategies to engage medical providers with patients with substance use disorders and in addiction care

Develop and test patient decision aids

Financing and payment

Develop and test new payment systems, including impacts on patients, clinicians, provider organizations and payers

Develop risk adjustment models for coordinated care payment systems

Develop and validate performance measures for coordinated care payment systems