Table 3.

Model #3: Group psychotherapy coupled temporally with individual primary care visits.

General overview and unique features: All patients with OUD are referred to one of the onsite B/N-prescribing physicians and also to the local integrated therapists when needed. Patients attend individual appointments with the physician, and groups are held separately, run by a psychotherapist and offered around the same time of the individual appointment. Every patient with addiction is welcome and encouraged to attend group, but only those requiring extra support and structure are required to attend as a condition for remaining in treatment. Pros: • Primary care providers with minimal addiction training can still offer addiction support at their site by referring to the B/N-prescribing providers and available groups. • Patients who are unable to attend the group sessions (due to schedule/logistics or cognitive/emotional concerns) are still able to get their addiction care needs met, thus increasing access to B/N treatment. • Uncoupling individual appointments from group visits allows patients to benefit from increased access to group psychotherapeutic support while receiving medical management frequency that is tailored to their status in recovery. • Patients struggling in their recovery can be addressed at an individual level, in a more private setting than would otherwise be allowed through a shared medical appointment visit approach. • For the prescribing physicians, knowing that patients will have additional support and monitoring from the therapist leading the group allows them to tailor discussion in their 1:1 time to issues that cannot be addressed in group. It also fosters clinically sophisticated team-based care, in which therapist and physician discuss patient care and share ideas and expertise. • From a clinical sustainability perspective, services are billed for both an individual physician visit as well as a group therapy session. Coordinating these appointments in the same half-day improves attendance at both. • For this type of coordinated care to work optimally, time should be allocated for the therapists and prescribing physicians to discuss challenging cases. However, even when time is not formally allocated, the ease of “on-the-fly” conversations in a primary care practice with fully integrated behavioral health services allows for informal care coordination to occur. Cons: • This model may discourage other providers from incorporating care for patients with OUD into their practice, since they may feel under-equipped if their clinical availability does not coincide with the therapist-led groups. • Patients required to attend group must attend a separate individual appointment to receive their B/N prescription; thus, there is an extra time requirement. Personnel and resources Provider type: 2internal medicine physicians; 2 backup B/N providers Behavioral health provider type: 1 psychologist Other staff: 1 OBOT RNCM, 1 medical assistant partnered with prescribing B/N physician for that session, usual clinic front desk staff Total resources: This site dedicates two 4-hour clinic session to GBOT per week; there are two primary care providers each utilizing 1/8 full-time equivalent (FTE), a psychologist using 1/4 FTE, a medical assistant and a front desk staff member,each using 1/10 FTE. The OBOT RNCM serves in a full-time role, carrying about 125 patients. Patient mix and group format Type of group: Mixed (patients in different stages of recovery) Number of weekly groups offered: 2; one group is offered after work hours Length of group: 60 minutes Average number of patients in group: 5–10 Psychotherapy techniques utilized: Cognitive behavioral therapy with a concentration on mindfulness, support, and skills development Workflow logistics: Requirements before starting group: Patients attend an individual appointment with the B/N-prescribing primary care provider (PCP). They are either referred by a PCP in the same clinic (who continues to manage patients for their non-addiction-related medical care) or the B/N-prescribing physician becomes these patients’ PCP (among new patients or those who have minimal connection to their previously assigned PCP). When prescriptions are provided: At individual appointments with the B/N-prescribing physician. For patients who have seen the prescriber prior to group, they get their prescription at the end of group via the OBOT RNCM. Individual visits offered:Yes. The B/N-prescribing physicians see patients with OUD individually during two designated half-day clinic sessions per week, coupled temporally with a group psychotherapy session run by the behavioral care provider. Most patients are required to attend group. Those deemed stable in their recovery or whose work schedules preclude group attendance are booked for individual appointments and, per the B/N-prescribing providers’ discretion, do not have to attend the group. The B/N-prescribing physicians will also see patients during other clinical hours throughout the week in order to accommodate those unable to attend the sessions exclusively designated for addiction care. Individual appointments are 20 minutes long and include urine toxicology testing, review of prior testing results, management of the patients’ addiction and other medical problems, and prescribing of B/N. If the patient has a different PCP, the B/N prescriber focuses on their addiction management and defers other medical care to the designated PCP. Monitoring and management: Toxicology testing: Urine toxicology samples are obtained prior to each individual appointment. Patient incentives for doing well: As patients get more stable in recovery, their visit intervals are increased, and they may no longer be “required” to attend groups. In general, patients attend group on the day they are seeing the prescriber for an individual visit. Some patients attend group more often than just the days of their individual visits, and all patients are welcome to attend as often as they want. How patients who are struggling are handled: Patients are addressed at individual appointments with the B/N-prescribing physician. Patients in need of more recovery support are asked to see their team more often (the shortest possible visit interval is weekly appointments); those needing more support are referred to an individual psychotherapist, 12-step meeting attendance, or an advanced level of addiction care. Team coordination: The integrated behavioral health care provider and B/N provider coordinate patient care on an as needed basis through electronic health record messaging and also via informal “on-the-fly” conversations. Billing for group: The psychologist bills 90853 for patients seen in group; the internal medicine physician bills 99213 or 99214, depending on level of complexity, for patients seen individually by the primary care provider before or after group. Duration this model has existed: 3 years Number of patients treated in group: The RNCM carries on average 100–200 patient caseload at any given point in time.