Goals: The Need An Approach: Integration / Coordination & Collaboration To Implement: System & Workflow / Electronic Health Record

1. Building an Collaborative Care
Infrastructure for Opioid-Addicted
Patients in Primary Care
Christopher Shanahan MD, MPH, FACP
Assistant Professor of Medicine
Dept. of Medicine, Section of General Internal Medicine
Director, Community Medicine Unit
Boston University School of Medicine
Board Certified:
Internal Medicine (ABIM)
Addiction Medicine (ABAM)
Conflicts of Interest - None
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2. Outline
The Need
An Approach
◦ Integration
◦ Coordination & Collaboration
To Implement
◦ System & Workflow
◦ Electronic Health Record
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3. THE NEED
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THE NEED AN APPROACH TO IMPLEMENT

4. 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 IMPLEMENT
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5. 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 IMPLEMENT
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6. Linkage of Addiction & Primary Care
for Substance Users Advocated
THE NEED AN APPROACH TO IMPLEMENT
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7. Linking Primary Care & Substance Abuse (SA) Care Services
Samet, et.al. 2001
Patients
 Care convenience  Patient satisfaction
Primary care / Mental health care provider
Promotes 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 NEED AN APPROACH TO IMPLEMENT
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8. The Case for Integration
Evidence-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 IMPLEMENT
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9. AN APPROACH
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THE NEED AN APPROACH TO IMPLEMENT

10. 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 IMPLEMENT
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11. Physical Health Needs
Low High
SubstanceUseNeed
High
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
• Crisis/ED based SU interventions
• Detox/sobering
• Medical/surgical inpatient
• Nursing home/home based care
• Wellness programming
• Other community supports
Low
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
• Crisis/ED based SU interventions
• Wellness programming
• Other community supports
Quadrant III
• 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 medical-surgical based BHC/care manager
competent in both MH/SU
• Specialty prescribing consultation
• Crisis/ED based SU interventions
• Medical/surgical inpatient
• Nursing home/home based care
• Wellness programming
• Other community supports
4 Quadrant Clinical Integration Model for SU Disorders
Mauer, B. 2006.
Quadrants I & III
• 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 medical-surgical based BHC/care manager
competent in both MH/SU
• Specialty prescribing consultation
• Crisis/ED based SU interventions
• Medical/surgical inpatient
• Nursing home/home based care
• Wellness programming
• Other community supports
THE NEED AN APPROACH TO IMPLEMENT
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12. Core Components for
Successful Integration
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THE NEED AN APPROACH TO IMPLEMENT
Coordination & Collaboration

13. 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.)
THE NEED AN APPROACH TO IMPLEMENT
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14. 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
THE NEED AN APPROACH TO IMPLEMENT
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15. TO IMPLEMENT
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THE NEED AN APPROACH TO IMPLEMENT

16. 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 / Triage
Program
Coordinator
NCM
Intake Evaluation NCM NCM
THE NEED AN APPROACH TO IMPLEMENT
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17. 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
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18. 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
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19. 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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20. 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
THE NEED AN APPROACH TO IMPLEMENT
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21. 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.
THE NEED AN APPROACH TO IMPLEMENT
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22. 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.)
THE NEED AN APPROACH TO IMPLEMENT
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23. 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
THE NEED AN APPROACH TO IMPLEMENT
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24. 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
THE NEED AN APPROACH TO IMPLEMENT
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25.  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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26. 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
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27. 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
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28.  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
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29. 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
THE NEED AN APPROACH TO IMPLEMENT
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30. Documentation & Communication - Telephone Screen
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31. 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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32. ThankYou
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