Continuity in Substance Abuse Care: Best Practices, Outcomes, and Costs
Jeanne A. Schaefer RN PhD
VA Palo Alto Health Care System
Palo Alto, CA
Funding Period: October 1999 - March 2002

BACKGROUND/RATIONALE:
Continuity of care (COC) is an essential component of high quality substance use disorder (SUD) treatment, but we know little about current COC practices within VA SUD programs. This project assessed VA SUD programs’ COC practices and examined their impact on patients' outcomes and health care costs.

OBJECTIVE(S):
The immediate objectives were to: (1) examine the relationship between COC practices and SUD patients' engagement in continuing outpatient SUD care and their symptoms and functioning, and (2) determine the cost consequences of variations in SUD programs' COC practices.

METHODS:
A nationwide survey of COC practices in VA intensive SUD programs was conducted and data were used to categorize programs as high and low on continuity. Twenty-eight SUD programs (13 high and 15 low) were recruited for a panel study. Baseline Addiction Severity Index (ASI) data were obtained from 878 patients at entry to treatment. At discharge, data (N=840) were obtained on the COC services staff provided to each patient, the amount and type of treatment provided, and patients' motivation for continuing care. At a four-month follow up, 615 patients (71%) completed a self-report ASI and questions about use of non-VA health care. Each of the 28 programs also completed a cost survey. Survey data were used to determine the operating costs for programs with high and low levels of COC.

FINDINGS/RESULTS:
Patient- and program-level factors were related to the receipt of COC services and engagement in continuing care. Married patients received fewer COC services, while more motivated patients received more services. Patients in inpatient/residential programs received fewer COC services. Treatment history and experiences, as well as COC, predicted patients’ engagement in continuing care. Patients who used SUD services during the prior year engaged in more continuing care during the four-month follow up period. Patients who received more intense treatment had fewer SUD visits during follow up. The overall amount of COC received by patients from program staff was significantly associated with more engagement in continuing care. Patients in the high COC group showed significantly more improvement on alcohol and drug use and employment problems between intake and the four-month follow up compared to patients in the low COC group. However, when patient, program, and COC factors were included together as predictors of outcome, the receipt of COC services and patient engagement in COC were no longer significant predictors. Preliminary cost findings suggest that direct operating costs of SUD programs are not related to the level of COC they provide.

IMPACT:
This project provides the first comprehensive data on VA COC practices against which future improvements in practices can be judged. COC measures developed in this project can be used by managers to monitor COC practices in SUD programs and identify areas for improvement. Preliminary findings indicate a need for further research to identify the patient and program characteristics that influence staff’s continuity of care practices. Lower levels of COC in inpatient/residential SUD programs suggests that managers and clinicians in these programs need to develop strategies to improve continuity for patients making the transition from inpatient/residential care to continuing outpatient care.

PUBLICATIONS:

Journal Articles

1. Schaefer JA, Harris AH, Cronkite RC, Turrubiartes P. Treatment staff's continuity of care practices, patients' engagement in continuing care, and abstinence following outpatient substance-use disorder treatment. Journal of Studies on Alcohol and Drugs. 2008; 69(5): 747-56.
2. Harris AH, McKellar JD, Moos RH, Schaefer JA, Cronkite RC. Predictors of engagement in continuing care following residential substance use disorder treatment. Drug and Alcohol Dependence. 2006; 84(1): 93-101.
3. Schaefer JA, Ingudomnukul E, Harris AH, Cronkite RC. Continuity of care practices and substance use disorder patients' engagement in continuing care. Medical Care. 2005; 43(12): 1234-41.
4. Schaefer JA, Cronkite R, Ingudomnukul E. Assessing continuity of care practices in substance use disorder treatment programs. Journal of Studies On Alcohol. 2004; 65(4): 513-20.

DRA: Health Services and Systems, Substance Abuse, Addictive Disorders
DRE: Quality of Care, Resource Use and Cost, Treatment
Keywords: Organizational issues, Outpatient, VA/non-VA comparisons
MeSH Terms: none