Continuity of Care

Goal 2A. Improving Continuity of Care

Background

The goal of enhancing retention of VHA patients in continuing outpatient SUD care is consistent with the VA/DoD Guideline for the Management of Substance Use Disorders and the OQP Continuity of Care (CoC) Performance Measure (PM).  The Practice Guideline and the PM are based on substantial data indicating that duration of care is the treatment factor most consistently associated with positive patient outcomes (e.g., Crits Cristoph & Siqueland, 1996; Donovan, 1998; Gerstein & Harwood, 1990; Moos et al., 1999; Onken et al., 1997; Simpson et al., 1979).  In addition, the latest review of controlled trials of continuing outpatient care by Work Group member James McKay (2007) found that seven of 11 trials comparing continuing care to no or minimal treatment had positive results.  A feature that generally distinguished studies with positive results was an active intervention to engage and retain patients in continuing care (see also McKay, 2005).  For example, findings from a recently completed HSR&D randomized clinical trial by Work Group member Steve Lash (Lash et al., 2007) found that an active Contracting, Prompting, and Reinforcing (CPR) intervention led to greater patient involvement in VA SUD continuing care and a higher rate of patient abstinence in comparison to treatment as usual.

Current Practice

FY07 standards for the OQP Continuity of Care (CoC) Performance Measure were 39% (meets) and 42% (exceeds), for 90-day retention of patients beginning new episodes of SUD specialty care.  National performance has improved steadily from below 30% in FY03 to 43.9% in FY07 (up from 36.6% in FY06) when the standard was met by 18 VISNs (up from 6 VISNs in FY06). Variability remains evident (VISN range of 31%-56% of patients meeting the CoC criteria).  At the organizational level, a recent study by Work Group member Jeanne Schaefer and colleagues (2005) found deficiencies in CoC practices at many VHA residential and intensive outpatient programs.  For example, SUD patients treated in inpatient/residential programs received significantly less coordinated care from staff, and staff made significantly fewer efforts to maintain contact with inpatients after discharge, than was true in intensive outpatient programs.

Implementation Approach and Impact

The interventions developed to enhance patient retention in continuing care will target organizational factors, providers, and patients.  For example, effective CoC practices (e.g., appointment reminders, joint discharge planning) were identified in a recently completed survey of VHA CoC practices by Dr. Schaefer.  The CPR intervention by Dr. Lash is an example of an effective provider mediated, patient focused intervention.  Ongoing OQP data collection will allow the impact of SUD QUERI interventions to be assessed via pre-post comparisons and  comparison of changes in performance on the CoC PM at intervention versus control sites.

The longer term implementation intervention will be guided by the results of several ongoing projects described below, as well as work accomplished toward Specific Aims 1, 2, and 3 above.  With one exception, these projects are funded as IIRs and we consider them pre-implementation ("intervention") projects in the QUERI pipeline.  One long-term implementation intervention developed with a Core LIP is a Consultation Resource Group available to providers who are having difficulty achieving adequate (or better) retention in continuing outpatient care. 

During FY07, Work Group members McKellar and Schaefer led a project to improve CoC performance at low-performing facilities by facilitating communication between staff at programs that were having difficulty meeting the CoC measure and staff at similar facilities who had found ways to achieve high performance.  In March, 2007, a solicitation was issued via email for high performing program leaders to participate in our Mentoring Program.  A total of 13 providers agreed to participate.  Once the consultant panel was officially convened, the available providers were identified in a spreadsheet that was distributed through the VHA Addictions listserv.  In addition, the function of the program and details for identifying a mentor were provided on two subsequent SUD Quarterly Conference Calls.  Members of the Work Group also answered phone calls from providers who requested additional information.  The mentoring program appeared to have a positive impact at several facilities.

Promoting Evidence-Based Specialty Care for Patients with SUD

The SUD QUERI continues its efforts to promote engagement and retention in specialty care as a final common pathway to promote evidence-based practices for treatment of SUD. To do so, the SUD QUERI implements practices that improve continuity of specialty care for SUD.

Observational studies indicate that duration of care is the treatment factor most consistently associated with positive patient outcomes; in addition, various forms of continuing care have produced superior outcomes to no or minimal treatment in about two-thirds of the relevant controlled studies. FY07 standards for the OQP Continuity of Care (CoC) Performance Measure were 39% (meets) and 42% (exceeds), for 90-day retention of patients beginning new episodes of SUD specialty care. National performance has improved steadily from below 30% in FY03 to 43.9% in FY07 (up from 36.6% in FY06) when the standard was met by 18 VISNs (up from 6 VISNs in FY06). Variability remains evident (VISN range of 31%-56%). Through biweekly conference calls, specific Work Group accomplishments in the past year include:

• Reported findings of LIP survey on CoC practices. Work Group members reported results of a telephone survey to assess differences in program policies and provider practices of 18 top- and 18 bottom-performing stations. The final report was discussed on national conference calls and distributed to the field
• Completed a CoC Implementation Project. Work Group members Drs. Schaeffer and McKellar generated and disseminated nationally a document addressing Frequently Asked Questions about CoC and the PM.
• Validation of the Performance Measure. Work Group member Dr. Harris led secondary analyses of the SUD QUERI Outcomes Monitoring Project to evaluate the association of self-reported clinical outcome to retention status based on the CoC PM. Results identified opportunities to refine the PM and have implications for outcome monitoring to guide clinical interventions including continuing care.
• Field Consultation on the Performance Measure. The Clinical Coordinator continued to serve as the CoC subject matter expert for OQP.
• Monitored multi-site pre-implementation intervention (IIR) projects. Work Group members continued 3 multi-site IIR projects to evaluate: 1) a contingency management intervention, 2) an enhanced version of a contracting-prompting-and reinforcing strategy and 3) an effectiveness trial of telephone case monitoring.
• Approved Letter of Intent for an SDP. In consultation with the Work Group, Dr. Krahn submitted a SDP entitled "Adoption of Process Improvement to Enhance Continuity of Care for Veterans with SUD's in VISN 12" that received encouraging reviews and that is being considered for re-submission. The project adopts methods from the RWJ-funded Network for the Improvement of Addiction Treatment.

Progress and Accomplishments

• Impacts, Contributions and Products
• Publications and Presentations
• Active and Completed Projects
• Planned Projects
• Implementation Pipeline (PDF)

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