RC Cronkite, Center for Health Care Evaluation, VA Palo Alto Health Care System and Stanford University

Objectives: The Institute of Medicine has identified continuity of care as an essential component of a high quality substance abuse (SA) treatment system. Yet, we know little about the specific continuity of care practices currently implemented in VA SA programs or the program factors associated with these practices. The aims of this study were: (1) to conduct the first systematic nationwide survey of VA intensive SA treatment programs’ continuity of care practices, (2) to develop a methodology for categorizing SA programs’ continuity of care practices as high or low in agreement with probable best practices, and (3) to identify program factors (services provided, patient-to-staff ratios, size) associated with high and low continuity of care practices.

Methods: A telephone survey of 278 VA SA treatment programs identified 152 programs that provide intensive treatment. Continuity of Care Practices Survey (CCPS)data were collected by telephone interview or self-report from intensive programs. SA programs were categorized as high or low on five dimensions of continuity of care - access to continuing outpatient care, constancy in patient and provider relationships,provider efforts to maintain contact with patients across levels of care, and provider efforts to connect patients to community resources and coordinate their treatment across levels of care. Profiles of continuity of care practices were developed and compared across programs that varied in type of service (inpatient vs outpatient),patient-to-staff ratios (number of unique patients per FTEE), and size (number of unique patients admitted per year and total program FTEE).

Results: CCPS data were obtained from 122 (80%) of 152 VA intensive SA programs. Overall, outpatient programs reported greater continuity in patient and provider relationships, more provider efforts to maintain contact with patients over time, and more coordination of treatment across levels of care than did inpatient programs. This pattern was more pronounced among inpatient programs. Programs with high patient-to-staff ratios provided patients with greater access to continuing outpatient SA care than programs with low patient-to-staff ratios. Programs with high patient-to-staff ratios also were more likely to report greater continuity in patient and provider relationships than programs with low patient-to-staff ratios. Programs with fewer FTEE made greater efforts to connect patients to resources and coordinate treatment across levels of care. The number of unique patients admitted was related to continuity of care practices in inpatient but not outpatient programs.

Conclusions: Continuity of care practices in outpatient programs are more congruent with probable best practices than are those in inpatient programs. Preliminary findings suggest that there may be programs of certain sizes or with particular patient-to-staff levels that are optimal for best continuity of care practices.

Impact: This study provides the first comprehensive assessment off continuity of care practices in substance abuse programs. These data are a baseline against which future improvements in the quality of VA continuity of care practices canbe evaluated. CCPS data will be valuable in an ongoing project that will examine the cost consequences of varying continuity of care practices and their impact on patients’engagement in continuing care and patients’ symptom and functioning outcomes.