When family medicine physician Dr. Jennifer Thomas started her first job after her residency, she said she had “no clue” how often she would encounter substance use disorder (SUD) needs in the primary care setting.
Thomas, co-national medical director for integrated care at the Collaborative Family Healthcare Association (CFHA), is now part of the movement to better integrate SUD screenings, treatment pipelines and follow-ups into primary care.
“We in integrated care should be a place, or aspire to be at a place, where behavioral health screenings and substance use screenings are part of all your visits,” Thomas told Addiction Treatment Business. “If we systematically screen the population we’ll catch folks a lot earlier and have a better chance at intervening early, decreasing morbidity mortality.”
CFHA is a cross-discipline association that aims to make integrated physical and SUD care the standard across the U.S. Its members include behavioral health providers, medical providers and payers, among others.
A team-based approach to care
Thomas participated in an online fellowship that trained primary care physicians in psychiatry.
Later she joined a collaborative care research study through the University of Washington Aims Center that provided collaborative care coaching and implementation.
“We gave it a shot, and boy did it take off,” Thomas said.
Collaborative care is a type of integrated care developed at the University of Washington. It requires a team of providers, including a psychiatric consultant, behavioral health care manager and the primary care physician to work together to treat the patient using measurement-based practices.
The first collaborative care study involved perinatal depression, but following its success, Thomas embarked on a study focusing on patients with opioid use disorder (OUD) and co-occurring mental health conditions. She now personally prescribes buprenorphine to between 20 and 30 patients and has provided care to hundreds of patients with SUDs.
“We screened every adult with a short opioid screener, [asking] ‘Are you using any opioids prescribed or otherwise?’” Thomas said. “If it was yes, then we would follow up with the use disorder criteria. Then if they had co-occurring depression or anxiety they were eligible for the collaborative care model.”
The integrated approach to OUD has made a “huge difference” for patients who were previously struggling greatly, Thomas said.
She has seen a particular improvement in patients through the use of SUBLOCADE, a subcutaneous buprenorphine injection administered once a month that significantly improves compliance.
A team-based approach is also critical in Geisinger’s approach to integrated care, facilitated by a $2.8 million grant from the U.S. Health Resource and Service Administration.
The grant provides the resources to train social workers and advanced practitioners in SUD care. These clinicians will work as a team with a primary care doctor to connect patients to withdrawal management, medications and counseling, as needed.
Geisinger is a non-profit system that generates $10 billion in annual revenues across 134 care sites. It includes a research institute and a health plan with 600,000 members and is a leading provider of value-based care.
“Much of addiction care has to be team-based,” Dr. Margaret Jarvis, chief of addiction services for Geisinger Addiction Medicine and the Geisinger Neuroscience Institute, told ATB. “Because folks with substance use disorders often have such needs in the social determinants of health and comorbidities, whether those are psychiatric comorbidities or physical health comorbidities.”
Treating SUDs can improve psychiatric disorders and physical health conditions, Jarvis said. Ignoring SUDs can, therefore, make a primary care physician’s job harder.
“That has to be balanced against the fact that … nobody signs up for that job unless they are really, really, really passionate about it because it is incredibly hard,” Jarvis said. “One of the things that we look at is how do we make their job easier? How do we give them tools so that if they run into this very common disorder they can recognize it and get that patient into treatment easily?”
In the future, the grant may be used to provide educational opportunities that will likely be directed toward advanced practitioners.
Exposing health care practitioners to SUDs early in their careers is one way to limit stigma, Jarvis said.
“The biggest challenge really is the stigma,” Jarvis said. “To the extent that that can be addressed, we will start seeing better and better care of people with substance use disorders.”
Improving the language used around SUDs and training clinicians to limit biases can also help mitigate the stigma.
Enhancing follow-ups to improve outcomes
While screening and connections are essential parts of SUD and primary care integration, recent research has demonstrated the promise of follow-ups even after a person is engaged in SUD treatment.
A study published in the journal ‘Alcohol: Clinical and Experimental Research’ found that patients who received regular recovery management checkups were significantly more likely to have received more days of SUD treatment and more days of abstinence than patients who did not receive the follow-ups.
The patients who received regular follow-ups were contrasted with patients who received screenings, brief interventions and referrals to treatment (SBIRT) in primary care settings.
“The evidence shows that the SBIRT model is really good at identifying people [with a SUD] and it’s pretty decent at the brief intervention component with low-risk people, especially with alcohol,” Dennis Watson, senior research scientist at Chestnut Health Systems, told ATB. “But when we get to the people with substance use disorders or individuals who need to be referred to treatment, that’s where the model does not really prove to be effective.”
Chestnut Health Systems is a private, not-for-profit 501(c)(3) offering behavioral health and human services in Illinois and Missouri, along with applied behavioral research and training.
For patients with higher acuity SUDs, recovery management checkups were effective at getting people in treatment and keeping them in treatment.
The recovery management checkup system involves a linkage meeting between a linkage manager and a patient identified to have an SUD. The manager uses motivational interviewing techniques designed to help individuals recognize any ambivalence about seeking treatment and help them overcome that ambivalence.
“If people still don’t want treatment, we’re not going to push them into it,” Watson said.”We’re just going to say, ‘Hey, you don’t want to go to treatment today. Great. Can we talk to you again tomorrow or next week?’ And we’re just going to keep engaging that person. Because there’s going to be that magic moment.”
Once a person agrees to treatment, the linkage manager will arrange transportation to an SUD facility within 24 to 48 hours. The manager then follows up on an almost daily basis via call or text to look for signs of potential relapse.
Over time, these follow-ups become less common, but patients will still attend linkage meetings every quarter.
The system operates on the basis of viewing addiction as a chronic disease, Watson said.
“It shouldn’t be handled in an acute care approach like it has been handled traditionally,” Watson said. “Individuals who got the linkage services through the recovery management checkup intervention were more likely to get connected to treatment, more likely to get to that treatment faster, more likely to have reduced days of substance use and more days of abstinence.”
The model also requires pre-established relationships with SUD treatment providers to facilitate quick referrals to care.
Economists are currently seeking to determine the model’s economic viability, Watson said, but prior work demonstrates that it is cost-effective in settings other than primary care.
Billing for integrated services
No matter the technique for integrating care, billing mechanisms can represent a significant hurdle.
Even if codes to bill for collaborative care do exist, it is sometimes not worth the trouble, Jarvis said.
“If you were only going to get paid $1.50 for an activity that is 10 or 15 minutes, it’s not worth it,” Jarvis said. “We’re starting the work of looking at that.”
Having direct billing mechanisms to cover integrated care services, rather than a value-based care incentive model, can be extremely helpful, Watson said. While value-based care may be a long-term solution to billing, most value-based arrangements have not significantly evolved to allow for integrated care.
“It is hard for other groups to wrap their heads around how treating substance use issues can benefit the overall health of their population and improve value-based care for their organization,” Watson said.
For now, a fee-for-service model may be the best aid to integration, according to Watson.
Clinicians, organizations and researchers across the primary care and SUD industries have identified integration as a worthy pursuit. But there is no clear-cut path.
“There are different groups that are experimenting with different ways of creating integration,” Jarvis said. “I want to emphasize that it is experimentation. We don’t know which models are going to work best yet. The good news is that we’re trying.”