Who leads addiction care from a clinical and coordination perspective has historically been a complicated question, partly because of how patients are referred into substance use disorder (SUD) treatment services and the nonlinear progression of recovery.

The question of who “quarterbacks” addiction treatment is still a complicated and, sometimes, confusing one. But it doesn’t always have to be, according to industry leaders.

To some degree, the clinical silos and lack of coordination reflect the varied nature of addiction and recovery itself, Dr. Ayesha Appa, assistant professor of medicine at the University of California, San Francisco, said during the Behavioral Health Business Addiction Treatment Forum in July.

Appa further noted that there are many “quarterbacks” for care across addiction treatment specialties and between organizations in the same specialty. Sometimes the point person coordinating care simply falls into that role regardless of their role or other duties.

“At UCSF, our quarterback is the addiction medicine physician,” Appa said. “I would say that’s fantastic for innovation in research and treatment. It’s not always by design; it’s by necessity. Sometimes we wish that quarterback was somebody closer to a care manager who is able to handle multiple cases with physicians.”

Such a model of care works to a degree within the large, multi-supported, if not somewhat “clunky,” academic medical setting. However, putting in this additional nonclinical work limits the capacity of clinicians to participate at the top of their license. Downstream effects of that include dubious cost-effectiveness and potential clinician retention challenges, Appa said.

For UCSF, the addiction treatment specialists have largely become the proverbial quarterbacks of care because “that position ends up being a person who isn’t willing to let the ball drop.”

Tried and true secret ingredients

Jeffersonville, Indiana-based LifeSpring Health Systems underwent a transformation starting in 2009. At the time, new research began to illustrate the dramatic gap in life expectancy between those with serious mental illness and related conditions, according to the nonprofit safety-net care provider’s CEO, Beth Keeney.

Today, research shows that those with SUDs have the highest years of potential life lost compared to those who do not: on average, dying 20 years earlier.

“We were seeing that in practice,” Keeney said. “We had care managers work with somebody on Friday, and then they would find them deceased on Monday. It was never for things like overdose or suicidality. It was for things like hypertension, untreated lung disease or poorly managed diabetes.”

So the organization evolved. It is now a federally qualified health center (FQHC), a community mental health center (CMHC) and is working on becoming a certified community behavioral health center (CCBHC). The overlap of these designations by the government means that LifeSpring Health Systems can provide “behavioral health and substance use disorder treatment as well as comprehensive primary care across the lifespan,” Keeney explained at the Forum.

The keys to adopting such a wide multispecialty model were a shift in culture and an electronic health record that could handle behavioral health and physical health care, including obstetric and pediatric care.

“It took us a long time to figure out how to do that well,” Keeney said. “The hardest part was figuring out how to get everybody on the same page.”

A focus on open and timely communication merges the cultural and technological strategies. As a manifestation of culture into operations, multidisciplinary care teams started conducting daily huddles.

Physical and behavioral health clinicians began to inform each other of and consult on each other’s clinical decisions. Occasionally, this is done in simple ways, such as walking down the hall to the office of a coworker.

Even within a behavioral health-only organization, special care has to be taken whenever a patient crosses the span between care levels or specialties, Jaime Vinck, president of Phoenix-based Meadows Behavioral Health, said at the event.

“Breaking down internal silos, both from a technology standpoint and a cultural standpoint, so that our communication is smooth, so that we can take our best self to our external partners, has been a huge priority,” Vinck said.

The company operates 12 outpatient locations and seven inpatient or residential facilities.

How you start matters

At Meadows Behavioral Health, two physicians review the cases of incoming patients to ensure the correct point of entry to the organization, ensuring that patients get the right care at the right time. They also assess the physical health of the patient.

Over the years, patients overall have become sicker than ever. That impacts their ability to face recovery.

“The last thing that we want to do is to bring someone into our care that isn’t physically capable of doing the work,” Vinck said. “Meadows is known for trauma work, and we have to have someone really at the top of their game in order to engage in that sort of work.”

These physicians work with referring physicians to get patients into the right level of care.

Similar collaborations have to happen between traditional providers and the ever-increasing number of digital providers as well. This is largely due to the nature of certain types of care simply being best performed in a dedicated facility with the appropriate level of care and oversight, such as medical detox.

Nick Mercadante, CEO of PursueCare, said that digital behavioral health providers ought to defeat the preconceived notion that these kinds of companies are only good for one thing: delivering medications to patients.

Still, there are some services that PursueCare has to provide patients via partnerships.

“What we try to do is become a quarterback, become a coordinator, and really dig in with case management,” Mercandante said at the Addiction Treatment Forum.

When PursueCare starts its engagement with patients, it considers as wide of a picture of the patient’s health as possible, including dental health and aspects of the social determinants of health such as food security. Such additional consideration is invaluable to patients’ success but comes at a price to the provider.

Mercandante and other panelists said that care coordination and planning activities are not paid for by many payers. This isn’t always the case. Indiana Medicaid covers care coordination, and Mercandante said there is more latitude among commercial health plans to address these challenges.

“But what we find is that patients are much, much more successful when they have that coordination,” Mercandante said.