(24) A Multipronged Approach to Improving Linkage to Outpatient Substance Use Treatment

Introduction: Untreated alcohol and opioid use disorders lead to increased morbidity, mortality and hospital spending (Englander, 2017). Treatment for these disorders decreases mortality and prevents relapse (Sordo, 2017, Dawson 2006, Timko 2006). Despite the availability of effective, evidence-based treatment, there are low rates of linkage to substance care among eligible patients who present to our institution’s primary care clinic. We conducted a quality improvement project aimed to increase linkage to substance use care within 30 days of the index primary care clinic encounter by 50% (8% in Oct 2019-Dec 2019 to 12% by June 2021).

Methods: Using our electronic medical record, daily lists of patients presenting to the primary care clinic with a diagnosis related to alcohol or opioid use were generated. Using these lists, eligible patients were identified and contacted by the social work team via telephone visits. In addition, we expanded access to substance disorder medications by expanding our institution's formulary. Lastly, we implemented a substance use disorder curriculum for primary care residents and attendings. Our process measure was percentage of eligible patients with documented social work outreach. The outcome measure was percentage of patients with a substance use treatment encounter within 30 days of their index encounter. Since this project relied on existing social work resources, our balancing measure was patient enrollment in a social work run depression and anxiety program. Manual chart review and electronic medical record pulls based on ICD10 codes for alcohol and opioid use disorder were used to analyze these measures. In addition, value and equity lenses were applied to the data.

Results: Identification of adult primary care clinic patients with a substance use related diagnosis increased from an average of 26 patients per month to 47 patients per month. From January 2021-June 2021, an average of 62% (N=11.3) of eligible patients had social work outreach per month versus 16% (N= 2.3) pre-intervention. Post-intervention, an average of 36% (N=6.5) of eligible patients were linked into care within 30 days compared to 8% (N=1) pre-intervention. A post-intervention equity analysis demonstrates that black males had the lowest rates of engagement in substance use care at 27%. An analysis of emergency room and inpatient visits 3 months pre- and post-linkage to care shows that the percentage of patients with substance use related unplanned visits decreased from 17.6% to 11.7%.

Conclusions: Our institution implemented a successful multidisciplinary quality improvement project that increased linkage to substance use treatment among adult primary care clinic patients from 8% to 36%. We accomplished this by implementing a process to rapidly identify and outreach patients with a substance use related diagnosis, expanding access to treatment and implementing a provider education curriculum. Equity analysis demonstrates that black male patients had the lowest rates of engagement in care. We plan to explore additional resources, such as peer navigation, in order to address this disparity in outcomes.

References:
Dawson DA, Grant BF, Stinson FS, Chou PS: Estimating the effect of help-seeking on achieving recovery from alcohol dependence. Addiction 101(6):824–834, 2006 16696626.

Englander H, Weimer M, Solotaroff R, et al. Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder. J Hosp Med. 2017;12(5):339–342. doi:10.12788/jhm.2736.

Grant BF, Goldstein RB, Saha TD, et al: Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry 72(8):757–766, 2015. 26039070.

Sordo Luis, Barrio Gregorio, Bravo Maria J, Indave B Iciar, Degenhardt Louisa, Wiessing Lucas et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies BMJ 2017; 357 :j1550.

Timko C, Debenedetti A, Moos BS, Moos RH: Predictors of 16-year mortality among individuals initiating help-seeking for an alcoholic use disorder. Alcohol Clin Exp Res 30(10):1711–1720, 2006

Diversity, Equity, and Inclusion: We performed a three-month post-intervention analysis comparing the race and ethnicity of the total patients identified with substance use who presented to clinic versus those who were engaged in care within 30 days of their visit. The overall rate of engagement in care for all races and ethnicities was 60%. Black and Hispanic patients had lower rates of engagement in care. Adding gender to the analysis shows that this was driven by males. Black males had the lowest rates of engagement in substance use care at 27% (3/11) followed by Hispanic males with a rate of 45% (9/20).