Kathleen Louden

May 10, 2013

CHICAGO — Outcomes can improve when addiction medicine physicians and primary care physicians work together to coordinate care, a panel of addiction specialists said, but there are obstacles to overcome before integrated care can become widespread in the United States.

"The rationale for integration is that it's good for patients, and it's good for providers. We providers can share the burden of taking care of complicated patients," said one of the speakers, Alexander Walley, MD, an internal medicine physician at Boston Medical Center in Massachusetts.

In addition, the Institute of Medicine has called for the coordination of medical and mental health services since 2006, Dr. Walley said during a symposium presented here at the American Society of Addiction Medicine (ASAM) 44th Annual Medical-Scientific Conference.

"There is really now a mandate for integrated care," he said.

The other speakers were Judith Martin, MD, deputy medical director of community behavioral services for the San Francisco Department of Public Health in California, and Daniel Alford, MD, MPH, an associate professor of medicine at Boston University School of Medicine.

The panel discussed the benefits and challenges of integrated care for addiction medicine and primary care. Dr. Martin and Dr. Walley also described successful models of integration with which they had been involved.

First, Dr. Martin, who also moderated the session, asked the large audience what information they wanted to hear. So many primary care providers and addiction medicine physicians responded that she declared, "I can say that there's a lot of interest in integration."

She told Medscape Medical News, "Just providing addiction care to our patients leaves blanks in other areas of care. Most addiction specialists recognize this, but the US healthcare system does not support integration."

Methadone Clinic as Medical Home

In her prior position at the Bay Area Addiction Research and Treatment (BAART) Programs' Turk Street Clinic in San Francisco, Dr. Martin helped operate a methadone maintenance treatment clinic for opioid-dependent individuals that also served as a patient-centered medical home for these medically vulnerable patients. Features of a medical home for primary care are consistent with those of an opioid-treatment program, according to Dr. Martin. They include long-term patient-provider relationships, team care, and a holistic view of patient care, as well as being the principal medical contact for many patients.

The methadone clinic, which had a community clinic license, offered some primary care services, such as having drug counselors serve as health coaches. These coaches met weekly with patients who had chronic medical conditions to ensure compliance with their medications. In addition, when disabled patients received their methadone, they also received some ancillary medication, such as antihypertensive agents.

In a quality improvement project involving 29 patients aged 60 years or older who together had spent a total of 383 days in the hospital or jail during 2010, Dr. Martin's group observed positive changes in 2011 after implementing the team care model. She said they surpassed their goal of decreasing the number of days the patients spent in the hospital or jail, with a 51% reduction from 383 days in 2010 to 186 the next year. Although the number of dosing days in the clinic increased slightly, she said they did not meet their benchmark for that quality measure.

Because some services went beyond the scope of care for which the methadone clinic was funded, Dr. Martin said that about two thirds of their primary care work was not reimbursed.

Another problem is that some addiction treatment facilities do not have a pharmacy or a license to dispense medications. An audience member suggested working with community pharmacies to seal all the medications for their patients in a blister pack.

Generally, medical care, mental health care, and substance use treatment each requires a separate license and payer contract arrangement, Dr. Alford told Medscape Medical News.

Addiction Treatment at HIV Clinic

Dr. Walley described a grant-funded program at Boston Medical Center called FAST PATH (Facilitated Access to Substance abuse Treatment with Prevention And Treatment of HIV).

The purpose of the program, whose federal funding ended last year, was to provide substance abuse treatment in conjunction with medical care and HIV risk reduction in primary care settings. One setting was a clinic to treat HIV-infected patients, and the other was a general medical clinic for patients at high risk for HIV infection, he said.

The multidisciplinary team included an internal medicine/addiction medicine physician, a substance abuse nurse, and a licensed alcohol and drug counselor with a master's degree. The team treated patients with alcohol or drug dependence, providing medical evaluation, primary care services, medication counseling, and group-based addiction counseling.

In a new quantitative study of 6-month outcomes in 215 patients with substance dependence, Dr. Walley reported good results (64%) regarding patient engagement in the addiction treatment program, defined as having 4 visits to the clinic in the first 44 days of treatment. Engagement was more than 7 times likelier if the patient received buprenorphine (adjusted odds ratio, 7.45; 95% confidence interval, 3.82 - 14.52), according to the data.

He said, "[Offering] buprenorphine was a powerful tool for engaging patients into this primary clinic–based addiction treatment."

Despite the good rate of participation in the program, 45% of the patients had persistent substance dependence at 6 months, Dr. Walley reported. Depression was associated with continued substance dependence.

He added that focus group research found that some patients liked the structure of the program, but others thought it was inflexible. Dr. Walley said, "Overall, patients appreciated the integration of medical and addiction care."

Challenges to Integrated Care

In discussing multidisciplinary integrated care for safe opioid prescribing to patients with chronic pain, Dr. Alford recommended that the primary care provider remain responsible for medication prescriptions. This approach, he said in response to a comment from an audience member, may prevent the problem of primary care physicians who do not want to oversee their opioid-dependent patients' care after referral to an addiction specialist.

Lack of funding or reimbursement for integrated care models was a frequent complaint from the speakers and audience members.

Dr. Alford said that telemedicine might be a solution to reducing the costs of care and overcoming a projected shortage of addiction specialists.

Another possible solution, he told Medscape Medical News, is multipurpose staff. "An integrated multidisciplinary care model is probably not sustainable long term without grant funding unless the staff person screening for unhealthy substance use also does general mental health screening, patient navigation around routine healthcare maintenance, etc."

Dr. Alford continued, "A lot of scenarios would benefit from integration in primary care using multidisciplinary teams, but until the way care is reimbursed is changed, it's not going to happen."

To prove the cost-effectiveness of integrated care, more research is needed, said ASAM President-Elect R. Jeffrey Goldsmith, MD, when asked by Medscape Medical News to comment on the presentations. Dr. Goldsmith, a psychiatrist in Cincinnati, Ohio, who attended but did not speak at the symposium, said that research should focus on models of care that are sustainable in the long term.

He also stressed that use of a team approach in integrated care should not neglect the one-on-one relationships of team members. "That's a frequently ignored part of collaboration," he stated. "Staff will be most satisfied if they get to know each other's strengths and weaknesses."

A 5-year grant from the Substance Abuse and Mental Health Services Administration funded the FAST PATH program at Boston Medical Center. None of the physicians interviewed disclosed any relevant financial relationships.

American Society of Addiction Medicine (ASAM) 44th Annual Medical-Scientific Conference. Symposium 10. Presented April 28, 2013.

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