Substance use disorders (SUDs) are an increasing public health concern in the US. The 2015 National Survey on Drug Use and Health indicated that 27 million people (8% of the US population) reported current use of recreational drugs or misuse of alcohol or prescription medications.1 The 2013 National Survey on Drug Use and Health indicated that 1.5 million veterans (roughly 6.6%) met the criteria for a SUD.2 More than 50% of patients awaiting entry into a SUD treatment program will never achieve admission due, in part, to long wait times.3-5
National attention has been focused on increasing veteran access to quality treatment based on evidence-based practices (EBPs). Several national legislative measures and treatment protocols have been implemented: the Uniform Mental Health Services in US Department of Veterans Affairs (VA) medical centers and clinics; Veterans Access, Choice, and Accountability Act (2014); Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) Training Program; and the Psychotropic Drug Safety Initiative (PDSI).6-8 Consistent with these directives and in line with American Society of Addiction Medicine (ASAM) and Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for medication-assisted therapies (MAT),the James A. Haley Veterans’ Hospital (JAHVH) Mental Health and Behavioral Sciences Service (MH&BSS) Substance Use Disorders Service (SUDS) in Tampa, Florida, implemented an evidence-based, treatment-on-demand model of care.9-11
Meeting SUD Treatment Needs
What does the new supervisor of a clinical program do when a 24-employee outpatient VA Alcohol and Drug Addiction Treatment Program (ADATP) has an average 33-day wait time for treatment with 54% of patients lost to care between initial evaluation and admission?12 Patients lacked consistent access to SUD pharmacotherapy. The national VA clinical performance indicators were substandard and there are no additional resources available to apply to the program.
At JAHVH the program supervisor enlisted hospital leadership to support program redesign. The redesign sought to improve operational efficiency and eliminate patient wait time; adopt national standards for assessment and treatment developed by ASAM; implement strictly evidence-based psychotherapeutic treatments; educate program psychiatrists about evidence-based psychopharmacologic treatments and hold them accountable for patient adherence; streamline documentation templates; free clinical providers from nonclinical tasks; create an inpatient addiction consult team to diagnose and treat chronic hospitalized patients with SUDs; ensure continuity of care; and, standardize consistent, objective measures of patient response to treatment to track the program’s effectiveness.
In this article, the authors provide an explanation of the clinical, theoretical foundation and the practical steps taken to design and implement this transformation. They then describe the lessons learned, hoping that their process will serve as a model for those in similar situations.
Program Redesign
July 1, 2015, a new program supervisor was hired and began a 2-month evaluation and analysis of the program with input from leadership, staff, and hospital/community stakeholders. September 1, the monthlong process of developing the redesign began. On September 30 the plan was presented to, and approved by, MH&BSS leadership. October was spent preparing for change with an implementation date of November 2 selected. On November 2, 2015, the complete redesign was implemented.