Process Changes
To achieve same-day access to clinical care, program leadership created a daily morning orientation group. Patients are scheduled or may attend as a walk-in. The orientation’s purpose is to explain what services are available and to offer each patient an opportunity for immediate evaluation and treatment. Staff schedules were modified to provide patient evaluation appointment slots immediately following orientation. The number of immediate evaluation slots was initially assessed by analyzing the demand for treatment over the previous 6 months, determining the daily mean, and setting the number of slots to accommodate 3 standard deviations above the daily mean. If a patient in a daily orientation group expresses a willingness to engage in treatment, he or she is immediately evaluated by a counselor during a 90-minute session and seen by a psychiatrist to determine whether pharmacologic treatment would be appropriate. If needed, the medication is prescribed that day. The primary purpose of the patient’s initial clinical evaluation is to determine the most appropriate level of care based on ASAM criteria. Also available were 90-minute afternoon evaluation appointments with psychiatrists for patients who walk into the clinic after the morning orientation group had ended.
Prior to the redesign, clinic psychiatrists were minimally prescribing evidence-based pharmacotherapy for sobriety support. At the time of redesign, only 8% of patients diagnosed with opioid use disorders (OUDs) were prescribed buprenorphine/naloxone or naltrexone. Just 1.9% of patients diagnosed with alcohol use disorder (AUD) were prescribed naltrexone or acamprosate. With the redesign, access to these medications has significantly expanded.
All templates were redesigned to ensure consistent documentation. This change decreased the overall provider task burden, and explicitly supported the use of ASAM multidimensional criteria and the Brief Addiction Monitor (BAM) to identify a pretreatment baseline score and track each patient’s clinical progress.13 Evidence-based written curricula were standardized for individual and group psychotherapies to reduce provider and programmatic variation.
The redesign creates distinct levels of care based on ASAM criteria, including harm reduction, ambulatory detoxification, outpatient group and individual psychotherapy, an evidence-based Intensive Outpatient Program (IOP), and aftercare. Application of the ASAM standards has allowed clinicians to make accurate placement decisions that best meet individual patient needs and to serve as effective stewards even with limited treatment and financial resources. Although JAHVH does not have a residential SUD program, procedures were developed to refer veterans to community-based residential treatment programs when appropriate.
Group Therapies
With the redesign, SUDS was no longer exclusively a 12-step program; however, it still supported and recognized the value of this approach for some patients. A psychologist periodically audits group sessions to prevent drift from that group’s curriculum. Counselors are assigned to weekly hour-long clinical supervision sessions with a psychologist to review patient care and reinforce the application of evidence-based individualized treatment.
After reviewing empirical literature and VA directives, CBT-SUD was adopted. It encompasses individual and group interventions, such as motivational interviewing (MI), contingency management (CM), and medication-assisted therapies as primary therapeutic treatment modalities, all of which have demonstrated efficacy as measured by length of sobriety postintervention.9,14,15