Clinical Staff Improvements
Staff were reorganized into 3 interdisciplinary treatment teams. A weekly team meeting is scheduled to coordinate care and discuss the treatment of complex patients. Clinical staff focus has shifted from case-management to diagnosis and treatment; now patients are referred to their primary care team’s social worker for case management services. Allowing clinical staff to focus solely on the diagnosis and clinical treatment of SUDs has significantly enhanced productivity and morale.
Staff receive training in the newly adopted interventions during brief monthly refresher courses provided by inhouse psychologists. Additional training includes participation in local and national SUD teleconferences and onsite meetings with experts in harm reduction and motivational interventions. During the transition, clinicians were encouraged to attend staff resiliency training. Continuing education was available to the SUDS psychiatrists and all inpatient and outpatient psychiatrists at JAHVH. Recently, this educational initiative was expanded to include all primary care and inpatient internal medicine physicians.
Implementation
On November 2, 2015, all planned programmatic changes were simultaneously implemented. On that day, clinician and patient schedules changed, the new EBP curriculum was administered, the use of streamlined documentation procedures began, and daily orientation groups followed by same-day evaluations were initiated.
The pretreatment sobriety requirement was eliminated as a barrier to care, and the program began to use a harm-reduction treatment track as recommended by ASAM guidelines. Patients with urgent or emergent medical or psychiatric problems were immediately assessed by SUDS health care providers and treated in the clinic or transported to the emergency department. Previously unavailable, patient access to ambulatory detoxification was initiated. The prescription of buprenorphine/naloxone for the treatment of OUD treatments increased from 1 prescriber to all 3.
Three months after program reorganization, the leadership reviewed overall workflow, conducted patient satisfaction surveys, and evaluated facility use and productivity. To address patient needs and facilitate optimal use of space, the number of same-day evaluation slots was reduced while the number of individual therapy slots was increased.
Staff meet in workgroups to discuss EBPs and further refine content with feedback from the supervisory clinician and team psychologists who routinely audit group therapy sessions. Staff report ongoing benefit from weekly supervision with a clinical psychologist. An inpatient addiction consultation team that uses existing manpower and resources has been developed.
Program Goals and Outcomes
The SUDS program serves more patients at multiple levels of standardized care with 2 fewer full-time positions. One counselor and one advanced practice registered nurse were reallocated to different programs within the JAHVH VA mental health clinic. Following a review of all program clinic profiles in the VA’s Computerized Patient Record System (CPRS) for utilization, accuracy, and necessity, and allowing for accurate program data capture, the transition resulted in a reduction of distinct clinics from 114 to 67 (-58.7%). In fiscal year 2018, review of CPRS yielded 19,786 total visits (3,645 unique visits).
Eliminate Patient Wait Tme
Patient wait time, as measured in CPRS from date of initial evaluation to date of treatment was reduced from an average of 33 days to 0 within 2 weeks of program implementation. A review of CPRS data also indicated that preadmission attrition dropped from 54% to < 1%; all patients desiring treatment are assigned a counselor and treatment is initiated the same day.