Abstract
Background:
Alcohol and opioid use disorders (AUD, OUD) cause significant morbidity and mortality among Veterans, yet only a minority receive evidence-based treatment.
Objective:
Beginning in February 2022, we piloted a telemedicine pharmacist-physician management model (PPMM) in 6 Veterans Health Administration (VHA) primary care community-based outpatient clinics (CBOCs) across one VHA Health Care System to improve rural Veteran access to medications for opioid and alcohol use disorder (MOAD).
Methods:
Veterans with AUD and/or OUD receiving primary care in participating CBOCs during the year following implementation were eligible for referral. Data obtained from study records and VHA electronic health records assessed patient sociodemographic and clinical characteristics and MOAD receipt among referred Veterans.
Results:
There were 2,274 Veterans diagnosed with AUD (n=2,062) and/or OUD (n=307) receiving primary care from CBOCs during the study period. Of this population, 111 (4.9%) Veterans were referred and received PPMM services (AUD: n=93; OUD: n=9; AUD and OUD: n=9), the mean age was 52 years, 92% were male, 68% white, and 39% lived in rural zip codes. Of the 102 Veterans referred to PPMM with AUD, 71% received medication. Of the 18 Veterans referred with OUD, 78% received medication. Most Veterans who were newly initiated on MOAD (N=74) received medication within 72 hours (N=50, 68%).
Conclusions:
In this pilot implementation of same-day telemedicine PPMM, high rates of MOAD receipt were seen among referred Veterans. However, most Veterans with AUD/OUD seen in participating clinics were not referred. Further evaluation of barriers and/or facilitators to referral are needed to increase program uptake.
Keywords: primary care, substance use disorder, Veterans, telemedicine, rural
Introduction:
Substance use disorders (SUDs) such as alcohol and opioid use disorders (AUD, OUD) are a major cause of morbidity and mortality among Veterans.1–2 Though high-risk substance use and drug overdose deaths have increased substantially since the COVID-19 pandemic,3–4 only a minority of patients receive evidence-based medication interventions for SUDs, and even fewer rural Veterans receive these treatments.5–6
Medications for opioid and alcohol use disorders (MOAD) are effective, first-line treatments for OUD and AUD.7–8 To increase treatment among rural Veterans and other underserved populations, the Veterans Health Administration (VHA) has prioritized improving access to MOAD through primary care, however these efforts have yielded limited success.5–6,9 Barriers to successful prescribing of MOAD in primary care include providers’ beliefs about the complexity of prescribing MOAD, low leadership support, providers’ lack of time, and challenges incorporating treatment in existing primary care provider (PCP) workflows.10–11 Thus, scalable approaches that can address these potential barriers are needed to promote adoption of MOAD in primary care settings that serve rural patients.
One approach utilized by VHA to expand health services for Veterans is a pharmacist-physician management model (PPMM), which utilizes clinical pharmacist collaboration with physicians to improve access to evidence-based treatment, often through telehealth services.12 PPMM models are shown to reduce barriers such as resource limitations and lack of leadership engagement; they also integrate well into primary care teams.13–14 PPMM has been piloted for SUD interventions within and outside VHA and found to be both a feasible and cost-effective approach.15–16 A benefit of telemedicine PPMM is that office-based MOAD can be prescribed over the phone and mailed out to patients the same day, decreasing time to treatment initiation — a particularly important consideration when treating SUD. Telemedicine PPMM also addresses common barriers to receiving SUD care reported by rural patients, such as stigma and challenges traveling large distances to specialty treatment facilities.17–19 Telemedicine PPMM has yet to be piloted within VA community-based outpatient clinics (CBOCs); to our knowledge it has also not been utilized to address AUD in addition to OUD in primary care.
We developed and implemented a pilot telemedicine PPMM to provide timely MOAD in six CBOCs in a Pacific Northwest VHA Health Care System, which serve a larger proportion of rural Veterans than the primary medical center. The pilot model consists of a primary care addiction-trained clinician and clinical pharmacy practitioner who, following a referral from CBOC PCPs, provide patients with same-day telephone assessment and MOAD initiation, if indicated. The model was conceptualized as a way to both reduce common patient (stigma, travel) and provider barriers (lack of time, discomfort with MOAD) that could also garner leadership support (low cost, reduced provider workload)11,14,16.
We evaluated the first 12 months of this service by describing the number and types of patients referred to and contacted by PPMM. Additionally, among those who received PPMM services, we evaluated the number of patients who received MOAD.
Methods
The pilot program took place within a VHA Health Care System in the Pacific Northwest, which includes two main campuses and six CBOCs. The six CBOCs provide primary care services throughout the region to both urban and rural Veterans, with the percentage of rural Veterans seen typically higher in CBOCs than main medical centers (regional CBOCs average between 20-80% rural Veterans).
Intervention
The PPMM was implemented in February of 2022. The team was led by an addiction board certified primary care provider (AJK) who had 15% protected time devoted to PPMM. As there was limited protected time designated for this project, AJK recruited a team of local SUD clinical pharmacists, primary care providers (PCPs) with experience in addiction medicine, and an addiction social worker, to promote timely follow-up of referrals and clinical interactions. The majority of PPMM clinical care during this pilot occurred during team members’ administrative time and/or time that was already dedicated to caring for Veterans with SUDs (i.e., no additional protected time was provided). Clerical staff member time was donated from the specialty addiction program to assist with scheduling. Each team member had slightly different roles. PCPs on the PPMM team provided initial assessment/SUD diagnosis and follow-up care for more complex Veterans (i.e., Veterans starting on buprenorphine, those with complex medical comorbidities, outpatient alcohol withdrawal symptoms). Clinical pharmacists were able to provide initial assessments if the patient had a chart diagnosis of SUD and provided follow-up for lower complexity patients (e.g., routine medication for alcohol use disorder [MAUD] starts, OUD follow-up visits). Both providers and pharmacists prescribed MOAD. Social workers provided time-limited behavioral therapy or harm reduction planning for patients who were interested.
The PPMM was launched concurrently at all six CBOCs in February 2022 via an electronic Microsoft Teams referral form. The program was advertised through clinic and mental health staff meetings where PPMM leadership delivered a brief verbal description of the service; a written description was also sent via email/electronic communications to all sites. The PPMM was described as a same-day telemedicine intervention primarily designed to help patients with AUD/OUD initiate MOAD. The logistics of the referral process were also discussed. To help maximize benefit and promote referral use, PCPs were encouraged to consider referral for any OUD or AUD concern if desired by the patient. The service workflow is outlined in Figure 1. PCPs and/or Patient Aligned Care Team (PACT) team members including nurses, social workers, psychologists and/or administrative assistants, identified eligible Veterans as having a substance-related concern based on clinical judgement, positive screening, and/or patient request. If the Veteran agreed to the referral, the provider placed an electronic referral to the PPMM team, who provided on-call staffing during clinic hours, Monday through Friday. A PPMM provider then contacted the Veteran via telephone on the same day as the referral, if possible. A total of three outreach calls were made to the Veteran on the day of referral, if not reached on the same day, three additional attempts were made on the subsequent business day. During the telephone visit, the PPMM provider completed a substance use assessment, formulated a management plan, prescribed medications for MOAD and/or linked the patient to SUD specialty care, if indicated. Level of care was assessed utilizing the ASAM criteria and the VHA’s Clinical Practice Guideline for the Management of Substance Use Disorders, which emphasizes a stepped-care approach to SUD treatment. 20–21 Not all patients contacted by the PPMM team were interested in MOAD or engagement in care; for those patients, brief motivational interviewing to support reduction in substance use and/or harm reduction strategies was conducted. Follow-up appointments with the PPMM team were arranged for patients who initiated MOAD or who were interested in referral to the social worker for behavioral treatment (time limited individual therapy, 6 individual 30-minute sessions). Veterans deemed to need a higher level of care20–21 (i.e., severe withdrawal risk, significant co-occurring medical or psychiatric conditions, unstable recovery environments) were referred to the specialty addiction treatment program. Most Veterans had 3-4 follow-up visits with the PPMM team to stabilize on medications prior to referral back to their PCP for ongoing maintenance.
Figure 1.
Overview of the Telemedicine Pharmacist-Physician Management Model service workflow.
Abbreviations: PCP: primary care provider, PPMM: Pharmacist-Physician Management Model, SUD: substance use disorder, MOAD: medication for opioid and alcohol use disorders
Data source and study population
Consults that took place over the 12-month period from February 2022 through January 2023 were included in the analysis.
Data sources included internal program records and electronic medical record data obtained through the VHA Corporate Data Warehouse (CDW). Veterans with a documented ICD-10 code for OUD and/or AUD during the 12 months before and/or 12 months after the launch of PPMM and who had ≥ 1 outpatient visit at a participating CBOC during the year following implementation were included in the analysis. We obtained data from internal program records to identify patients who were referred to PPMM. Patients who had received care within a PPMM clinic at least 1 time during the study year were deemed to have been evaluated by the PPMM team. Veterans were excluded from the analysis if they died during the year following implementation.
Measures
For patients who were referred to PPMM and did not complete a visit, internal program records were reviewed to identify why they did not complete a visit and reasons were defined categorically (inaccurate consult, unable to reach, declined visit, already enrolled in specialty addiction care). Time to first PPMM visit was calculated as the number of days between the date of the referral and the date of the initial visit with a PPMM provider. To characterize the cohort, we obtained data from CDW to assess patient sociodemographic characteristics (age, sex, race, ethnicity, marital status, VHA service connection level, rurality, housing instability), clinical characteristics in the year prior to the implementation year (SUD diagnoses, mental health diagnoses), and MOAD receipt during the 90 days prior to the implementation year. We defined rurality using Rural-Urban Commuting Area (RUCA) codes for patients’ home zip code and housing instability using clinic stop codes and ICD codes.22–23 Prescription receipt was defined as any prescription of a medication for OUD (buprenorphine or naltrexone) or a medication for AUD (naltrexone, acamprosate, disulfiram, topiramate) by any prescriber (PPMM team member, PCP, specialty provider, etc.) during the year of implementation. Time to MOAD initiation was defined as days to the first prescription receipt for MOAD following the initial PPMM visit during the implementation year. If a patient was prescribed MOAD within the 90 days prior to their first PPMM visit, their record was manually reviewed. If the patient had an overlapping prescription for MOAD (i.e., no treatment discontinuation between starting medication and first PPMM visit) they were excluded from the time to initiation measure (examples included patients who needed bridge buprenorphine prescriptions or those who were already on MOAD who wanted to discuss alternative treatments).
Analysis
Descriptive statistics were utilized to describe demographic and clinical characteristics of patients referred to PPMM during the year of implementation. We evaluated the number of CBOCs and proportion of PCPs and other PACT team members who used PPMM during the implementation year. We assessed the proportion of CBOC patients with OUD/AUD referred to PPMM during the implementation year as well as the proportion of those referred who received MOAD. To examine these patterns for “medication naïve” patients, we looked at these same outcomes among participants with no MOAD receipt 90 days prior to the implementation year.
Results
Clinic Implementation
All 6 CBOCs successfully referred >1 Veteran to the PPMM service during the implementation year. Most completed referrals were for AUD (n=102, 91%). The number of referrals and unique PCPs/PACT team members making referrals varied between clinics (Tables 1&2). Over half of all PCPs within the six CBOCs referred to PPMM at least once during the implementation year and 40% of providers who referred to the PPMM service were non-PCP PACT team members (RN, PharmD, psychologist).
Table 1.
Proportion of primary care providers (PCPs) and other team member referrals to the physician-pharmacist management program (PPMM) during implementation year.a
Clinic
Total clinic staff who referred to PPMMb, (N)
Total PCPs who referred to PPMM, N(%)
Non-PCP clinic staffc who referred to PPMM, N(%)
PCPs per Clinic, (N)
Referrals from PCPs, N (%)
1
14
9 (64.3%)
5 (35.7%)
11
9 (81.82%)
2
11
7 (63.6%)
4 (36.4%)
16
7 (43.75%)
3
18
8 (44.4%)
10 (55.6%)
12
8 (66.67%)
4
3
3 (100.0%)
0
5
3 (60.0%)
5
2
2 (100.0%)
0
6
2 (33.33%)
6
11
6 (54.5%)
5 (45.5%)
12
6 (50.0%)
Total
59
35 (59.3%)
24 (40.7%)
62
35 (56.45%)
Table 2.
Veterans with alcohol and/or opioid use disorder at each specific clinic site and the number of physician-pharmacist management model (PPMM) referrals per clinic site during implementation yeara.
Clinic
Total, (N)
Rural, N(%)
AUD, N(%)
OUD, N(%)
AUD PPMM Visits, N(%)
OUD PPMM Visits, N(%)
Total PPMM Visits,b, N(%)
1
383
90 (23.5)
356 (93.0)
50 (13.1)
19 (5.3)
5 (10.0)
21 (5.5)
2
676
394 (58.3)
607 (89.8)
105 (15.5)
25 (4.1)
7 (6.7)
28 (4.1)
3
470
241 (51.3)
411 (87.4)
76 (16.2)
28 (6.8)
2 (2.6)
29 (6.2)
4
160
144 (90.0)
148 (92.5)
17 (10.6)
10 (6.8)
1 (5.9)
11 (6.9)
5
171
25 (14.6)
150 (87.7)
23 (13.5)
3 (2.0)
2 (8.7)
5 (2.9)
6
414
108 (26.1)
390 (94.2)
36 (8.7)
17 (4.4)
1 (2.8)
17 (4.1)
Total
2274
1002 (44.1)
2062 (90.7)
307 (13.5)
102 (4.9)
18 (5.9)
111 (4.9)
PPMM Patient Referrals
There were 2,274 Veterans diagnosed with AUD, OUD or both AUD/OUD who received primary care in the six intervention clinics during the study period: AUD (n=2,062) and/or OUD (n=307) (Table 3). Of this population, 141 (6.2%) Veterans were referred to PPMM. Of those, 111 Veterans received PPMM services (AUD: n=93; OUD: n=9; AUD and OUD: n=9). Of the Veterans who completed a PPMM visit, 77% had a visit within 24 hours and 87% were reached within 72 hrs. There were 30 Veterans who did not receive services: 16 (53%) could not be reached, 9 (30%) were inaccurate referrals, 3 (10%) were already enrolled in specialty addiction care and 2 (7%) declined visits. The mean age of Veterans who received PPMM was 52 years, 92% were Male, 68% White, 39% lived in rural zip codes and 12% received MOAD in the 90 days prior to implementation (Table 3). Veterans who were referred appeared similar to the baseline population, except that they had a lower mean age, a higher proportion were service connected ≥50%, and a lower proportion had bipolar disorder (Table 3).
Table 3.
Baseline characteristics of Veterans with alcohol and/or opioid use disorder referred to the Pharmacist-Physician Management Model as well as those not referred, receiving care within participating Community Based Outpatient Clinics (CBOCs) from February 2022-January 2023.
CBOC Patients (N=2,274)
PPMM Patients (N=111)
Age, M(SD)
M 55.4
SD 15.5
M 51.7
SD 14.3
N
%
N
%
Race/Ethnicity
White
1728
76.0
76
68.5
Black
135
5.9
7
6.3
Hispanic/Latino
107
4.7
6
5.4
American Indian/Alaska Native
26
1.1
2
1.8
Asian/Pacific Islander
74
3.3
4
3.6
Multiple
39
1.7
4
3.6
Unknown
165
7.3
12
10.8
Sex
Male
2081
91.5
102
91.9
Female
193
8.5
9
8.1
Marital
Married
1031
45.3
49
44.1
Divorced/Separated
720
31.7
33
29.7
Single/Widowed
474
20.8
25
22.5
Unknown
49
2.2
4
3.6
Service Connected ≥50%
1380
60.7
79
71.2
Rural
1002
44.2
43
38.7
Housing Instability
141
6.2
7
6.3
Substance Use Disordersa
Alcohol
2062
90.7
102
91.9
Opioid
307
13.5
18
16.2
Cannabis
138
6.1
3
2.7
Cocaine
40
1.8
1
0.9
Other Stimulant
60
2.6
4
3.6
Sedative
10
0.4
0
0.0
Other
44
1.9
2
1.8
Mental Health Disordera
Psychotic
63
2.8
1
0.9
Bipolar
118
5.2
1
0.9
Depressive
869
38.2
39
35.1
Anxiety
548
24.1
27
24.3
PTSD
797
35.1
37
33.3
MOAD 90 days prior to implementation year
MAUD
153
6.7
10
9.0
MOUD
83
3.7
4
3.6
MOAD Receipt
Of the 102 Veterans who had a PPMM visit for AUD, 72 (71%) received MAUD. Of the 18 Veterans who were seen for OUD, 14 (78%) received medication for opioid use disorder (MOUD). For patients with no MOAD receipt 90 days prior to the implementation year, 67.4% of those with AUD received MAUD and 71.4% of those with OUD received MOUD. Most Veterans who were newly initiated on MOAD (N=74) received medication within 72 hours (N=50, 68%).
Discussion
Integrating a pilot same-day telemedicine SUD PPMM into a VHA primary care setting provided timely SUD assessment, management, and prescribing of evidence-based MOAD. Most patients who were referred were started on MOAD, though the majority of patients with AUD or OUD receiving care within intervention clinics were not referred to the PPMM.
In this pilot, most Veterans who were referred to the PPMM service were referred for AUD, not OUD. This likely reflects the high prevalence of AUD in the Veteran population as well as the need for improved access to MAUD. In a 2015 survey of Veterans seen at outpatient VHA health systems, alcohol was the most reported substance used, and 10% of those surveyed met criteria for AUD, twice the number of those who met criteria for other SUDs.24 Despite its prevalence, AUD is known to be undertreated with pharmacotherapy, both within and outside the VA.5,7 Over 70% of patients with AUD who were contacted by the PPMM service received MAUD, a much higher proportion than the VHA national average. This difference was consistent among Veterans who were medication naïve, highlighting that this intervention may be a way to engage first-time treatment seeking individuals onto MAUD.
Relative to referrals for AUD, there was a lower rate of referrals to the PPMM for Veterans with OUD. The reasons for this remain unclear but may include known barriers such as higher rates of stigma against disclosing an OUD, limited provider knowledge and education on addressing OUD, and a lack of formal screening to identify substance use disorders other than alcohol in VHA primary care, 25–26 which is evaluated through annual Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) testing throughout VHA.21 There have been several large scale efforts to improve MOUD prescribing, specifically buprenorphine, at the VHA in recent years, so referral may be lower because patients were already on treatment.27–28 A large percentage of Veterans with OUD also seek care at VHA or community-based opioid treatment programs (OTP) for methadone, which cannot be prescribed by non-OTP providers.29 Veterans with OUD identified in primary care are often seen at the intersection of chronic pain and OUD, and do not always endorse an OUD diagnosis, which may also contribute to the low number of Veterans with OUD who were referred to the PPMM.30 While the need for in-person visits for prescribing of MOUD is an often-cited barrier to pharmacological care for OUD6,31, buprenorphine can be prescribed for the treatment of OUD via telemedicine even if no prior in-person medical evaluation has been performed.32 Further recommendations to improve uptake include: 1) targeted surveillance of and outreach to Veterans with OUD, 2) universal screening for SUDs, and 3) support for PCPs around the diagnosis of OUD.
In this PPMM, Veterans accessed this program through direct referrals by a provider (patients could not self-refer). While many PCPs referred to the program at least once during the implementation year, the percentage of PCPs who referred varied considerably across CBOCs (30-100%). While most referrals came from PCPs, we were surprised to find that over 40% came from non-PCP team members. This likely highlights the strong team-based care paradigm at the VHA,33 as well as the importance of non-physicians in completing many of the VHA screening tools, such as alcohol screening, which may have driven nurse and non-physician referrals.21 Further research is needed to understand the difference in referral patterns across CBOCs, if there was a difference in patient uptake by the type of provider who referred them, as well as strategies to encourage buy-in across implementation sites and provider-types.
Though the PPMM was effective at getting referred patients started on MOAD, the reach of this pilot was small (only 6.2% of Veterans in the intervention clinics with AUD or OUD were referred to the program). While this is consistent with uptake of SUD treatment in general populations34, our hope was that the PPMM would have had a greater referral and uptake among Veterans. Provider level factors such as knowledge and experience with the service and/or MOAD11,26, may have affected their readiness to make referrals. Patients may not have wanted to engage (we did not collect information on who was offered and declined the service). While reasons for lack of patient engagement are unknown, stigma and shame surrounding SUDs are well-known barriers for patients seeking care, which may have contributed to the low uptake.26,30 Additionally, limited awareness and misconceptions about MOAD often make patients hesitant to discuss substance use concerns in primary care settings, potentially affecting their engagement in this program35. Qualitative work is needed to better understand patient and provider facilitators and barriers to accessing care, including reasons for unsuccessful contact with referred patients and additional ways to improve intervention uptake and delivery.
Our study had limitations. This pilot evaluation was descriptive in nature, and future work is needed to assess the rate of MOAD prescribing over time, as well as the impact of this intervention on outcomes such as retention, reduction in substance use, and adherence to pharmacotherapy. This program was implemented within one health system in the VHA with pre-existing infrastructure to support telemedicine-based care, limiting its generalizability. In other healthcare settings, this structure may not exist, thus impairing the feasibility of implementing such a consultation service. Future work is needed to expand and evaluate the program in other settings.
Conclusions
In this pilot implementation of a same-day telemedicine PPMM for MOAD, patients who were referred and evaluated were highly likely to start MOAD. However, a significant population of Veterans with AUD/OUD seen in participating CBOCs were not referred to the program. Further evaluation of barriers and/or facilitators to referral is needed to guide improved program uptake.
Acknowledgments:
The authors thank Thomas Carr, Jeremiah Alexander, Oluwasey Adetunji, Carly Hood for providing clinical support.
Funding Source:
This work was supported by the U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health (NOMAD PROJ-04132) and by K24 AA027483.The views expressed are those of the authors and do not represent the views of the U.S. Department of Veterans Affairs, the Veterans Health Administration Office of Rural Health, or the U.S. Government.
Footnotes
Conflict of Interest: The authors do not declare financial conflicts of interest.
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