Literature Collection

BACKGROUND: People living in precarious socio-economic conditions are at greater risk of developing mental and physical health disorders, and of having complex needs. This places them at risk of health inequity. Addressing social determinants of health (SDH) can contribute to reducing this inequity. Case management in primary care is an integrated care approach which could be an opportunity to better address SDH. The aim of this study is to better understand how case management in primary care may address the SDH of people with complex needs. METHODS: A case management program (CMP) for people with complex needs was implemented in four urban primary care clinics. A qualitative study was conducted with semi-structured interviews and a focus group with key informants (n = 24). An inductive thematic analysis was carried out to identify emerging themes. RESULTS: Primary care case managers were well-positioned to provide a holistic evaluation of the person's situation, to develop trust with them, and to act as their advocates. These actions helped case managers to better address individuals' unmet social needs (e.g., poor housing, social isolation, difficulty affording transportation, food, medication, etc.). Creating partnerships with the community (e.g., streetworkers) improved the capacity in assisting people with housing relocation, access to transportation, and access to care. Assuming people provide their consent, involving a significant relative or member of their community in an individualized services plan could support people in addressing their social needs. CONCLUSIONS: Case management in primary care may better address SDH and improve health equity by developing a trusting relationship with people with complex needs, improving interdisciplinary and intersectoral collaboration and social support. Future research should explore ways to enhance partnerships between primary care and community organizations.

Older adults with opioid use disorder (OUD) are a growing population with high levels of multimorbidity and social complexity. While treatment gaps for OUD exist across the lifespan, older adults face specific barriers to diagnosis, treatment, and harm reduction services. Current care models are often poorly equipped to address medical and social complexity or provide integrated care, and the geriatric workforce has traditionally had little training on managing OUD and other substance use disorders. There are also specific payment and insurance coverage gaps that may disproportionately impact older adults, including limited service coverage and poor reimbursement for integrated care and wraparound services. To address these gaps, there are opportunities to shape policy and redesign systems to improve access and quality of care. We must continue to adapt our care models to provide integrated treatment that is age-friendly, appropriate, and acceptable to older adults with OUD. Maintaining and expanding insurance coverage-including preserving Medicaid access, expanding Medicare coverage, and improving reimbursement within the care continuum-is a critical lever to ensuring older adults receive accessible, high-quality OUD care. There are also opportunities to improve workforce training and support across acute, postacute, and outpatient care settings. Methadone reform is another important area that could disproportionately improve care for older adults and those with multimorbidity. Finally, tailoring low-barrier, telehealth, and other nontraditional OUD care models to serve older adults is an important but underexplored area. By leveraging policy strategies to promote the incorporation of age-friendly care within the addiction space, clinicians and policymakers can promote access and bolster the quality of addiction care across the continuum.

PURPOSE: The purpose of this paper is to examine the current provision of opioid substitution therapy (OST) during and immediately following release from detention in prisons in England and Wales. DESIGN/METHODOLOGY/APPROACH: A group of experts was convened to comment on current practices and to make recommendations for improving OST management in prison. Current practices were previously assessed using an online survey and a focus group with experience of OST in prison (Webster, 2017). FINDINGS: Disruption to the management of addiction and reduced treatment choice for OST adversely influences adequate provision of OST in prison. A key concern was the routine diversion of opiate substitutes to other prisoners. The new controlled drug formulations were considered a positive development to ensure streamlined and efficient OST administration. The following patient populations were identified as having concerns beyond their opioid use, and therefore require additional considerations in prison: older people with comorbidities and complex treatment needs; women who have experienced trauma and have childcare issues; and those with existing mental health needs requiring effective understanding and treatment in prison. ORIGINALITY/VALUE: Integration of clinical and psychosocial services would enable a joint care plan to be tailored for each individual with opioid dependence and include options for detoxification or maintenance treatment. This would better enable those struggling with opioid use to make informed choices concerning their care during incarceration and for the period immediately following their release. Improvements in coordination of OST would facilitate inclusion of strategies to further streamline this process for the benefit of prisoners and prison staff.