Literature Collection

Addressing substance use disorders and social determinants of poor health at a population level is a major national healthcare priority. One promising model to improve healthcare outcomes for patients with these conditions is the Vulnerable Veteran Innovative Patient-Aligned Care Team (PACT) Initiative, or VIP - an interdisciplinary, team-based primary care delivery model designed to address the needs of vulnerable patients in the Veterans Health Administration. VIP establishes a single, integrated primary care environment for the management of substance use disorders, mental illness, social determinants of poor health, and complexities in care resulting from the co-occurrence of these conditions. We describe the origination, goals, and evolution of VIP to provide an example of how clinics and health systems can address vulnerable patient populations within a primary care clinic framework. While ongoing evaluation will be essential to understand its impact on patient outcomes and its sustainability and scalability in the future, VIP holds promise as a novel model to improve care for patients with addiction and other vulnerabilities.

Addressing substance use disorders and social determinants of poor health at a population level is a major national healthcare priority. One promising model to improve healthcare outcomes for patients with these conditions is the Vulnerable Veteran Innovative Patient-Aligned Care Team (PACT) Initiative, or VIP - an interdisciplinary, team-based primary care delivery model designed to address the needs of vulnerable patients in the Veterans Health Administration. VIP establishes a single, integrated primary care environment for the management of substance use disorders, mental illness, social determinants of poor health, and complexities in care resulting from the co-occurrence of these conditions. We describe the origination, goals, and evolution of VIP to provide an example of how clinics and health systems can address vulnerable patient populations within a primary care clinic framework. While ongoing evaluation will be essential to understand its impact on patient outcomes and its sustainability and scalability in the future, VIP holds promise as a novel model to improve care for patients with addiction and other vulnerabilities.

SETTING: Alberta is a prairie province located in western Canada, with a population of approximately 4.3 million. In 2016, 363 Albertans died from apparent drug overdoses related to fentanyl, an opioid 50-100 times more toxic than morphine. This surpassed the number of deaths from motor vehicle collisions and homicides combined. INTERVENTION: Naloxone is a safe, effective, opioid antagonist that may quickly reverse an opioid overdose. In July 2015, a committee of community-based harm reduction programs in Alberta implemented a geographically restricted take-home naloxone (THN) program. The successes and limitations of this program demonstrated the need for an expanded, multi-sectoral, multi-jurisdictional response. The provincial health authority, Alberta Health Services (AHS), used previously established incident command system processes to coordinate implementation of a provincial THN program. OUTCOMES: Alberta's provincial THN program was implemented on December 23, 2015. This collaborative program resulted in a coordinated response across jurisdictional levels with wide geographical reach. Between December 2015 and December 2016, 953 locations, including many community pharmacies, registered to dispense THN kits, 9572 kits were distributed, and 472 reversals were reported. The provincial supply of THN kits more than tripled from 3000 to 10 000. IMPLICATIONS: Alberta was uniquely poised to deliver a large, province-wide, multi-sectoral and multi-jurisdictional THN program as part of a comprehensive response to increasing opioid-related morbidity and mortality. The speed at which AHS was able to roll out the program was made possible by work done previously and the willingness of multiple jurisdictions to work together to build on and expand the program.

AIMS: To compare healthcare costs over 2 years between those who did and did not receive an alcohol brief intervention (BI) among adult primary care patients screening positive for unhealthy alcohol use. DESIGN: Population-based observational study, using electronic health record data. SETTING: Kaiser Permanente Northern California, a non-profit, integrated healthcare delivery system of socio-economically and demographically diverse members in California, USA. PARTICIPANTS: Adult primary care patients, aged 18-85 years, who screened positive for unhealthy alcohol use between 1 January 2014 and 31 December 2017 as part of a systematic alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) program (n = 287 551). Patients either received a BI for unhealthy alcohol use (BI group) or did not receive a BI (non-BI group). MEASUREMENTS: Total emergency department (ED) and inpatient costs summarized in 6-month intervals from index screening through 24 months post-index; multivariable models examined associations between BI receipt and cost, and potential moderation by patient characteristics (age, sex, race/ethnicity, insurance type, clinical characteristics including body mass index, smoking status, physical activity level, the Charlson index of comorbidity, baseline drinking levels, drug and alcohol use disorders and mental health conditions in the prior year and the corresponding cost in the year prior to index date). FINDINGS: Adjusting for patient characteristics and prior-year cost, the largest declines in cost were found in the 6 months immediately following the index date for both BI and non-BI groups, and patients receiving a BI had greater reductions [estimate = -$209, 95% confidence interval (95% CI) = -$298 to -$119; estimate = -$11, 95% CI = -$14 to -$7, respectively] in total and ED costs, respectively, during this period compared with those who did not. Patients with a Charlson score ≥3 receiving a BI had lower total costs (estimate = -$621, 95% CI = -$1196 to -$46) and lower ED costs (estimate = -$24, 95% CI = -$47 to -$1) over 2 years, and patients with AUD receiving a BI had lower ED costs (estimate = -$33, 95% CI = -$66 to $0, respectively) than those who did not. CONCLUSION: Among US adult primary care patients screening positive for unhealthy alcohol use, individuals who receive an alcohol brief intervention at the time of screening appear to have statistically significantly greater declines in healthcare costs in the 6 months following screening than individuals who do not receive an alcohol brief intervention. Moreover, receipt of an alcohol brief intervention appears to be associated with statistically significantly lower costs in two particularly vulnerable (and historically costly) patient groups: patients with alcohol use disorders and those with a Charlson score ≥3 (indicative of significant medical comorbidity).