Outpatient continuing care after residential substance use disorder treatment in the US Veterans Health Administration: Facilitators and challenges

ABSTRACT

Background: In the U.S. Veterans Health Administration (VHA), residential treatment programs are an important part of the continuum of care for patients with substance use disorders (SUDs). Outpatient continuing care after residential treatment helps maintain early recovery and treatment gains. Knowing more about the drivers of variation in continuing care practices and performance across residential programs might inform quality improvement efforts. Methods: Metrics of continuing care were operationalized and calculated for each of VHA's 63 SUD Residential Rehabilitation Treatment Programs (SUD RRTPs) and 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track in fiscal year 2012. Management and frontline staff of these programs were then interviewed to learn what factors might contribute to high or low program performance on the metrics compared with national averages. Results: Among SUD RRTPs, the mean rate of outpatient SUD/MH continuing care was 59% within 7 days and 80% within 30 days, and the mean rate of SUD continuing care was 63% within 30 days. Among MH RRTPs with a SUD track, these rates were 56%, 75%, and 36%, respectively. There was substantial variability in continuing care rates across the 97 programs: 21%–93% for SUD/MH care within 7 days, 36%–100% for SUD/MH care within 30 days, and 4%–91% for SUD care within 30 days. Interviews with representatives of 44 programs revealed key facilitators of continuing care: accountability of program staff, predischarge scheduling, predischarge introductions to continuing care providers, strong patient relationships, accessibility, and persistent emphasis. Key challenges included inadequate program staffing, lack of program staff accountability, and poor accessibility. Conclusions: Wide variation in continuing care rates across programs and identification of common facilitators at high-performing programs suggest substantial opportunity for improvement for programs with lower performance.

KEYWORDS:

• Quality improvement
• quality measurement
• residential treatment
• standards of care
• substance use disorders

Funding

This work was funded in part by the United States Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (RRP-12-468) and a VA Research Career Scientist Award to Dr. Harris (RCS-14-232). The views expressed are those of the authors and do not represent the position or policy of the Department of Veterans Affairs or the United States Government. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

The authors declare that they have no conflicts of interest.

Author contributions

A.D.R. had primary responsibility for writing and revision of the manuscript. A.H.S.H. and J.L.B. were responsible for conception and design of the study. L.S.E. and T.E.P. assisted in recruitment of program managers and frontline staff, conducted the interviews, analyzed the qualitative data, and summarized results for the manuscript. S.G. and T.B. analyzed the quantitative data. All authors participated in interpretation of the results and revision of the manuscript.