Learning Objectives

By the end of this topic, the student should be able to:

  • Review collaboration within interdisciplinary teams caring for persons using opioids and persons who have an opioid use disorder.
  • Discuss examples of Continuum of Care models relevant to the care of persons who use opioids or persons that have an opioid use disorder.
  • Recognize when consultation or referrals to another professional or service organization are necessary

Key Concepts

  • Collaborative care involves a number of health professionals working with a person who uses opioids to comprehensively address issues related to opioid use.
  • The team can consist of professionals from a variety of health disciplines.
    • The team may frequently work with community service organizations such as those providing at-home supports.
  • Understanding when and how to facilitate the referral process is important in care provision.

Collaborative Care

Interdisciplinary team members all contribute important information to the multidimensional assessment. In the care of persons who use opioids and persons who have an opioid use disorder, the interdisciplinary team may involve Registered Nurses and Nurse Practitioners, Physiotherapists, Occupational Therapists, Social Workers, Psychologists, Addiction Counsellors, Pharmacists and Primary Care and Specialist Physicians.

In many cases, it is also important to include the client and family caregivers as part of the team consistent with adopting a person-centred approach to care.

Interprofessional collaborative practice is a hallmark in effective collaborative care.

  • Collaborative care (CC) interventions involve a number of health disciplines working together with persons who use opioids either in primary care or in a specialty care model (Unützer, 2013)
    • The CC model is an evidence-based approach that integrates physical and behavioural health and social services to involve regular or proactive monitoring and treatment
  • There is evidence to confirm that using the CC approach improves outcomes
    • For example, Watkins et al. (2017) carried out a randomized controlled trial comparing CC to usual primary care in the context of opioid use disorders. Those who received CC were more likely to report abstaining from opioids six months after receiving treatment
  • Effective collaborative care programs have structures and processes that support the linking of interventions, redesigning usual care and focusing on quality improvement
  • Kates at al. (2011) provides a comprehensive discussion of common components of effective CC programs, including:
    • A care coordinator/case manager
    • Access to specialist consultation (pain specialist, psychiatrist, addictions medicine specialists for example)
      • Strategies to facilitate referrals
        • Providers should not delay in referring persons when there is a need
        • The consultant or person receiving the referral should receive all relevant information
          • The referring provider should make the referral as specific as possible by explaining reason for the referral
        • Providers should maintain a current list specialists and community service organizations
        • Providers and consultants should establish effective, bidirectional communication using technological means where possible
      • Well-developed educational materials
      • Use of evidence-informed treatment guidelines
      • Appropriate and comprehensive screening
      • Access to psychological and behavioural therapies
      • Support for self-management
      • Proactive follow-up (in person/virtual/telephone)
  • Collaborative Care makes use of the approach that care of persons using opioids and persons with opioid use disorders require engagement on a continuum, at times needing interdisciplinary, specialty provider consultation and intervention. Continuum of care is a well-established concept (Evashwick, 1989) that has been embraced in the design and evaluation of services and interventions for persons in groups with a variety of health care needs and challenges.

Comprehensive addiction evaluation and individualized treatment plans should be supported over usual primary care. Watch the following video from the Opioid Partnership, which describes collaborative care.

(Chang et al., 2017)

Next, take a moment to review the Opioid Partnership’s advice on collective decision making.

(Chang et al., 2017)

The Continuum of Care

The Continuum of care is a system of care that is integrated for the purpose of guiding and following persons over time. The care in this continuum is provided in a comprehensive manner and is appropriate to all levels and intensities required by persons in the system (Evashwick, 1989).

  • A person’s journey through the continuum of care is not always linear
    • Some may use all components of the continuum while others may not
    • Some may revisit different components as needed
  • Some persons who experience chronic problems related to social determinants of health may need to be supported by additional services in the community to address food security and shelter or transportation

In the context of opioid use and opioid use disorders, a Continuum of Care approach has been used to ensure evidence-based practices reach individuals, families and community members in the reduction of opioid-overdoses (Winhusen et al., 2020). 

 

The HEALing Communities study (Winhusen et al., 2020) is an ongoing project involving the implementation of the Opioid-overdose reduction Continuum of Care Approach (ORCCA). The ORCCA is an excellent example and includes interventions that are focused in the following domains:

Primary prevention

  • Focused on persons not using opioids
    • Involving safer opioid prescribing and dispensing

Secondary prevention

  • Focused on persons at risk and using opioids
    • Overdose education and naloxone distribution

Tertiary prevention

  • Focused on persons at diagnosis with an opioid use disorder to recovery
    • Care coordination and support for treatment engagement/retention
    • Effective medication for opioid use disorder
    • Behavioural programs and support services
    • Mental health services
    • Peer navigation
    • Housing and community programs access support

The Continuum of Care approach has also been used in an evolving program to structure care to promote resilience for veterans, military members and first responders and their families in the United States using an adaptation of the Evidence-Informed Model of Human Resistance, Resilience and Recovery (Kaminsky et al., 2006). This approach is also relevant in the person-centred care in the context of opioid use and is an example that providers may find useful to consider. Read about the Hoplite Continuum of Care Model.

References

Evashwick C. (1989). Creating the continuum of care. Health Matrix, 7(1):30-9.

Kaminsky, M., McCabe, O., Langlieb, A. & Everly, G. (2007). An evidence-informed model of human resistance, resilience and recovery: The Johns Hopkins outcome-driven paradigm for disaster mental health services. Brief Treatment and Crisis Intervention, 7(1):1-11

Kates, N., Mazowita, G., Lemire, F., Jayabarathan, A., Bland, R., Selby, P., . . . Audet, D. (2011). The evolution of collaborative mental health care in Canada: A shared vision for the future. Canadian Journal of Psychiatry, 56(5), I1-I10.

Santana, M.J., Manalili, K., Jolley, R.J., Zelinsky, S., Quan, H., Lu, M., (2018). How to practice person-centred care: A conceptual framework. Health Expectations 21, 429–440.

Taha, S. (2018). Best practices across the continuum of care for treatment of opioid use disorder. Canadian Centre on Substance Use and Addiction.

Unützer, J., Harbin, H., Schoenbaum, M., & Druss, B. (2013). The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Centers for Medicare & Medicaid Services. https://www.chcs.org/media/HH_IRC_Collaborative_Care_Model__052113_2.pdf

Van Eeghen, C. O., Littenberg, B., & Kessler, R. (2018). Chronic care coordination by integrating care through a team-based, population-driven approach: A case study. Translational Behavioral Medicine, 8(3), 468–480.

Watkins, K. E., Ober, A. J., Lamp, K., Lind, M., Setodji, C., Osilla, K. C., Hunter, S. B., McCullough, C. M., Becker, K., Iyiewuare, P. O., Diamant, A., & Heinzerling, K., & Pincus, H. A. (2017). Collaborative care for opioid and alcohol use disorders in primary care: The SUMMIT randomized clinical trial. JAMA Internal Medicine, 177(10), 1480–1488.

Winhusen, T., Walley, A., Fanucchi, L.C., Hunt, T., Lyons, M., Lofwall, M., Brown, J.L., Freeman, P.R., Nunes, E., Beers, D., Saitz, R., Stambaugh, L., Oga, E.A., Herron, N., Baker, T., Cook, C.D., Roberts, M.F., Alford, D.P., Starrels, J.L., Chandler, R.K. (2020). The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study. Drug and Alcohol Dependence 217, 108325.