In March 2018, the Vulnerable Veteran – Innovative Patient Aligned Care Team (PACT) Initiative or VIP Initiative was started by the Veteran Health Administration (VHA) Veteran Integrated Service Network (VISN) 19 and the Salt Lake City Veterans Administration Health Care System (SLCVAHCS). The overarching goal of the VIP Initiative is to improve the health of Veterans who are particularly vulnerable due to medical disease and/or their social determinants through a unique longitudinal, primary care and consultative service delivery model.
VISN 19 is known for its exemplary clinical and research activities. The goal of this initiative is to enhance collaboration between the SLC HSR&D Center for Innovation (COIN) and VISN 19 leadership that will serve clinical and research missions. To build this collaboration, we address priorities identified by VISN 19 leaders.
Learn more about VISN 19 here.
A focus of this collaborative clinical, education, and clinical service project was to provide comprehensive primary and coordinated care for patients with co-occurring medical disease and/or social determinants of health.
The Veterans who have been targeted by this initiative are those Veterans with:
- unhealthy alcohol use and/or addiction disorders
- co-occurring addiction and pain disorders
- social determinants (e.g., homeless or at-risk for homelessness)
- high utilizers of health care services
- potentially high risk for opioid medication influenced morbidity in need of risk assessment and risk mitigation
- those who may need high intense, high-frequency primary care engagement
These Veteran populations are often disengaged from traditional primary care services, need services that are not readily available, or may require non-traditional service engagement. The VIP initiative consists of three clinical arms (VIP 1, VIP 2, VIP 3) which are intertwined but independent in function. The initiative has been designed to ensure that all three clinical arms can be a replicable model of care across the VISN and the VA nationally.
VIP INPUTS & OUTPUTS:
VIP 1 - SLC Vulnerable Veteran PACT
The primary goal of the VIP-1 PACT is to empanel eligible patients to primary care at the VASLCHCS and to integrate and collaborate their care among inpatient, urgent care, and specialty care services. The VIP-1 serves as the Center of Excellence and model a PACT that serves vulnerable patient populations.
VIP 2 - VISN 19 Services and Education PACT
The primary goals of the VIP-2 PACT are to 1) provide direct, remote clinical services to Veterans, 2) provide e-consultation regarding vulnerable Veteran patient population across the VISN, 3) provide mentoring of VA providers, and 4) provide education and consultative services to VA providers regarding vulnerable Veteran care issues (e.g., addiction, opioid risk assessment/mitigation). The intention of the VIP-2 is to extend the VIP-1 model of care to other CBOCs and Facilities in VISN 19 and to serve both staff (education) and Veterans (clinical service).
VIP 3 – High Utilizer Engagement Program
The primary goal of this VIP-3 PACT is to describe and evaluate the population of Veterans in VISN 19 who use health care services (e.g., emergency room, inpatient hospitalization) to a high degree and offer and evaluate interventions or implement process changes to mitigate that high use. VIP-3 will outreach to “high utilizer” patients who may or may not be served by VIP-1 or VIP-2 clinics and be more of a consultation and patient-directed service than a traditional primary care PACT.
The VIP has a newly active consult service that any ED staff (or anyone for that matter) can use to refer and alert the VIP Primary Care Team about a patient who might benefit from follow-up by the VIP team.
For VA Clinicians/Providers:
The new VIP consult that can be found under the Consult menu, under Primary Care. Anyone, especially staff in the ED, inpatient setting, CBOCs, etc. can use the consult for one of two purposes:
To alert the VIP team about a patient who might be appropriate for VIP Primary Care PACT – primarily patients with substance use disorders and complicated social, pain, and psychiatric disorders
To have the patient be seen by the VIP team in a consultative visit to assist the established primary care team with the direction of treatment for patients with substance use disorders and complicated social, pain, and psychiatric disorders
Chart review and consultative advice for next steps for patients with substance use disorders and complicated social, pain, and psychiatric disorders
VIP MAJOR ACCOMPLISHMENTS:
- 1482+ patients served
- 786+ patients currently empaneled to VIP clinicians (VIP clinicians are primary care providers of record)
- 120 e-consult completed
- 134 consultative visits completed
- Interdisciplinary teams established within Primary Care organizational chart
- 4 Physicians (3 with addiction medicine certification; all x-waivered clinicians)
- 1 Advanced Practice Registered Nurse
- 2 Mental health trained pharmacists
- 2 Registered Nurses
- 1 Social Work
- 2 Medical Assistant/Licensed Practical Nurse
- 1 Administrative Assistant
- Led to reduction in direct acute care (ED and Hospitalization) costs to the VASLCHCS of nearly $5 million over 18 months ($10 million estimated over 3 years since VIP initiation)
- Major training sites for Addiction Medicine/Psychiatry, Internal Medicine, and Pharmacy trainees
- Leadership in training programs
- Developed tight collaborative relationships with Mental Health, Addiction, Pain, Palliative Care and other services
- Training and mentorship activities across the VISN
- Established monthly VIP monthly newsletters
- Established monthly VIP Chats, webinar to the nation regarding addiction topics
- Developed leadership with co-VIP Evaluation Directors
- Collaborate funded research externally, particularly Minneapolis, Denver, Alabama-Birmingham, Chicago.
- Collaborated with national and programmatic initiatives on the regional and national level
- Helped launch two VA HSR&D career development awardees and developing another’s application
- Worked with several faculty and trainees on their quality improvement projects
- Authored and published many papers that 1) reflect direct VIP accomplishments, 2) reflect VIP affiliated work with other teams, and 3) reflect content related to VIP mission.
Prior VIP Clinical Staff
- Amy De La Garza, MD
- Amy L. Butz, PharmD, Psychiatric Pharmacist Practitioner
- Sean Erickson, Advanced Practice Nurse
- Jeremy Patton, Social Worker
- Devon Cornish, Admin/Clerk
- Shannon Cowley, MSA
- Eric Johnson, Admin/Clerk
- Robin Palmer, Nurse Care Manager
- Jeanine Thome, RN
- Norma Rae Cutter, LPN
- Heather Duningan, MSA
- Connie Howard, LPN
- Deborah Hollberg, LPN
- Tania Knight, RN
- Christine Openshaw, Medical Support Assistant
- Andrea Nichols, RN
- Cinnamon Paviolo, LPN
- Benjamin Rollins, APRN
- Marnie Wilson, LCSW
Gordon AJ, Drexler K, Hawkins EJ, Burden J, Codell NK, Mhatre-Owens A, Dungan MT, Hagedorn H. Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities. Subst Abus. 2020;41(3):275-282. doi: 10.1080/08897077.2020.1787299. PMID: 32697170; PMCID: PMC7849630.
DeRonne BM, Wong KR, Schultz E, Jones E, Krebs EE. Implementation of a pharmacist care manager model to expand availability of medications for opioid use disorder. Am J Health Syst Pharm. 2021 Feb 8;78(4):354-359. doi: 10.1093/ajhp/zxaa405. PMID: 33326564.
Lei J, Butz A, Valentino N. Management of kratom dependence with buprenorphine/naloxone in a veteran population. Subst Abus. 2021;42(4):497-502. doi: 10.1080/08897077.2021.1878086. Epub 2021 Feb 22. PMID: 33617752.
Codell N, Kelley AT, Jones AL, Dungan MT, Valentino N, Holtey AI, Knight TJ, Butz A, Gallop C, Erickson S, Patton J, Hyte-Richins LJ, Rollins BZ, Gordon AJ. Aims, development, and early results of an interdisciplinary primary care initiative to address patient vulnerabilities. Am J Drug Alcohol Abuse. 2021 Mar 4;47(2):160-169. doi: 10.1080/00952990.2020.1832507. Epub 2020 Dec 10. PMID: 33301347; PMCID: PMC8062280.
Hawkins EJ, Danner AN, Malte CA, Blanchard BE, Williams EC, Hagedorn HJ, Gordon AJ, Drexler K, Burden JL, Knoeppel J, Lott A, Sayre GG, Midboe AM, Saxon AJ. Clinical leaders and providers' perspectives on delivering medications for the treatment of opioid use disorder in Veteran Affairs' facilities. Addict Sci Clin Pract. 2021 Sep 6;16(1):55. doi: 10.1186/s13722-021-00263-5. PMID: 34488892; PMCID: PMC8419813.
Kelley AT, Dungan MT, Gordon AJ. Barriers and Facilitators to Buprenorphine Prescribing for Opioid Use Disorder in the Veterans Health Administration During COVID-19. J Addict Med. 2021 Sep-Oct 01;15(5):439-440. doi: 10.1097/ADM.0000000000000786. PMID: 33323694; PMCID: PMC8489586.
Spelman JF, Edens EL, Maya S, Moore BA, Boggs A, MacLean RR, Ackland P, Becker WC, Lynch D, Garcia-Vassallo M, Burgo AL, Rosen MI, Gordon AJ. A Facility-Wide Plan to Increase Access to Medication for Opioid Use Disorder in Primary Care and General Mental Health Settings. Fed Pract. 2021 Oct;38(10):460-464. doi: 10.12788/fp.0186. PMID: 34733066; PMCID: PMC8560103.
Hawkins EJ, Malte CA, Gordon AJ, Williams EC, Hagedorn HJ, Drexler K, Blanchard BE, Burden JL, Knoeppel J, Danner AN, Lott A, Liberto JG, Saxon AJ. Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System. JAMA Netw Open. 2021 Dec 1;4(12):e2137238. doi: 10.1001/jamanetworkopen.2021.37238. PMID: 34870679; PMCID: PMC8649831.
Gordon AJ, Kenny M, Dungan M, Gustavson AM, Kelley AT, Jones AL, Hawkins E, Frank JW, Danner A, Liberto J, Hagedorn H. Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings. Am J Addict. 2022 Mar;31(2):152-158. doi: 10.1111/ajad.13260. Epub 2022 Feb 3. PMID: 35118756.
Jones AL, Kelley AT, Suo Y, Baylis JD, Codell NK, West NA, Gordon AJ. Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities. J Gen Intern Med. 2022 Feb 22:1–9. doi: 10.1007/s11606-022-07456-x. Epub ahead of print. PMID: 35194740; PMCID: PMC8862702.
Radmall AO, Calder S, Codell N, Kelley AT, Hawkins E, Jones AL, Hagedorn H, Reynolds MA, Gordon AJ. Roles and perceptions of nurses during implementation of a medication treatment for opioid use disorder national initiative. J Addict Nurs. 2022;33(2):70-79. PMID: 3564010
Wyse JJ, Mackeu K, Lovejoy TI, Kansagara D, Tuepker A, Gordon AJ, Korthuis TP, Herreid-O’Neill A, Williams B, Morasco BJ. Expanding access to medications for opioid use disorder through locally initiated implementation. Addict Sci Clin Pract. 2022;17(1):32. PMID: 35725648
Kelley AT, Wilcox J, Baylis JD, Crossnohere NL, Magel J, Jones AL, Gordon AJ, Bridges JFP. Increasing Access to Buprenorphine for Opioid Use Disorder in Primary Care: an Assessment of Provider Incentives. J Gen Intern Med. 2022 Dec 5. doi: 10.1007/s11606-022-07975-7. Epub ahead of print. PMID: 36471194
Lott AM, Danner AN, Malte CA, Williams EC, Gordon AJ, Halvorson MA, Saxon AJ, Hagedorn HJ, Sayre GG, Hawkins EJ. Clinician Perspectives on Delivering Medication Treatment for Opioid Use Disorder during the COVID-19 Pandemic: A Qualitative Evaluation. J Addict Med. 2023 Mar 2. doi: 10.1097/ADM.0000000000001156. Epub ahead of print. PMID: 36862502