AMERSA Annual Meeting, November 5 th, 2015 Stephen Holt, MD, MS, Nora Segar, MD, Dana Cavallo, PhD, Jeanette Tetrault, MD Department of Internal Medicine, Yale University School of Medicine 1

Disclosure Dr. Holt has no financial relationship or any real or apparent conflict(s) of interest that may have a direct bearing on this presentation(s) 2

Needs and Objectives Substance use disorders are highly prevalent Little curricular time devoted to training in Addiction Medicine (AM) Our objectives in creating the Addiction Recovery Clinic (ARC): – Provide outpatient clinical services – Educate about biologic basis for addiction – Educate about available treatment options 3

Identified potential collaborators Clinical Psychologist (Dana Cavallo, PhD) Chief Resident (Nora Segar, MD) Discussed funding with program director Agreed to provide 0.1 Full-Time Equivalent (FTE) for all three attendings Substituted for 0.1 FTE of outpatient precepting, inpatient attending, or personal patient panel Defined educational structure Rotation schedule, # of residents per session Educational objectives Evaluation system How we did it… 4

The ARC Social Worker Chief Resident Attending Psychologist Medical Assistant Addiction Medicine Fellow 5

2-4 Internal Medicine Trainees during each session 6

7:40 - 8:10 Teaching Core AM topics 8: :50 Patient Care 20 patients 16 established 4 new Wk 1 TWThF AM Addiction Clinic PsychiatryDidacticsAMB Didactics PM Continuity ClinicStudent HealthRheum ClinicHospital Follow-Up Wk 2MTWThF AM Community Outreach Addiction ClinicPsychiatryDidacticsAMB Didactics PMContinuity Clinic Student HealthRheum ClinicHospital Follow-Up Wk 3MTWThF AM Community Outreach Addiction ClinicPsychiatryDidacticsAMB Didactics PMContinuity Clinic Student HealthRheum ClinicHospital Follow-Up Wk 4MTWThF AM Community Outreach Addiction ClinicPsychiatryDidacticsAMB Didactics PMContinuity Clinic Student HealthRheum ClinicHospital Follow-Up Wk 5M AM Community Outreach PMContinuity Clinic 4-week Ambulatory Immersion Block Schedule 7 X 3 Years

Naltrexone, IM/PO Acamprosate Disulfiram Topiramate Counseling Case Management Referral to IOP, other services prn Buprenorphine Naltrexone Referral for methadone Contingency Management Description of Services 8

Patient Referral Sources Inpatient service – Teaching Service – Addiction Medicine Consult Service Residents’ own continuity practice An intensive outpatient program (IOP) affiliated with Yale-New Haven Hospital Self-referrals 9

10 ARC Evaluation Methods Trainee Evaluation – Entrustable Professional Activity (EPA)-based evaluation system ARC Evaluation – Clinical practice data – Patient satisfaction surveys – Resident satisfaction surveys

Evaluation of Trainees Entrustable Professional Activity (EPA)-based system with ten domains Sample EPA Domain: Addiction Medicine Fund of Knowledge 11

ARC Evaluation: Clinical Practice Data (12 months) CharacteristicN = 97 (new patients) Average age44 years Male gender62% Primary diagnosis Opioid use disorder Alcohol use disorder Cocaine use disorder 63% 25% 6% Insurance Medicaid Commercial Medicare Self-Pay 66% 19% 9% 3% Referral Mechanism Outpatient Inpatient Inpatient Consult Self-Referral 47% 35% 8% 7% total visits 12.0 visits per session No-shows = 33.5%

N=31 94% of patients report the ARC probably or definitely helped them to cope with their addiction 84% of patients report they were definitely satisfied with the overall treatment they have received “I finally feel like I am treated as a person, not like an addict.” ARC Evaluation: Patient Satisfaction 13

ARC Evaluation: Trainee Surveys Overall, ARC rotation highly regarded Common themes have included: – Appreciated role-modeling by faculty – Emphasized utility of pre-clinic teaching on AM topics – Importance of continuity of care from week to week Great enthusiasm for Addiction Medicine – 28% (11 of 39) trainees and 45% (9 of 20) faculty have registered for or completed buprenorphine training 14

The ARC provides access to care for patients with addiction The ARC is a novel approach to teaching Addiction Medicine to Internal Medicine trainees Trainees are very satisfied learning Addiction Medicine in this setting Lessons Learned 15

16 Transitioning stable patients back into resident continuity practice Assess impact of ARC on trainee interest in and competence in Addiction Medicine over 3 years of training Future Directions

Thank you! 17