March 03, 2025

Creating Realistic Follow-Up Plans for Unstable Patients

28 minutes

EP 02

🎙 Special Series: Advances in Buprenorphine Education

This episode is part of a special series on improving hospital and clinic-based buprenorphine treatment for opioid use disorder.

In this episode of ASAM Practice Pearls, Dr. Shawn Cohen is joined by addiction medicine experts Dr. Carolyn Chan and Dr. Stephen Holt. Together, they explore effective strategies for managing unstable patients and creating realistic follow-up plans that prioritize patient engagement and continuity of care.

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Host

Shawn Cohen, MD

Dr. Shawn Cohen is an addiction medicine doctor at Yale New Haven Hospital. He provides care on a hospital-based addiction consult service and is interested in lowering barriers to MOUD, improving the care of patients experiencing alcohol withdrawal, and making the hospital a more person-centered and less stigmatizing place for people who use substances.

Experts

Carolyn Chan, MD MHS

Dr. Carolyn Chan is board-certified in both internal and addiction medicine. She completed her IM residency at UH Hospitals Cleveland Medical Center, followed by an addiction medicine and medical education fellowship at Yale. She provides care in both inpatient and outpatient addiction medicine settings. Currently, she is the Program Director of the University of Cincinnati Addiction Medicine Fellowship and is committed to educating all health professionals on how to provide evidence-based care to individuals with substance use disorders.

Stephen Holt, MD, MS, FACP, FASAM

Dr. Stephen Holt has been an attending physician at Yale-New Haven Hospital since 2008 and is an Associate Professor of Medicine at Yale School of Medicine. He is the Director of the Yale Addiction Recovery Clinic and the Associate Program Director for Yale's Primary Care Internal Medicine Residency Program. He is board-certified in Addiction Medicine and Internal Medicine. He has published and lectures frequently on a variety of addiction medicine topics and has won numerous teaching awards at the local, regional, and national levels.

📖 Show Segments

00:04 – Introduction

00:50 – Case Scenario: Unstable Patient Follow-up

02:17 – Building Low-Barrier Clinics

06:15 – Building Partnerships with Community Resources

09:26 – Troubleshooting Patient Engagement

16:11 – Navigating Complex Patient Scenarios

19:54 – Strategies for Reengaging Patients in Care

23:50 – Reducing Barriers and Integrating Harm-Reduction in Clinics

25:25 – Revisit Case Scenario

27:20 – Conclusion and Additional Learning Opportunities

📋 Key Takeaways

Build strong relationships. Foster connections with patients and providers across inpatient, outpatient, and community settings to ensure seamless transitions.

Prioritize warm handoffs. Maintain continuity of care through compassionate, consistent communication.

Stay proactive. Reach out to patients who miss appointments via phone calls or secure messaging to encourage reconnection and demonstrate support.

Align care with patient goals. Tailor treatment plans to individual needs, acknowledging their personal circumstances and preferences.

Minimize barriers to care. Offer flexible scheduling, telehealth options, and accommodating policies, such as walk-in availability and relaxed late arrival rules.

Emphasize harm reduction. Incorporate approaches like long-acting buprenorphine and methadone when appropriate.

Use monitoring tools thoughtfully. Leverage urine toxicology as a supportive tool rather than a punitive measure.

Adapt treatment plans as needed. Avoid punitive measures and modify strategies when current approaches are ineffective.

Engage community resources. Collaborate with local organizations to support patient re-engagement.

Leverage peer support. Utilize peer recovery coaches or case managers to provide continuous patient support.

Support prescriber confidence. Offer training and resources to address concerns about managing substance use treatment.

Develop sustainable follow-up plans. Implement practical, actionable steps to create personalized follow-up plans that meet patient needs.

Maximize telehealth benefits. Ensure compliance with local and federal regulations while expanding access to care.

🔗 Resources

ASAM’s Advanced Buprenorphine Education Series: Explore here.

American Society of Addiction Medicine. Engagement and Retention of Nonabstinent Patients in Substance Use Treatment: Clinical Consideration for Addiction Treatment Providers. October 2024. Read more.

Henssler J, Müller M, Carreira H, Bschor T, Heinz A, Baethge C. Controlled drinking–non-abstinent versus abstinent treatment goals in alcohol use disorder: a systematic review, meta‐analysis and meta‐regression. Addiction. 2021 Aug;116(8):1973–1987. doi: 10.1111/add.15329.

Additional information on SUD privacy 42 CFR part 2: View here.

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