Garcia Vasallo Launches Training Program to Enhance Substance Use Disorder Care in Underserved Communities

Yale Psychiatry’s Gabriela García Vassallo, MD, assistant professor of psychiatry based at the VA Connecticut Healthcare System in West Haven, has helped to launch a training program that brings enhanced substance use disorder care to underserved communities.

Dr. García Vassallo spearheaded the effort to create a two-day addiction mini-residency training initiative that helps interprofessional clinical teams learn more specialized treatments for opioid use disorder. The program was rolled out in partnership with the Caribbean VA Healthcare System in San Juan, Puerto Rico earlier this year.

The curriculum was created in 2018 and was born out of the VA’s Supporting Community Outpatient, Urgent Care and Telehealth Services (SCOUTS) initiative, a national push to expand access to buprenorphine, a medication used for the treatment of opioid use disorder, outside of specialty care. Social workers, chaplains, psychologists, psychiatrists, and peer specialists collaborated to develop the program by interviewing primary care providers to determine what material would be most helpful to include, Dr. García Vassallo said.

“We started to see how much people loved it and saw how our reach was limited to Connecticut while we were conducting sessions in person. We always said that we’d go virtual one day,” she said.

Shortly after, the COVID-19 pandemic arrived in the U.S. and the program was forced onto a virtual platform to continue. But the change allowed for a broader reach, and participation was opened to those beyond those working in Connecticut. People responded, and participants logged on from across the country.

“We saw people logging in from California and all across the U.S.,” Dr. García Vassallo said. “People were coming at 5 in the morning their time and we realized that people really wanted to learn this.”

To support a bigger expansion, the group teamed up with the VA’s Simulation, Learning, Education and Research Network (SimLEARN) program and the Extension for Community Healthcare Outcomes (VA-ECHO), which connects specialists to primary care teams based in more rural areas.

At the West Haven VA, ECHO is co-led by Ellen Edens, MD associate professor of psychiatry and lead for the Substance-related and Addictive disorders program of the National Expert Consultation and Specialized Services, and David Moore, MD, PhD, assistant professor of psychiatry and director of the VISN 1 Clinical Resource Hub. Drs. Moore and Edens were able to secure grant funding to provide administrative support for Dr. García Vassallo and her team.

“In West Haven or at Yale, we often take for granted that if for some reason someone in a particular corner of Connecticut is not able to get to the VA for treatment, they probably can get something in their local community, but that is not always the case nationally,” Dr. Moore explained. “Our mission with ECHO is to train and support rural and underserved facilities. These facilities have less access to academic affiliates than Yale, where there is a steady flow of providers that treat patients and provide training. With these programs, we look to help these facilities adopt more specialized treatments.”

The devastation leveled to Puerto Rico and its residents by hurricanes, earthquakes, and the COVID-19 pandemic, in addition to limited local resources and national support, has only exacerbated Puerto Rico’s struggles amid the opioid crisis. Treatment on the island is very limited to specialty care, and

substance use in general is highly stigmatized. The VA is uniquely positioned to provide more resources to patients.

While the San Juan VA was looking for a curriculum to bring to its site and ultimately increase the number of people receiving treatment, there was also a personal connection for Dr. García Vasallo: she was born and raised in San Juan and attended medical school there prior to arriving at Yale to complete her addiction fellowship at the West Haven VA.

She also had first-hand experience working at the San Juan VA in the aftermath of Hurricane Maria, and had connections there.

“I knew people there, and there was a lot of enthusiasm and interest. Their desire for this was so clear - they had already put a team together. They were ready,” Dr. García Vasallo said. “They’re using this curriculum so they can train people and expand.”

“We have an incredibly talented, compassionate team of people there, and the great thing about being able to go virtual is that we can now collaborate.”

Dr. Moore said: “With Puerto Rico being physically isolated and under-resourced, it was really a very high priority site. Gabriela has been really leading the effort in not only how to develop novel trainings, but is taking it to the next level and has really standardized the train-the-trainer process.”

The curriculum uses non-traditional strategies that are based on adult education best practices, Dr. García Vassallo said. Topics include stigma, the use of motivational interviewing, harm reduction strategies, and the differences between addiction and dependence, with a strong focus on using buprenorphine to treat opioid use disorder and other comorbid conditions such as stimulant use and chronic pain.

“Overcoming stigma is a big part of the curriculum, and ultimately that helps improve patient care,” Dr. García Vassallo explained.

On the second day, participants practice the skills they’ve learned through video, case discussions, and role play.

“When they leave, they’ve acquired the skills through practice and have increased their confidence to implement what they’ve learned,” Dr. García Vassallo said. “We do all these interactive things to have people embody what we’re trying to teach them and hopefully change their practice. Our material has the potential and the ability to make everyone feel included, and they can digest the information better.”

It was through offering the program in collaboration with the San Juan VA that sparked a plan to translate the curriculum into Spanish to make it more accessible. From there, it will be offered at the national level in Spanish who prefer to access the material and practice the skills in that language.

With a growing pool of teachers and a developing network of educators, Dr. García Vassallo hopes that the mini-residency will only further facilitate growth, collaboration, and both interprofessional and intergenerational learning. Sites in Texas, Florida, and other states across the country have expressed interest in participating.