Bowe, & Alex Sox-Harris Center for Innovation to Implementation - - PowerPoint PPT Presentation
Andrea Finlay, PhD, Laura Ellerbe, Anna Rubinsky, Shalini Gupta, Tom Bowe, & Alex Sox-Harris Center for Innovation to Implementation (Ci2i) VA Palo Alto Health Care System National Center on Homelessness Among Veterans Department of
Andrea Finlay, PhD, Laura Ellerbe, Anna Rubinsky, Shalini Gupta, Tom Bowe, & Alex Sox-Harris
Center for Innovation to Implementation (Ci2i) VA Palo Alto Health Care System National Center on Homelessness Among Veterans Department of Veterans Affairs June 26, 2017
Employed and funded 100% by the Department of Veterans Affairs. No other disclosures.
Funding Sources: Health Services Research & Development (HSR&D) QUERI Rapid Response Project (RRP 12-468) HSR&D Career Development Award (CDA 13-279, PI: Finlay) HSR&D Research Career Scientist (RCS 14-232, PI: Harris) Role of the funding source: The views expressed in this presentation are those of the authors and do not necessarily reflect the position nor policy
government.
6% of VA patients have alcohol use disorder (AUD),
AUD is more prevalent among special populations
33% of veterans exiting prison (Finlay et al., 2015) 57% of veterans exiting jails or in treatment courts (Finlay et al., 2014) 49% of veterans receiving homeless services (Tsai et al., 2014)
For veterans who need intensive treatment and
63 Substance Use Disorder (SUD) Residential
Rehabilitation Treatment Programs (RRTPs)
34 Mental Health Residential Rehabilitation Treatment
Programs with an SUD track
Pharmacotherapy for AUD - naltrexone, acamprosate,
Barriers
Program treatment philosophy Lack of access to prescribing physicians Lack of training or knowledge about addiction medications Low perceived patient demand
Facilitators
More education to patients and providers Increased involvement of physicians in alcohol treatment
(Harris et al., 2013; Oliva et al., 2011)
What are the perceived barriers to and facilitators of
Consolidated Framework for Implementation Research (CFIR)
Inner setting - cultural or structural context in which the
implementation occurs
Outer setting – external policies and incentives, patients needs and
resources
Characteristics of individuals – knowledge and beliefs about the
intervention, other personal attributes, self-efficacy
Intervention characteristics – key aspects of intervention that
influence success of implementation
Process – planning, execution, evaluation of implementation
(Damschroeder et al., 2009)
Sample
63 directors, program managers, and/or staff from 44 of
97 VA residential programs
Qualitative Interviews
Using fiscal year 2012 VA administrative data, a program
profile was calculated for each residential program
Unique profile was shared with participants at the start
average
Interviews were audiotaped and transcribed
Interviews
Participants from programs with low rates of receipt of
pharmacotherapy for AUD were asked about barriers to receipt of these medications
Participants from programs with high rates of receipt of
pharmacotherapy for AUD were asked about facilitators to receipt of these medications
All programs were asked about their overall approach or
philosophy to addiction pharmacotherapy
Analysis
Thematic analysis to identify barriers and facilitators (Braun &
Clark, 2006; Vaismoradi et al., 2013)
Themes were organized and matched with domains and
constructs from the CFIR
15,056 patients admitted to residential SUD treatment
12 to 689 patients per program 12% average rate of receipt of pharmacotherapy for
0% to 50% across programs
Culture – General norms/program philosophy
Negative program norms (barrier) Passive openness/interest (facilitator) Active encouragement/promotion (facilitator)
Implementation Climate – shared receptivity of
Negative receptivity to pharmacotherapy (barrier) Passive openness/interest (facilitator) Active encouragement/promotion (facilitator)
Implementation Climate - Learning Climate
Prescriber education (facilitator) Program staff education (facilitator)
Readiness for Implementation – Available Resources
Access to prescribers/specialists (barrier & facilitator)
Readiness for Implementation – Leadership Climate
Leadership support or lack thereof (barrier & facilitator)
Networks & Communication
Initiated by referring programs (facilitator) Care coordination within residential program (barrier &
facilitator)
Care coordination with outside providers/programs
(barrier & facilitator)
Patient needs & resources
Perceived patient attitudes/needs/interest (barrier &
facilitator)
Patient education (facilitator)
External policies & incentives
Policy restrictions (barrier)
Knowledge & belief of intervention
Limitations in prescriber/staff knowledge (barrier)
Cost
Cost restriction (barrier)
Education and training for providers and patients
Academic detailing improved prescribing of
pharmacotherapy for AUD (Harris et al., 2016)
Increase care coordination across settings
17
Contact information: Andrea Finlay Andrea.Finlay@va.gov
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101 Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci, 4, 50 Finlay, A. K., Smelson, D., Sawh, L., McGuire, J., Rosenthal, J., Blue-Howells, J., . . . Harris, A. H. S. (2014). U.S. Department of Veterans Affairs Veterans Justice Outreach program: connecting justice-involved veterans with mental health and substance use disorder treatment. Criminal Justice Policy Review, 27(2), 203-222 Finlay, A. K., Stimmel, M., Blue-Howells, J., Rosenthal, J., McGuire, J., Binswanger, I., . . . Timko, C. (2015). Use of Veterans Health Administration mental health and substance use disorder treatment after exiting prison: the Health Care for Reentry Veterans program. Administration and Policy in Mental Health Harris, A. H. S., Bowe, T., Hagedorn, H., Nevedal, A., Finlay, A. K., Gidwani, R., . . . Christopher, M. M. (2016). Interrupted time-series analysis of a multifaceted academic detailing program to increase pharmacotherapy for alcohol use disorder. Addiction Science & Clinical Practice, 11(1), 15. Harris, A. H. S., Ellerbe, L., Reeder, R. N., Bowe, T., Gordon, A. J., Hagedorn, H., . . . Trafton, J. A. (2013). Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers. Psychol Serv, 10(4), 410-419. Harris, A. H. S., Oliva, E. M., Bowe, T., Humphreys, K. N., Kivlahan, D. R., & Trafton, J. A. (2012). Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: Patterns of receipt and persistence. Psychiatric Services, 63(7), 679-685. Oliva, E. M., Maisel, N. C., Gordon, A. J., & Harris, A. H. (2011). Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Curr Psychiatry Rep, 13(5), 374-381. Tsai, J., Kasprow, W. J., & Rosenheck, R. A. (2014). Alcohol and drug use disorders among homeless veterans: prevalence and association with supported housing outcomes. Addict Behav, 39(2), 455-460. Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci, 15(3), 398-405.