Implem lementing enting the e Continuu ntinuum m of Car are e - PowerPoint PPT Presentation

Implem lementing enting the e Continuu ntinuum m of Car are e for r Su Subst stance ance Us Use e Di Diso sorder rders s in in P Pri rimar ary y Car are: e: Find Fi ndings ings an and Les essons sons Lea earned rned from the e SU SUMM MMIT T St Study dy Karen Lamp, MD, Venice Family Clinic Allison Ober, MSW, PhD, RAND Corporation Tobin Shelton, LCSW, Venice Family Clinic Statewide wide Integrat egrated ed Care e Conf nfere erence nce Octobe ober 25, 2017

INTRODUCTION 10/25/17 Slide 2

Today’s objectives • Describe and discuss a model for integrating the continuum of care for substance use disorders (SUDs) into primary care services in a federally qualified health center • Discuss barriers and solutions to integrating the continuum of care for substance use disorders into primary care services of a federally qualified health center • Share key elements of sustaining the continuum of care for substance use disorders in primary care 10/25/17 Slide 3

In the beginning…. Partnership between RAND Corporation and Venice Family Clinic began in 2012 – Opportunity to participate in NIH/NIDA funded research – Chance to add a new service line to our primary care menu – Participation provided a substantial funding opportunity for VFC 10/25/17 Slide 4

Venice Family Clinic That’s me! • Community Health Center located on Westside of Los Angeles • Venice Family Clinic is the medical home for 25,000 people • $37M annual budget 10/25/17 Slide 5

RAND Corporation Non-profit research • institute headquartered in Santa Monica, CA • RAND Health conducts research and analysis to improve health services and policy 10/25/17 Slide 6

Welcome addition or clinic disruption? • Opioid epidemic had not yet gained widespread public attention in 2012 • VFC was in midst of implementing EMR • Primary care overload/burn out was a significant dynamic at the clinic • Anticipating ACA’s impact • Expected to be flooded with new patients • New and stable funding for the clinic • Adding SUD services tested the VFC’s culture and attitudes 10/25/17 Slide 7

Key perceived barriers • Identified barriers to integrating SUD treatment prior to the study • Barriers fell into three areas: 1. Training 2. Resources 3. Culture 10/25/17 Slide 8

Key perceived tr traini aining ng barriers • Providers don’t feel knowledgeable enough to provide SUD treatment • Providers worry that they haven’t had adequate training to treat SUD patients • There is too much staff turnover – it’s hard to keep everyone trained 10/25/17 Slide 9

Key perceived re resour ources ces barriers • There isn’t enough time to commit to SUD patients • There is not enough staff to provide SUD treatment 10/25/17 Slide 10

Key perceived cul ultura tural barriers • There is a lack of motivation to provide SUD treatment • SUD treatment should have a dedicated provider or specialty clinic • There are barriers to treating the homeless population • Patients with mental health comorbidities may not be appropriate 10/25/17 Slide 11

Key perceived cul ultura tural barriers • The clinic may attract too many SUD patients who would disrupt the clinic (Stigma/bias) • The clinic has a no-narcotic policy • Providers fear SUD treatment will not remain a priority among leadership (Sustainability) 10/25/17 Slide 12

SUMMIT Study Overview 10/25/17 Slide 13

We set out to address barriers and implement the continuum of care for substance use disorder (SUD) treatment 6-session MI- Brief Screening by Warm handoff based Therapy Intervention by Medical to a Care by Behavioral Medical Assistants Coordinator Health Providers Therapists Medications Prescribed by Medical Providers Extended – release Buprenorphine/ injectable naloxone naltrexone (opioids) (alcohol) (BUP/NX) (XR-NTX) 10/25/17 Slide 14

We examined the effectiveness of a two- part implementation intervention • Goal: To prepare the organization to deliver Organizational SUD treatment services using collaborative Readiness care (CC) Intervention • Evaluated using a pre-post design • Goal: To increase patient linkage to and primary Collaborative Care care providers’ use of medication -assisted Intervention treatment (MAT) and brief treatment (BT) for opioid and alcohol use disorders (OAUD)* • Evaluated using a randomized design * We focus used ed on OAUD becau ause e both oth have e a substan tanti tial al impact act on publ blic ic health lth and there ere are medicat dications ons considered idered to be best t practi ctices ces for treating ating these se disorder ers 10/25/17 Slide 15

We started with the organizational readiness intervention Patient Service Service Organizational Organizational Utilization and Delivery Readiness Readiness Clinical Intervention Outcomes Intervention Outcomes • Plan for change Acceptability Collaborative Care • • XR-NTX, BUP/NX (CC) and Brief Therapy • Educate providers • Appropriateness utilization versus • Redesign service • Feasibility • OAUD abstinence delivery system Usual Care • Willing to Use BT • Incorporate quality or MAT improvement Adoption of BT or • MAT 10/25/17 Slide 16

The organizational readiness intervention consisted of a cluster of implementation strategies Educate Restructure Incorporate Plan for Providers Delivery Quality Change Systems Improvement • Gathered info • Educated all • Created new • Conducted about current providers at workflow for Plan-Do-Study- processes every level patients with Act cycles to • Obtained • Identified MAT OAUDs introduce new feedback on and BT • Developed practices perceived champions treatment and Pilot tested all • barriers from • Informed CC protocols practices all staff and stakeholders • Adapted leadership (e.g., Boards of protocols to through focus Directors) address groups and barriers interviews 10/25/17 Slide 17

We measured organizational readiness outcomes at four time points through provider focus groups, interviews and surveys Service Utilization Service Organizational Organizational and Clinical Delivery Readiness Readiness Outcomes Intervention Outcomes Intervention • Plan for change Acceptability Collaborative Care • • XR-NTX, BUP/NX (CC) and Brief Therapy • Educate providers • Appropriateness utilization versus • Redesign service • Feasibility • OAUD abstinence delivery system Usual Care • Willing to Use BT or MAT Adoption of BT or • MAT 10/25/17 Slide 18

18 months after we started organizational readiness, we implemented and tested the CC service delivery intervention Service Utilization Service Organizational Organizational and Clinical Delivery Readiness Readiness Outcomes Intervention Outcomes Intervention • Plan for change Acceptability Collaborative Care • • XR-NTX, BUP/NX (CC) and Brief Therapy • Educate providers • Appropriateness utilization versus • Redesign service • Feasibility • OAUD abstinence delivery system Usual Care • Willing to Use BT or MAT RCT Adoption of BT or • MAT 10/25/17 Slide 19

The CC intervention was designed to facilitate treatment linkage and retention Care Experts available Coordination for consultation and Monitoring and supervision CC encourages the delivery of evidence-based treatments Patient Patient Registry Self-Mgmt. Materials 10/25/17 Slide 20

After the RCT, we measured patient service utilization and clinical outcomes Service Utilization Service Provider Organizational and Clinical Delivery Implementation Readiness Outcomes Intervention Outcomes Intervention • Plan for change Acceptability Collaborative Care • • XR-NTX, BUP/NX (CC) and BT utilization • Educate providers • Appropriateness versus OAUD abstinence • • Redesign service • Feasibility delivery system Usual Care • Willing to Use BT or MAT Adoption of BT or • MAT 10/25/17 Slide 21

Needless to say, we had our work cut out for us ... 10/25/17 Slide 22

... and things didn’t always go exactly as planned, but we did it. 10/25/17 Slide 23

Participant enrollment took place between June 3, 2014 and January 15, 2016 • All clinic patients were screened for risky alcohol or opioid use at every visit (about 15,000 patients of 15,753 visits, about 95% of all visits) • 4-6% screened positive for risky or worse substance use • Patients that consented were referred to a survey interviewer for further screening and enrollment • We enrolled 392 individuals and had a 69% 6- month follow-up rate 10/25/17 Slide 24

Key Organizational Readiness Findings 10/25/17 Slide 25

Medical providers’ perceptions of ease of use and compatibility of medical treatment for alcohol use disorders increased one year after organizational readiness intervention 7 Pre-Intervention 6 Post-Intervention 4.77* 4.77* 5 4 3.36 3.05 3 2 1 XR-NTX Ease of Use XR-NTX Compatibilitiy with (1=Extremely Disagree - Current Practices 7=Extremely Agree) (1=Extremely Disagree - 7 Extremely Agree) *p<.05 10/25/17 Slide 26