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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

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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: Fi Find 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

  • ber 25, 2017
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INTRODUCTION

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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

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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

  • ur primary care menu

– Participation provided a substantial funding opportunity for VFC

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Venice Family Clinic

  • Community Health Center

located on Westside of Los Angeles

  • Venice Family Clinic is the

medical home for 25,000 people

  • $37M annual budget

That’s me!

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RAND Corporation

  • Non-profit research

institute headquartered in Santa Monica, CA

  • RAND Health conducts

research and analysis to improve health services and policy

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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

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Key perceived barriers

  • Identified barriers to integrating SUD treatment prior

to the study

  • Barriers fell into three areas:

1. Training 2. Resources 3. Culture

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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

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Key perceived re resour

  • urces

ces barriers

  • There isn’t enough time to commit to SUD patients
  • There is not enough staff to provide SUD treatment
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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

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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)

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SUMMIT Study Overview

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We set out to address barriers and implement the continuum of care for substance use disorder (SUD) treatment

Screening by Medical Assistants Brief Intervention by Medical Providers Warm handoff to a Care Coordinator Medications Prescribed by Medical Providers 6-session MI- based Therapy by Behavioral Health Therapists Extended – release injectable naltrexone (alcohol) (XR-NTX) Buprenorphine/ naloxone (opioids) (BUP/NX)

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We examined the effectiveness of a two- part implementation intervention

Organizational Readiness Intervention Collaborative Care Intervention

  • Goal: To prepare the organization to deliver

SUD treatment services using collaborative care (CC)

  • Evaluated using a pre-post design
  • Goal: To increase patient linkage to and primary

care providers’ use of medication-assisted treatment (MAT) and brief treatment (BT) for

  • pioid and alcohol use disorders (OAUD)*
  • Evaluated using a randomized design

*We focus used ed on OAUD becau ause e both

  • th have

e a substan tanti tial al impact act on publ blic ic health lth and there ere are medicat dications

  • ns considered

idered to be best t practi ctices ces for treating ating these se disorder ers

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We started with the organizational readiness intervention

Organizational Readiness Outcomes Organizational Readiness Intervention

  • Acceptability
  • Appropriateness
  • Feasibility
  • Willing to Use BT
  • r MAT
  • Adoption of BT or

MAT

  • XR-NTX, BUP/NX

and Brief Therapy utilization

  • OAUD abstinence
  • Plan for change
  • Educate providers
  • Redesign service

delivery system

  • Incorporate quality

improvement

Service Delivery Intervention

Collaborative Care (CC) versus Usual Care

Patient Service Utilization and Clinical Outcomes

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The organizational readiness intervention consisted of a cluster of implementation strategies

Plan for Change Educate Providers Incorporate Quality Improvement Restructure Delivery Systems

  • Gathered info

about current processes

  • Obtained

feedback on perceived barriers from all staff and leadership through focus groups and interviews

  • Educated all

providers at every level

  • Identified MAT

and BT champions

  • Informed

stakeholders (e.g., Boards of Directors)

  • Created new

workflow for patients with OAUDs

  • Developed

treatment and CC protocols

  • Conducted

Plan-Do-Study- Act cycles to introduce new practices

  • Pilot tested all

practices

  • Adapted

protocols to address barriers

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We measured organizational readiness

  • utcomes at four time points through

provider focus groups, interviews and surveys

Organizational Readiness Outcomes Organizational Readiness Intervention

  • Acceptability
  • Appropriateness
  • Feasibility
  • Willing to Use BT
  • r MAT
  • Adoption of BT or

MAT

  • XR-NTX, BUP/NX

and Brief Therapy utilization

  • OAUD abstinence
  • Plan for change
  • Educate providers
  • Redesign service

delivery system

Service Delivery Intervention

Collaborative Care (CC) versus Usual Care

Service Utilization and Clinical Outcomes

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18 months after we started organizational readiness, we implemented and tested the CC service delivery intervention

Organizational Readiness Outcomes Organizational Readiness Intervention

  • Acceptability
  • Appropriateness
  • Feasibility
  • Willing to Use BT
  • r MAT
  • Adoption of BT or

MAT

  • XR-NTX, BUP/NX

and Brief Therapy utilization

  • OAUD abstinence
  • Plan for change
  • Educate providers
  • Redesign service

delivery system

Service Delivery Intervention

Collaborative Care (CC) versus Usual Care RCT

Service Utilization and Clinical Outcomes

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The CC intervention was designed to facilitate treatment linkage and retention

Patient Self-Mgmt. Materials Care Coordination and Monitoring Patient Registry Experts available for consultation and supervision

CC encourages the delivery of evidence-based treatments

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After the RCT, we measured patient service utilization and clinical outcomes

Provider Implementation Outcomes Organizational Readiness Intervention

  • Acceptability
  • Appropriateness
  • Feasibility
  • Willing to Use BT
  • r MAT
  • Adoption of BT or

MAT

  • XR-NTX, BUP/NX

and BT utilization

  • OAUD abstinence
  • Plan for change
  • Educate providers
  • Redesign service

delivery system

Service Delivery Intervention

Collaborative Care (CC) versus Usual Care

Service Utilization and Clinical Outcomes

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Needless to say, we had our work cut out for us ...

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... and things didn’t always go exactly as planned, but we did it.

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Participant enrollment took place between June 3, 2014 and January 15, 2016

  • All clinic patients were screened for risky alcohol or
  • pioid 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

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Key Organizational Readiness Findings

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3.05 3.36 4.77* 4.77* 1 2 3 4 5 6 7 XR-NTX Ease of Use (1=Extremely Disagree - 7=Extremely Agree) XR-NTX Compatibilitiy with Current Practices (1=Extremely Disagree - 7 Extremely Agree) Pre-Intervention Post-Intervention

*p<.05

Medical providers’ perceptions of ease of use and compatibility of medical treatment for alcohol use disorders increased one year after organizational readiness intervention

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Medical providers’ perceptions of appropriateness in primary care also improved after one year

3.00 4.53* 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 SUD Can be Effectively Treated in Primary Care (1=Strongly Disagree - 5=Strongly Agree) Pre-Intervention Post-Intervention

*p<.05

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General clinic staff perceptions of appropriateness also improved after one year

3.17 3.17 2.94 4.53* 4.25* 3.89 1 2 3 4 5 6 7 SUD Can be Effectively Treated in Primary Care SUD Can be Effectively Treated at VFC Providing Medication to People with SUD Fits with Clinic Mission and Goals Pre-Intervention Post-Intervention

*p<.01

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All staff perceptions of acceptability and appropriateness improved and were sustained

  • ver time

1 1.5 2 2.5 3 3.5 4 4.5 5 Plannin Planning Pilot Pilot RCT RCT Pos Post-RCT t-RCT Substance use disorders can be effectively treated in primary care Substance use disorders can effectively be treated at [this clinic] Providing medications to patients with alcohol or opioid use disorders fits with [THIS CLINIC'S] mission and goals Providing counseling to patients with alcohol or opioid use disorders fits with [THIS CLINIC'S] mission and goals

(Orga ganizati tion

  • nal Readiness

ess)

Differences from first to last year, p < 0.001;

Agreement

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Fast forward five years ..., the majority of medical providers attended training and many are prescribing MAT

  • 24/28 providers trained on use of extended-release

naltrexone (XR-NTX)

  • 16 have prescribed XR-NTX
  • 21/28 attended buprenorphine/naloxone training

(BUP/NX); 10 have X-waivers

  • 10 have prescribed BUP/NX
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In the words of one VFC medical provider: “SUMMIT has completely changed the culture of care at Venice Family Clinic”

clinic

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Key Findings: CC versus Usual Care

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The majority of participants were male; one third were Hispanic, almost half were White; more than one third were homeless

Overall (n=377*) % Usual Care (n=187) % CC (n=190) % Male 80 80 79 Ethnicity (% Hispanic) 31 32 30 Race White 44 45 42 Black 13 14 13 Multi-Racial/Other 41 39 43 Homeless Status Homeless 37.1 40.7 33.5 *Analytic sample size

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Half of the patients had alcohol use disorders without an opioid use disorder

Overall (n=377) % Usual Care (n=187) % CC (n=190) % Alcohol Only 54 52 56 Heroin, with or without Alcohol or Prescription Opioids 31 34 27 Prescription Opioid Dependence with our without Alcohol 16 24 27

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CC patients were more likely to receive any evidence-based practice, and more likely to receive BT but not more likely to receive MAT than UC patients

39 35.8 13.4 16.8 10.5 12.6

Percent Evidence-based Practices

ICC UC **p<.0001

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CC patients were more likely to be abstinent from all substances 6 months after enrollment than UC patients

32.8 26.3 22.3 15.6

Percent Abstinence Outcomes

ICC UC *p<.05

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SUMMIT Study Take-Aways

Take-away y 1: A strat rategy egy consisting isting of BOTH TH organiza anizatio tional nal readin dines ess s and collaborativ aborative e care can facilitat itate e implemen lementat tation n of SUD D treat eatmen ment t in n primar imary care e and nd lead to improved ed patien ient t

  • utcom
  • mes

es Take-away y 2: A collaborativ aborative care e servic vice e deliver ery y inter erven enti tion

  • n is

critical tical to helpin ping g pati tient nts s initiat tiate e SUD D treatmen atment t in prima imary y care Take-away y 3: Pa Pati tien ents ts who receiv eive e any treatme eatment nt (wit ith h CC) ) do bett etter er than n those se who do not, regar gardless dless of type of treatmen atment Take-away y 4: Despit pite e perceiv eived ed barrier riers, s, treatme eatment nt can be success essfully ully integrat egrated ed

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Overcoming Barriers to Integrating SUD Treatment in Primary Care

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Overcoming barriers

  • Understand the perceived barriers in your organization so

you can address them effectively

  • 1. Training
  • 2. Resources
  • 3. Culture
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Overcoming TRAINING barriers: Lack of expertise and need for technical support

Med edic ical Provid ider ers: s: – XR-NTX training: 2 ½ hours in person – BUP/NX training: 4 hours in person, 4 hours on- line module – Cash incentives for providers to get X-waiver Beh ehaviora ioral Hea ealth h Provi vide ders: s: – 8+ hours of MI-based brief therapy intervention *Plus: Ref efre resher her Train inin ings gs and accessible Expe pert t Consulta ltati tion

  • n
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Overcoming TRAINING Barriers: Written procedures for referral and treatment

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Overcoming RESOURCE barriers

  • Develop warm handoff with care manager into behavioral

health

  • Additional time (30 minutes) for providers for new SUMMIT

clients

  • Providers given permission to just address patient’s

addiction at SUMMIT visit

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Overcoming CULTURAL barriers

  • Identify motivated champions to spread buy-in

– Clinical leadership champion (CMO) – Behavioral health champion (Director of BH) – Medical provider champion (AMD)

  • Show early successes through small pilots

– P-D-S-A (Plan-Do-Study-Act) – Use your champions for the pilots

  • Train all staff in HARM REDUCTION philosophy
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Sustainability and New Directions for SUMMIT

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Sustain by developing workforce

Staffin ing: g:

  • HRSA MAT Expansion
  • Add expertise and new staff—CADC, CAADE, dedicated case

management, prescribers (currently 10)

  • Provide clear information about transition
  • Expand education and training -- Workshops and trainings
  • n harm reduction, MAT etc…
  • Merger with syringe exchange and HIV program (Common

Ground)

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Sustain by trusting what works

Ope peration ions s and d clin inic ical: l:

  • Screenings and referrals (PHQ-9; NIDA quick screen bi-

annual)

  • Co-location of BH and medical services already in place
  • Care coordination
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Sustain by learning from others

  • Treating Addiction in Primary Care (TAPC) involvement
  • RAND relationships
  • Encouraging continuing education webinars
  • Expert consultation
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Sustain by learning from participants

Sug ugge gesti tions:

  • ns:
  • “I don’t like that our sessions are limited to 45 min. And

rooms are not always available.”

  • “Healthier snacks…potluck.” “Pizza night would be good.”
  • “I think we should go outside and walk and talk to the

people outside [these] walls about our program we can be good in a pack.”

  • “Meditation”
  • “How do we [SUMMIT staff] cope?”
  • “Will this program change/go away?”
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Positi sitive feedba eedback: ck: Wh What at does es SUM UMMI MIT T mean ean to you? u?

  • “SUMMIT gave me a new life I was re-born with happiness by

talking about my pain, distress etc. I’ve been able to see life in a different positive way through the pain of my fellows and love, compassion, understanding of the SUMMIT group of women…”

  • “Support, family.”
  • “This is the place where I learned I actually had options for my

life and things could get better.”

  • “Community, safety, support, love, hope, encouragement,

laughter, purpose.”

  • “People to love and care about me in this sometimes cold world.”

Sustain by learning from participants

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Working with clinic staff and providers

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Sustain by helping staff visualize workflow

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NEW! – Team of BH professionals!

  • Case

e managemen nagement t to support transportation, linkage to care, and personal and professional goals

  • Indiv

ividu idual al and/or /or group up thera erapy with addiction counselor or LCSW to support emotional and community health

  • Suppor

port t groups ps focused on individualized treatment plan— bio-psycho-social-spiritual

IMP MPOR ORTANT! NT! On Ongoing going ca care co coor

  • rdina

dination tion sustaine tained d from m SUMMIT MMIT ha has be been en cr criti tical cal to supp ppor

  • rtin

ting g rela lationships tionships wi with th me medical ical provider viders s an and sta taff

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Harm reduction on the continuum of care

Accept epting ng us use as f s fact: t:

  • We are inviting people who use alcohol or other drugs inside

Being ng honest

  • nest about
  • ut what

t is s available: ble:

  • The range of care from coffee and fliers to MAT; counseling; support

through in-home induction; referral to sober living…. Sett etting ng shor

  • rt-term

erm and achie ievable able goals s WITH TH partic icip ipants ants:

  • The person can only benefit from care if we view them as self-governing
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Near future goals for SUMMIT at VFC

  • Group refill clinic
  • Evaluate and implement SBIRT for teens
  • Start group for people affected by AOD (CRAFT)
  • Build more effective working relationships with other

agencies

  • Hub and spoke model
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Ongoing challenges

  • Expanding SUMMIT program across sites
  • Time and capacity for ongoing education around issues of SUD
  • Maintaining clinic workflow while upholding values of harm

reduction

  • How to capture data outside of medical infrastructure

– E.g.: “touches” with case manager; participant-specific goals.

  • Same-day billing
  • Referrals to inpatient, detox and residential.
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Conclusions and Next Steps

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Despite perceptions of multiple barriers, SUD treatment can be successfully implemented in primary care

  • An organizational readiness intervention can help overcome

barriers and change the culture of care to include SUD treatment

  • A CC service delivery intervention can improve linkage to care

and outcomes

  • A specialized workforce, funding support and listening to

patients and providers can help sustain a newly integrated SUD program

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However, the glass is only half full

72% of patients who needed SUD treatment did not get it 28% of patients going to primary care for something

  • ther than an

SUD got SUD treatment!

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Next steps

  • Learn more about what patients need to respond to

screening and initiate SUD treatment in primary care

  • Continue to study SUMMIT data to

– Better understand patient factors that predict use of medication and brief treatment – Better understand provider barriers and facilitators to prescribing medication – Learn about sustainability

  • Continue to share our findings
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Study publications to date

  • 1. Watkins, K.E., Ober, A.J., Lamp, K., Lind, M., Setodji, C.M., Osilla, K.C., Hunter, S.B.,

McCullough, C.M., Becker, K., Iyiewuare, P.O., Diamant, A., Heinzerling, K., & Pincus, H.A. (2017). Collaborative Care for Opioid and Alcohol Use Disorders in Community Health Clinics. JAMA Internal Medicine, 8(4).

  • 2. Watkins, K.E., Ober, A.J., Lamp, K., Lind, M., Diamant, A., Osilla, K.C., Heinzerling, K., Hunter,

S.B., & Pincus, H.A. Implementing the chronic care model for opioid and alcohol use disorders in primary care. Progress in Community Health Partnerships: Research, Education, and

  • Action. In press.
  • 3. Storholm, E.D, Ober, A.J., Hunter, S.B., Becker, K, & Watkins, K.E. Barriers to integrating the

continuum of care for opioid and alcohol use disorders in primary care: A qualitative longitudinal study. Journal of Substance Abuse Treatment. In press.

  • 4. Iyiewuare, P.O., McCullough, C., Ober, A., Becker, K., Osilla, K., & Watkins, K.E. Demographic

and mental health characteristics of individuals who present to community health clinics with substance misuse. Journal of Primary Care and Community Health. In press.

  • 5. Kulesza, M., Watkins, K.E., Ober, A., Osilla, K., & Ewing, B. Internalized stigma as an

independent risk factor for substance use problems among primary care patients: Rationale and preliminary support. Drug and Alcohol Dependence. In press.

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Study publications to date (continued)

6. Ober, A.J., Watkins, K.E., Hunter, S.B., Ewing, B., Lamp, K., Lind, M., Becker, K., Heinzerling, K., Osilla, K.C., Diamant, A., & Setodji, C.M. Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: Findings from the SUMMIT

  • study. BMC Family Practice. Under review.

7. Ober, A.J., Watkins, K.E., Lamp, K., Lind, M., Osilla, K.C., Heinzerling, K.G., De Vries, D., Iyiewuare, P.O., & Diamant, A. (2017). SUMMIT Study Protocol: Step-by-Step Procedures for Providing Screening, Brief Intervention, and Treatment Services to Primary Care Patients with Opioid or Alcohol Use Disorders. Santa Monica, CA: RAND Corporation, TL-219-NIDA. Available at: https://www.rand.org/pubs/tools/TL219.html 8. Heinzerling, K.G., Ober, A.J., Lamp, K., De Vries, D., & Watkins, K.E. SUMMIT: Procedures for medication-assisted treatment of alcohol or opioid dependence in primary care. Santa Monica, CA: RAND Corporation, TL-148-NIDA, 2016. Available at: http://www.rand.org/pubs/tools/TL148.html 9. Osilla, K.C., D’Amico, E.J., Lind, M., Ober, A.J., & Watkins, K.E. Brief treatment for substance use disorders: A guide for behavioral health providers. Santa Monica, CA: RAND Corporation, TL-147-NIDA, 2016. Available at: http://www.rand.org/pubs/tools/TL147.html

  • 10. Ober A.J., Watkins K.E., Hunter S.B., Lamp K., Lind M., & Setodji C.M. (2015). An
  • rganizational readiness intervention and randomized controlled trial to test strategies for

implementing substance use disorder treatment into primary care: SUMMIT study protocol. Implementation Science, 10(66).

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Many people contributed to this project (it takes a village ...)

  • Kate Watkins (PI)
  • All of the staff at Venice

Family Clinic

  • Kirsten Becker
  • Allison Diamant
  • Brett Ewing
  • Keith Heinzerling
  • Sarah Hunter
  • Erik Storholm
  • Praise Iyiewuare
  • Mimi Lind
  • Colleen McCullough
  • Karen Osilla
  • Claude Setodji
  • Chau Pham
  • Tiffany Hruby

Project funded by NIDA R01DA034266 and Alkermes for XR-NTX

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Questions? Karen: klamp@mednet.ucla.org Allison: ober@rand.org Tobin: tdshelton@mednet.ucla.org

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Several factors influenced who received any evidence-based practice

  • Those more likely to receive any evidence based practice ...

– were older (p<.0001) – were stably housed (i.e., not homeless (P<.01) – had more severe SUDs (p<.05) – had greater perceptions of self-stigma around their SUD (p<.05)

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Several factors influenced who received MAT

  • Those more likely to receive MAT among those with an AUD

– were older (OR = 1.07, CI = 1.03, 1.11, p<.05) – had received BT prior to MAT (OR = 3.34, CI = 1.35, 8.91, p<.01)

  • Those more likely to receive MAT among those with an OUD

– were older (OR = 1.06, CI = 1.03, 1.10, p<.01) – male gender (OR = .37, CI = 0.16, 0.85, p<.05) – working full-time (OR = 3.26, CI = 1.14, 9.28, p<.05) – had more negative consequences from substance use (OR = 1.14, CI = 1.02, 1.28, p<.05)