1. Strategies to Implement and Sustain Medication Use for Alcohol and Opioid Disorders

2. Contributors  University of Wisconsin-Madison  James H. Ford II  Kim Johnson  Oregon Health and Sciences University  Raina Croff  Dennis McCarty  Treatment Research Institute  Mady Chalk  Duke University  Kelly Alanis-Hirsch  University of California at San Francisco  Laura Schmidt

3. Acknowledgments  Funding for this project was provided by a grant from the National Institute on Drug Abuse (R01 DA029716).  Dr. McCarty is the Principal Investigator on Research Service Agreements from Alkermes, Inc. and Purdue Pharma.  Ms. Johnson has funding from Alkermes and has served on the advisory committee for Orexeo.

4. Medication Research Partnership  Involved 13 treatment providers in Delaware, Maryland, New Jersey and Pennsylvania contracting with a national commercial health plan.  Nine programs assigned to intervention group received training in the Advancing Recovery systems change model  Four programs served as comparison sites.  All sites participated in qualitative interview about  Systems changes supporting integration of medication into treatment, and  Financial, administrative and technical barriers to medication use and its sustainability.

5. Advancing Recovery Model Conditions for Change Customer Leadership Clear Aim Business Case Levers for Change Financing Regulation and Policies Inter-organizational relationships Operations Customer Impact Supports for Change Payer/provider partnership Use of rapid change cycles Coaching/technical assistance Schmidt, Laura A., et al. "Advancing Recovery: implementing evidence-based treatment for substance use disorders at the systems level." Journal of studies on alcohol and drugs 73.3 (2012): 413.

6. Study Methodology  Utilized a “pre/during/post” design consisting of five interviews per site  Baseline: Reference point for agency culture and treatment philosophy.  Implementation: Provided data on barriers to integrating medication into treatment and strategies utilized to make policy and process changes.  Follow-up: Captured detail on processes used to initiate, test and sustain changes to support use of medications.

7. Intervention Agency Overview AgencyMedicationsMRP Target Program Targeted changes Reduce Time to First Dose Begin/ Increase referrals Achieve buy-in Begin/Increase Education Increase access points Increase patient engagement Increase prescribing practices AMethadone, buprenorphine, naltrexone and XRN Detox and residential XX (increase) BMethadoneDetox and residential X (staff & board) CDisulfram, Naltrexone, XRN, Acamprosate Detox and residential X DXRNDetox and residential X (Community, family & patient) X EAcamprosate, XRN (refer out) Outpatient X (begin) X (Begin, patient) FXRN, buprenorphineYoung adult Detox and outpatient X (increase) X (Begin, staff & patient) GBuprenorphine (refer out) Outpatient X (staff) X HBuprenorphineOutpatientX X X IXRNDetox and residential X (increase)

8.  Understand and communicate benefits and impact of medications  Take steps to enhance staff engagement and buy-in  Secure senior leadership support for use of medications in the organization  Develop systems to track outcomes  Integrate medications into organizational culture  Enhance inter-agency collaboration and payer relationships Implementation and Sustain Strategies

9. Communicate Benefits to Staff/Clients BarrierStrategyExample QuotationProvider Benefit Staff medical knowledge Provide staff education about benefits of medication “What do I need to know about [each medication] so if a patient asks me, what can I say about it?” Provides a unified philosophy for consistent information about medications Client medication knowledge Have knowledgeable staff prepare medication summary “Asked the Medical Director, because he's an advocate for using medications, to write a small summary for each one.” Prepares clients for more informed conversations

10. Staff Buy-in and Enagement BarrierStrategyExample QuotationProvider Benefit Staff resistance Regular clinical staff meetings “[do] more for our staff morale…it gives the staff that option to communicate with us and to voice their displeasure, to voice their frustrations. …And I think that’s more important than anything, because if they feel a sense of being heard and feeling that trust from us, then they’re going to be able to trust.” Instills a sense of staff ownership which is an important aspect of achieving buy-in

11. Senior Leadership Support BarrierStrategyExample QuotationProvider Benefit Absence knowledge of medication benefits Provide staff education about benefits of medication “[outcomes are] being shared with our leadership staff. … and they are measuring to make sure that we're taking advantage of this particular medication.” Enhances leadership support for use of medications Medication use is not consistent with agency mission Educate board and secure their support for use of medications “[It is] a big risk … and that was one of the big [cultural] shifts that our Board had to make in the transition.” Change in agency mission which was a crucial part of medication implementation

12. Systems to Track Outcomes BarrierStrategyExample QuotationProvider Benefit Inadequate availability of systems to track outcomes in real time Develop internal to track key agency outcomes “Need a snapshot of who you've got where, what level of care, where they're coming from, what medications…and [we] want all this information collected along the way, so that it's readily accessible to us” Allows staff and leadership in the agency to see and track in real time the benefits of medications on client outcomes

13. Integrate into Culture BarrierStrategyExample QuotationProvider Benefit Medication use goes against agency culture Take steps to incorporate medication philosophy into all aspects of the organization “Every person who is opiate or alcohol dependent would be…meeting with either a nurse, a nurse practitioner or a physician assistant no matter at what level of care, no matter what satellite office, [and have the] opportunity to…discuss medication.” Consistency in how clients have access to supports related to medications Engage leadership in supporting the cultural change “organizational culture starts at the top and leadership follow-up…that’s going to be our key to success with sustainability.” Increases likelihood that changes will be sustained

14. Inter-agency collaboration and payer relationship BarrierStrategyExample QuotationProvider Benefit Payer policy inhibits client access to medications Work with payer to modify contract to pay for medication “Wrote into our contract that if we get one of their patients and … order [XRN] they will allow us to bill them so that we don't have a loss on purchasing [Rx]. … was a big deal to get amended verbiage in our contract.” Ability to prescribe medication without a financial impact Staff education or client access Work with Pharma rep on education and linkages to prescribers “[the representative] gives us handouts and informational pamphlets. … will go in and … train new staff.” Facilitate staff education and client access to prescriber

15. Limitations  Interviewing one person tells the story but limits perspectives  Limited responses from control sites as sustainability questions not asked until 3 rd interview  Results limited to relationship with one major health plan in a defined geographic area.  Qualitative analysis not alone sufficient to document impact of implementation and sustainability

16. Implications  Implementation of medications differs from other types of organizational change.  Implementation and sustainability required  Complex interventions,  In some programs, change in organizational philosophy.  Multifaceted approach and coordination across multiple internal and external stakeholders

17. Questions