Retention in medication-assisted treatment (MAT) is critical to achieving positive patient outcomes and minimizing the risk of overdose. Engagement is key to retention in treatment, both in the early stages during intake and induction and over the longer course of treatment. Practices or clinics should:
- Create a culture within their program that promotes engagement.
- Recognize that the patient experience at the clinic may undermine efforts to provide care, as punitive or dismissive staff may discourage patient followup.
- Understand that, while staff attitudes and behaviors are important to all patients, patients with substance use disorders can be particularly sensitive to these interactions.
In addition, flexibility around workflows can promote engagement. At a minimum, these should address the process for engaging patients at their first contact and through their first visit. For example, walk-in appointment times for MAT services can be an effective strategy to help encourage patients to return to the clinic.
Practices should also consider how to reach out and re-engage patients if there is a break in their treatment. Patient-centered communications and processes are key elements of Engaging and Educating Patients, Families, and Their Caregivers, as discussed later in the Playbook.
The practice rapidly initiates treatment to address practical barriers to participation via patient-centered operations, workflows, and communications.
How Do You Do It?
Maximize Engagement During Intake and Induction
When patients express interest in treatment for opioid use disorder, it is important to start them in MAT as soon as possible. Ideally, treatment should be initiated on the day of first contact if feasible. Relationships and communication are essential to engagement and retention in treatment. A number of strategies can help increase initial patient engagement:
- Convey hope and speak empathetically.
- Ask open-ended questions to make patients feel welcome.
- Build a connection by asking patients about their story.
- Ask why recovery is important to them—what it will mean to their life and their family’s life—and what their goals are.
- Identify what barriers or challenges might limit their ability to remain in treatment and discuss the best times and methods to get in touch.
- Consider asking patients to commit to coming to the first session and remaining for at least four sessions.
- Manage expectations by educating them on what to expect over the course of treatment.
Providers and practices may experience practical limitations that cause delays in starting treatment, but these delays should be minimized when possible. Waiting lists too often mean missed opportunities to engage patients in treatment and can result in continued opioid use and lost connections.
These best practices can help engage patients if a waiting list is necessary:
- Consider whether you can connect patients to another provider in the community who may have openings.
- Make a point of staying in touch with each person on the waiting list at least weekly. Identify those in higher need of treatment, encourage participation in psychosocial support, and update them on their position.
- Offer patients recovery-oriented reading materials and give them a list of available peer recovery support programs.
- Prioritize for treatment patients who have a significant other or family member already in treatment, women who are pregnant, or those who exhibit high-risk behaviors.
Intake and assessment protocols should be designed to minimize the time between first contact and starting medications to treat opioid use disorder. Starting patients on medication on the same day as they are first seen is ideal. If same-day inductions are not feasible given practice or provider limitations, patients should be started on medications as soon as possible.
Practices should thoughtfully review their workflows and remove any nonessential steps that might delay starting patients on medication.
To facilitate medication initiation, practices may want to:
- Consider postponing paperwork or assessments that can wait until after the patient has started on medication. This approach will help reduce the number of patients lost to treatment initiation and followup.
- Brainstorm how staff roles and responsibilities can be shifted to maximize efficiency of provider time.
- Think about which other staff can be trained to perform certain steps of the intake and induction process, to take some of the burden off the prescribers. For example, a behavioral health provider or nurse care manager can collect most of the patient information and assessment data during intake before the patient sees the prescriber. Or, a health care navigator can help collect relevant information and conduct outreach or follow up with patients.
- Consider workload requirements for providers in the few weeks immediately after the first visit. Overscheduling providers to accommodate subsequent weekly visits after the first visit will lead to provider burnout.
Promote Ongoing Followup and Engagement
Providers must keep in mind that the patients’ interests, goals, and life situations can change over the course of treatment, which may require adjustments to the treatment approach. It should be a routine practice to involve patients in developing and periodically updating their treatment plans. Listening, communicating empathetically, and using motivational interviewing are essential to building relationships throughout treatment.
Patients who are struggling or continuing to use other substances will need more outreach and followup. Follow up with patients who miss an appointment, find out why they missed, and schedule the next appointment. Practices may want to monitor patient no-show rates by individual providers and work with the providers to reduce those rates.
Ongoing engagement may be the responsibility of different types of staff, such as a counselor, a case manager, or an engagement specialist. The staffing configuration will vary depending on payment restrictions in each State.
For example, in the Massachusetts Model, the nurse care managers take on many of the responsibilities for patient monitoring and followup to help relieve the burden on the physicians’ workload. This model may be more viable in settings that allow billing for nurse visits. However, sometimes it may be more advantageous for staff to still provide important nonbillable services to allow prescribers to see more patients and bill for those services. Whatever the staff configuration, communications and relationships to build patient engagement and retention in treatment are crucial.
What Not To Do
- Don’t delay treatment due to requirements to complete paperwork that can wait.
- Don’t treat workflows as static processes. Re-evaluate workflows to identify points where patients are failing to initiate treatment or are being lost to followup, and adjust as needed to promote retention and engagement.
- Don’t fail to recognize that every patient faces a distinct set of challenges that may interfere in engagement or retention in treatment. Tailor treatment approaches and services to their needs.
- Don’t underestimate the importance of empathetic communication, listening, and relationship building to engage and retain patients in treatment.