"Enhancing the Access and Quality of MAT for Individuals With Opioid Use Disorder (OUD) in Rural Pennsylvania’s Medicaid Primary Care Practices," Pennsylvania State Department of Human Services in partnership with the Pennsylvania Office of Mental Health and Substance Abuse Services and the University of Pittsburgh.
Key Lessons Learned in Medication-Assisted Treatment Implementation
- Provider Recruitment: A flexible approach in working with rural primary care providers (PCPs) has facilitated recruitment and implementation. This approach includes allowing PCPs to choose which MAT drugs (buprenorphine or naltrexone) to prescribe, as well as preference for referral to an addiction specialist for induction before participating in the patient’s ongoing management.
- Stigma: Some physicians and staff experience stigma toward treating patients with addiction. Education and training focused on this barrier have helped overcome stigma-related issues.
- Care Management Support: The grantee was also able to recruit several physicians after they realized they would receive assistance in connecting patients with substance use disorder/mental health treatment and in other functions associated with managing patients with complex needs.
- Reimbursement for MAT: Primary care clinics often have questions related to reimbursement for MAT, and the grantee’s ability to link clinic staff with Medicaid managed care organizations has helped address this issue.
- Demands on the Time of Rural PCPs: Initial participation in educational webinars and calls has been low, likely due to the high-demand on the time of rural PCPs. The grantee has modified the approach by posting educational materials to the Project RAMP website so that PCPs can use them at their convenience.
- Communication Breakdown Between Providers: Poor communication between treatment and service providers has affected patient treatment engagement. The grantee has focused on developing communication plans for participating entities to improve communication.
- High Staff Turnover: Participating practice sites have had high rates of staff turnover that has affected MAT implementation. New champions must be identified quickly and booster trainings should be offered as soon as possible to new staff.
- Continuous Quality Improvement and Performance Measurement: Having clinics collect their own data on measures related to treatment for OUD, developing reports with suggested areas of improvement, and reviewing that data with them in quasi-real-time may improve implementation, ongoing technical assistance, and sustained engagement with providers.
- Recruitment: 26 practices, 28 physicians, and 15 nurse practitioners and 6 physician assistants. All practices are providing buprenorphine, naltrexone, or both, or are currently in training to do so.
- Among 13 practices reporting during the most recent quarter, over 500 patients are receiving buprenorphine or naltrexone from RAMP clinics.
- Use of primary care by Medicaid enrollees with OUD: 4.1 visits per person-year in rural Pennsylvania counties (based on the grantee’s Medicaid claims analysis). This finding represents an intervention point for PCPs.
- The grantee has 24 primary care practices conducting screening, brief intervention, and referral to treatment (SBIRT) and providing buprenorphine or naltrexone treatment. Three primary care practices are currently in training.
- The implementation team provides comprehensive technical assistance and support to all project sites both in person and via phone and email. Site liaisons are in contact with sites as needed; most sites engage in at least weekly communication with the site liaison.
- Thirteen practices are currently conducting MAT continuous quality improvement (CQI) efforts with the RAMP team, and the team is working to finalize MAT CQI implementation within four other practices sites in 2020 Q1.
- The RAMP team transitioned seven practices into the sustainability phase during 2019 Q4 that will continue to provide SBIRT and MAT services without the support of Project RAMP.
- The grantee has successfully trained 174 clinical providers and staff and 34 administrative staff, including 35 physicians and 21 nurse practitioners and 10 physician assistants.
- The grantee has adopted a flexible approach to training to meet the demands of busy primary care practices.
- The grantee has created an online training curriculum of webinars and resources for participating practices to support their knowledge and implementation of MAT, to view when convenient for them.
Conferences & Publications
AcademyHealth Annual Conference on the Science of Dissemination and Implementation in Health
December 14, 2019
North American Primary Care Research Group Meeting
November 11, 2019
Pennsylvania Medication Assisted Treatment Regional Summits
October – November, 2019
Various Locations in Pennsylvania
Addiction Health Services Research Conference
October 16, 2019
Park City, UT
Medicaid Medical Director’s Network Meeting
September 17, 2019
Pennsylvania Invigorating Public Health Conference
April 2, 2019
Family Medicine Education Consortium Annual Meeting
November 9, 2018
Rye Brook, NY
Addiction Health Services Research Conference
September 17, 2018
Oral Presentation Poster
- Cole ES, DiDomenico E, Cochran G, Gordon AJ, Gellad WF, Pringle J, Warwick J, Chang CH, Kim JY, Kmiec J, Kelley D, Donohue JM. The role of primary care in improving access to medication-assisted treatment for rural Medicaid enrollees with opioid use disorder. J Gen Intern Med. 2019 Jun;34(6):936-943. doi: 10.1007/s11606-019-04943-6. Epub 2019 Mar 18. PMID: 30887440.
- Cochran G, Cole ES, Warwick J, Donohue JM, Gordon AJ, Gellad WF, Bear T, Kelley D, DiDomenico E, Pringle J. Rural access to MAT in Pennsylvania (RAMP): a hybrid implementation study protocol for medication assisted treatment adoption among rural primary care providers. Addict Sci Clin Pract. 2019 Aug 1;14(1):25. doi: 10.1186/s13722-019-0154-4. PMID: 31366408; PMCID: PMC6670171.
- Cole ES, DiDomenico E, Green S, Heil SKR, Hilliard T, Mossburg SE, Sussman AL, Warwick J, Westfall JM, Zittleman L, Salvador JG. The who, the what, and the how: A description of strategies and lessons learned to expand access to medications for opioid use disorder in rural America. Subst Abus. 2021;42(2):123-129. doi: 10.1080/08897077.2021.1891492. Epub 2021 Mar 9. PMID: 33689594.
- Cole ES, Drake C, DiDomenico E, Sharbaugh M, Kim JY, Nagy D, Cochran G, Gordon AJ, Gellad WF, Pringle J, Warwick J, Chang CH, Kmiec J, Kelley D, Donohue JM. Patterns of clinic switching and continuity of medication for opioid use disorder in a Medicaid-enrolled population. Drug Alcohol Depend. 2021 Apr 1;221:108633. doi: 10.1016/j.drugalcdep.2021.108633. Epub 2021 Feb 16. PMID: 33631544.
- Cochran G, Cole ES, Sharbaugh M, Nagy D, Gordon AJ, Gellad WF, Pringle J, Bear T, Warwick J, Drake C, Chang CH, DiDomenico E, Kelley D, Donohue J. Provider and patient-panel characteristics associated with initial adoption and sustained prescribing of medication for opioid use disorder. J Addict Med. 2021 May 10. doi: 10.1097/ADM.0000000000000859. Epub ahead of print. PMID: 33973921.