Literature Collection

Evidence-based treatment of opioid use disorder, the prevention of opioid overdose and other opioid-related harms, and safe and effective pain management are priorities for the Veterans Health Administration (VHA). The VHA Office of Health Services Research and Development hosted a State-of-the-Art Conference on "Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety" on September 10-11, 2019. This conference convened a multidisciplinary group to discuss and achieve consensus on a research agenda and on implementation and policy recommendations to improve opioid safety for Veterans. Participants were organized into three workgroups: (1) managing opioid use disorder; (2) Long-term opioid therapy and opioid tapering; (3) managing co-occurring pain and substance use disorder. Here we summarize the implementation and policy recommendations of each workgroup and highlight important cross-cutting issues related to telehealth, care coordination, and stepped care model implementation.

BACKGROUND: People with chronic general medical conditions who have comorbid depression experience poorer health outcomes. This problem has received scant attention in low- and middle-income countries. The aim of the ongoing study reported here is to refine and promote the scale-up of an evidence-based task-sharing collaborative care model, the Mental Health Integration (MhINT) program, to treat patients with comorbid depression and chronic disease in primary health care settings in South Africa. METHODS: Adopting a learning-health-systems approach, this study uses an onsite, iterative observational implementation science design. Stage 1 comprises assessment of the original MhINT model under real-world conditions in an urban subdistrict in KwaZulu-Natal, South Africa, to inform refinement of the model and its implementation strategies. Stage 2 comprises assessment of the refined model across urban, semiurban, and rural contexts. In both stages, population-level effects are assessed by using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework with various sources of data, including secondary data collection and a patient cohort study (N=550). The Consolidated Framework for Implementation Research is used to understand contextual determinants of implementation success involving quantitative and qualitative interviews (stage 1, N=78; stage 2, N=282). RESULTS: The study results will help refine intervention components and implementation strategies to enable scale-up of the MhINT model for depression in South Africa. NEXT STEPS: Next steps include strengthening ongoing engagements with policy makers and managers, providing technical support for implementation, and building the capacity of policy makers and managers in implementation science to promote wider dissemination and sustainment of the intervention.

BACKGROUND: Although costs are of key importance to clinic leadership when considering adoption of new programs, few studies examine real-world resource needs associated with implementing complex interventions for chronic conditions in primary care. This analysis sought to identify the costs necessary to implement the evidence-based collaborative care model (CoCM), an integrated behavioral health program for common mental disorders in primary care. METHODS: Ten federally qualified health centers (FQHCs) adopted CoCM as part of a larger national randomized trial evaluating implementation strategies for CoCM when adapted for perinatal mental health. The Cost of Implementing New Strategies (COINS) tool was used to assess implementation costs associated with activities completed by sites as they progressed through the implementation process. National wage norms were used to calculate cost estimates for staff time. RESULTS: On average, clinics spent $40,778 (SD=$30,611) on implementation, with clinics ranging widely from $4,502 to $103,156. Three out of 10 participating clinics achieved competency in the intervention during the 2-year implementation period. Costs among competent clinics ranged from $20,944 to $65,415 (mean=$41,788). Clinics that did not achieve competency were more varied, with both the lowest and highest resource use. Significant staff effort was required to complete all implementation stages; clinical staff and program champions showed greatest effort. CONCLUSIONS: Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites who did not achieve competence. Additional work is needed to identify optimal site resource investment related to implementation success for CoCM. TRIAL REGISTRATION: ClinicalTrials.gov.NCT02976025. Registered on November 23, 2016.

BACKGROUND: Little is known about effective implementation processes by which counties can improve community services to keep people with mental illness and substance use disorders out of the local jails. This study examines hypothesized implementation mechanisms (relationship building, performance monitoring, interagency coordination, capacity building, and infrastructure programming) as predictors of outcomes (improved community services) and as mediators of the effects of a national implementation intervention (Stepping Up [SU]), on community services. METHODS: A survey was conducted of mental health, substance use, jail, and probation administrators in 519 U.S. counties, of which 328 counties participated in a national jail reform effort (SU). Survey data were combined with descriptive data from the U.S. Census Bureau. Predictors included hypothesized implementation mechanisms (performance monitoring, interagency coordination teams, creating integrated systems of care, capacity building, relationship building, and quality programming). Covariates included county sociodemographic characteristics (e.g., size of county, size of jail, etc.) and general county service characteristics (e.g., primary care physicians per capita, Medicaid expansion). Implementation outcomes included number of evidence-based practices (EBPs) and evidence-based mental health treatments (MH-EBTs) for individuals with mental illness involved with justice systems. Multilevel regression analyses examined cross-sectional: (1) effects of Stepping Up on outcomes; (2) effects of implementation mechanisms on implementation outcomes; and (3) implementation mechanisms as mediators of the effects of Stepping up on implementation outcomes. FINDINGS: SU was found to significantly predict the number of EBPs and MH-EBTs controlling for various demographic characteristics of the counties. When implementation mechanisms were added to these models, SU is no longer statistically significant. Instead, two implementation mechanisms (performance monitoring and interagency coordination) and Medicaid funding significantly predicted the availability of both EBP and/or MH-EBT. Other factors that predicted MH-EBTs include relationship building size of the county, rate of primary care physicians, rate of MH providers in the county, and jail population size. Mediation models found that SU significantly predicted these evidence-based outcomes through implementation mechanisms except interagency coordination. CONCLUSIONS: Little is known about the implementation mechanisms to decarcerate and build programming for MH services in a county. SU is an important attribute to facilitate reform both directly and indirectly through implementation mechanisms. Counties can benefit from use of relationship building activities to advance policy and service reform efforts, identifying performance metrics of their system, and having infrastructure available to improve the availability of EBPs. Overall, policy changes are possible, but an emphasis should be on strategies that increase the availability of EBPs and MH-EBTs.

Hub-and-spoke (H&S) partnerships for managing opioid use disorder vary by U.S. state. This column provides the first description of the development of an H&S partnership in Tennessee, a Medicaid nonexpansion state. Medicaid expansion allows states to fund evidence-based substance use disorder treatment and community-based psychosocial interventions. In an H&S model in a Medicaid nonexpansion context, federal grant support must fund not only treatment itself but also the creation and maintenance of parallel billing and documentation processes for various partners, reducing the funds available for patient care.

OBJECTIVES: The COVID-19 pandemic led to the closure of the IDEA syringe services program medical student-run free clinic in Miami, Florida. In an effort to continue to serve the community of people who inject drugs and practice compassionate and non-judgmental care, the students transitioned the clinic to a model of TeleMOUD (medications for opioid use disorder). We describe development and implementation of a medical student-run telemedicine clinic through an academic medical center-operated syringe services program. METHODS: Students advertised TeleMOUD services at the syringe service program on social media and created an online sign-up form. They coordinated appointments and interviewed patients by phone or videoconference where they assessed patients for opioid use disorder. Supervising attending physicians also interviewed patients and prescribed buprenorphine when appropriate. Students assisted patients in obtaining medication from the pharmacy and provided support and guidance during home buprenorphine induction. RESULTS: Over the first 9 weeks in operation, 31 appointments were requested, and 22 initial telehealth appointments were completed by a team of students and attending physicians. Fifteen appointments were for MOUD and 7 for other health issues. All patients seeking MOUD were prescribed buprenorphine and 12/15 successfully picked up medications from the pharmacy. The mean time between appointment request and prescription pick-up was 9.5 days. CONCLUSIONS: TeleMOUD is feasible and successful in providing people who inject drugs with low barrier access to life-saving MOUD during the COVID-19 pandemic. This model also provided medical students with experience treating addiction during a time when they were restricted from most clinical activities.

PURPOSE: To describe the development, implementation, and feasibility of a novel training program for community pharmacists transitioning to clinical ambulatory care positions. SUMMARY: A primary care-focused ambulatory care pharmacist training program was initiated in an integrated healthcare system in Utah in response to community pharmacy closures. The program aimed to transition community pharmacists into clinical ambulatory care positions utilizing a competency framework designed to cultivate skills in applying clinical knowledge, communication, managing clinic workflow, and professional development. Nine pharmacists in the program (trainees) were each paired with 1 to 2 pharmacists (mentors) with robust experience in ambulatory care practice. Trainees participated in independent study, didactic instruction, and hands-on experiences tailored to their roles as either embedded or telehealth pharmacist trainees. They worked toward meeting clinical skills and professional engagement objectives outlined in a competency framework, with the goal of progressing to independent practice within 6 to 12 months. While these objectives guided development, completion timelines were adapted in response to evolving roles and operational challenges. Embedded pharmacist trainees completed 70% of the clinical skills objectives after 6 months and 74% of the professional engagement objectives after 12 months. Telehealth pharmacist trainees completed 100% of the clinical skills objectives after 6 months and 56% of the professional engagement objectives after 12 months. Trainees reported increased confidence in most clinical skills areas but less motivation for professional engagement activities at 6 months. Mentors found the program design suitable but suggested a higher mentor-to-trainee ratio to manage workload. CONCLUSION: This program served as a novel, practice-based approach to train and transition community pharmacists into clinical ambulatory care positions. Its successful implementation demonstrates a feasible strategy for workforce redeployment, offering a model that may inform future training initiatives in evolving healthcare settings.