Literature Collection

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.

BACKGROUND: Although opioid agonist therapy is effective in treating opioid use disorders (OUD), retention in opioid agonist therapy is suboptimal, in part, due to quality of care issues. Therefore, we sought to describe the planning and implementation of a quality improvement initiative aimed at closing gaps in care for people living with OUD through changes to workflow and care processes in Vancouver, Canada. METHODS: The Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative followed the Institute for Healthcare Improvement's Breakthrough Series Collaborative methodology over 18-months. Teams participated in a series of activities and events to support implementing, measuring, and sharing best practices in OAT and OUD care. Teams were assigned monthly implementation scores to monitor their progress on meeting Collaborative aims and implementing changes. RESULTS: Seventeen health care teams from a range of health care practices caring for a total of 4301 patients with a documented diagnosis of OUD, or suspected OUD based on electronic medical record chart data participated in the Collaborative. Teams followed the Breakthrough Series Collaborative methodology closely and reported monthly on a series of standardized process and outcome indicators. The majority of (59%) teams showed some improvement throughout the Collaborative as indicated by implementation scores. CONCLUSIONS: Descriptive data from the evaluation of this initiative illustrates its success. It provides further evidence to support the implementation of quality improvement interventions to close gaps in OUD care processes and treatment outcomes for people living with OUD. This system-level approach has been spread across British Columbia and could be used by other jurisdictions facing similar overdose crises.

OBJECTIVES: To integrate a computerized adaptive test for depression into the electronic health record (EHR) and establish systems for administering assessments in-clinic and via a patient portal to improve depression care. MATERIALS AND METHODS: This article reports the adoption, implementation, and maintenance of a health information technology (IT) quality improvement (QI) project, Patient Outcomes Reporting for Timely Assessment of Life with Depression (PORTAL-Depression). The project was conducted in a hospital-based primary care clinic that serves a medically underserved metropolitan community. A 30-month (July 2017-March 2021) QI project was designed to create an EHR-embedded system to administer adaptive depression assessments in-clinic and via a patient portal. A multi-disciplinary team integrated 5 major health IT innovations into the EHR: (1) use of a computerized adaptive test for depression assessment, (2) 2-way secure communication between cloud-based software and the EHR, (3) improved accessibility of depression assessment results, (4) enhanced awareness and documentation of positive depression results, and (5) sending assessments via the portal. Throughout the 30-month observational period, we collected administrative, survey, and outcome data. RESULTS: Attending and resident physicians who participated in the project were trained in depression assessment workflows through presentations at clinic meetings, self-guided online materials, and individual support. Developing stakeholder relationships, using an evaluative and iterative process, and ongoing training were key implementation strategies. CONCLUSIONS: The PORTAL-Depression project was a complex and labor-intensive intervention. Despite quick adoption by the clinic, only certain aspects of the intervention were sustained in the long term due to financial and personnel constraints.