Literature Collection

BACKGROUND: Unhealthy substance use (USU) is common and ranges from use above guideline-recommended levels to severe substance use disorder. USU results in substantial morbidity and mortality yet primary care practices rarely systematically screen, diagnose, and treat USU. Supporting Unhealthy Substance use care Through a whole person Approach and user centered INtegration into primary care (SUSTAIN) tests whether the implementation of a co-designed change package for USU improves patient function. The protocol for SUSTAIN is presented here. METHODS: SUSTAIN is a cluster randomized controlled implementation trial of a customized approach to identify and treat USU in primary care. The sample includes 24 primary care clinics in two practice-based research networks (PBRNs). In phase one, primary care practice champions and patients with lived USU experience co-design a change package to identify and treat USU. In phase two, we test the effectiveness of the change package versus usual care and evaluate the implementation of the change package. Data will be collected from 24 clinics (50 patients per clinic for total of 1200 patients) through patient surveys and the electronic health record. Patients surveyed must be 18 or older and screen positive for USU using the Tobacco, Alcohol, Prescription medication and other Substance use part one (TAPS-1) tool. Primary outcomes include mental and physical health patient function scales measured using Patient Reported Outcomes Measurement Information System (PROMIS-29-v2). Secondary outcomes are prevalence of USU, recovery, health care utilization, USU screening rates, provision/referral to behavioral health services and prescription of appropriate medications. We will also evaluate implementation outcomes by surveying 96 practice representatives (4 at each clinic) and conduct qualitative interviews with 20 patients and 20 practice leaders to assess their experience with the intervention and its implementation. CONCLUSIONS: The SUSTAIN trial creates and tests an implementation package approach to address USU in diverse primary care settings. The SUSTAIN change package aims to transform how primary care practices care for individuals with USU to improve patient outcomes and enhance community well-being.

OBJECTIVE: To assess multi-level factors influencing the sustainability of 26 social care pilots integrating medical and social services for Medicaid enrollees across California in newly developed Medicaid benefits. STUDY SETTING AND DESIGN: This qualitative study assessed the sustainability of Whole Person Care (WPC) pilots implemented between 2016 and 2021. Pilots (n = 26) represented a majority of counties in California. DATA SOURCES AND ANALYTIC SAMPLE: Primary qualitative data were collected between June and August 2021 and included 58 hour-long, semi-structured individual and group interviews with administrators, middle managers, and frontline case management staff representing all WPC pilots. We used hybrid inductive-deductive thematic analysis to identify and analyze patterns, and outliers, in factors influencing sustainment. Deductive codes included established implementation science factors influencing the sustainability of new programs (e.g., innovation characteristics, capacity, processes and interactions, and context). PRINCIPAL FINDINGS: Of 26 WPC pilots, 22 pilots sustained WPC by contracting with Medicaid managed care plans to provide services as part of newly developed Medicaid benefits. Three pilots chose not to sustain before the pilot period ended and one pilot decided not to sustain following completion of the full pilot. Factors influencing sustainability included: (1) program adaptability and flexibility; (2) funding structure and reimbursement requirements; (3) shared leadership with managed care plans; and (4) whether pilots chose to build out program infrastructure internally or contracted out core components to partner organizations. Many pilots, particularly those in rural areas, indicated that system and policy changes introduced as part of transitioning pilot services into Medicaid benefits reduced the sustainability of WPC for participating providers. CONCLUSIONS: Multi-level factors including program adaptability, funding, leadership, and capacity to build out infrastructure influenced the sustainability of WPC pilots. These findings have significant implications for health equity as equitable distribution of services, resources, and benefits from these programs can be supported through sustained implementation over time.

BACKGROUND: Efforts to integrate substance use disorder treatment into primary care settings are growing. Little is known about how well primary care settings can sustain treatment delivery to address substance use following the end of implementation support. METHODS: Data from two clinics operated by one multi-site federally qualified health center (FQHC) in the US, including administrative data, staff surveys, interviews, and focus groups, were used to gather information about changes in organizational capacity related to alcohol and opioid use disorder (AOUD) treatment delivery during and after a multi-year implementation intervention was executed. Treatment practices from the intervention period were compared to practices after the intervention period to examine whether the practices were sustained. Data from staff surveys and interviews were used to examine the factors related to sustainment. RESULTS: The two clinics sustained multiple components of AOUD care 1 year following the end of implementation support, including care coordination, psychotherapy, and medication-assisted treatment. Some of the practices were modified over time, for example, screening became less frequent by design, while use of care coordination and psychotherapy for AOUDs expanded. Participants identified staff training and funding for medications as key challenges to sustaining treatment. CONCLUSIONS: Following a multi-year implementation intervention, a large FQHC continued to deliver AOUD treatment. Access to external funding and staff support appeared to be critical elements for sustaining care over time. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01810159.