Literature Collection

Children with complex health and behavioral health conditions face challenges accessing coordinated health and community-based services. Adverse childhood experiences (ACEs), social determinants of health, and care delivery silos can lead to negative long-term outcomes. This paper provides an update on the Integrated Care for Kids (InCK) model from the Centers for Medicare &Medicaid Services' Innovation Center and discusses barriers and facilitators to program implementation in the seven communities. The three core InCK activities-supported by flexible alternative payment models-are early identification, risk stratification, and service integration. Challenges include obtaining the appropriate Medicaid and Children's Health Insurance Program (CHIP) authorities, sharing data across non-traditional partners, assessing impact in non-clinical domains, and evaluating the program's impact on child health. InCK enables innovation in value-based purchasing by creating a guiding framework that allows states to design and implement a service delivery and payment model that accounts for the heterogeneity of Medicaid programs.

BACKGROUND: Substance use is common among U.S. military veterans and veterans are at high risk for negative consequences associated with substance use, such as injection-related infections and overdose. Although harm reduction services (HRS) are highly evidence-based, implementation in traditional healthcare settings has been limited. This formative, qualitative study sought to identify barriers and facilitators to the integration of HRS and identify appropriate implementation strategies to support the optimized integration of a comprehensive bundle of HRS in the Veterans Health Administration (VHA). METHODS: Semi-structured interviews explored how harm reduction is currently understood by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis and the Practical, Robust Implementation and Sustainability Model (PRISM) implementation framework was used to organize findings. Results were then mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR - ERIC) tool. RESULTS: 15 interviews with VHA providers were conducted across 5 sites. Respondents reported that current HRS are fragmented and dependent on the knowledge, time, and comfort level of individual providers. Stigma around substance use at the patient, provider, and institutional levels was noted to be a key barrier to HRS adoption. Based on identified barriers and facilitators, strategies that may be effective for increasing adoption of HRS include engagement of champions, communication and educational strategies, and adaptation of existing infrastructure. CONCLUSIONS: Many of the barriers identified in this formative study may be addressed using evidence-based implementation strategies. Additional research is needed to identify implementation strategies that are effective for addressing stigma, which is perceived to be a persistent challenge to the provision of integrated harm reduction services.