Engaging Patients in Treatment for OUD

Person-centered care is respectful and responsive to what the patient says they need and want from treatment. In this approach, you meet the patient where they are and try to understand what they value.

It is important to:

• Create a respectful culture within your practice that promotes patient trust, sense of safety, and engagement in treatment;
• Recognize that a patients negative experience at your practice can undermine your efforts to provide care, as judgmental or dismissive staff may discourage patients from returning; and
• Understand that, while staff attitudes and behaviors are important to all patients, patients with OUD can be particularly sensitive to these interactions.

For more discussion on stigma and how to counter it go to Confront Stigma as a Barrier to Care and Train Staff on Patient Engagement to Create a Welcoming Environment.

Establishing a positive rapport between patients and patient-facing staff can help create a supportive practice environment that promotes treatment engagement and retention.² First impressions can be powerful determinants of patients engagement and commitment to treatment.^3,4 Keeping the intervention person-centered is key. Several strategies can increase early patient engagement:^1,5,6

• Convey hope and speak empathically, as you would with any other patient.
• Ask open-ended questions to make patients feel welcome.
• Build a connection by asking patients about their story.
• Ask why recovery is important to themwhat it will mean to their life and their familys lifeand what their treatment goals are.
• Identify what barriers or challenges might limit their ability to remain in treatment (e.g., transportation, inconsistent phone access) and discuss the best times and methods to get in touch.
• Consider asking patients to commit to coming to the first session and attending at least four sessions.
• Manage expectations by educating patients on what to expect over the course of their treatment.
• Practice shared decision-making.⁷

Minimize any delays in care. When patients express interest in treatment for OUD, it is important to start them on MOUD as soon as possible, ideally on the same day they are first seen. It is helpful if your staff can call ahead to ensure the pharmacy has the buprenorphine formulation in stock before sending the patient to fill a prescription. If a same day start of MOUD is not feasible, start patients on medications as soon as possible. This approach will help reduce the number of patients lost to treatment initiation and follow-up.

Similarly, avoid delays in procuring medication.

Periodically review your workflows and remove any nonessential steps that might delay starting patients on medication for OUD. For example, you may want to:

• Consider postponing paperwork or assessments that can wait until after the patient has started on medication;
• Brainstorm how staff roles and responsibilities can be shifted to maximize prescriber efficiency. Consider which tasks, such as collecting patient information and assessment data, monitoring patients during MOUD starts, and conducting outreach or follow up with patients, can be delegated to other team members;
• Consider reducing providers workloads in the few weeks immediately following the first visit. Overscheduling subsequent weekly visits can lead to provider burnout; and
• Consider providing walk-in clinic hours or evening/weekend appointments that can accommodate diverse schedules.⁸

Practical limitations may cause delays in starting treatment, but it is important to minimize these whenever possible. When appropriate, connect patients with an in-person or telehealth MOUD provider who can provide treatment rapidly. If you cannot do this, refer the patient immediately.

Patients interests, goals, and life situations may evolve during treatment, requiring adjustments to the treatment plan. Involve patients in developing and updating their plans. Use empathic communication, listen without judgement, and use motivational interviewing techniques to help build your relationship with patients and sustain their engagement throughout treatment.

In addition to providing a welcoming, nonjudgemental environment, practices can take steps to promote ongoing treatment engagement. Practice and provider efforts can include aspects of treatment that can keep people coming back such as:

• Higher doses of buprenorphine when clinically indicated;
• Outreach to patients who miss appointments to understand the reason and to schedule their next appointment;
• Contingency management such as rewards for negative urine screens; and
• Flexible clinic hours.

It may also be helpful to track no-show rates by providers within your practice and collaborate with them to reduce those rates.

For practices providing a more comprehensive array of services for people with OUD, ongoing engagement may be the responsibility of different types of staff, such as counselors or case managers. The staffing configuration will vary depending on your practice and any state-specific payment restrictions.

For example, in the Massachusetts nurse care manager model,⁹ nurse care managers assume many responsibilities for patient monitoring and follow-up, helping reduce prescribers workloads. This model may be more viable in settings that allow billing for nurse visits. However, sometimes it may be more advantageous for staff to still provide important nonbillable services to allow prescribers to see more patients and bill for those services. Whatever the staff configuration, strong communication and fostering relationships to build patient engagement and retention in treatment are crucial.

There is evidence that primary care clinics that have nurse care managers provide more medications for OUD than those without.¹⁰ There is also evidence that the Collaborative Care^11-13 or psychiatric consultant model improves access to care, and outcomes related to opioid use in primary care settings, including among patients with co-occurring pain and mental health disorders.¹³ Other studies have demonstrated positive outcomes when peer recovery coaches,¹⁴ clinical pharmacists,¹⁵ or others serve as care managers or in other important team roles. It is not clear how much the professional identity of the care manager matters, but a team with at least one prescriber and a care manager is important. Examine what is feasible in your setting and work to create workflows and roles to make MOUD treatment possible.