Pre-Implementation Planning

Support from clinic leadership, providers, and staff is essential to successfully treating patients with OUD. Identifying champions within your practice—both among leadership and providers—is key. These champions may include program directors, physicians, nurse practitioners, physician assistants, or other office staff. While official titles are important, qualities such as compassion for individuals with OUD and a strong motivation to provide life-saving medications may matter more when selecting these champions.

Establish a Pre-Implementation Planning Team for the clinical champions to lead. The team should include representatives from all staff roles to better understand how offering MOUD and related services will impact the organization and its workflows. This approach will ensure the protocols are both feasible and acceptable to staff.

Depending on the size of your organization, multiple levels of clinic staff may play a role in the practice's success:

• Senior leadership (e.g., program director, clinical director, financial lead) can provide direction and communication support for providing MOUD and related services, as well as allocate the necessary resources for implementation.
• Mid-level managers or clinical staff (e.g., clinical manager, office manager, billing manager) can help acquire resources and solve problems during implementation, particularly those that may emerge in larger multisite organizations.
• Frontline staff (e.g., prescriber, nurse, medical assistant, office staff) can help staff adjust to changes in workflow and to solve day-to-day implementation challenges.

The Pre-Implementation Planning Team should develop the Implementation Plan guided by the following considerations:

• Your local context: Know how the opioid epidemic is affecting your community and those you serve. This information may include the types of opioids used (particularly fentanyl) and their adulteration with other substances (e.g., xylazine), prevalence of opioid misuse, OUD, and opioid-related overdoses. Consider the treatment needs in the community and whether prescribing providers are sufficiently available. Assess the attitudes and policies toward medications to treat OUD from other systems and organizations within the community, including pharmacies, SUD treatment programs, the court system, hospitals or emergency departments, and acute care centers. Also, think about what other health issues or SUDs are affecting the community.
• Your goals: Define the scope of the goals and objectives you seek to achieve. For example, consider what level of care you will provide (e.g., OUD treatment medications only, starting MOUD treatment, MOUD maintenance only after buprenorphine is started elsewhere, HCV/HIV screening and treatment). Consider whether you will provide additional services and if so, what they will be.
• How you will define the care team: Determine the roles and responsibilities of clinicians and other staff who will be on the care team. Identify champions within the practice and consider who will serve in various necessary roles.
• How you will identify patients with OUD to treat and assess their needs: If you plan to focus on medication maintenance, consider what referral sources exist in your area. Also, decide whether to screen for OUD and related conditions within your practice and what screening tools you will use.¹ For more information see Screening and Diagnosis.
• Your community and clinical partners: Just as with any patient with a chronic condition, individuals with OUD may require services beyond the scope of your primary care practice. These needs may include issues such as food, housing, employment, childcare, or transportation that your practice cannot address directly. In these cases, it is important to identify and connect patients with appropriate community resources. For patients with more severe conditions, a referral to an OTP for methadone or a program offering more intensive services, such as intensive outpatient or residential care, may be necessary. It is important to identify what resources are available to address these or other needs in your area, and ideally to develop collaborative relationships with them so that closed loop referrals with ongoing communication and progress reporting are possible
• Whether pharmacies in your community will reliably fill your MOUD prescriptions: Patients typically need to visit local pharmacies to obtain the MOUD you prescribe, so it is worthwhile to know which pharmacies stock the medications. Some formulations are more challenging to procure, such as long-acting injectable (LAI) buprenorphine which is subject to Risk Evaluation and Mitigation Strategy (REMS) regulations.^2,3 Industry representatives can be helpful as you navigate the regulations.
  
  Some pharmacies are reluctant to stock buprenorphine medications for fear of being identified in the Suspicious Opioid Reporting System^4,5 that was established to limit diversion of the medication. This is a national problem that remains to be adequately addressed. It is worthwhile to monitor your patient's ability to fill their prescriptions at certain locations, and it may be necessary to route the prescriptions to more collaborative pharmacies. Also, online pharmacies are now available to fill in the gap when local options are limited.
• Whether you can partner with providers who provide care via telehealth or other virtual means: There are now several organizations that provide MOUD, counseling or psychotherapies, peer support, and other recovery support services via telehealth or smartphone-based apps. Some of these organizations collaborate with primary care providers and can offer needed services you are not well positioned to provide to your patients. As with any external partner, you need to be attentive to the quality of the services they offer and the care with which they manage sensitive information, perhaps by checking with other providers who've made use of the organization. Developing a true partnership with some of these organizations may be possible and can be mutually beneficial.
• What resources you will need to implement your plan: Assess what resources you will need and what is available, including human, technological, and financial resources. For instance, practice coaches or facilitators may be useful when implementing a substantial change, such as integrating behavioral health care or medications for OUD. They can help guide the process and build internal resources to sustain the work over time.
• How you will communicate this plan to staff: For successful implementation, changes must be communicated to all staff. Your Implementation Plan should describe how you will train and communicate with staff to help make this change smooth. Promote staff engagement by inviting them to participate in this plan. See Clinicwide Orientation to Treating Patients with OUD.
• How you will make this treatment of OUD practice sustainable: Long-term sustainability and stability of your OUD treatment practice requires staff retention, continuing education for all staff, and community support. Ongoing quality improvement to identify problems and address them in real time is extremely helpful. Plan how you will finance services for patients with OUD, researching reimbursement rates and payment models in your payer mix and state. Read more about these considerations in the sections on Approaches to Quality Improvement and Financial Sustainability.
• How you will measure success: Determine what data you will collect and how they will be used to evaluate implementation efforts. For example, retention in treatment is probably the most important measure of success given the strong evidence linking retention and positive patient outcomes. Measures that should be considered will be discussed in greater detail in the sections on Monitor Patient Outcomes.
• How long this should take: Develop a realistic timeline for the planning, training, and implementation process. Include periodic training to account for changes in the field, staff turnover, and as a 'refresher' for staff.

Once you have developed a plan, the team should develop a process for implementation. Consider how decisions will be made and how the process will be monitored. Establish a timeline to keep your organization on track. Your timeline should allow flexibility because unexpected issues may arise. Consider implementing whole-person treatment for patients with OUD in stages if needed.

Practice facilitation: For practices that hope to provide whole-person care for patients with OUD, formal practice facilitation or practice coaching can be very helpful.^6-8 High quality practice facilitation can help organize implementation and quality improvement processes as they integrate medications and other services to treat patients with OUD. Some states have built a practice facilitation component into the technical assistance they offer through State Opioid Response Grants or using other funding streams. Practice facilitation services vary in quality and cost, but there is strong evidence that they can greatly improve results if done well. Learn more about Practice Facilitation | Agency for Healthcare Research and Quality.