Access to treatment for opioid use disorder (OUD) is a challenge in rural settings and communities of color due, in part, to the limited availability of healthcare providers equipped and willing to provide medications for opioid use disorder (MOUD). Recent discussion has explored the role of pharmacies in enhancing access to MOUD within underserved areas. However, pharmacies face multiple obstacles related to expanded responsibilities in dispensing MOUD, especially in rural and other communities.
To address this issue, the National Drug Abuse Treatment Clinical Trials Network (CTN) funded a study (CTN-0124) to examine the practicality of expanding pharmacy roles in treating OUD in underserved communities.
The NIATx Foundation helped to lead the nine-month engineering systems analysis, assessing the existing system, envisioning an ideal future state, identifying gaps, and highlighting improvement opportunities. The study, Delivering MOUD to the Underserved: How Can Pharmacies Really Helped?, was published in the October 15, 2024 edition of the Journal of Studies on Alcohol and Drugs.
The opioid and other substance use crises remain one of the nation’s most pressing public health challenges. Despite the recognized efficacy of pharmacotherapy, the challenge of implementing evidence-based practice (EBP) persists, with several barriers hindering the successful implementation of medications for opioid use disorder (OUD) and alcohol use disorder (AUD). Combatting the substance use disorder (SUD) crisis requires effective approaches that employ a comprehensive strategy for implementing EBPs that work in conjunction with behavioral therapies.
Solution
States play a pivotal role as public policy champions in shaping and advancing transformative healthcare practices, such as the broad use of pharmacotherapies for SUDs. Hospital emergency departments (EDs) can further serve as a critical access point for individuals to start treatment for SUD.
The State of Vermont has become a trendsetter in treating OUDs by developing the Hub-and-Spoke (H&S) model of SUD treatment. Building on this foundation, Vermont introduced the Rapid Access to Medication (RAM) for OUD initiative and the subsequent Rapid Treatment Access (RTA) for AUD initiative to improve the responsiveness of the treatment system for individuals seeking SUD treatment.
Both initiatives leveraged team-based and individual learning collaborative sessions using change strategy tools, such as NIATx coaching, the walk-through, and the Plan-Do-Study-Act (PDSA) cycles. Vermont’s implementation approach’s core components involved selecting a relevant aim, assembling dedicated teams, pilot testing, providing individual and group coaching to practitioners, and emphasizing continuous improvement.
The Time-to-Treatment Tracking Tool (T5) and Incentive Payment Opportunity (IPO) provided financial incentives for providers who accomplished items on a checklist within three days of treatment initiation, ranging from conducting community provider sessions to providing rapid treatment access. The T5 helped identify both real and perceived barriers to treatment access and pinpoint gaps in service provision.
Outcomes
In the RAM project, 13 out of 14 Vermont-based hospital EDs established protocols for starting individuals with OUD on MOUD, along with a warm handoff to a designated outpatient treatment provider for continuation after discharge. These individuals are also offered support from a recovery coach in the ED. In the RTA program, 92% of respondents engaged in improving access to AUD treatment, and 100% of respondents supported using medication to manage alcohol withdrawal.
The innovative approach used to refine and improve Vermont’s substance use treatment landscape has brought about transformative change in addressing OUD and AUD. The RAM and RTA initiatives are creating a paradigm shift in the provision of treatment, with the State taking the lead in promoting a timeliness standard for MOUD and AUD service initiation. These initiatives recognize and reward an integrated community-based treatment system responsive to individuals seeking treatment. They further support hospital EDs in starting individuals on medications to treat OUD and AUD during an ED stay and facilitating access to continued medication after discharge.
Vermont is well-positioned to proceed with the RAM and RTA initiatives. Of equal importance, these initiatives present a replicable framework for spreading and scaling up EBPs in other states to address three clear aims:
Initiate treatment for OUD or AUD, including medications, within three days of initial contact.
The Culturally and Linguistically Appropriate Services (CLAS) Standards as a Catalyst for Prevention: A Learning Collaborative (CLAS Learning Collaborative) gave participants the skills to improve service delivery and integrate culturally responsive strategies into their organizational structures. The CLAS Learning Collaborative presented cultural competence not as a distinct knowledge base, but as a framework to incorporate CLAS Standards, leadership development, and process improvement into the inner workings of an organization.
Process
A request for applications was announced, and participation was open to OhioMHAS-certified prevention agencies. Eleven unique prevention agencies serving urban, rural, and suburban communities in NE, NW, Central, and SW Ohio, as well as Appalachia Ohio, were selected to participate in the learning collaborative.
Twenty-nine participants representing the 11 agencies attended a two-day summit to initiate prevention and agency-specific CLAS Standards change projects. All agencies were given the opportunity to assess their agency’s understanding and utilization of the National CLAS Standards using a customized NIATx Foundation CLAS Assessment (NFCA™) tool provided by Prevention Action Alliance in collaboration with NIATx. This assessment was used as the baseline measurement to track progress and outcomes for the project.
A combination of collaborative and individual organization coaching sessions were provided during the three months after the summit. All teams participated in these learning collaborative webinars during the implementation phase of the collaborative to share ideas, successes, and challenges with others in the collaborative. Throughout the process, the learning collaborative coaches provided technical assistance through Zoom meetings, phone, and email feedback on plans and implementation. This included a review of each organization’s strategic plan prior to implementation.
At the conclusion of the CLAS Learning Collaborative, all the participating organizations came together to celebrate and present their respective change project in a “5×5” PowerPoint presentation (i.e., five slides in five minutes).
Next Steps
The trainers will be meeting with each agency again to review their NIATx Foundation CLAS Assessment (NFCA™) and progress made over the course of the project. A more formal report will be created and published. The collaborative team will continue to meet and consider ways to support this group of CLAS Standards Collaborative alumni, as well as ways that we can expand upon this work.
The NIATx Foundation is partnering with Train for Change to provide an ASAM Implementation Guide training that aids organizations in using NIATx’s evidence-based process improvement model to help treatment programs and systems improve care and find a balance between fidelity to standards and the flexibility to meet the needs of patients. This training is essential for leadership to implement the ASAM Criteria and make organizational changes that support its fidelity.
This training teaches the NIATx model for process improvement in conjunction with the ASAM Criteria Implementation Guide as a foundational, straightforward way to implement, improve and sustain fidelity to the ASAM Criteria. Focusing on the NIATx Five Principles, the training provides a science-based foundation for evolving a culture of continuous improvement within the organization, not only for the ASAM Criteria but for any improvement or implementation project, Trauma Informed Care, Motivational Interviewing, CBT, Decreasing “no shows,” EHR, Treatment Plan Quality, Documentation, etc.
This training is an evolution of a Training for Trainers model. It goes beyond the single strategy and frequently ineffective belief that more trainers and training creates change. Although training and local expertise is an important component of implementation, it is commonly the only piece and is typically ineffective for implementation and sustainability.
Dates
This training consists of FIVE 2-hour sessions (one session/week for 5 weeks):
Session 1: March 14 Session 2: March 21 Session 3: March 28 Session 4: April 4 Session 5: April 11
Registration
This event is open to the public. The registration fee is $649.00/person and includes a printable electronic handout and/or an electronic training journal to use as a resource during the training. For more information, please contact: candacel@trainforchange.net or call 1-775-434-1562.
• 2.0 NAADAC Continuing Education Credits (CEs) per session for a total of 10 CEs. • A copy of “The ASAM Criteria Implementation Guide”
Note: Participants must attend all 5 sessions to receive CEs. Full attendance and participation is required in all 5 sessions to receive full credit. Partial credit cannot be issued. Sessions cannot be made up at a later date. ABSOLUTELY NO REFUNDS WILL BE ISSUED IF A SESSION IS MISSED.
Pre-requisites:
• Completion of a 2-day ASAM Criteria Skill Building Training (3rd or 4th Edition) • Possession of the Third or Fourth Edition of the ASAM Criteria (separate purchase) • Competency with ASAM Criteria • Agreement to complete up to 1 hour of out-of-session work between sessions
About the Trainers
Scott Boyles is a licensed addiction counselor, MINT trainer and the Senior National Training Director for Train for Change Inc.® Mr. Boyles has spent more than three decades in the behavioral health field and has many years of experience working with the ASAM Criteria. Mr. Boyles is one of the original early adopters of the ASAM criteria, starting in 1991.Before becoming a full-time trainer, Mr. Boyles used the criteria professionally as a counselor and director. From 2007-2011, Mr. Boyles also served as a member of the ASAM Steering Committee for the ASAM Patient Placement Criteria. He also spent many years as a site reviewer, monitoring programs’ application of the criteria. Mr. Boyles’ experience at all levels of service and observation has enabled him to understand trainees’ needs in both education and application at different levels of the service system. Since 1993, he has trained more than 8,000 people in proper use of the criteria. Mr. Boyles has passion and expertise in system-change approaches to support effective implementation and use of the ASAM criteria. He is well-known for his information, engaging, and entertaining trainings, which include practical, real-world applications.
Mathew Roosa, LCSW-R is a consultant who provides training, coaching, technical assistance and planning support to universities, research studies, governments and health and human service provider organizations. He was a founding member of NIATx, and currently works part time at the UW Madison Center for Health Enhancement Systems Studies (CHESS). Focusing on quality/ process improvement and implementation of evidence based practices, Mr. Roosa’s experience also includes psychotherapy for mental health and substance use in agencies and private practice, teaching at the undergraduate and graduate levels in Human Services and Social Work, agency administration, and governmental planning.
This webinar will provide a brief introduction to the ASAM Criteria Implementation Guide and the new training, “Implementation, Improvement, Sustainability, and Coaching of the ASAM Criteria: A How-to, Science-Based Approach,” offered in partnership with the NIATx Foundation and Train For Change.
Train for Change, a division of The Change Companies, bridges the gap between knowledge of “what works” in addiction treatment and helping providers develop requisite skills in these practices for use in real-world settings.
As one of the largest providers of community-based health services and housing in New York State, Services for the Underserved (S:US) provides services to make sure every New Yorker has a home and can create a life of purpose. S:US values continuous quality improvement and engages in ongoing efforts to improve its services and internal practice.
S:US recently experienced a transition in leadership, including the creation of an Innovation and Quality (I&Q) Team with new staff tasked with working on S:US programs in partnership with senior leadership, program evaluation, and Quality Assurance (QA) Teams. This presented an opportunity to explore alternatives for enhancing the quality of S:US’s services and programs, focusing on the fundamental question: What model would be most effective for orienting the I&Q Team efforts and aligning I&Q with agency priorities?
Solution
S:US reached out to several consultants and organizations to help its quality improvement efforts and contracted with the NIATx Foundation as a consultant who could:
Offer familiarity with S:US’s program types and licensing bodies; and
Provide onsite, hands-on training and coaching.
NIATx worked with S:US to implement the learning collaborative model, focusing on 11 programs covering a wide range of service types (e.g., supportive housing, homeless services, clinic service, Assertive Community Treatment (ACT), care coordination). The learning collaborative approach provided S:US with a variety of methods for sharing innovative ideas to implement positive change.
Using this approach, NIATx consultants provided the following services:
Developed a plan to support the 11 identified programs, as well as the I&Q Team, with the ultimate objective to transfer the tools and implementation of the model from NIATx to the I&Q Team for ongoing sustainment.
Conducted a live meeting with executive leadership to engage and energize executive sponsorship for the I&Q Team’s improvement efforts.
Facilitated a Change Leader Academy (CLA) training with supervisors for the 11 programs to implement a structured, team-based approach to change management.
Engaged in ongoing monthly coaching for the I&Q Team on the NIATx approach and tools (e.g., walkthroughs, flow charts, nominal group technique) and how to effectively coach their 11 sites through the implementation process.
Developed and implemented change projects for the 11 programs.
Conducted a mid-project meeting to assess progress and will follow-up with a final meeting to evaluate lessons learned and celebrate results.
Outcomes
This project has a six-month timeframe. Over the first half of the project, members of the I&Q Team successfully learned the NIATx approach and have supported program use of the NIATx tools to begin implementing change. The program sites were encouraged to define their own improvement projects and to gather feedback from service recipients, according to the NIATx principal of understanding the customer. The nominal group technique has further helped the I&Q Team members and sites identify strategies for implementing these improvements.
As this project progresses, the program sites are beginning to incorporate NIATx’s plan-do-study-act (PDSA) change model, developing baseline data, implementing changes, and measuring the results of their efforts. The sites are clearly motivated to seek measurable improvements that enhance the collective experience of the people they serve.
Patients were coming to Main Street Addiction Recovery Center unvaccinated and uncertain about getting the COVID vaccine. However, news about filling emergency rooms and spread of the Delta variant has caused growing concern. In addition, the Recovery Center is working to keep their patient population safe and build trust that the facility is a protective environment to receive care. To create this safer environment and offer patients an important public health service, Main Street Addiction Recovery Center decided to commence the braided strategy of administering COVID vaccines.
There were two key steps required to implement this braided strategy:
The Center had to apply to become a COVID vaccine provider from the local public health department and secure promotional COVID vaccine materials and doses of the vaccine (once approved).
Workflow needed to be adjusted so patients (and even members of the public) could receive the vaccine without interrupting existing clinical workflows.
Based on NIATx guidance, the Center established a NIATx team to quickly implement the new service. The team completed a NIATx Charter Form, which outlined how the change would be tested and implemented. They developed a flowchart of the new workflow and conducted a patient simulation walkthrough to work out the initial kinks of the service. Once the service was tested on a half-dozen patients, the team reconvened to finalize how the service would be delivered. A private exam room was created off the lobby where patients could get their vaccines, as well as extended release naltrexone injections. The flowchart also included the required steps to receive revenue for the service. Finally, a sustain leader was assigned to the project so the Center can ensure the service continues to work effectively.
Mutually Beneficial Outcomes of Braided Strategies
Patients can conveniently receive a service that could prevent sickness, long-term disability, or even death without having to schedule another appointment, fill out paperwork, etc.
The Recovery Center realizes multiple benefits, including:
Keeping staff safe.
Earning additional (limited) revenue from administering the vaccine.
Preventing lost revenue from patients who have avoided the Recovery Center out of concerns for their safety (a reality during the initial COVID pandemic).
Establishing the Center’s reputation with patients and the public as more than a behavioral health provider.
Of the 140 patients served thus far, there have been zero lost charges and a significant increase in reported patient satisfaction at the ease of getting protection from COVID.
Patients were walking into the Northeast Recovery Center with symptoms of fevers and joint or stomach pain. Over time, the Center often learned that the patients were having symptoms of HIV or HCV (Hepatitis C). Use of alcohol, crack cocaine, meth, poppers (amyl nitrite), opioids, and heroin are all closely associated with incidence of HCV and HIV. Both HCV and HIV significantly compromise the auto-immune system, and HIV left untreated progresses to AIDS, which can be deadly and severely hamper quality of life.
The diminishing health of these patients was very concerning to the Recovery Center, especially as they witnessed how these health conditions impact the individual’s treatment recovery. As a health services provider, Northeast Recovery felt they had an obligation to address these diseases linked to substance misuse.
Mutually Beneficial Outcomes of Braided Strategies
Patients can be tested for HIV and HCV sickness and, if positive, receive health care services that will considerably diminish the impact of these serious diseases. At Northeast Recovery, all patients at intake are now given the chance to opt out of HIV and HCV blood testing.
The Recovery Center realizes multiple benefits, including:
Being able to bill for these two tests and for any HCV/HIV services they provide (or refer patients to their local HCV/HIV specialty provider).
Providing a considerable public health benefit by helping infected individuals learn how to prevent the spread and harmful effects of these diseases.
Developing a mutually beneficial relationship with the local HCV/HIV provider, which has begun providing Northeast with SUD referrals.
The local Emergency Department (ED) is continually calling the Main Street Recovery Center for assistance with overdose patients and currently provides referrals to the Center without any coordination of services. Main Street Recovery wanted to directly address this issue, as did the local ED. The ED first discussed the option of having a peer recovery specialist or even a therapist located at certain times in the ED; however, Main Street and the ED agreed this was too labor intensive. Instead, ED and Main Street decided to have the ED induct eligible patients wanting to begin Suboxone therapy and then provide three-day Suboxone starter kits.
To make this possible, Main Street trained ED staff on how to:
Reduce stigma,
Assess for OUDs,
Assess for Suboxone eligibility, and
Have conversations with patients about Suboxone care and use.
Once a patient is given the first dose and a three-day Suboxone “booster pack,” the patient is given a referral to Main Street and all paperwork is sent to Main Street.
Mutually Beneficial Outcomes of Braided Strategy
ED has a strategy of how to triage patients who present in opioid withdrawal—a strategy they feel reduces return ED visits and even saves lives.
The Recovery Center appreciates the public health benefit and the new patients that are referred from the ED. These patients often have insurance, are adherent to their regimen, and increase treatment group census. Main Street feels this is a great example of how a braided strategy can benefit the patient, the service provider, and the community!
The program has experienced a 92% follow-up rate for referred patients.
Opioid Use Disorder (OUD) is a chronic condition that affects an estimated 2.4 to 5 million Americans. It is also estimated that of the individuals with OUD, only 21% have received any past-year substance abuse treatment, and only 15-20% of those have received Medication for Opioid Use Disorder (MOUD).
The APT Foundation, Inc. (APT) is a Connecticut-based not-for-profit community-based organization that specializes in the treatment of substance use disorders. To address the growing opioid epidemic, APT began using the Network for the Improvement of Addiction Treatment (NIATx) rapid-cycle model to improve treatment access and program outcomes especially wait time to treatment. Since May of 2007, APT has continued to use the NIATx model to sustain results and navigate current treatment challenges associated with COVID-19.
NIATx Approach
The NIATx-informed open-access treatment model uses process improvement strategies to improve treatment access and capacity. Patient waiting time to treatment is a key metric to improve overall patient care and outcomes. Opioid Treatment Programs (OTPs) have traditionally operated under the assumption that a fixed number of individuals can be treated at any given time; when demand for treatment exceeds allocated treatment slots, prospective patients are turned away or assigned to a waiting list. Waiting times of at least one month for methadone maintenance are common in the U.S. These excessive wait times remain a significant barrier to treatment, as they minimize the problem and cause prospective patients to not enter treatment at all.
APT recognized a real need to shift the treatment model and create process efficiencies that provide enough capacity to allow for immediate access to prospective patients. Using the NIATx approach, APT began development and implementation of the open-access model to support this objective in two phases:
Phase 1: APT began using the NIATx rapid-cycle model in May 2007. A walk-through of existing intake procedures identified multiple possible barriers involving wait time and access. The change team initiated a series of related change projects to improve these areas.
Phase 2: In fall 2007, change teams identified barriers to access, retention, and expanding treatment capacity. The development and implementation of key elements of the open-access model occurred during this phase, including walk-in evaluations, same-day treatment initiation, and provision of drop-in groups.
Change projects to address barriers to methadone maintenance access or retention include the following:
Barrier
Change Project
Long waiting time
Walk-in screening, intake, medical screening, and methadone or buprenorphine initiation are available same day, Monday through Friday, if indicated. Physical exams are performed on a walk-in basis and tuberculosis tests are read after admission to eliminate long waiting time.
Financial costs to patients
Eligible patients are admitted irrespective of insurance coverage or ability to self-pay; following admission, patients without insurance are assisted with procurement (e.g., Medicaid).
Counseling
The primary mode of counseling has changed to drop-in groups that allow for more patient flexibility, with individual counseling available, as needed or as requested by the patient.
Dosing & medication
Standardized protocol and procedures have been implemented for methadone dosing and take-home medication eligibility.
Discharge criteria
Administrative discharge criteria have been updated, and patients are discharged only after review by clinical team and approval of CEO confirming safety risk or absence of treatment efficacy.
Outcomes
Through the open-access model, prospective patients are rapidly enrolled in APT’s methadone maintenance treatment—irrespective of ability to pay—and provided real-time access to multiple voluntary treatment options. Based on data collected through routine quality assessment, this open-access model appears to improve treatment access, capacity, and financial sustainability without evidence of deleterious effects on treatment outcomes. Specifically, the following outcomes were realized between the period of July 2006 (pre-model) through June 2015:
Patient census increased by 183%, from 1,431 to 4,051.
Average waiting-time days decreased from 21 to 0.3 (same day) without apparent deleterious effects on rates of retention, non-medical opioid use, or mortality.
Net operating margin rose from 2% to 10%, while state-block grant revenues declined 14%, and the proportion of total revenue from state-block grant revenue decreased from 49% to 24%.
During the first five years of the open-access model, most patients were screened, assessed, and medicated on the same day. Reduced waiting time was achieved partly by shortening delays between initial screening, intake, and admission. Relative to national statistics from 2003 to 2012, when patient census (or treatment capacity) increased only 37%, APT’s census increased 183% over ten years following implementation of the open-access model. The model provides services immediately and offers a potentially important approach for eliminating extant treatment access issues through drop-in counseling that offers more patients access and choice about counseling.
COVID-19 Response
The COVID-19 pandemic has presented complex challenges related to maintaining treatment to respond to increased demand brought on by psycho-social isolation, while reducing transmission of COVID-19. Correspondingly, APT has set important goals of reducing in-person contact between patients and staff and identifying opportunities for social distancing to reduce transmission of COVID-19, while maintaining access to treatment through no wait times and walk-in evaluations.
One of the top NIATx principles to create change is to understand and involve customers. APT’s COVID-19 response has focused largely on understanding patient needs and resources to make individual and aggregate process changes following the NIATx approach. As soon as federal guidance was released on March 16, 2020, APT implemented the following process changes:
Increased the number of doses of take-home medication for stable patients. Of the facility’s 4,500 patients, 2,000 were transitioned to receiving a supply of medication that would last at least 14 days. This huge staff effort has resulted in a highly successful process that has significantly decreased the number of in-person interactions required.
Created a standard medical and COVID-19 safety sheet/checklist. Standard questions are used to measure stress, COVID-19 symptoms, and treatment concerns/status. This allows for data and trend analysis to inform future changes.
Implemented telehealth protocol. Clinicians are conducting regular telephone check-ins with patients, sometimes almost daily depending on the patient’s risk factors and pre-existing conditions. These phone calls also use a standard checklist to help assess trends.
APT has found the changes implemented above to respond to COVID-19 have allowed the facility to continue providing treatment to patients and, in several cases, have improved treatment approaches, particularly for those with access issues. For example, telehealth visits remove barriers to transportation and provide more flexibility for patients in scheduling. APT is still conducting 20-30 walk-in evaluations per week but has the appropriate processes and protocol in place to minimize in-person contact, transition patients to telehealth options once admitted, and reduce COVID-19 transmission.
