ADaPT
ADaPT-OUD
Hildi Hagedorn, PhD and her team have been working with 8 VA sites to increase the use of medications for treating opioid use disorders (OUD). Medication treatment for OUD (M-OUD) is an effective way to manage cravings, withdrawal symptoms and prevent relapse and overdose. It also makes it more likely for patients to stay in treatment for this chronic disease. Yet, less than half of Veterans with an OUD diagnosis are receiving MAT. Dr. Hagedorn’s team worked with VHA facilities interested in increasing access to Veterans with OUD at their facility by using an external facilitation intervention. Six months into the intervention, we’ve learned it takes more than training to make this happen.
Advancing pharmacological treatment for opioid use disorders (AdaPT-OUD): Early implementation barriers, facilitators and progress
BACKGROUND: Within the Veterans Health Administration (VHA), access to medication treatment for opioid use disorder (M-OUD) varies dramatically by facility. The overall study objective is to increase implementation of M-OUD in 8 low adopting VHA facilities using an external facilitation intervention. Here we present results of the developmental evaluation which identified barriers and facilitators to implementation, as well as 6-month progress of the first seven enrolled facilities.
METHODS: Eight VHA sites in the lowest quartile of M-OUD prescribing rates nation-wide were randomly selected to receive the intervention consisting of a developmental evaluation, a site visit and 12 months of external facilitation. Each site was matched to other low adopter control sites. The developmental evaluation consisted of qualitative interviews with 10 leaders and clinical staff from each site. Interview transcripts were rapidly analyzed using matrices to identify barriers and facilitators using i-PARIHS constructs. At each site visit, the facilitators worked with the site team to create their own action plan to improve access at their site. Facilitation efforts included monthly facilitation calls, quarterly reports tracking progress, cross-site collaboration calls and newsletters. Sites were also encouraged to contact facilitators as needed. The seven sites enrolled for 6+ months were compared to their control sites on percent of patients with OUD receiving M-OUD at 6 months post-intervention kick-off.
FINDINGS: Perceptions of the innovation (M-OUD) were not a common barrier; however, occasionally M-OUD did not fit with providers’ existing values regarding OUD treatment. Recipients (providers) did not have adequate training in M-OUD, had misconceptions about OUD and its treatment, and did not feel they could prescribe without ample ancillary staff support. Implementation of M-OUD outside of substance use disorder specialty care did not fit with the existing clinical context, e.g., siloed care, lack of fully functional interdisciplinary teams. Facilitators include leadership support, the strong national emphasis on the opioid epidemic and on-site clinical expertise. All seven sites showed increases in percent of patients with OUD receiving M-OUD (mean increase = 6.81% range: 3.35- 9.9%) outperforming many control sites (mean increase = 6.66%; range: -0.91 – 28.54%).
IMPLICATIONS: Preliminary results support the effectiveness of the external facilitation intervention. While initial training and education appear to be essential ingredients to promote readiness of the recipients to consider adoption, addressing contextual issues unique to each site related to policies, clinic structures, and cross-clinic communication are required for successful implementation.
PUBLICATIONS/PRESENTATIONS:
1.Hagedorn H, Kenny M, Gordon AJ, Ackland PE, Noorbaloochi S, Yu W, Harris AHS. Advancing pharmacological treatments for opioid use disorder (ADaPT-OUD): protocol for testing a novel strategy to improve implementation of medication-assisted treatment for veterans with opioid use disorders in low-performing facilities. Addiction science & clinical practice. 2018 Dec 13; 13(1):25.
2. Valenstein-Mah, H., Hagedorn, H., Kay, C.L., Christopher, M.L., & Gordon, A.J. (2018). Underutilization of the current clinical capacity to provide buprenorphine treatment for opioid use disorders within the Veterans Health Administration. Substance Abuse. 39(3): 286-288. DOI: 10.1080/08897077.2018.1509251.
3. Hagedorn, H., (2019, November). Advancing Pharmacological Treatments for Opioid Use Disorders (AdaPT-OUD): Early Implementation Barriers, Facilitators and Progress. Cyberseminar presented to the VHA QUERI Implementation Research Group.
4.Hagedorn, H., (2019, October). Advancing Pharmacological Treatments for Opioid Use Disorder (AdaPT-OUD): Early Implementation Barriers, Facilitators and Progress. Cyberseminar presented to the VHA QUERI Implementation Facilitation Learning Collaborative.
5.Hagedorn HJ, Kenny ME, Ackland P, Salameh H, Gordon AJ. (October, 2019). Advancing pharmacological treatment for opioid use disorders (AdaPT-OUD): Barriers and facilitators during early implementation. Paper presented at Addiction Health Services Research Annual Conference, Park City, UT.
6.Hagedorn HJ, Kenny ME, Clothier B, Bangerter A, Noorbaloochi S, Gordon AJ. (October, 2019). Advancing pharmacological treatment for opioid use disorders (AdaPT-OUD): Implementation phase. Paper presented at Addiction Health Services Research, Park City, UT.
7.Hagedorn HJ, Kenny ME, Clothier B, Bangerter A, Noorbaloochi S, Gordon AJ. (October, 2019). Advancing pharmacological treatment for opioid use disorders (AdaPT-OUD): Implementation phase. Paper presented at VHA Health Services Research & Development/Quality Enhancement Research Initiative National Conference, Washington, DC.
8.Valenstein-Mah, H, Hagedorn, H., Kay, C. L., Gordon, A. J. (2018, October). Buprenorphine treatment for Opioid Use Disorders within the Veterans Health Administration. Paper presented at Addiction Health Services Research, Savannah, GA.
AUTHOR/FUNDING INFORMATION: This study was funded by HSR&D (IIR 16-145). Led by Hildi J. Hagedorn, Minneapolis VA Health Care System and University of Minnesota School of Medicine, Adam J. Gordon, University of Utah School of Medicine, VA Salt Lake City Health Care System, with support of Marie Kenny, Princess Ackland, Hope Salameh, Barbara Clothier, Ann Bangerter, and Siamak Noorbaloochi from the Minneapolis VA Health Care System and Matthew Dungan from the Salt Lake City VA Health Care System.
