Background
Methods
Study setting and participants
Organizational readiness implementation intervention
Process category 1: Plan for change
Strategy 1: Convene a collaborative researcher-clinic implementation team [28, 64]
Strategy 2: Assess barriers and resources and “present state” workflow [65, 66]
Strategy 3: Develop “future state” workflow and clinic-specific implementation protocols [28, 64]
Strategy 4: Select and train “champions” [64]
Process category 2: Educate at all levels
Strategy 5: Training and technical assistance [75‐77]
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All clinic providers, administrators, staff at all levels of the organization, and volunteers (approximately 100 staff members and clinic volunteers): A 30-min “all-staff” kick-off meeting that included an overview provided by the researchers of the significance of incorporating SUD treatment into primary care, a review of how clinic workflow would accommodate SUD treatment (i.e., the “future state” workflow), and a brief informative talk by a local, well-respected local psychologist who specializes in integration of SUD treatment in primary care;
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Prescribing medical providers: XR-NTX training consisting of 2.5 h of training for all prescribing medical providers (physicians, physician assistants, nurse practitioners) provided by an addiction medicine physician (7 participated in training during the first 18-months); “Provider’s Clinical Support System for Medication-Assisted Treatment (PCSS-MAT)” training on BUP/NX, which required completion of a 3.75-h on-line module followed by 4.25 h of in-person training by an addiction medicine physician and receipt of the X-waiver1 for BUP/NX prescribing (7 participated in training during the first 18-months);
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Behavioral health providers: A 1-h overview (8 participated in the first 18 months), plus 16 h of training on the MI/CBT-based brief therapy for licensed clinical social workers (LCSWs), conducted by a psychologist with expertise in MI and CBT (5 participated in the first 18 months).
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SUD care coordinators (2 care coordinators participated): 8 h of training on care coordination and motivational interviewing techniques provided by the researchers and the MI/CBT expert. The two care coordinators in this study were paraprofessionals who also had other responsibilities at the clinic;
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Nurse practitioners and physician assistants (3 and 2, respectively, participated in training during the first 18 months): 1 h of training on administering XR-NTX conducted by an addiction medicine physician;
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Clinic pharmacists and pharmacy technicians (4 and 3, respectively, participated): 1-h of training on medications to be provided to patients and pharmacy procedures for administering XR-NTX (BUP/NX was not provided by the clinic pharmacy), conducted by an addiction medicine physician.
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Medical assistants, call center staff, discharge coordinators: 1 h of training on SUD screening and referral procedures with two booster trainings and individual trainings for volunteers, who also conducted screenings, conducted by research staff.
Process category 3: Restructure delivery systems
Strategy 6: Pre-test protocols using plan-do-study-act (PDSA) cycles, pilot test protocols, complete protocol adaptation
Data collection procedures and measures
Procedures
Measures
Analysis
Results
Participant characteristics
All staff | Medical providers | Behavioral health providers | Non-provider staff | ||||||
---|---|---|---|---|---|---|---|---|---|
N | Missing | Mean/% | N | Mean/% | N | Mean/% | N | Mean/% | |
Age | 66 | 3 | 44.41 | 15 | 45.13 | 8 | 44.50 | 43 | 44.14 |
Female | 56 | 13 | 83.58 | 13 | 86.67 | 5 | 62.50 | 38 | 86.36 |
Highest Education | 2 | ||||||||
< High School/High School | 9 | 13.43 | 0 | 0.00 | 1 | 12.50 | 8 | 18.18 | |
Associates/Bachelor Degree | 13 | 19.40 | 0 | 0.00 | 1 | 12.50 | 12 | 27.27 | |
Doctoral | 13 | 19.40 | 12 | 80.00 | 1 | 12.50 | 0 | 0.00 | |
Masters | 9 | 13.43 | 3 | 20.00 | 5 | 62.50 | 1 | 2.27 | |
Other | 9 | 13.43 | 0 | 0.00 | 0 | 0.00 | 9 | 20.45 | |
Some College | 14 | 20.90 | 0 | 0.00 | 0 | 0.00 | 14 | 31.82 | |
Time at Current Position | 2 | ||||||||
3–10 Years | 19 | 28.36 | 4 | 26.67 | 3 | 37.50 | 12 | 27.27 | |
< 3 Years | 13 | 19.40 | 4 | 26.67 | 1 | 12.50 | 8 | 18.18 | |
> 10 Years | 35 | 52.24 | 7 | 46.67 | 4 | 50.00 | 24 | 54.55 | |
Race/ethnicity | 16 | ||||||||
White | 12 | 22.64 | 9 | 75.00 | 1 | 16.67 | 2 | 5.71 | |
Black | 2 | 3.77 | 1 | 8.33 | 0 | 0 | 1 | 2.86 | |
Asian | 1 | 1.89 | 1 | 8.33 | 0 | 0 | 0 | 0 | |
Hispanic/Latino | 37 | 69.81 | 1 | 8.33 | 5 | 83.33 | 31 | 88.57 | |
Other | 1 | 1.89 | 0 | 0 | 0 | 0 | 1 | 2.86 |
Pre-post organizational readiness intervention results
Acceptability
Pre-Intervention | Post-Intervention | Difference | |||||||
---|---|---|---|---|---|---|---|---|---|
Mean | SD | Range | Mean | SD | Range | Mean | SD |
P-value^
| |
Acceptability | |||||||||
Prescribing Medical Providers
| |||||||||
Ease of Use (Extremely Disagree = 1; Extremely Agree = 7) | |||||||||
Ease of Use of XR-NTX (N = 11)†
| 3.05 | 1.29 | 1–4.5 | 4.77 | 1.23 | 3–7 | 1.73 | 1.69 | 0.012* |
Ease of Use of BUP/NX (N = 9)†
| 2.94 | 1.40 | 1–4.5 | 2.50 | 1.09 | 1–4 | −0.44 | 1.42 | 0.500 |
Effectiveness (Not Effective = 1; Very Effective = 4) | |||||||||
… medical treatments for alcohol use disorders (N = 9) | 2.33 | 0.71 | 1–3 | 3.22 | 0.44 | 3–4 | 0.89 | 0.78 | 0.031 |
… medical treatments for opioid use disorders (N = 9) | 2.44 | 0.73 | 1–3 | 3.00 | 0.5 | 2–4 | 0.56 | 0.73 | 0.125 |
… mental health treatments for alcohol use disorders (N = 10) | 2.90 | 0.74 | 2–4 | 3.20 | 0.42 | 3–4 | 0.30 | 0.67 | 0.193 |
… mental health treatments for opioid use disorders (N = 10) | 2.90 | 0.74 | 2–4 | 3.10 | 0.57 | 2–4 | 0.20 | 0.63 | 0.343 |
Difficulty discussing … (Very Difficult = 1; Not at all Difficult = 4) | |||||||||
… alcohol abuse with your patients (N = 12) | 3.25 | 0.45 | 3–4 | 3.25 | 0.75 | 2–4 | 0.00 | 0.60 | 1.000 |
… opioid abuse with your patients (N = 12) | 2.67 | 0.65 | 2–4 | 3.08 | 0.79 | 2–4 | 0.42 | 1.00 | 0.175 |
Appropriateness | |||||||||
Prescribing Medical Providers
| |||||||||
Compatibility of SUD Treatment with Primary Care (Strongly Disagree = 1; Strongly Agree = 5) | |||||||||
Substance use disorders can be effectively treated in a primary care setting (N = 12) | 3.00 | 0.60 | 2–4 | 4.25 | 0.87 | 2–5 | 1.25 | 0.97 | 0.006* |
Substance use disorders can be effectively treated at [THIS CLINIC] (N = 12) | 2.83 | 0.83 | 1–4 | 3.17 | 0.83 | 2–4 | 0.33 | 0.98 | 0.398 |
Providing medications to patients with alcohol or opioid use disorders fits with [THIS CLINIC’S] mission and goals (N = 12) | 3.17 | 1.19 | 1–5 | 3.17 | 0.83 | 2–4 | 0.00 | 1.21 | 1.000 |
Providing counseling to patients with alcohol or opioid use disorders fits with [THIS CLINIC’S] mission and goals (N = 12) | 4.42 | 0.67 | 3–5 | 3.67 | 0.98 | 2–5 | −0.75 | 0.62 | 0.002* |
Compatibility with Current Practice (Extremely Disagree = 1; Extremely Agree = 7) | |||||||||
Perceived Compatibility of XR-NTX with current practices (N = 11)†
| 3.36 | 1.79 | 1–7 | 4.77 | 1.33 | 2–7 | 1.41 | 1.14 | 0.004* |
Perceived Compatibility of BUP/NX with current practices (N = 8)†
| 3.13 | 2.03 | 1–7 | 2.63 | 1.38 | 1–5 | −0.50 | 1.34 | 0.375 |
General Clinic Staff
| |||||||||
Compatibility of SUD Treatment in Primary Care (Strongly Disagree = 1; Strongly Agree = 5) | |||||||||
Substance use disorders can be effectively treated in a primary care setting (N = 35) | 3.17 | 1.01 | 1–5 | 4.06 | 0.76 | 1–5 | 0.89 | 1.08 | <.0001** |
Substance use disorders can be effectively treated at [THIS CLINIC] (N = 35) | 3.17 | 0.98 | 1–5 | 3.86 | 0.77 | 2–5 | 0.69 | 1.08 | <.0001** |
Providing medications to patients with alcohol or opioid use disorders fits with [THIS CLINIC’S] mission and goals (N = 35) | 2.94 | 0.97 | 1–5 | 3.89 | 0.76 | 2–5 | 0.94 | 1.24 | <.0001** |
Providing counseling to patients with alcohol or opiate use disorders fits with [THIS CLINIC’S] mission and goals. (N = 36) | 3.72 | 0.94 | 1–5 | 3.67 | 1.07 | 2–5 | −0.06 | 1.43 | 0.817 |
Feasibility | |||||||||
Prescribing Medical Providers
| |||||||||
Feel prepared to … (Not at all Prepared = 1; Very prepared = 4) | |||||||||
… identify patients with alcohol use disorders (N = 12) | 3.42 | 0.67 | 2–4 | 3.92 | 0.29 | 3–4 | 0.50 | 0.52 | 0.031 |
… identify patients who are using illegal opiates such as heroin (N = 11) | 3.27 | 0.65 | 2–4 | 3.45 | 0.52 | 3–4 | 0.18 | 0.60 | 0.625 |
… identify patients who are misusing (N = 12)or abusing prescription opioids (N = 12) | 3.00 | 0.60 | 2–4 | 3.33 | 0.65 | 2–4 | 0.33 | 0.49 | 0.125 |
Intent/willingness to adopt ebp | |||||||||
Prescribing Medical Providers
| |||||||||
Perceived demonstrability (Extremely Disagree = 1; Extremely Agree = 7) | |||||||||
… of XR-NTX (N = 11)†
| 4.21 | 1.20 | 1.67–6.33 | 4.85 | 0.91 | 4–7 | 0.64 | 1.11 | 0.086 |
… of BUP/NX (N = 9)†
| 4.11 | 1.28 | 1.67–6.33 | 3.30 | 1.31 | 1–5.33 | −0.81 | 1.11 | 0.058 |
Would consider using in current practice (Extremely Disagree = 1; Extremely Agree = 7) | |||||||||
I would consider using XR-NTX in my practice (N = 11) | 4.09 | 1.87 | 2–7 | 5.55 | 1.13 | 4–7 | 1.45 | 1.81 | 0.037 |
I would consider using BUP/NX in my practice (N = 10) | 3.80 | 1.69 | 2–7 | 4.30 | 2.16 | 1–7 | 0.50 | 1.72 | 0.469 |