Background
The Sustained Patient-centered Alcohol-related Care (SPARC) trial
Methods/design
Setting
SPARC intervention
Context
Condition | Screen | Assess | Manage |
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SPARC clinical care | |||
Unhealthy alcohol use | DSM-5 AUD Symptom Checklist [59] | • Preventive brief intervention • Shared decision-making: AUD treatment options • AUD medications as indicated • Warm handoffs to LICSWs | |
Other Behavioral Health Integration implemented at same time supported by the SPARC trial | |||
Depression and suicidality | PHQ-2 [86] | • Shared decision-making: depression treatment options • Depression medications as indicated • Crisis response plan • Warm handoffs to LICSWs | |
Cannabis use | DSM-5 DUD Symptom Checklist [59] | • Shared decision-making about treatment options • Warm handoffs to LICSWs | |
Drug use | Single item [91] | DSM-5 DUD Symptom Checklist [59] | • Shared decision-making about treatment options • Prescribe or refer for medications for opioid use disorder • Warm handoffs to LICSWs |
The three SPARC implementation strategies
Partner with a local implementation team • Initial clinic leadership meeting—to schedule meetings and form local implementation team • Initial local implementation team meetings—two 2-h meetings • Weekly 1-h meetings with local implementation team • Monthly meetings with local implementation team and leaders (behavioral health and PC) | |
Trainings • One-hour training for all PC providers and staff together • One-hour PC provider and RN training • One-hour MA training for medical assistants and licensed practical nurses • Learning sessions for PC champions from local implementation teams every 2 weeks by telephone | |
Addressing stigma • Ten-minute white board video reframing alcohol and heath by Dr. Mike Evans [67] • Handout reframing alcohol and health (Additional file 2) |
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During the usual care phase (1 month prior to preparation), the practice coach, PI, and behavioral health leaders have an initial in-person meeting with local clinic leadership to provide an overview of the implementation timeline, guidance for choosing the clinic’s interdisciplinary local implementation team, and set the local meeting schedule. The local implementation team includes an MA, PC provider, and LICSW from each clinic, at a minimum, and if possible a registered nurse (RN), the clinic manager, and the PC clinic medical director.
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The preparation phase begins 2 months before each clinic’s randomly assigned launch date for SPARC clinical care (and Behavioral Health Integration). At the start of the preparation phase, practice coaches have two 2-h meetings to introduce local implementation team members to SPARC clinical care, as well as Behavioral Health Integration generally. The goal of this meeting is to build team cohesiveness and engage team members in sharing how providing integrated behavioral health care will benefit their patients and support the clinic’s mission. Practice coaches and the team also develop a deeper understanding of the clinic’s mission, patients, staff, communication practices, and workflows. Subsequently, coaches meet weekly with the local implementation team for the remainder of the preparation phase while they pilot and iteratively adapt the core workflow to fit with the clinic’s local culture, develop job aids and clinical tools, and make communication plans with the rest of the PC clinic. The coach also teaches quality improvement skills to team members.
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The active implementation phase begins on the randomly assigned day when the clinic is intended to launch SPARC (and Behavioral Health Integration) clinical care. During active implementation, the coach has weekly meetings with the local implementation team for 3 months, and then every other week meetings for the last month. These plan-do-check-adjust (PDCA) meetings use performance feedback data to help teams identify gaps in SPARC and Behavioral Health Integration clinical care and test solutions. One meeting per month is replaced with a larger “PDCA meeting” with local and/or regional leaders and behavioral health partners to increase sustainability by problem-solving larger systemic issues.
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The sustainment phase begins after the 4 months of active implementation have concluded, when clinics are no longer supported by a practice coach. During sustainment, clinics receive monthly performance monitoring and feedback and have quarterly PDCA meetings with Behavioral Health Service leaders.
Methods for evaluating the impact of the SPARC intervention
Study design and sample
Randomization
Quantitative evaluation
Category | Measure | Description |
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Primary outcomes | ||
Prevention | Alcohol Brief Intervention | Indicator for whether a patient had a brief intervention documented in the EHR* on the day of, or in the 14 days following a PC visit, and had a positive alcohol screen on the day of the visit or in the prior 365 days* |
Treatment | Treatment for Newly Diagnosed AUD (NCQA) | Indicator for whether a patient had a new AUD diagnosis* and initiated and engaged in AUD treatment* |
Intermediate outcomes | ||
Prevention | Alcohol screening documented | Indicator for whether a patient had AUDIT-C screening documented in the EHR on the day of the visit or in the prior 365 days |
Prevention | Positive alcohol screen | Indicator for whether a patient screened positive on the AUDIT-C (3–12 women and 4–12 men) |
Prevention | High-positive alcohol screen | Indicator for whether a patient had a high-positive AUDIT-C score (7–12 points) |
Assessment | Assessed for DSM-5 AUD symptoms | Indicator for whether a patient with a high-positive screen completed an AUD Symptom Checklist on the day of the visit or in the prior 365 days |
Identification | Past-year AUD diagnosis | Indicator for whether a patient had an AUD diagnosis defined as an ICD code for an AUD diagnosis per NCQA anywhere in or outside KPWA (e.g. includes claims) on the day of the PC visit or in the prior 365 days |
Identification | New AUD diagnosis | Indicator that a “past-year AUD diagnosis” (defined immediately above) was new on the day of the PC visit, based on no AUD diagnosis in the prior 365 days |
Treatment | Initiation of AUD treatment (NCQA) | Indicator for whether a patient received a “new AUD diagnosis” (defined above) and initiated AUD treatment in the following 14 days, per HEDIS ICD codes |
Treatment | Engagement in AUD treatment (NCQA) | Indicator for whether a patient who initiated AUD treatment (defined above) had another 2 treatment visits in the following 30 days after initiation (“engagement”) per HEDIS ICD codes |
Statistical analysis
Primary analyses compare months before vs. months after the assigned launch date (usual care + preparation phases vs. active implementation + sustainment phases). Secondary analyses a. Usual care vs. active implementation b. Usual care vs. sustainment c. Active implementation vs. sustainment |