Background
Expanding MAT through primary care
Methods
Study design and population
Setting
Project team
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PA Medicaid Managed Care Organizations (MCOs).
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An Implementation Team located within the University of Pittsburgh School of Pharmacy.
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Addiction medicine clinical and educational programs within the UPMC Western Psychiatric Institute and Clinic and the University of Utah.
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Local care management professionals.
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A Project Evaluation Team based at the University of Pittsburgh and University of Utah; comprised of addiction medicine, internal medicine, health policy, and social work faculty and staff.
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Participating primary care practices and the patients which they serve.
Partner roles, site identification, and recruitment
Practice-based MAT delivery model intervention
Screening, care management referral, and assessment
Treatment recommendation and induction
Care management and psychosocial services
PCP clinical support
Financial support
Implementation process
Vision | Leadership | Performance measurement | Internal learning | External learning | Organizational culture/behavior | Organizational structure |
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Develop site-specific vision statement that interfaces with RAMP project implementation vision statement, e.g.: [Name of Primary Care Practice] will increase patient access to MAT and addiction specialty services in [the community] by providing the highest quality MAT services to our patients who suffer from opioid use disorder | Identify system/site decision makers for collaboration and engagement Identify champions to support implementation at each site Provide ongoing support to site/system leaders throughout the implementation process | Develop core set of data components for primary care, care management, and others to collect in the course of delivering the project activities Assist sites in collection of data components, tailoring methods to sites’ capabilities Clean, verify, and report back aggregated data to sites for performance improvement planning | Employ Lean principles to support sites to improve implementation Employ Lean Rules in Use to ensure implementation process/roles are accurately specified Update/improve performance management reports continuously to ensure understanding and identification of needed changes Assign/monitor performance benchmarks to metrics to provide sites and RAMP team targets for implementation efforts | Develop curriculum and training to provide skills/resources to physicians, advanced practice professionals, care management staff, and other involved staff that these professionals and the Implementation Team identify as important Update/modify curriculum and training topics based on site requests/needs, including attainment buprenorphine prescribing waivers | Perform brief organizational health assessments of systems and sites to determine level of implementation difficulty in order to anticipate barriers and required resources to support implementation | Facilitate primary care sites to participate in 1 of 4 MAT models to enhance site engagement/sustainability, which include (1) Site performs all aspects of MAT and patient monitoring (2) Site performs all aspects of MAT, and patient monitoring is referred to community partners (3) Site screens patients for potential MAT need and refer patients to “hubs” for induction and monitoring (4) Site screens patient for MAT need and refers to “hub” for induction, monitoring, and primary care services Implementation model involves “concierge technical assistance,” i.e., ongoing quasi real-time individualized assistance aimed at providing sites what they need when they need it determined via regular communication |
Quality improvement efforts
Outcome evaluation
Measure | Operational definition |
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Supply measures
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Percent of physicians certified to prescribe buprenorphine | Number of physicians on SAMHSA list of buprenorphine or naltrexone prescribers/# Medicaid-participating physicians in county |
Percent of primary care practices delivering MAT | Number of physicians with any prescribing of buprenorphine or naltrexone/# Medicaid-participating physicians in county measured in claims data |
Prevalence measures
| |
OUD diagnoses | OUD ICD-9/ICD-10 code on inpatient, outpatient or professional claims |
Overdose events | Inpatient stays or ED visits with an opioid overdose ICD-9/ICD-10 code |
OUD diagnoses among those with evidence of misuse of prescription opioids | Rate of OUD diagnosis among those with opioid misuse using an algorithm from Sullivan et al. [46] that uses # prescribers, # pharmacies, and # days short- and long-acting opioids |
Utilization measures
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Use of MAT | Any prescription fill for buprenorphine or IM naltrexone among those with OUD |
Use of psychosocial supports | Any visit with a service code for psychosocial support for OUD |
Access to counseling for OUD | Any visit with a service code for counseling regarding psychosocial and pharmacologic treatment options among those with OUD |
Duration of MAT | Number of months with proportion of days covered > 80% |
Access to tele-psychiatry | Any visit with a service code for a tele-psychiatry visit |
Outcome measures
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Likelihood of any and SUD or mental health-related emergency department visit | SUD or mental health ICD-9/ICD-10 code as primary diagnosis for an emergency department visit |
Likelihood of any and SUD or mental health-related inpatient hospitalization | SUD or mental health ICD-9/ICD-10 code as primary diagnosis for an inpatient hospitalization |