Background
Alcohol and opioid use disorders are pervasive public health problems that are frequently under-identified and untreated. An estimated 15.1 million people suffer from an alcohol use disorder in the United States (US) and an estimated 4.8 million misuse opioids [
1]. The consequences of alcohol and opioid use disorders include increased risk of disease, injury, disability, and death [
2,
3]. Furthermore, the societal costs for each of these disorders are estimated to be several billions annually [
4,
5]. Nevertheless, only a small fraction of people in need of treatment for alcohol or opioid misuse access it in any given year [
6]. Research suggests that limited availability, lack of insurance coverage, waitlists, and stigma prevent those in need of specialty substance use treatment from accessing it [
7].
Efforts are underway to integrate substance use disorder treatment into primary care to increase access to treatment for the millions of people who never receive it in specialty care [
8,
9]. Health care coverage changes in the US have supported the provision of behavioral health care in general medical settings [
10,
11]. In addition, treatments for substance use disorders, including medication-assisted treatment for alcohol and opioid use disorders (AOUDs), have been shown to be effective when delivered in primary care settings (e.g., [
12,
13]). Frequently primary care is the first and only contact individuals have with the health care system, and most people visit primary care at least once a year [
14], making the primary care visit an opportunity to reach a population that may otherwise be untreated.
The sustainment of evidence-based practices after implementation support ends is an understudied area in health care. It is an important public health issue, as investments supporting the implementation of evidence-based practices are wasted if they are unable to be sustained following an initial implementation support period [
15]. A review of the literature by Stirman et al. [
16] concluded that the research on health care program sustainability is fragmented and underdeveloped. In general, implementation theories suggest that various external, internal, practice, and process-specific supports are needed for an organization to continue delivering evidence-based treatments after initial support ends (e.g., the Exploration, Preparation, Implementation, Sustainment (EPIS) model and the Consolidated Framework for Implementation Research (CFIR) [
10,
17,
18]). External or “outer setting” supports refer to factors outside of the organization implementing the practice, such as the policy and fiscal environment as well as community support and aspects of the targeted patient population. Internal or “inner setting” supports refer to factors within the organization, such as leadership and staff backing, climate and culture, and internal resources to implement the practice. Also, elements of the evidence-based practice itself, such as its complexity, compatibility, and/or fit within the organization, are thought to impact sustainability. Finally, the process by which the evidence-based practice is adopted and implemented over time has also been identified as critical for continuation.
A growing number of empirical studies on the sustainability of evidence-based behavioral health treatment programs following the end of initial support have been conducted since the Stirman et al.’s [
16] review. In general, the results from these studies are consistent with what implementation theory predicts, that is, factors related to the external, internal, practice and process are relevant to sustainability (e.g., [
19‐
22]). Many studies also suggest that while elements of an evidence-based practice may be sustained, it is typical for some adaptation to occur whereby “partial” rather than “full” sustainment is more likely. For example, Aarons and colleagues [
15,
23] found that many community-based sites continued to deliver a child neglect intervention following an initial implementation support period showing “operational” sustainment. However, the “structural” elements that help ensure quality delivery, such as ongoing coaching and supervision, were discontinued. These findings suggest that although an evidence-based treatment may be continued following the end of initial support, the fidelity may be compromised and inhibit provision of the outcomes achieved under more ideal conditions.
Recent empirical evidence supports the idea that multiple factors may be responsible for the continuation of substance use disorder treatment changes in routine practice settings [
24,
25]. For example, our previous work has shown that four main factors were associated with sustainment: external setting characteristics (including funding stability and community partnerships); inner setting characteristics (including political support, organizational capacity, and clinical supervisor turnover rates); intervention characteristics (such as staff perceptions of the treatment’s complexity, relative advantage, and perceived success); and finally, the implementation process (i.e., the number of staff certified to deliver the treatment during the implementation period) [
24,
25]. However, these studies were conducted in routine substance use treatment programs, not in primary care settings. Several factors unique to primary care could impact the sustainability of substance use disorder treatment. For example, primary care settings are more likely to have a physician on staff, which could positively impact the sustainability of medication-assisted treatment [
26,
27]. However, given the core mission of the primary care setting is general health treatment rather than care for substance use, this could potentially have a negative impact on sustainment of treatment for these conditions. In a related study, Krist and colleagues [
28] examined the adoption and continuation of an electronic substance use screening procedure among nine diverse primary care settings, including federally qualified health centers (FQHCs) in the US. They found that none of the primary care clinics continued the screening procedure as implemented during the research study, but six of the nine settings continued to implement certain elements of the screening. These findings suggest adaptation was necessary and “full sustainment” of the screening procedure delivered during the initial support period was not feasible.
This mixed methods study examines whether the extent to which AOUD treatment was sustained following the end of an implementation intervention in a large FQHC. FQHCs are community health clinics that receive support from the US government to provide primary care and other services to medically underserved populations. The study focused on AOUDs because these disorders are common among primary care patients and because there are effective, FDA-approved medications for use in medical settings [
29‐
35]. More specifically, we examined treatment sustainment by examining AOUD care receipt and medicated-assisted prescribing behaviors over time to examine whether the treatment was continued at levels achieved during the implementation support period. Also, we used staff surveys to assess perceived treatment effectiveness and perceived compatibility, two characteristics theorized to be associated with implementation [
18]. Finally, we conducted staff interviews and focus groups to identify facilitating and inhibiting factors to AOUD treatment sustainment. We anticipated that care would be continued, but that the delivery might be adapted to fit the resources available.
Discussion
In this study, we found that a large FQHC in the US continued to provide AOUD treatment after the end of implementation support. Regarding some elements of care, including care coordination and psychotherapy, organizational capacity increased following the loss of implementation support, suggesting that these aspects had become important components to the organization to maintain over time. Leadership support and the external context appeared to be the main drivers for these findings, given that opportunities were available and the organization applied and successfully received additional financial support to continue these elements after the implementation support ended. Consequently, those additional funds helped to provide staffing to expand services to individuals identified with an AOUD in their clinics. More specifically, the funds allowed the clinic to hire staff to provide care coordination and provide a full spectrum of behavioral treatments, including both group and individual therapy and case management. These additional funds were obtained without the direct assistance of the research team, that is, clinic leadership sought the funding without researcher support. These findings suggest that a multi-year implementation support approach led the FQHC staff to take advantage of changes in the external context that helped increase attention and treatment options available to address AOUDs in their setting.
Regarding staff perceptions, we found that primary care staff were supportive of the concept of providing care for AOUDs in their setting and these perceptions improved over time as the FQHC instituted practices as part of a multi-year implementation support effort. The staff reported that the AOUD treatment had become institutionalized and fit within the clinic’s philosophy and mission to treat the “whole person.” Given that clinic staff had learned how to address substance use, they stated that they did not perceive a reason to discontinue it following the end of implementation support.
However, it is also important to note that sustaining treatment for AOUDs into these primary care settings required adaptation. For example, the clinics modified the care model that reduced staff effort, for example, rather than screen at every visit, the organization shifted to a 6-month screening protocol. There was also suggestion that the structured elements of the AOUD psychotherapy might be discontinued over time which may negatively impact treatment fidelity and ultimately, outcomes. Clinic staff also expressed concern over sustainability, especially around two factors, staff turnover and the provision of medications. More specifically, respondents indicated that although current staff were trained to address substance use disorders, staff turnover could result in a lack of expertise without a plan in place so that new staff had the requisite skills or that the clinic had ongoing access to addiction training. Related to this, we found a slight reduction in the percentage of providers prescribing medications for opiate use, but not for alcohol use. We are unsure whether this reduction in prescribing behaviors for opiate use disorders will result in patient-level access problems because staff reported that patients eligible for opiate use medications may have been referred to prescribing physicians to help manage their care. Also, respondents reported that the medications were expensive and staff were unsure how patients could afford them in the long term. Thus, staff reported that they were not sure they felt comfortable promoting medication-assisted treatment if access to the medications could not be ensured. Of note, recent changes in reimbursement policies for the federally funded health care program (i.e., Medicaid) since this study ended may help to alleviate these concerns; however, these policies can change and may be region-specific making access dependent on local policies.
These findings are consistent with the studies in behavioral health (i.e., mental health and/or substance use) care settings which have found that multiple factors appear critical to the sustainment of evidence-based practice use [
21,
23‐
25]. These studies indicate that a confluence of leadership and staff support are important, along with access to continued resources to maintain the practice under study. The significance of leadership and its impact on organizational culture and climate has been noted previously in the field (e.g., [
44]). This study demonstrated that another vital leadership component is a proactive stance to obtaining external funding to continue practices following the loss of initial implementation support. Specific to the provision of AOUD treatment in primary care, additional training opportunities, especially in light of staff turnover, are an important element for long-term sustainment.
We also have evidence that external policies play an important role in practice sustainment. In this project, funding opportunities were available for the organization to continue to support AOUD care following the intervention period and policy changes that helped sustain access to medication-assisted treatment occurred. If these external factors were not present, it may have been very challenging for the clinic to continue or expand AOUD care, as observed in this study.
For other FQHCs or primary care organizations who may be interested in implementing or sustaining an AOUD program, we learned that ongoing funding and leadership support are critical to ensuring adequate organizational capacity (e.g., trained staff and access to medications) to support care. Implementing and sustaining an AOUD treatment program in primary care requires attention to multiple factors over time, both within and external to the organization, to ensure its longevity. For example, our research suggests that the following are needed: (1) a plan to train or hire staff with AOUD expertise when there is attrition; (2) the development of feasible protocols to identify and refer patients in need of AOUD treatment; and (3) long-term access to evidence-based care (e.g., medications and psychotherapy).
Limitations
A few limitations to our study should be noted. An important component to the continuum of care is screening. Due to changes in screening procedures and to the electronic health record system over the study period, we were not able to capture accurate screening rates to compare across the study time points. The study is also limited in that it examined the experience at only two clinics operated by one FQHC. Results may differ in different settings and circumstances. We also may have missed input from staff that chose not to participate in the data collection activities. We also did not include qualitative information about sustainability planning that may occur in the preparation or implementation phases. Strengths include that we obtained feedback from multiple perspectives within the study setting, including administrative and front-line staff using both quantitative and qualitative approaches which led to rich and in-depth examination about the support needed to continue treatment for substance use disorders in primary care.