Implementation Facilitation as a Model for …Implementation Facilitation as a Strategy for...
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Implementation Facilitation as a Strategy for Expanding Medications for Addiction Treatment
(MAT) in California’s Hub and Spoke System
O C TO B E R 1 7 TH , 2 0 1 9
Presenters: Lauren Caton, Mark McGovern
UCLA Integrated Substance Use Program Collaborators:
Kendall Darfler, Valerie Pierce Antonini, Gloria Miele, Karen Oliver,
Rick Rawson
Consultants: Karen Oliver
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California Opioid Landscape
opioid-related overdose deaths /
100,000 residents (2018)2
Map of California counties with and without Opioid Treatment Programs
(OTP) Data source: Department of Health Care Services (2019)
Many counties with highest overdose rates have
no access to MAT through Opioid Treatment
Programs (OTPs)1
Opioid overdose death rates continue to ↑in CA every year2
1) Darfler et al (2019) 2) CDPH (2019)
5.4 %
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California Hub & Spoke Model
• 18 “Hub” or OTPs (Opioid Treatment
Programs)
• 178 “Spoke” or OBOTs (Office-based Opioid
Treatment)
• Federally Qualified Health Center (FQHCs)
• SUD Treatment
• Health Center
• Hospital
• Private Practice
• OBOTs with few or no patients are in high
overdose death rate counties1: • Few patients - Lassen, Siskiyou, Humboldt
• No OBOTs - Modoc, Del Norte and Yuba
1) Darfler et al (2019)
Availability of Productive Spokes in
Counties with High Overdose Death
Rates (2019)
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Implementation Facilitation as a Strategy
• Pairing experienced local practitioners (DATA 2000 of “X-Waivered” Prescribers) with
prescribers newly implementing a given procedure
• Uses interpersonal relationships to address adoption challenges through tailored problem
solving and support1
• Mental health integration in primary care settings2
• Research utilization among nurse practitioners4
• Significant ↑ in uptake of evidence-based practice in clinical settings facing challenges to
implementation2,3
1) Stetler, 2006 2) Kirchner et al, 2014 3) Ritchie et al, 2017 4) Dougherty, 2010
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Implementation Facilitation Program Goals:
Expand Patient MAT Access
Increase Waivered Prescriber Network in
CA
Provide Prescriber Coaching
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Implementation Facilitation within CA Hub & Spoke
14 active facilitators across the 18 hub “OTPs”
o 6 had prior relationship or work w/ hub
o 8 were matched from the community
Barriers Addressed
o Attitudes & Stigma
o Low provider self-efficacy
o Workflow and resources
o Leadership support
o Lack of expertise for complex cases
o Support for newer prescribers
Data Collection: Quarterly Implementation Facilitation Tracking Forms
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Clinics Engaged through the IF Program (n=34)
13%
26%
35%
26%No Waivered Providers | NoPatients
X-Waivered Providers | NoPatients
X-Waivered Providers | < 4patients
X-Waivered Providers | 5+ patients
34 active clinics
Source: CA H&SS Implementation Facilitation Tracking Forms
From Sept. 2018 to June 2019
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77% growth
since program start
41% growth
since program start246
276291
348
73 8095
129
0
100
200
300
400
Sept 2018 Dec 2018 Mar 2019 June 2019
To
tal #
of w
aiv
ere
d p
rovid
ers
Waivered Prescriber Growth by Engagement
non-IF engaged clinics (n=154) IF-engaged clinics (n=34)
Increased waiver prescriber growth among
IF-engaged clinics compared to non IF-engaged clinics
12%5.4%
19.5%
9.5%18.8%
35.8%
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84% growth
since program start
42% growth
since program start
225
294
404
320
7383 76
134
0
100
200
300
400
Sept 2018 Dec 2018 Mar 2019 June 2019
To
tal #
of p
atie
nt in
itia
tion
s
Patients Initiating Buprenorphine by Engagement Type
non-IF engaged clinics (n=154) IF-engaged clinics (n=34)
Increased growth in patients initiating buprenorphine among
IF-engaged clinics compared to non IF-engaged clinics
30.7%
37.4%
↓8.4%13.6%
76.3%
↓20.8%
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33%
15% 14% 15%
67%
60%50%
40%
20%32%
40%
5% 5% 5%
0%
20%
40%
60%
80%
100%
Sept 2018 Dec 2018 Mar 2019 June 2019
% o
f cl
inic
s in
cat
ego
ry
Clinic Category Growth by non IF-engaged clinics (n=154)
29%
8% 7%13%
71%
46%36%
40%
38%50%
40%
8% 7% 7%
Sept 2018 Dec 2018 Mar 2019 June 2019
Clinic Category Growth by IF-engaged clinics (n=34)
Among spokes with no provider or no patients from onset:
Faster transition to higher patient loads for clinics engaged through the IF
program
Clinic Category
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Implications for Addiction Health Services Field
Successes
↑ support for newer providers
↑ in patient loads for clinics with lower
numbers
Limitations
Lack of mandated facilitation tracking
Low overall clinic engagement
Next Steps
Investigating strong facilitator
components
Increased adoption speed for
evidence-based practices
More tailored approach for adapting
training needs to context
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ReferencesDarfler, K., Urada, D., Sandoval, J., Santos, A., Gregorio, L., Vazquez, E., Caton, L.,
Antonini, V., Hall, E., Joshi, V., Teruya, C. (2019). California State Targeted Response to the Opioid Crisis: 2019 Evaluation Report. Los Angeles, CA: UCLA Integrated Substance Abuse Programs
Dougherty, E. (2010). Facilitation as a role and process in achieving evidence-based practice in nursing: a focused review of concept and meaning. Worldviews Evid Based Nurs. 7(2):76-89.
Kirchner J., Ritchie M., Pitcock J., Parker A., Curran M., Fortney J. (2014). Outcomes of a partnered facilitation strategy to implement primary care-mental health. Journal of General Internal Medicine. 29(54), 904 – 912.
Ritchie M., Parker L., Edlund E., Kirchner J. (2017). Using implementation facilitation to foster clinical practice quality and adherence to evidence in challenged settings: a qualitative study. BMC Health Services Research, 17(1).
Stetler C., Legro W., Rycroft-Malone C., Curran G., Guihan, M. (2006). Role of “external
facilitation” in implementation research findings: A qualitative evaluation of facilitation experiences in the Veterans Health Administration. Implementation Science. 1(1).
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Presentation Contacts
• Mark McGovern | mpmcg@stanford,edu
Stanford University School of Medicine
• Lauren Caton | [email protected]
Stanford University School of Medicine
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Questions?
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Supplemental Slides
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Clinic Engagements* by Activity Type (n=235)
40%
28%
22%
9%Planning
Leading & Managing Change
Monitoring progress & ongoingimplementation
Sustaining Change
*engagements - contact with an active or potential clinic, includes repeated interactions with the same clinic
~70% interactions
focused on early-
stage activities
Source: CA H&SS Implementation Facilitation Tracking Forms
From Sept. 2018 to June 2019
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Breakdown of Spokes by Type
Overall Hub & Spoke System
• Federally Qualified Health
Center (FQHCs) (55%)
• SUD Treatment (30%)
• Health Center (17%)
• Hospital (10%)
• Private Practice (6%)
• Pain Clinic, Behavioral
Health, Telemedicine
Engaged through IF program
• Federally Qualified Health
Center (FQHCs) (31%)
• Health Center (31%)
• SUD Treatment (19%)
• Behavioral Health (6%)
• Telehealth, Private Practice,
Pain Clinic, Hospital
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Tracking Form
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2.82.9
2.4
3.2
2.6
3.2 3.32.9
0
1
2
3
4
5
Sept 2018 Dec 2018 Mar 2019 June 2019
Ave
rage
Un
its
per
Mo
nth
Average indicator per clinic non IF-engaged (n=154)
Waivered Prescribers Patients Initating Buprenorphine
2.73.1
3.74.1
2.7
3.2 3.0
3.6
Sept 2018 Dec 2018 Mar 2019 June 2019
Average indicator per clinic IF-engaged (n=25)
Waivered Prescribers Patients Initating Buprenorphine
14% program growth 50% program growth
11% program growth 34% program growth
Higher average waivered prescribers and patients initiating buprenorphine
per clinic for IF-engaged clinics