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Seliski N, Madsen T, Eley S, Colosimo J, Engar T, Gordon A, Barnett C, Humiston G, Morsillo T, Stolebarger L, Smid MC, Cochran G. Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol. Addict Sci Clin Pract 2024; 19:63. [PMID: 39228007 PMCID: PMC11369999 DOI: 10.1186/s13722-024-00496-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 08/19/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Opioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study. METHODS This is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement. DISCUSSION Most ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality. TRIAL REGISTRATION ClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 - Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991 .
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Affiliation(s)
- Natasha Seliski
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Suite A, Salt Lake City, UT, 84108, USA.
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, 50 N. Medical Drive, Salt Lake City, UT, 84132, USA
- Wound Care and Hyperbaric Medicine, St. Mark's Hospital, 1200 East 3900 South #G175, Salt Lake City, UT, 8412, USA
| | - Savannah Eley
- Castleview Hospital, 300 N Hospital Drive, Price, UT, 84501, USA
| | | | - Travis Engar
- Castleview Hospital, 300 N Hospital Drive, Price, UT, 84501, USA
| | - Adam Gordon
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | | | - Grace Humiston
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
| | - Taylor Morsillo
- Utah Department of Health and Human Services, 195 North, West, Salt Lake City, UT, 1950, 84116, USA
| | - Laura Stolebarger
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, School of Medicine, University of Utah Health, 30 North 1900 East #2B200, Salt Lake City, UT, 84132, USA
| | - Gerald Cochran
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
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2
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McLeman B, Gauthier P, Lester LS, Homsted F, Gardner V, Moore SK, Joudrey PJ, Saldana L, Cochran G, Harris JP, Hefner K, Chongsi E, Kramer K, Vena A, Ottesen RA, Gallant T, Boggis JS, Rao D, Page M, Cox N, Iandiorio M, Ambaah E, Ghitza U, Fiellin DA, Marsch LA. Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations. Addict Sci Clin Pract 2024; 19:18. [PMID: 38500166 PMCID: PMC10949656 DOI: 10.1186/s13722-024-00452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care. METHODS This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber). DISCUSSION This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes. TRIAL REGISTRATION The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www. CLINICALTRIALS gov/study/NCT05310786?id=NCT05310786&rank=1.
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Affiliation(s)
- Bethany McLeman
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA.
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.
| | - Phoebe Gauthier
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Laurie S Lester
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Vernon Gardner
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
| | - Sarah K Moore
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Paul J Joudrey
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lisa Saldana
- Lighthouse Institute, Chestnut Health Systems, Eugene, OR, USA
| | - Gerald Cochran
- University of Utah, Salt Lake City, UT, USA
- Greater Intermountain Node, NIDA Drug Abuse Treatment Clinical Trials Network, Salt Lake City, UT, USA
| | | | | | | | | | | | | | - Tess Gallant
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Jesse S Boggis
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Deepika Rao
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Nicholas Cox
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | | | - Ekow Ambaah
- Harbor Care Health & Wellness, Nashua, NH, USA
| | - Udi Ghitza
- National Institute on Drug Abuse, North Bethesda, MD, USA
| | - David A Fiellin
- New England Consortium Node, NIDA Drug Abuse Treatment Clinical Trials Network, New Haven, CT, USA
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lisa A Marsch
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
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3
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McCormack RP, Rotrosen J, Gauthier P, D'Onofrio G, Fiellin DA, Marsch LA, Novo P, Liu D, Edelman EJ, Farkas S, Matthews AG, Mulatya C, Salazar D, Wolff J, Knight R, Goodman W, Williams J, Hawk K. Implementing Programs to Initiate Buprenorphine for Opioid Use Disorder Treatment in High-Need, Low-Resource Emergency Departments: A Nonrandomized Controlled Trial. Ann Emerg Med 2023; 82:272-287. [PMID: 37140493 PMCID: PMC10524047 DOI: 10.1016/j.annemergmed.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 05/05/2023]
Abstract
STUDY OBJECTIVE We hypothesized that implementation facilitation would enable us to rapidly and effectively implement emergency department (ED)-initiated buprenorphine programs in rural and urban settings with high-need, limited resources and dissimilar staffing structures. METHODS This multicenter implementation study employed implementation facilitation using a participatory action research approach to develop, introduce, and refine site-specific clinical protocols for ED-initiated buprenorphine and referral in 3 EDs not previously initiating buprenorphine. We assessed feasibility, acceptability, and effectiveness by triangulating mixed-methods formative evaluation data (focus groups/interviews and pre/post surveys involving staff, patients, and stakeholders), patients' medical records, and 30-day outcomes from a purposive sample of 40 buprenorphine-receiving patient-participants who met research eligibility criteria (English-speaking, medically stable, locator information, nonprisoners). We estimated the primary implementation outcome (proportion receiving ED-initiated buprenorphine among candidates) and the main secondary outcome (30-day treatment engagement) using Bayesian methods. RESULTS Within 3 months of initiating the implementation facilitation activities, each site implemented buprenorphine programs. During the 6-month programmatic evaluation, there were 134 ED-buprenorphine candidates among 2,522 encounters involving opioid use. A total of 52 (41.6%) practitioners initiated buprenorphine administration to 112 (85.1%; 95% confidence interval [CI] 79.7% to 90.4%) unique patients. Among 40 enrolled patient-participants, 49.0% (35.6% to 62.5%) were engaged in addiction treatment 30 days later (confirmed); 26 (68.4%) reported attending one or more treatment visits; there was a 4-fold decrease in self-reported overdose events (odds ratio [OR] 4.03; 95% CI 1.27 to 12.75). The ED clinician readiness increased by a median of 5.02 (95% CI: 3.56 to 6.47) from 1.92/10 to 6.95/10 (n(pre)=80, n(post)=83). CONCLUSIONS The implementation facilitation enabled us to effectively implement ED-based buprenorphine programs across heterogeneous ED settings rapidly, which was associated with promising implementation and exploratory patient-level outcomes.
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Affiliation(s)
| | - John Rotrosen
- New York University Grossman School of Medicine, New York, NY
| | | | - Gail D'Onofrio
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - David A Fiellin
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - Lisa A Marsch
- Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Patricia Novo
- New York University Grossman School of Medicine, New York, NY
| | - David Liu
- National Institute on Drug Abuse, Rockville, MD
| | - E Jennifer Edelman
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - Sarah Farkas
- New York University Grossman School of Medicine, New York, NY
| | | | | | | | | | | | | | | | - Kathryn Hawk
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
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4
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Stein BD, Saloner B, Kerber R, Sorbero M, Gordon AJ. Subsequent Buprenorphine Treatment Following Emergency Physician Buprenorphine Prescription Fills: A National Assessment 2019 to 2020. Ann Emerg Med 2022; 79:441-450. [PMID: 35305851 PMCID: PMC9038689 DOI: 10.1016/j.annemergmed.2022.01.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Buprenorphine treatment for opioid use disorder provided in the emergency department with subsequent buprenorphine treatment by community prescribers is associated with improved outcomes, but the frequency with which this occurs is unknown. We examined the rates of subsequent buprenorphine treatment for buprenorphine-naïve individuals filling buprenorphine prescriptions from emergency physicians and initiated buprenorphine treatment and how such rates varied before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS Using pharmacy claims capturing an estimated 92% of prescriptions filled at US retail pharmacies, we identified buprenorphine prescriptions filled between February 1, 2019, and November 30, 2020, written by emergency physicians. In this observational study, we calculated the rate at which patients subsequently filled buprenorphine prescriptions from other nonemergency clinicians, the frequency with which subsequent filled prescriptions were from different types of prescribers, and the changes in the rates of subsequent prescriptions following the declaration of the COVID-19 public health emergency. RESULTS We identified 22,846 prescriptions written by emergency physicians and filled by buprenorphine-naïve patients. They were most commonly paid for by Medicaid and were in metropolitan counties; 28.5% of patients subsequently filled buprenorphine prescriptions written by other clinicians. Adult primary care physicians and advanced practice providers (eg, physician assistants and nurse practitioners) were responsible for most of the subsequent prescriptions. The rates of subsequent prescriptions were 3.5% lower after the COVID-19 public health emergency declaration. CONCLUSION The majority of patients filling buprenorphine prescriptions written by emergency physicians do not subsequently fill prescriptions written by other clinicians, and the rates of subsequent prescriptions were lower after the declaration of the COVID-19 public health emergency. These findings highlight the need for a system of care that improves buprenorphine treatment continuity of care for patients with opioid use disorder from emergency settings to community treatment providers.
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5
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Saxon AJ, Edelman EJ. Introduction to the Special Series: National Drug Abuse Treatment Clinical Trials Network and the Opioid Use Disorder Care Continuum-20 years of research informing practice. Addict Sci Clin Pract 2022; 17:7. [PMID: 35109940 PMCID: PMC8809224 DOI: 10.1186/s13722-022-00291-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S. Columbian Wy., Seattle, WA, 98108, USA.
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Hawk K, McCormack R, Edelman EJ, Coupet E, Toledo N, Gauthier P, Rotrosen J, Chawarski M, Martel S, Owens P, Pantalon MV, O’Connor P, Whiteside LK, Cowan E, Richardson LD, Lyons MS, Rothman R, Marsch L, Fiellin DA, D’Onofrio G. Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder. JAMA Netw Open 2022; 5:e2144955. [PMID: 35076700 PMCID: PMC8790663 DOI: 10.1001/jamanetworkopen.2021.44955] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Emergency departments (EDs) are increasingly initiating treatment for patients with untreated opioid use disorder (OUD) and linking them to ongoing addiction care. To our knowledge, patient perspectives related to their ED visit have not been characterized and may influence their access to and interest in OUD treatment. OBJECTIVE To assess the experiences and perspectives regarding ED-initiated health care and OUD treatment among US patients with untreated OUD seen in the ED. DESIGN, SETTING, AND PARTICIPANTS This qualitative study, conducted as part of 2 studies (Project ED Health and ED-CONNECT), included individuals with untreated OUD who were recruited during an ED visit in EDs at 4 urban academic centers, 1 public safety net hospital, and 1 rural critical access hospital in 5 disparate US regions. Focus groups were conducted between June 2018 and January 2019. MAIN OUTCOMES AND MEASURES Data collection and thematic analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework with evidence (perspectives on ED care), context (ED), and facilitation (what is needed to promote change) elements. RESULTS A total of 31 individuals (mean [SD] age, 43.4 [11.0] years) participated in 6 focus groups. Twenty participants (64.5%) identified as male and most 13 (41.9%) as White; 17 (54.8%) reported being unemployed. Themes related to evidence included patients' experience of stigma and perceived minimization of their pain and medical problems by ED staff. Themes about context included the ED not being seen as a source of OUD treatment initiation and patient readiness to initiate treatment being multifaceted, time sensitive, and related to internal and external patient factors. Themes related to facilitation of improved care of patients with OUD seen in the ED included a need for on-demand treatment and ED staff training. CONCLUSIONS AND RELEVANCE In this qualitative study, patients with OUD reported feeling stigmatized and minimized when accessing care in the ED and identified several opportunities to improve care. The findings suggest that strategies to address stigma, acknowledge and treat pain, and provide ED staff training should be implemented to improve ED care for patients with OUD and enhance access to life-saving treatment.
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Affiliation(s)
- Kathryn Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ryan McCormack
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York
| | - E. Jennifer Edelman
- Yale School of Public Health, New Haven, Connecticut
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nicolle Toledo
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Phoebe Gauthier
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - John Rotrosen
- Department of Psychiatry, NYU Grossman School of Medicine, New York
| | - Marek Chawarski
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Shara Martel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patricia Owens
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael V. Pantalon
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patrick O’Connor
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lauren K. Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Center for Addiction Research, University of Cincinnati, Cincinnati, Ohio
| | - Richard Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lisa Marsch
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David A. Fiellin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
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7
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Kim B, Miller CJ, Ritchie MJ, Smith JL, Kirchner JE, Stolzmann K, Connolly SL, Drummond KL, Bauer MS. Time-motion analysis of external facilitation for implementing the Collaborative Chronic Care Model in general mental health clinics: Use of an interval-based data collection approach. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221086275. [PMID: 37091094 PMCID: PMC9924237 DOI: 10.1177/26334895221086275] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time-motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time-motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time-motion data. Methods: We analyzed EF time-motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4-6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, "a two-week interval") at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation's beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation's beginning, middle, and end differed from the interval data's averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time-motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time-motion data.
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Affiliation(s)
- Bo Kim
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
| | - Christopher J. Miller
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
| | - Mona J. Ritchie
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - Jeffrey L. Smith
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - JoAnn E. Kirchner
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Samantha L. Connolly
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
| | - Karen L. Drummond
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - Mark S. Bauer
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
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