Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review.

Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.

Multi-pilot implementation experiences of patient-centered pathology reports: lessons learned for the advancement of patient-centered tools for cancer decision-making.

PURPOSE: New federal legislation in the United States grants patients expanded access to their medical records, making it critical that medical records information is understandable to patients. Provision of informational summaries significantly increase patient perceptions of patient-centered care and reduce feelings of uncertainty, yet their use for cancer pathology is limited. METHODS: Our team developed and piloted patient-centered versions of pathology reports (PCPRs) for four cancer organ sites: prostate, bladder, breast, and colorectal polyp. The objective of this analysis was to identify common barriers and facilitators to support dissemination of PCPRs in care delivery settings. We analyzed quantitative and qualitative data from pilot PCPR implementations, guided by the RE-AIM framework to explore constructs of reach, effectiveness, adoption, implementation, and maintenance. RESULTS: We present two case studies of PCPR implementation - breast cancer and colorectal polyps-that showcase diverse workflows for pathology reporting. Cross-pilot learnings emphasize the potential for PCPRs to improve patient satisfaction, knowledge, quality of shared decision-making activities, yet several barriers to dissemination exist. CONCLUSION: While there is promise in expanding patient-centered cancer communication tools, more work is needed to expand the technological capacity for PCPRs and connect PCPRs to opportunities to reduce costs, improve quality, and reduce waste in care delivery systems.

Integrating Routine Screening for Opioid Use Disorder into Primary Care Settings: Experiences from a National Cohort of Clinics.

BACKGROUND: The U.S. Preventive Services Task Force recommends routine population-based screening for drug use, yet screening for opioid use disorder (OUD) in primary care occurs rarely, and little is known about barriers primary care teams face. OBJECTIVE: As part of a multisite randomized trial to provide OUD and behavioral health treatment using the Collaborative Care Model, we supported 10 primary care clinics in implementing routine OUD screening and conducted formative evaluation to characterize early implementation experiences. DESIGN: Qualitative formative evaluation. APPROACH: Formative evaluation included taking detailed observation notes at implementation meetings with individual clinics and debriefings with external facilitators. Observation notes were analyzed weekly using a Rapid Assessment Process guided by the Consolidated Framework for Implementation Research, with iterative feedback from the study team. After clinics launched OUD screening, we conducted structured fidelity assessments via group interviews with each site to evaluate clinic experiences with routine OUD screening. Data from observation and structured fidelity assessments were combined into a matrix to compare across clinics and identify cross-cutting barriers and promising implementation strategies. KEY RESULTS: While all clinics had the goal of implementing population-based OUD screening, barriers were experienced across intervention, individual, and clinic setting domains, with compounding effects for telehealth visits. Seven themes emerged characterizing barriers, including (1) challenges identifying who to screen, (2) complexity of the screening tool, (3) staff discomfort and/or hesitancies, (4) workflow barriers that decreased screening follow-up, (5) staffing shortages and turnover, (6) discouragement from low screening yield, and (7) stigma. Promising implementation strategies included utilizing a more universal screening approach, health information technology (HIT), audit and feedback, and repeated staff trainings. CONCLUSIONS: Integrating population-based OUD screening in primary care is challenging but may be made feasible via implementation strategies and tailored practice facilitation that standardize workflows via HIT, decrease stigma, and increase staff confidence regarding OUD.

Program Adaptations to Provide Harm Reduction Services During the COVID-19 Pandemic: A Qualitative Study of Syringe Services Programs in the U.S.

Syringe services programs (SSPs) are essential to preventing injection drug use-related infections and overdose death among people who use drugs (PWUD). The novel coronavirus (COVID-19) pandemic initially impeded SSPs' operations. To effectively support these programs, information is needed regarding SSPs' experiences adapting their services and the challenges posed by COVID-19. We conducted qualitative interviews with leadership and staff from a sample of 31 U.S. SSPs. Respondents discussed urgent concerns including reduced reach of services, suspended HIV/hepatitis C testing, high COVID-19 risk among PWUD, and negative impacts of isolation on overdose and mental health. They also noted opportunities to improve future services for PWUD, including shifting to evidence-based distribution practices and maintaining regulatory changes that increased access to opioid use disorder medications post-pandemic. Findings can inform efforts to support SSPs in restoring and expanding services, and provide insight into SSPs' role in engaging PWUD during the COVID-19 response and future emergencies.

RESUMEN: Los programas de servicios de jeringas (reconocido como SSP en inglés) son esenciales para prevenir las infecciones relacionadas con el consumo de drogas inyectables y la muerte por sobredosis entre las personas que consumen drogas (reconocidos como PWUD en ingles). La nueva pandemia del coronavirus (COVID-19) inicialmente impidió las operaciones de los SSP. Para apoyar eficazmente estos programas, se necesita información sobre las experiencias de los SSP que adaptan sus servicios y los desafíos que plantea COVID-19. Realizamos entrevistas cualitativas con el liderazgo y el personal de una muestra de 31 SSPs de EE.UU. Los encuestados discutieron las preocupaciones urgentes, incluyendo la reducción del alcance de los servicios, la suspensión de las pruebas de VIH/hepatitis C, el alto riesgo de COVID-19 entre la PWUD, y los impactos negativos del aislamiento en las sobredosis y la salud mental. También identificaron las oportunidades de mejorar los servicios futuros para las PWUD, incluyendo el cambio a prácticas de distribución basadas en evidencias y el mantenimiento de cambios regulatorios que aumentaran el acceso a medicamentos para el trastorno por consumo de opiáceos después de la pandemia. La información que se encontró en este estudio se puede utilizar junto los esfuerzos para apoyar a los SSP en la restauración y expansión de los servicios, y proporcionar información sobre el papel de los SSP en la participación de PWUD durante la respuesta covid-19 futuras emergencias.

Empathy as a predictor of peripersonal space: Evidence from the crossmodal congruency task.

To investigate whether individual differences in Empathy predict the characteristics of Peripersonal Space (PPS) representations, we asked participants to complete the IRI questionnaire and a visuo-tactile crossmodal congruency task (CCT) as an index of PPS. In the CCT, they responded to the elevation of a tactile target while ignoring a visual distractor presented at the same (i.e. congruent) or different (i.e. incongruent) elevation. The target-distractor distance was also manipulated in depth, with visual distractors randomly presented at near, middle or far locations (0 cm, 25 cm or 50 cm). The near and middle crossmodal congruency effects (CCE) were inversely related to participants' scores on the Empathic Concern sub-scale (EC). Furthermore, the slope of participants' CCE across locations was related to EC scores, with flatter slopes for higher EC individuals. Thus, higher EC individuals showed reduced visuo-tactile integration responses within PPS and a reduced differentiation between PPS and extra-personal space (EPS).

Qualitative inquiry into perceptions of HIV pre-exposure prophylaxis among people who inject drugs living with hepatitis C in Seattle, WA, USA.

BACKGROUND: The incidence of HIV among persons who inject drugs (PWID) in the USA has been increasing since 2014, signaling the need to identify effective ways to engage PWID in HIV prevention services, namely pre-exposure prophylaxis (PrEP). Yet, the uptake of PrEP in this population is minimal compared to other populations at risk of HIV acquisition. In this work, we sought to explore knowledge, attitudes, and perspectives of PrEP acceptability among PWID. METHODS: In the context of a pilot study to explore the acceptability of pharmacy-based hepatitis C virus (HCV) treatment, we conducted semi-structured interviews (n = 24) and focus groups (n = 4, 16 participants) with people who were living with HCV and reported active injection drug use (≤ 90 days since last use). Participants were asked open-ended questions about their familiarity with and motivation to use PrEP. As part of a sub-analysis focused on PrEP, qualitative data were analyzed using a Rapid Assessment Process, where three coders used structured templates to summarize qualitative data and iteratively reviewed coded templates to identify themes. Participants also completed short quantitative questionnaires regarding drug use history and attitudes toward health concerns. RESULTS: Forty-seven percent of participants expressed having little or no concern regarding HIV acquisition. Targeted analyses focused on HIV prevention identified three themes, which help characterize behavioral determinants of nonadoption. First, knowledge of PrEP was limited among PWID and influenced by infrequent open community discussions around HIV risk. Second, PWID perceived sexual behaviors-but not injection drug use-as a motivator for HIV risk prevention. Finally, PWID identified many individual and environmental barriers that hinder PrEP uptake. CONCLUSION: Among PWID, PrEP is rarely discussed and concerns about the feasibility of using daily PrEP are common. Taken with the prevalent perception that drug use is not a high risk for HIV acquisition, our findings point to opportunities for public health work to target PrEP education to PWID and to leverage other successful interventions for PWID as an opportunity to provide PrEP to this vulnerable population.

Responding to a surge in overdose deaths: perspectives from US syringe services programs.

BACKGROUND: US overdose deaths have reached a record high. Syringe services programs (SSPs) play a critical role in addressing this crisis by providing multiple services to people who use drugs (PWUD) that help prevent overdose death. This study examined the perspectives of leadership and staff from a geographically diverse sample of US SSPs on factors contributing to the overdose surge, their organization's response, and ongoing barriers to preventing overdose death. METHODS: From 2/11/2021 to 4/23/2021, we conducted semi-structured interviews with leadership and staff from 27 SSPs sampled from the North American Syringe Exchange Network directory. Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process. RESULTS: Respondents reported that increased intentional and unintentional fentanyl use (both alone and combined with other substances) was a major driver of the overdose surge. They also described how the COVID-19 pandemic increased solitary drug use and led to abrupt increases in use due to life disruptions and worsened mental health among PWUD. In response to this surge, SSPs have increased naloxone distribution, including providing more doses per person and expanding distribution to people using non-opioid drugs. They are also adapting overdose prevention education to increase awareness of fentanyl risks, including for people using non-opioid drugs. Some are distributing fentanyl test strips, though a few respondents expressed doubts about strips' effectiveness in reducing overdose harms. Some SSPs are expanding education and naloxone training/distribution in the broader community, beyond PWUD and their friends/family. Respondents described several ongoing barriers to preventing overdose death, including not reaching certain groups at risk of overdose (PWUD who do not inject, PWUD experiencing homelessness, and PWUD of color), an inconsistent naloxone supply and lack of access to intranasal naloxone in particular, inadequate funding, underestimates of overdoses, legal/policy barriers, and community stigma. CONCLUSIONS: SSPs remain essential in preventing overdose deaths amid record numbers likely driven by increased fentanyl use and COVID-19-related impacts. These findings can inform efforts to support SSPs in this work. In the face of ongoing barriers, support for SSPs-including increased resources, political support, and community partnership-is urgently needed to address the worsening overdose crisis.

Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care.

BACKGROUND: Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions. OBJECTIVE: We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients. DESIGN: Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination. PARTICIPANTS: Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network. INTERVENTION: Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients. KEY MEASURES: Program evaluation metrics included estimated hospital days saved and program acceptance by care team members. KEY RESULTS: During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment. CONCLUSIONS: Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.

Factor structure and correlates of the Mandarin version of the Managing the Emotions of Others (MEOS) scale.

The English-language version of the Managing the Emotions of Others (MEOS) scale has been found to have a six-factor structure. This includes two pairs (Enhance, Divert and Worsen, Inauthentic) that respectively describe prosocial and non-prosocial interpersonal emotion management, together with an emotional concealment factor (Conceal) and a factor assessing poor self-rated emotional skills. A Mandarin translation of the MEOS was completed by 277 Chinese student participants. Factor analysis indicated a four-factor structure comprising a merged Enhance/Divert factor, together with Worsen, Inauthentic and Conceal factors. The emergence of a different factor structure compared to Western samples may be related to culture-dependent attitudes to emotional expression. The associations of the MEOS factors with Five-Factor model personality, the Dark Triad and trait emotional intelligence (EI) were examined; these were similar to but generally weaker than those found for the English-language version.

Lawton IADL scale in dementia: can item response theory make it more informative?

BACKGROUND: impairment of functional abilities represents a crucial component of dementia diagnosis. Current functional measures rely on the traditional aggregate method of summing raw scores. While this summary score provides a quick representation of a person's ability, it disregards useful information on the item level. OBJECTIVE: to use item response theory (IRT) methods to increase the interpretive power of the Lawton Instrumental Activities of Daily Living (IADL) scale by establishing a hierarchy of item 'difficulty' and 'discrimination'. METHODS: this cross-sectional study applied IRT methods to the analysis of IADL outcomes. Participants were 202 members of the Scottish Dementia Research Interest Register (mean age = 76.39, range = 56-93, SD = 7.89 years) with complete itemised data available. RESULTS: a Mokken scale with good reliability (Molenaar Sijtsama statistic 0.79) was obtained, satisfying the IRT assumption that the items comprise a single unidimensional scale. The eight items in the scale could be placed on a hierarchy of 'difficulty' (H coefficient = 0.55), with 'Shopping' being the most 'difficult' item and 'Telephone use' being the least 'difficult' item. 'Shopping' was the most discriminatory item differentiating well between patients of different levels of ability. CONCLUSIONS: IRT methods are capable of providing more information about functional impairment than a summed score. 'Shopping' and 'Telephone use' were identified as items that reveal key information about a patient's level of ability, and could be useful screening questions for clinicians.

Item response theory analysis of cognitive tests in people with dementia: a systematic review.

BACKGROUND: Performance on psychometric tests is key to diagnosis and monitoring treatment of dementia. Results are often reported as a total score, but there is additional information in individual items of tests which vary in their difficulty and discriminatory value. Item difficulty refers to an ability level at which the probability of responding correctly is 50%. Discrimination is an index of how well an item can differentiate between patients of varying levels of severity. Item response theory (IRT) analysis can use this information to examine and refine measures of cognitive functioning. This systematic review aimed to identify all published literature which had applied IRT to instruments assessing global cognitive function in people with dementia. METHODS: A systematic review was carried out across Medline, Embase, PsychInfo and CINHAL articles. Search terms relating to IRT and dementia were combined to find all IRT analyses of global functioning scales of dementia. RESULTS: Of 384 articles identified four studies met inclusion criteria including a total of 2,920 people with dementia from six centers in two countries. These studies used three cognitive tests (MMSE, ADAS-Cog, BIMCT) and three IRT methods (Item Characteristic Curve analysis, Samejima's graded response model, the 2-Parameter Model). Memory items were most difficult. Naming the date in the MMSE and memory items, specifically word recall, of the ADAS-cog were most discriminatory. CONCLUSIONS: Four published studies were identified which used IRT on global cognitive tests in people with dementia. This technique increased the interpretative power of the cognitive scales, and could be used to provide clinicians with key items from a larger test battery which would have high predictive value. There is need for further studies using IRT in a wider range of tests involving people with dementia of different etiology and severity.

Expressing one's feelings and listening to others increases emotional intelligence: a pilot study of Asian medical students.

BACKGROUND: There has been considerable interest in Emotional Intelligence (EI) in undergraduate medical education, with respect to student selection and admissions, health and well-being and academic performance. EI is a significant component of the physician-patient relationship. The emotional well-being of the physician is, therefore, a significant component in patient care. The aim is to examine the measurement of TEIQue-SF in Asian medical students and to explore how the practice of listening to the feelings of others and expressing one's own feelings influences an individual's EI, set in the context of the emotional well-being of a medical practitioner. METHODS: A group of 183 international undergraduate medical students attended a half-day workshop (WS) about mental-health and well-being. They completed a self-reported measure of EI on three occasions, pre- and post-workshop, and a 1-year follow-up. RESULT: The reliability of TEIQue-SF was high and the reliabilities of its four factors were acceptable. There were strong correlations between the TEIQue-SF and personality traits. A paired t-test indicated significant positive changes after the WS for all students (n=181, p=.014), male students (n=78, p=.015) and non-Japanese students (n=112, p=.007), but a repeated measures analysis showed that one year post-workshop there were significant positive changes for all students (n=55, p=.034), female students (n=31, p=.007), especially Japanese female students (n=13, p=.023). Moreover, 80% of the students reported that they were more attentive listeners, and 60% agreed that they were more confident in dealing with emotional issues, both within themselves and in others, as a result of the workshop. CONCLUSION: This study found the measurement of TEIQue-SF is appropriate and reliable to use for Asian medical students. The mental health workshop was helpful to develop medical students' EI but showed different results for gender and nationality. The immediate impact on the emotional awareness of individuals was particularly significant for male students and the non-Japanese group. The impact over the long term was notable for the significant increase in EI for females and Japanese. Japanese female students were more conscious about emotionality. Emotion-driven communication exercises might strongly influence the development of students' EI over a year.

Prospective randomized pilot study of a novel patient-centered pathology report for colorectal polyps.

Objective: US patients have increased access to their medical records, yet the information is not always understandable. To improve patient understanding, we tested a patient-centered pathology report (PCPR) containing results for recent colon cancer screening or surveillance colonoscopy. Methods: A pilot randomized trial assessed the impact of addition of the PCPR to a standard pathology report on knowledge accuracy, decisional self-efficacy and control, and therapeutic alliance. Results: 55 participants were enrolled; 20 participants in the intervention group and 24 controls completed follow-up. There was no significant difference in polyp knowledge between groups at baseline or 30-days, with similar confidence in understanding their diagnoses, decisional self-efficacy, and therapeutic alliance. Most participants receiving a PCPR felt that it helped them understand their diagnosis better and should always be provided with the standard pathology report. Conclusion: Although patient attitudes toward the PCPR were positive, receiving it did not significantly improve knowledge accuracy or measures of self-efficacy. Further iterations should be explored to communicate key knowledge about colorectal polyp results. Innovation: A stakeholder-driven approach to PCPR development facilitated construction of a personalized document that has potential to increase patient's understanding for their results and needed follow-up.

Integrating Opioid Use Disorder Treatment Into Primary Care Settings.

Importance: Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. Objective: To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. Design, Setting, and Participants: This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Exposure: Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Measures: Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Results: Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. Conclusions and Relevance: The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Syringe Service Program Perspectives on Barriers, Readiness, and Programmatic Needs to Support Rollout of the COVID-19 Vaccine.

BACKGROUND: We explored syringe service program (SSP) perspectives on barriers, readiness, and programmatic needs to support coronavirus disease 2019 (COVID-19) vaccine uptake among people who use drugs. METHODS: We conducted an exploratory qualitative study, leveraging an existing sample of SSPs in the United States. Semistructured, in-depth interviews were conducted with SSP staff between February and April 2021. Interviews were analyzed using a Rapid Assessment Process, an intensive, iterative process that allows for rapid analysis of time-sensitive qualitative data. RESULTS: Twenty-seven SSPs completed a qualitative interview. Many SSP respondents discussed that COVID-19 vaccination was not a priority for their participants because of competing survival priorities, and respondents shared concerns that COVID-19 had deepened participant mistrust of health care. Most SSPs wanted to participate in COVID-19 vaccination efforts; however, they identified needed resources, including adequate space, personnel, and training, to implement successful vaccine programs. CONCLUSIONS: Although SSPs are trusted resources for people who use drugs, many require additional structural and personnel support to address barriers to COVID-19 vaccination among their participants. Funding and supporting SSPs in the provision of COVID-19 prevention education and direct vaccine services should be a top public health priority.

Barriers and facilitators to implementing a Pharmacist, Physician, and Patient Navigator-Collaborative Care Model (PPP-CCM) to treat hepatitis C among people who inject drugs.

BACKGROUND: Direct-acting antivirals (DAAs) offer an unprecedented opportunity to eliminate hepatitis C virus (HCV) infection, yet barriers among people who inject drugs (PWID) remain. Having pharmacists provide care through collaborative drug therapy agreements (CDTAs) offers a promising solution. We developed and piloted a Pharmacist, Physician, and Patient Navigator-Collaborative Care Model (PPP-CCM) which utilized pharmacists to directly deliver HCV care at community organizations serving PWID. We conducted formative evaluation of the PPP-CCM pilot to characterize implementation experiences. METHODS: The PPP-CCM was implemented from November of 2020 through July of 2022. Formative evaluation team members observed implementation-related meetings and conducted multiple site visits, taking detailed fieldnotes. Fieldnotes were iteratively reviewed to identify barriers and facilitators to implementation and used to inform 7 key informant interviews conducted with programmatic staff at the end of the pilot. All data were analyzed using a Rapid Assessment Process (RAP) guided by the Consolidated Framework for Implementation Research (CFIR). The formative evaluation team shared results with program stakeholders (pharmacists, physicians, and other site staff) to verify and expand on learnings. RESULTS: Evaluation of PPP-CCM revealed 5 themes, encompassing all CFIR domains: 1) PPP-CCM was feasible but challenging to deliver efficiently; 2) the pharmacist role and characteristics (e.g., being flexible, available, and patient-centered) were key to PPP-CCM successes; 3) the PPP-CCM team met challenges engaging patients over time, but some team-based strategies helped; 4) community site characteristics (e.g., existing trusting relationships with PWID and physical space that enabled program visibility) were important contributors; and 5) financial barriers may limit PPP-CCM scale-up and sustainability. CONCLUSION: PPP-CCM is a novel and promising approach to HCV care delivery for PWID who may previously lack engagement in traditional care models, but careful attention needs to be paid to financial barriers to ensure scalability and sustainability.

Augmenting systems-level implementation of patient-reported outcomes for depression care through the use of structured analysis and design technique.

Background: Health systems increasingly need to implement complex practice changes such as the routine capture of patient-reported outcome (PRO) measures. Yet, health systems have met challenges when trying to bring practice change to scale across systems at large. While implementation science can guide the evaluation of implementation determinants, teams first need tools to systematically understand and compare workflow activities across practice sites. Structured analysis and design technique (SADT), a system engineering method of workflow modeling, may offer an opportunity to enhance the scalability of implementation evaluation for complex practice change like PROs. Method: We utilized SADT to identify the core workflow activities needed to implement PROs across diverse settings and goals for use, establishing a generalizable PRO workflow diagram. We then used the PRO workflow diagram to guide implementation monitoring and evaluation for a 1-year pilot implementation of the electronic Patient Health Questionnaire-9 (ePHQ). The pilot occurred across multiple clinical settings and for two clinical use cases: depression screening and depression management. Results: SADT identified five activities central to the use of PROs in clinical care: deploying PRO measures, collecting PRO data, tracking PRO completion, reviewing PRO results, and documenting PRO data for future use. During the 1-year pilot, 8,596 patients received the ePHQ for depression screening via the patient portal, of which 1,719 (21%) submitted the ePHQ; 367 patients received the ePHQ for depression management, of which 174 (47%) submitted the ePHQ. We present three case examples of how the SADT PRO workflow diagram augmented implementation monitoring, tailoring, and evaluation activities. Conclusions: Use of a generalizable PRO workflow diagram aided the ability to systematically assess barriers and facilitators to fidelity and identify needed adaptations. The use of SADT offers an opportunity to align systems science and implementation science approaches, augmenting the capacity for health systems to advance system-level implementation. Plain Language Summary: Health systems increasingly need to implement complex practice changes such as the routine capture of patient-reported outcome (PRO) measures. Yet these system-level changes can be challenging to manage given the variability in practice sites and implementation context across the system at large. We utilized a systems engineering method-structured analysis and design technique-to develop a generalizable diagram of PRO workflow that captures five common workflow activities: deploying PRO measures, collecting PRO data, tracking PRO completion, reviewing PRO results, and documenting PRO data for future use. Next, we used the PRO workflow diagram to guide our implementation of PROs for depression care in multiple clinics. Our experience showed that use of a standard workflow diagram supported our implementation evaluation activities in a systematic way. The use of structured analysis and design technique may enhance future implementation efforts in complex health settings.

Health care-seeking experiences for people who inject drugs with hepatitis C: Qualitative explorations of stigma.

INTRODUCTION: People who inject drugs (PWID) have complex health needs and often experience poor health outcomes. For PWID, intersectional experiences of stigma and other social vulnerabilities may influence their experiences navigating medical care. We conducted a targeted subanalysis of qualitative interview data collected to inform development of a community-pharmacist care model for hepatitis C (HCV) among PWID to explore intersectional influences on health care-seeking experiences. METHODS: The study recruited participants from community organizations in Seattle, Washington, and participants were eligible if they reported injection drug use within 3 months and having HCV. Study staff conducted semi-structured interviews and two independent coders transcribed and initially analyzed them using a Rapid Assessment Process, guided by the Consolidated Framework for Implementation Research. Themes emerged regarding intersections of stigma and social vulnerabilities; thus, we conducted a targeted subanalysis guided by Fundamental Cause Theory and Earnshaw et al.'s Stigma Framework. RESULTS: Forty participants (65% male; 47% non-white) reported multiple social vulnerabilities (e.g., regarding unstable housing and food insecurity). Qualitative analysis identified that receiving health care in the context of social vulnerability is challenging and burdensome (Theme 1); health care interactions are fraught with stigma stemming from intersectional vulnerabilities (Theme 2); and the belief that abstaining from drug use is needed to prove worthiness for care (Theme 3). PWID described experiencing multiple social vulnerabilities (e.g., unmet basic needs) that made seeking health care burdensome. Interactions with health care teams further reinforced participants' feelings of shame about their drug use, which influenced how participants expressed their care preferences and felt heard by providers. And as PWID navigated health care, they felt that their status as an active drug user was used to control and sometimes coerce their access to services, discouraging PWID from seeking needed care. CONCLUSIONS: Stigma and social vulnerabilities play a pervasive and intersecting role in the health care-seeking experiences of PWID and negatively impact their ability to navigate and receive care they need. Evidence-based stigma reduction interventions at multiple levels, coupled with person-centered approaches to care delivery, may help to mitigate negative impacts.

Barriers to engaging people who use drugs in harm reduction services during the COVID-19 pandemic: A mixed methods study of syringe services program perspectives.

BACKGROUND: Syringe services programs (SSPs) provide critical evidence-based public health services that decrease harms from drug use for people who use drugs (PWUD). Many SSPs have experienced significant and evolving COVID-19-related disruptions. We aimed to characterize the impacts of COVID-19 on SSP operations in the United States approximately one year into the pandemic. METHODS: Participating sites, selected from a national sample of SSPs, completed a semi-structured interview via teleconference and brief survey evaluating the impacts of COVID-19 on program operations. Data collection explored aspects of program financing, service delivery approaches, linkages to care, and perspectives on engaging PWUD in services one year into the pandemic. Interview data were analyzed qualitatively using Rapid Assessment Process. Survey data were analyzed using descriptive statistics and triangulated with qualitative findings. RESULTS: 27 SSPs completed study-related interviews and surveys between February 2021 - April 2021. One year into the pandemic, SSPs reported continuing to adapt approaches to syringe distribution in response to COVID-19, and identified multiple barriers that hindered their ability to engage program participants in services, including 1) isolation and decreased connectivity with participants, 2) resource restrictions that limit responsiveness to participant needs, 3) reduced capacity to provide on-site HIV/HCV testing and treatment linkages, and 4) changing OUD treatment modalities that were a "double-edged sword" for PWUD. Quantitative survey responses aligned with qualitative findings, highlighting increases in the number of syringes distributed, increases in mobile and home delivery services, and reductions in on-site HIV and HCV testing. CONCLUSION: These data illuminate persistent and cascading risks of isolation, reduced access to services, and limited engagement with program participants that resulted from COVID-19 and continue to create barriers to the delivery of critical harm reduction services. Findings emphasize the need to ensure SSPs have the resources and capacity to adapt to changing public health needs, particularly as the COVID-19 pandemic continues to evolve.