Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: findings from the SUMMIT study.

BACKGROUND: Millions of people with substance use disorders (SUDs) need, but do not receive, treatment. Delivering SUD treatment in primary care settings could increase access to treatment because most people visit their primary care doctors at least once a year, but evidence-based SUD treatments are underutilized in primary care settings. We used an organizational readiness intervention comprised of a cluster of implementation strategies to prepare a federally qualified health center to deliver SUD screening and evidence-based treatments (extended-release injectable naltrexone (XR-NTX) for alcohol use disorders, buprenorphine/naloxone (BUP/NX) for opioid use disorders and a brief motivational interviewing/cognitive behavioral -based psychotherapy for both disorders). This article reports the effects of the intervention on key implementation outcomes. METHODS: To assess changes in organizational readiness we conducted pre- and post-intervention surveys with prescribing medical providers, behavioral health providers and general clinic staff (N = 69). We report on changes in implementation outcomes: acceptability, perceptions of appropriateness and feasibility, and intention to adopt the evidence-based treatments. We used Wilcoxon signed rank tests to analyze pre- to post-intervention changes. RESULTS: After 18 months, prescribing medical providers agreed more that XR-NTX was easier to use for patients with alcohol use disorders than before the intervention, but their opinions about the effectiveness and ease of use of BUP/NX for patients with opioid use disorders did not improve. Prescribing medical providers also felt more strongly after the intervention that XR-NTX for alcohol use disorders was compatible with current practices. Opinions of general clinic staff about the appropriateness of SUD treatment in primary care improved significantly. CONCLUSIONS: Consistent with implementation theory, we found that an organizational readiness implementation intervention enhanced perceptions in some domains of practice acceptability and appropriateness. Further research will assess whether these factors, which focus on individual staff readiness, change over time and ultimately predict adoption of SUD treatments in primary care.

Dermatologic care in the homeless and underserved populations: observations from the Venice Family Clinic.

Dermatologic care in the homeless and impoverished urban underserved populations is rarely described despite the wide prevalence of skin concerns in this population. Because the homeless population may be subject to increased sun exposure compared to the nonhomeless population, they also may be at increased risk for skin cancer. We sought to describe the spectrum of dermatologic diseases seen in a free clinic in Venice, California--the Venice Family Clinic (VFC)--as well as the differences in diagnoses between the homeless and nonhomeless patients seen at this clinic. A retrospective chart review was performed of dermatology patients (N = 82) seen at VFC throughout the 2006 calendar year. The homeless population (n = 22) was found to have more diagnoses of malignant/premalignant growths (25% [16/64] of all homeless diagnoses) compared to their nonhomeless (n = 60) counterparts (6.1% [8/132] of all nonhomeless diagnoses; P < .0001). This difference was sustained when ethnicity was controlled, with 29.6% [16/54] of diagnoses in the homeless white group consisting of malignant/ premalignant growths compared to 8.9% [4/45] of diagnoses in the nonhomeless white cohort (P < .005). Homeless patients may have a higher incidence of skin cancers and precancerous skin lesions due to increased sun exposure and/or limited access to dermatologic care.

Predictors of treatment initiation for alcohol use disorders in primary care.

BACKGROUND: We identified predictors of receiving treatment (brief therapy [BT] and/or extended-release injectable naltrexone [XR-NTX]) for the treatment of alcohol use disorders (AUDs) in primary care. We also examined the relationship between receiving BT and XR-NTX. METHODS: Secondary data analysis of SUMMIT, a randomized controlled trial of collaborative care. Participants were 290 individuals with AUDs who reported no past 30-day opioid use and who were receiving primary care at a multi-site Federally Qualified Health Center. Bivariate and multivariate analyses examined predictors of BT and/or XR-NTX. RESULTS: Thirty-two percent (N = 93) received either BT or XR-NTX, 28% (N = 82) received BT and 13% (N = 37) received XR-NTX; 9% (N = 26) received both BT and XR-NTX. Older age, white race, talking with a professional about alcohol use and having more negative consequences all predicted receipt of evidence-based treatment; being homeless was a negative predictor. The predictors of receiving BT included not being homeless and previously talking with a professional; the predictors of receiving XR-NTX included older age, white race and experiencing more negative consequences. In 80% of those who received both BT and XR-NTX, receipt of BT preceded XR-NTX. CONCLUSIONS: Patient factors were important predictors of receiving primary-care based AUD treatment and differed by type of treatment received. Receiving BT was associated with subsequent use of XR-NTX and may be associated with a longer duration of XR-NTX treatment. Providers should consider these findings when considering ways to increase primary-care based AUD treatment.

Implementing the Chronic Care Model for Opioid and Alcohol Use Disorders in Primary Care.

BACKGROUND: Effective treatments for opioid and alcohol use disorders (OAUD) are available, yet only a small percentage of those needing treatment receive it. OBJECTIVES: This paper describes a collaborative planning and development process used by researchers and community providers to apply the chronic care model to the delivery of treatment for OAUD in primary care. The goal was to develop and implement an intervention that would support the delivery of brief psychotherapy and medication-assisted treatment (MAT). METHODS: We used focus groups and interviews to identify barriers and facilitators, and organized the results using the chronic care model. We then identified implementation strategies, the intended organizational changes, and the materials necessary to carry out each strategy, and pilot-tested the process. RESULTS AND CONCLUSIONS: We describe the methods and outcomes of the collaborative planning and development process, and discuss implications of the work for the integration of substance use treatment with primary care.

Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial.

Importance: Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD. Objective: To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care. Design, Setting, and Participants: A randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months. Interventions: Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41(11.7) years for the CC group, and 43 (12.2) yearsfor the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals. Main Outcomes and Measures: The primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD. Results: At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P < .001). A higher proportion of CC participants reported abstinence from opioids or alcohol at 6 months (32.8% vs 22.3%); after linear probability model adjustment for covariates (ß = 0.12; 95% CI, 0.01-0.23; P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.7%; adjusted OR, 3.54; 95% CI, 2.02-6.20; P < .001; engagement, 15.5% vs 4.2%; adjusted OR, 5.89; 95% CI, 2.43-14.32; P < .001) as was abstinence from opioids, cocaine, methamphetamines, marijuana, and any alcohol (26.3% vs 15.6%; effect estimate, ß = 0.13; 95% CI, 0.03-0.23; P = .01). Conclusions and Relevance: Among adults with OAUD in primary care, the SUMMIT collaborative care intervention resulted in significantly more access to treatment and abstinence from alcohol and drugs at 6 months, than usual care. Trial Registration: clinicaltrials.gov Identifier: NCT01810159.

An organizational readiness intervention and randomized controlled trial to test strategies for implementing substance use disorder treatment into primary care: SUMMIT study protocol.

BACKGROUND: Millions of people who need treatment for substance use disorders (SUD) do not receive it. Evidence-based practices for treating SUD exist, and some are appropriate for delivery outside of specialty care settings. Primary care is an opportune setting in which to deliver SUD treatment because many individuals see their primary care providers at least once a year. Further, the Patient Protection and Affordable Care Act (PPACA) increases coverage for SUD treatment and is increasing the number of individuals seeking primary care services. In this article, we present the protocol for a study testing the effects of an organizational readiness and service delivery intervention on increasing the uptake of SUD treatment in primary care and on patient outcomes. METHODS/DESIGN: In a randomized controlled trial, we test the combined effects of an organizational readiness intervention consisting of implementation tools and activities and an integrated collaborative care service delivery intervention based on the Chronic Care Model on service system (patient-centered care, utilization of substance use disorder treatment, utilization of health care services and adoption and sustainability of evidence-based practices) and patient (substance use, consequences of use, health and mental health, and satisfaction with care) outcomes. We also use a repeated measures design to test organizational changes throughout the study, such as acceptability, appropriateness and feasibility of the practices to providers, and provider intention to adopt the practices. We use provider focus groups, provider and patient surveys, and administrative data to measure outcomes. DISCUSSION: The present study responds to critical gaps in health care services for people with substance use disorders, including the need for greater access to SUD treatment and greater uptake of evidence-based practices in primary care. We designed a multi-level study that combines implementation tools to increase organizational readiness to adopt and sustain evidence-based practices (EBPs) and tests the effectiveness of a service delivery intervention on service system and patient outcomes related to SUD services. TRIAL REGISTRATION: Current controlled trials: NCT01810159.