Utilizing PRISM and RE-AIM to implement and evaluate the Rural Telementoring Training Center (RTTC) for health care workforce development in rural communities.

Introduction: Amid rural health worker shortages and hospital closures, it is imperative to build and maintain the local workforce. Telementoring (TM) or technology-enabled mentoring, is a tool for improving health care quality and access by increasing workforce capacity and support. The national Rural Telementoring Training Center (RTTC) was developed to compile and disseminate TM best practices by delivering free training, tools, and technical assistance to support the implementation, sustainability, and evaluation of new and current TM programs for rural health workers. This paper details how the Practical, Robust Implementation and Sustainability Model (PRISM) was used to understand the context that shaped implementation as well as how Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) was concurrently applied to frame outcomes. Methods: The RTTC has three implementation strategies: outreach, training and technical assistance (TTA), and a Quality Measure Toolkit. Ongoing periodic reflections with the RTTC team, informed by PRISM, were collected, as were RE-AIM outcomes. Central to this design was the continuous review of incoming data in team meetings to inform programmatic changes by identifying challenges and applying modifications to strategies in real time. Results: Major implementation changes discussed during reflections included providing timely and relevant messaging through various platforms, streamlining and customizing a TTA approach, and offering different options for accessing the Toolkit. The outreach strategy resulted in high Reach across the US, with over 300 organizations contacted. The effectiveness of the RTTC was demonstrated by counts of people engaging with outreach (ex. over 8,300 impressions on LinkedIn), the website (over 6,400 views), and e-bursts (33% open rate). Moreover, there were 32 TTA requests and 70 people accessing the Toolkit. Adoption was demonstrated by 27 people participating in TTA and 14 individuals utilizing the Toolkit. Discussion: The integration of PRISM and RE-AIM frameworks promoted a holistic implementation and evaluation plan. Using PRISM, the RTTC team was able to reflect on the implementation strategies through the lens of contextual factors and make rapid programmatic changes within team meetings. That process resulted in outcomes framed by RE-AIM. The integration of two frameworks in tandem provided an adaptive and comprehensive approach to implementing a large-scale, national program.

Adapting and scaling a single site DEA X-waiver training program to a statewide initiative: Implementing GetWaiveredTX.

OBJECTIVES: To address the critical need for opioid use disorder (OUD) treatment by rapidly planning and implementing a statewide DEA X-waiver training initiative expanding office-based OUD treatment in Texas by: (1) facilitating access to buprenorphine waiver trainings to targeted regions and health care providers across the state; and (2) supporting completion of DEA X-waiver requirements. METHODS: We used a transdisciplinary and theory-driven approach to adapt and rapidly scale up an existing, previously successful DEA X-waiver initiative. Pre-implementation activities included a literature review to identify OUD treatment barriers and demographic analyses to identify high-need areas of the state. We used geospatial mapping methods to identify regions with highest point prevalence of opioid-overdose mortality and low access to a buprenorphine provider. The study team used the Replicating Effective Programs (REP) framework developed by the Centers for Disease Control and Prevention to support implementation of evidence-based practices. RESULTS: In six months, we trained 451 waiver eligible providers, 133 (29%) of whom received waivers by 6 months post-training. Of the 163 (36.1%) providers who completed the post-waiver evaluation, 97% reported that they were satisfied or very satisfied with the training. Our initiative delivered high quality education to providers and increased the number of waiver trainers in Texas from eight to thirteen. CONCLUSIONS: Despite recent changes to the DEA X-waiver process, barriers to treating OUD with buprenorphine remain. Lack of education and experience treating substance use disorders remains a significant factor in limiting clinician comfort in prescribing buprenorphine. The research team successfully adapted a Texas-wide initiative to increase the number of office-based providers eligible to prescribe buprenorphine for OUD from an existing single-site initiative. Attentiveness to barriers pre-implementation and to adaptations during implementation enabled moderate impact across a large network in a short time and facilitated program sustainment.

Confronting challenges to opioid risk mitigation in the U.S. health system: Recommendations from a panel of national experts.

BACKGROUND: Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors. OBJECTIVE: We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S. DESIGN: We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems. PARTICIPANTS: Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated. APPROACH: Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation. KEY RESULTS: Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery. CONCLUSIONS: Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.

Implementing prescription drug monitoring and other clinical decision support for opioid risk mitigation in a military health care setting: a qualitative feasibility study.

Objective: Chronic noncancer pain is a highly prevalent condition among service members returning from deployment overseas. The US Army has a higher rate of opioid misuse than the civilian population. Although most states and many health care systems have implemented prescription drug monitoring programs (PDMPs) or other clinician decision support (CDS) to aid providers in delivering guideline-recommended opioid therapy, similar tools are lacking in military health settings. Materials and Methods: We conducted a pre-implementation feasibility and needs assessment guided by the Promoting Action Research in Health Services framework. Twenty-six semistructured interviews were conducted with providers from a large military health system (MHS) to assess baseline knowledge and practices in opioid risk mitigation and providers' preferences and needs for a military-based PDMP or other CDS. Results: Military health care providers reported complex decision-making around opioid prescribing and monitoring, varied knowledge and use of existing clinical informatics, and concerns about the feasibility of implementing a military-based PDMP in their context. However, providers indicated a need for training and CDS to support opioid risk mitigation for their patients. Discussion: This article describes providers' knowledge and behaviors around opioid risk mitigation in the MHS, and views on the potential usefulness of a military-based PDMP or other CDS. This pre-implementation study provides a model for using qualitative methods to assess feasibility and inform planning and development of CDS in complex health care settings. Conclusion: Military providers were skeptical regarding the feasibility of MHS-based PDMP implementation, but provided important recommendations for CDS to support safe and appropriate opioid prescribing in military health care.