Identifying the Physical and Mental Healthcare Needs of Opioid Treatment Program Clients.

Background: Individuals with opioid use disorder (OUD) often have significant medical and behavioral health needs that are unaddressed. Opioid treatment programs (OTP) are uniquely positioned to provide integrated services for OUD, physical and mental health but are underutilized for this purpose. This study aims to describe the physical and mental healthcare needs of OTP clients in order to inform integrated care implementation in OTPs. Method: OTP clients (n = 1261) in an integrated care program in the Bronx borough of New York City were assessed for mental health symptoms (e.g., anxiety, depression), chronic disease indicators (e.g., blood pressure, cholesterol), and general functioning (e.g., capability of managing healthcare needs). Results: Symptoms of anxiety, post-traumatic stress, and depression were common. Self-reported health status and level of functioning were generally poor. Heavy smoking and obesity were the most frequent physical health risks. Other chronic disease indicators (e.g., blood pressure) showed 25-46% may be at risk. Sixty percent had multiple mental health risks and 85% had multiple physical health risks. Older clients had a higher rate of hypertension and diabetes risk than younger clients. Conclusions: Integrated care programs in OTPs must be prepared to address and coordinate care for chronic mental and physical health conditions in addition to OUD.

Together in care: Lessons learned at the intersection of integrated care, quality improvement, and implementation practice in opioid treatment programs.

Background: Integrated care programs that systematically and comprehensively address both behavioral and physical health may improve patient outcomes. However, there are few examples of such programs in addiction treatment settings. This article is a practical implementation report describing the implementation of an integrated care program into two opioid treatment programs (OTPs). Method: Strategies used to implement integrated care into two OTPs included external facilitation, quality improvement (QI) processes, staff training, and an integrated organizational structure. Service, implementation, and client outcomes were examined using qualitative interviews with program staff (n = 16), program enrollment data, and client outcome data (n = 593) on mental health (MH), physical health, and functional indicators. Results: Staff found the program to generally be acceptable and appropriate, but also noted that the new services added to already busy workflows and more staffing were needed to fully reach the program's potential. The program had a high level of penetration (∼60%-70%), enrolling over 1,200 clients. Staff noted difficulties in connecting clients with some services. Client general functioning and MH symptoms improved, and heavy smoking decreased. The organizational structure and QI activities provided a strong foundation for interactive problem-solving and adaptations that were needed during implementation. Conclusions: This article highlights an example of the intersection of QI and implementation practice. Simplified QI processes, consistent post-implementation meetings, and change teams and champions facilitated implementation; however, ongoing training and support, especially related to data are needed. The OTP setting provided a strong foundation to build integrated care, but careful consideration of new workflows and changes in philosophy for staff is necessary.Plain Language Summary: Providing medical and behavioral health treatment services in the same clinic using coordinated treatment teams, also known as integrated care, improves outcomes among those with chronic physical and behavioral health conditions. However, there are few practical examples of implementation of such programs in addiction treatment settings, which are promising, yet underutilized settings for integrated care programs. A multi-sectoral team used quality improvement (QI) and implementation strategies to implement integrated care into two opioid treatment programs (OTPs). The program enrolled over 1,200 clients and client general functioning and mental health (MH) symptoms improved, and heavy smoking decreased. Qualitative interviews provided important information about the barriers, facilitators, and context around implementation of this program. The OTP setting provided a strong foundation to build integrated care, but careful consideration of new workflows and changes in philosophy for staff, as well as ongoing training and supports for staff, are necessary. This project may help to advance the implementation of integrated care in OTPs by identifying barriers and facilitators to implementation, lessons learned, as well as providing a practical example of potentially useful QI and implementation strategies.

A facilitation model for implementing quality improvement practices to enhance outpatient substance use disorder treatment outcomes: a stepped-wedge randomized controlled trial study protocol.

BACKGROUND: The misuse of and addiction to opioids is a national crisis that affects public health as well as social and economic welfare. There is an urgent need for strategies to improve opioid use disorder treatment quality (e.g., 6-month retention). Substance use disorder treatment programs are challenged by limited resources and a workforce that does not have the requisite experience or education in quality improvement methods. The purpose of this study is to test a multicomponent clinic-level intervention designed to aid substance use disorder treatment clinics in implementing quality improvement processes to improve high-priority indicators of treatment quality for opioid use disorder. METHODS: A stepped-wedge randomized controlled trial with 30 outpatient treatment clinics serving approximately 2000 clients with opioid use disorder each year will test whether a clinic-level measurement-driven, quality improvement intervention, called Coaching for Addiction Recovery Enhancement (CARE), improves (a) treatment process quality measures (use of medications for opioid use disorder, in-treatment symptom and therapeutic progress, treatment retention) and (b) recovery outcomes (substance use, health, and healthcare utilization). The CARE intervention will have the following components: (1) staff clinical training and tools, (2) quality improvement and change management training, (3) external facilitation to support implementation and sustainability of quality improvement processes, and (4) an electronic client-reported treatment progress tool to support data-driven decision making and clinic-level quality measurement. The study will utilize multiple sources of data to test study aims, including state administrative data, client-reported survey and treatment progress data, and staff interview and survey data. DISCUSSION: This study will provide the field with a strong test of a multicomponent intervention to improve providers' capacity to make systematic changes tied to quality metrics. The study will also result in training and materials that can be shared widely to increase quality improvement implementation and enhance clinical practice in the substance use disorder treatment system. TRIAL REGISTRATION: Trial # NCT04632238NCT04632238 registered at clinicaltrials.gov on 17 November 2020.