QUERI – Quality Enhancement Research Initiative

Facilitated Practice Redesign to Address the Opioid Epidemics

VA Connecticut Healthcare System, New Haven, CT

Overview:

Opioid overdose and the condition that drives it – opioid use disorder (OUD) – are major causes of morbidity and mortality among Veterans and high-priority targets for quality improvement in the VA healthcare system. However, access to effective treatment of opioid use disorder (OUD) —medication-assisted therapy (MAT)—remains limited in the VA New England Healthcare System ( 1). While we know MAT prevents overdose and suicide, as well as medical complications associated with addiction, some facilities are falling short. Therefore, in collaboration with 1 Leadership, the overall goal of this PII start-up project is to deploy implementation facilitation—an evidence-based implementation strategy—to improve the uptake of and adherence to the Stepped Care for OUD model, thereby improving the rates of MAT among Veterans with opioid use disorder (see figure below) at two VA facilities with the lowest proportion of Veterans on MAT: VAMC Manchester, NH and the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA.

Aims

• Apply formative evaluation methods at two implementation sites to further develop the implementation facilitation strategy – and assess its effectiveness in achieving implementation outcomes including:
• Proportion of primary care and mental health providers trained in OUD diagnosis and triage,
• Number of providers certified to prescribe buprenorphine, and
• Availability and uptake of non-pharmacological chronic pain treatment
• Examine the implementation facilitation strategy’s impact on clinical targets as measured by:
  • Change in proportion of Veterans with opioid use disorder on For example, compared to pre-implementation periods, implementation sites will observe a 20% increase in proportion of Veterans with OUD on MAT.
  • Change in length of MAT treatment episodes, as a marker of retention in For example, compared to pre-implementation periods, implementation sites will observe a 20% increase in the mean time patients are in treatment.
  • Prepare a plan for broader dissemination of the implementation facilitation strategy by preliminarily evaluating its costs using budget impact analysis and developing an online implementation toolkit.

Methodology

This PII start-up project will employ well-established formative evaluation methods to evaluate the effectiveness of and drive refinements to our implementation strategy. Additionally, investigators will use an interrupted time series design to assess the impact of their project on important clinical targets, specifically, the proportion of Veterans with OUD on MAT and retention in treatment on MAT. Finally, they will evaluate cost using budget impact analysis and develop a web- based implementation toolkit to serve as an implementation manual for future dissemination.

Expected Impacts

These evaluation and product development efforts will prime successful scale-up and dissemination efforts should the implementation facilitation strategy demonstrate effectiveness.

Principal Investigator: William Becker, MD (William.Becker4@va.gov ); 1 Project Lead: Lisa Lehmann, MD, PhD (Lisa.Lehmann@va.gov ).

Operations Partner(s): I, VA New England Healthcare System