LEARNING COLLABORATIVES implementation support and sustainment strategy FOR MAT

LEARNING COLLABORATIVE STRATEGY FOR TEAMS OR ORGANIZATIONS TO IMPROVE Institute for Healthcare Improvement QI approach Evidence-based method to implement EBPs, improve adherence to guidelines, enhance quality & reduce practice variation (Nadeem et al, Milbank Qt, 2013; Schouten et al, Brit Med J, 2008) Distinct from: A. Didactic training; B. ECHO (practice based learning focused on providers); C. Clinical supervision (practice based learning focused on clinicians); D. Meetings Modality: Face-to-face and teleconference sessions Activities: CME lecture; shared QI data collection and reporting, case presentations; PDSA rapid cycle change techniques, and practice- based problem solving (multi-component strategy) Works best when: Key players attend; group trust and cohesion are established; humility and humor are ubiquitous, and nourishment is provided

VERMONT’S RESPONSE A MODEL FOR THE REST OF THE COUNTRY Openly acknowledged by Governor as public health crisis Design of “HUB” and “SPOKE” model HUB: Specialty care Opioid Treatment Programs (OTPs) for methadone, buprenorphine and naltrexone SPOKE: General Office-based Opioid Treatment (OBOT) practices for buprenorphine and naltrexone Financing and workforce to support practice Activities to expand access and availability--quantity Activities to ensure quality

SERVICES THAT ADDRESS SOCIAL DETERMINANTS PATIENT-CENTERED MEDICAL HOME/NEIGHBORHOOD ADDICTION AS CHRONIC MEDICAL CONDITION Specialty Care OTP Primary Care OBOT PCMH SERVICES THAT ADDRESS SOCIAL DETERMINANTS

LEARNING COLLABORATIVES TO IMPROVE CARE OF PERSONS WITH OPIOID USE DISORDER Emphasis on ACCESS—What about QUALITY? Doing it poorly may be worse than not doing it at all Issues before medical board, patient abandonment, diversion Addiction is a chronic medical condition for which “no one should go in there alone” Partnership between local clinical-scientific leadership team plus content and implementation “experts” Defined CME content, feasible logistics, and doable yet meaningful QI measures that practices could collect & report

Figure 1: CONSORT Flow chart of practices participating in the learning collaborative from 2012 through 2016 Analytic sample Practices completing all sessions Practices participating Cohort OBOT Learning Collaboratives 1 (2012-13) n=12 n=10 2 (2013-14) n=16 n=14 n=13 3 (2014-15) n=18 n=7 4 (2015-16) n=15 n=11 n=6

Figure 2: Percent of patients with a documented opioid use disorder

Figure 3: Percent of unstable patients seen weekly

Figure 4: Percent of patients completing a monthly urine drug screen

Figure 5: Percent of patients for whom the prescription monitoring program was accessed at intake and quarterly

CALIFORNIA H&SS LC APPROACH WORK IN PROGRESS CME TOPICS Evidence for addiction medication in general and specialty health care Assessing patients for appropriateness Addiction medications prescribing practices Treatment response monitoring Team-based care using MAT in general and specialty practice settings The Hub & Spoke Model: Patient Centered Medical Home/Neighborhood QI MEASURES Introduction to QI and PDSA techniques DSM5 Checklist, ASAM3, TNQ Buprenorphine @ 16mg; methadone @ 80 mg OBOT Stability Index; UDS quarterly or more; PDMP admission and quarterly; use of standardized tools; retention rates Patient satisfaction; Team climate; network analysis MOU, ROI forms in place; Vermont Stability Index; Referral and completed linkage rates

CALIFORNIA H&SS LC APPROACH PRACTICE PRESENTATIONS Tap into regional expertise and experience Initiate or deepen connections “Our” patients vs. “yours” or “mine” Use measures to make transparent and define comfort zone for patient transfer (“OPEN TABLE” concept) Expand network through other connections (e.g. Coalitions) Discuss and examine practice policies (e.g. cannabis and/or other substance use, diversion, obstreperous behaviors, beliefs about duration of medication course) Professional peer recovery support group

CALIFORNIA H&SS LC APPROACH TECHNIQUES TO LEVERAGE QI MEASURES

CALIFORNIA H&SS LC APPROACH DETAILS TO FOLLOW Five regional LC cohorts 8-10 face-to-face sessions over 2 years Attendance: Physician, practice administrator, nurse and BHC QI measure collection and reporting Web-based practice policy and workflow information and resource exchange Access to webinars and trainings (UCLA, CSAM, CHCF) Facilitated by Dr. Gloria Miele and UCLA implementation support team

CALIFORNIA H&SS UNPRECEDENTED OPPORTUNITY To save lives and to foster recovery To succeed or fail as care providers To innovate or do more of the same To destroy stigma and discrimination for persons who suffer addiction To bring care of addiction into the “big house” of health care To develop practices, processes and relationships that last--- SUSTAINMENT

MARK McGOVERN PROFESSOR OF PSYCHIATRY AND BEHAVIORAL SCIENCES DIRECTOR, CENTER FOR HEALTH SERVICES AND IMPLEMENTATION RESEARCH DIVISION OF PUBLIC MENTAL HEALTH AND POPULATION SCIENCES MEDICAL DIRECTOR OF BEHAVIORAL HEALTH INTEGRATION DIVISION OF PRIMARY CARE AND POPULATION HEALTH, DEPARTMENT OF MEDICINE STANFORD UNIVERSITY SCHOOL OF MEDICINE 1520 PAGE MILL ROAD, SUITE 158 PALO ALTO, CALIFORNIA 94304 mpmcg@Stanford.edu