1. LEARNING COLLABORATIVES
implementation support and sustainment strategy FOR MAT

2. 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

4. 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

5. 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

6. 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

7. 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
( )
n=12
n=10 2
( )
n=16
n=14
n=13 3
( )
n=18
n=7 4
( )
n=15
n=11
n=6

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

9. Figure 3: Percent of unstable patients seen weekly

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

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

12. 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
16mg; 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

13. 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

14. CALIFORNIA H&SS LC APPROACH TECHNIQUES TO LEVERAGE QI MEASURES

15. 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

16. 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

17. 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