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2023 HSR&D/QUERI National Conference Abstract

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4127 — Clinical Pharmacy Practitioners as Boundary Spanners in Rural Substance Use Disorder Treatment Clinics: An Evaluation

Lead/Presenter: Jane Moeckli,  COIN - Iowa City
All Authors: Moeckli JK (Center for Access & Delivery Research and Evaluation, Veterans Rural Health Resource Center - Iowa City, Iowa City VAHCS), Mohr, DC (Center for Healthcare Organization and Implementation Research, Boston VAHCS, Boston University) Pomales TO (Center for Access & Delivery Research and Evaluation, Veterans Rural Health Resource Center-Iowa City, Iowa City VAHCS) Kleinberg, F (Bedford VAHCS) McDannold, S (Bedford VAHCS) McCullough, M (Center for Healthcare Organization and Implementation Research, Bedford VAHCS, University of Massachusetts, Lowell)

Medications for opioid use disorder (MOUD) and medication assisted treatment (MAT) for alcohol disorder (AUD) are gold standard treatments for substance use disorders (SUD), yet the persistent national shortage of qualified providers to deliver MOUD and MAT limits access. The stakes are high – in a recent study, Veterans who did not receive MOUD had a more than four-fold increase in suicide/overdose death compared to those who did. Rural Veterans are at a deeper disadvantage – in 2018, only 27% of rural-dwelling Veterans received MOUD compared with 34% of urban-dwelling Veterans. The VA Clinical Pharmacy Practice Office (CPPO), in partnership with the Office of Rural Health, extended its Clinical Pharmacist Rural Veteran Access (CRVA) Initiative to embed Clinical Pharmacist Practitioners (CPPs) in rural teams to provide SUD treatment. Our evaluation examined how CPP’s delivered SUD care and managed interprofessional clinical relationships to improve access to MAT for Veterans with AUD and MOUD.

Semi-structured interviews were conducted using MS Teams with the first cohort of CPPs and their interprofessional team members (site champions, psychiatrists, psychologists, and clinical social workers). Interviews addressed program implementation activities, team integration, experiences delivering SUD care to Veterans, and burnout. Through a thematic content analysis of coded transcripts, focusing specifically on structures and processes of SUD care, implementation, and CPP emotional labor with Veteran patients, we examined boundary-spanning activities that impacted delivery of MAT for Veterans.

Fifty-nine participants (31 providers; 15 CPP; 13 champions) across substance use, mental health, primary care, and pain services were interviewed. Boundary spanning is defined as individuals who adopt the role of linking an organization’s internal and external networks and processes of care. We identified 4 types of CPP boundary spanning activities used to enhance SUD care for Veterans: 1) Role communication and relationship building in early implementation to integrate into interprofessional teams; 2) Outreach and education to promote adoption and encourage expansion of SUD services; 3) Care coordination for SUD care and connecting Veterans to primary and specialty care; and 4) Facilitating Veteran connections to mental health through deep listening and non-stigmatizing approaches to SUD care. Boundary spanning work is essential to securing Veterans SUD care, but it is a less visible form of labor. Members of CPPs’ interprofessional teams benefit from yet have limited knowledge of the extent of CPPs’ boundary spanning work.

CPPs participating in interprofessional SUD care do substantial work across units within their organizations to build their practice, promote expansion of SUD services, and coordinate care for rural Veterans, yet the invisibility of this work to their teams and the program funding office raises concerns about job satisfaction and eventual burnout.

Identifying boundary spanning activities highlights how critical CPPs are to SUD care and to supporting their interprofessional care teams. Implementing performance metrics that account for boundary spanning activities would make success of the CRVA-SUD program sustainable.