Research indicates that the duration of continuing care participation following initial substance use disorder (SUD) treatment is important for achieving good treatment outcomes. The Contracts, Prompts, and Reinforcement (CPR) intervention has demonstrated an increase in the duration of participation, resulting in improved treatment outcome. CPR, which has been positively reviewed by the SAMHSA as an evidenced-based treatment, includes behavioral contracting, appointment prompting and social reinforcement of treatment participation and abstinence. The current project was a qualitative pre-implementation study aimed at identifying barriers and facilitators to implementation of CPR and providing the information necessary to undertake a Phase 3 implementation trial.
The guiding implementation model for the current project was Evidence-Based Quality Improvement (EBQI)and the aims and data collection were informed by this model. EBQI is an adaptation of the Plan-Do-Study-Act cycles of Continuous Quality Improvement (CQI) that emphasize empirical evidence and the involvement of clinical and implementation experts (i.e., researchers). Researchers contribute knowledge of the evidence base, as well as materials, procedures, and tools needed for successful implementation. Clinicians and administrators contribute local knowledge needed to tailor the evidence based practice for their own particular needs and organizational capabilities.
The project had the following aims:
Assessment of barriers and facilitating factors for implementation of CPR.
Development of CPR fidelity measures.
Development of a prototypic CPR Tool Kit, including materials for marketing the intervention.
Formative evaluations were conducted with staff from residential SUD treatment programs across 3 sites. Key informant interviews were completed with opinion and program leaders (n = 6) and with a focus group of core clinical staff at each site (n=14). Data were subsequently analyzed using grounded theory, in which data collection, coding, analysis, and interpretation are integrated activities. Through coding for salient categories, we identified constellations of meaningful events, phenomena, processes, beliefs, and activities according to whether these factors were barriers or facilitators to the implementation of CPR.
Fidelity measures were developed for each of the core CPR components. Components determined to be non-critical based on data from the qualitative analysis were excluded. Fidelity Measures were designed to be user-friendly for clinicians and supervisors.
When developing the tool kit, we created a concise and attractive informational brochure to disseminate in print and PDF format. The research-focused treatment manual was rewritten to create a clinically-focused manual with the design and content of the manual shaped by the findings of our qualitative analyses. We also revised the CPR treatment materials to maximize accessibility, flexibility, and utility for clinicians.
We identified recurring factors that were broadly categorized as perceived barriers and facilitators to local implementation of CPR and divided these according to whether they were specific to CPR or were more generic to SUD treatment.
Facilitators - The existence of supportive CPR outcome data was seen by participants as an intervention-specific facilitator. Contracts were generically seen as facilitating positive behavior change, and the contracting portion of CPR was seen as attractive. Additional CPR-specific facilitators were: the inclusion of 12 Step activities in CPR contracting, the immediate reinforcement of incremental recovery accomplishments, the current presence of CPR-like program elements, low implementation costs, and relative ease of required staff training. Generic facilitators included: recognizing the value of drug testing, viewing recovery as a process marked by incremental progress, acceptance of planned reinforcement as a therapeutic intervention, and valuing sustained involvement in continuing care.
Barriers - Perceived barriers to implementation included: staff attitudes (or doctrines) about the nature of those with SUDs (a generic concern) and concern that CPR might coddle clients or allow for manipulation (CPR-specific concerns). Some clinicians saw CPR as too structured and constraining and did not see drug testing as necessary or helpful (generic). Others saw drug testing as impossible or impractical given the specifics of their staffing or their relationship with their laboratory (generic). Others cited program policy aimed at moving Veterans on through continuing care services to make room for newcomers (generic). CPR-specific barriers included the perception that the intervention's reinforcers as impotent or that use of an Honor Roll violates confidentialty. Across data collection sites, both program leaders and line staff, expressed concerns about the staff time it would take to implement CPR, particularly the prompting component.
Based on the findings, we translated the research manual into a clinical manual, focusing on clinical relevance and adaptability. For example, the clinical protocol for Contracting now includes skip rules facilitated in the electronic version through inclusion of hyperlinks. We have included a "Frequently Asked Questions" (FAQ) section that directly addresses concerns raised in our qualitative analyses and offers constructive and proven suggestions. We have edited the original research templates for prompts and certificates to make them customizable and have provided them in print and electronic versions. All materials (i.e., manuals, brochures, sample prompts and reinforcers, and CD) are assembled in a zippered bag with the QUERI name and logo. A model toolkit has been provided to QUERI, one will be provided to each site that participated in this study, and the remainder will be available upon request to interested sites.
CPR has been shown to meaningfully increase Veterans' continuing care attendance and to improve substance use outcomes. Despite this, it is not widely used. The current study prepares us to disseminate CPR widely across SUD treatment programs. With the planning stage of the EBQI approach substantially complete, we can turn our attention to addressing identified barriers to CPR implementation. With knowledge of facilitating factors and a user-friendly tool kit available, we are in a better position to move ahead with broader implementation. Data demonstrate that wider dissemination of CPR will better serve Veterans' needs, and improve a range of relevant program performance and outcome measures.
External Links for this Project
None at this time.