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RRP 12-449 – HSR&D Study

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RRP 12-449
Implementing Symptom Monitoring in Substance Use Disorder Specialty Care Programs
Elizabeth V Gifford PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: January 2013 - June 2014

BACKGROUND/RATIONALE:
Promoting symptom monitoring and measurement-based care in SUD treatment programs was given the highest priority among all potential strategic planning goals by the QUERI for SUD Executive Committee and its VHA Operations Partners. Monitoring symptoms to inform treatment decisions is recommended in the VA/DoD Clinical Practice Guideline for Management of SUD and is required by the Office of Mental Health Services (OMHS) Handbook on VHA Programs for Veterans with SUD. The Mental Health Initiative Operating Plan for FY11-FY13 specifies use of the Brief Addiction Monitor (BAM) to accomplish this aim, and OMHS is currently finalizing specifications for a transformational initiative (T-21) metric requiring BAM implementation for symptom monitoring in VHA SUD specialty care programs. In preparation for the FY13 BAM performance measure, the External Peer Review Program (EPRP) is collecting chart data from approximately 100 patients at 22 SUD specialty care programs reporting BAM implementation. This dataset provides an important opportunity to verify and learn from high-performing sites.

OBJECTIVE(S):
Conducting a mixed methods study combining a field study of BAM implementation practices in high and low implementation SUD specialty care programs and a survey of directors and providers on barriers and facilitators to implementation.

Using the Proctor Implementation Outcomes Framework to characterize promising practices for BAM implementation and derive hypotheses for an SDP.

Disseminate promising practices to inform a potential performance metric via CESATE and SUD QUERI activities, and OMHS/OMHO partners.

METHODS:
We collected in-depth data at six high-implementation and two low-implementation programs. Both clinicians and local clinical leadership were interviewed, and site visitors observed clinical and program implementation in situ. Information about the implementation practices and the pathways these programs took relative to their specific contexts, barriers, and facilitators were collected to determine how different approaches worked in different contexts. Data collection was informed by the Proctor Implementation Outcomes Framework to classify practices related to successful implementation outcomes. The interview data is being analyzed to generate hypotheses based on these classifications. The survey has been developed and will be disseminated nationally. Under the direction of OASC, the survey will close by June 9th.

FINDINGS/RESULTS:
All 8 site visits are complete. Site visitors interviewed a total of 64 providers and conducted 17 clinical observations (with at least one at each site). In depth qualitative data analysis is underway. A preliminary look at the data revealed several potential themes at the high-implementing sites. Visitors observed providers with time dedicated to implementation drove higher BAM utilization. High implementation sites had strong program leadership that influenced practices. Providers that regularly use the BAM, had general positive feedback about the utility, and often liked that the BAM was shorter than the ASI. Some high implementing sites monitor their own data or do chart audits to track the programs progress on implementation. More formal qualitative analysis will explore these themes and reveal additional information.

IMPACT:
Study results will (a) provide guidance on promising practices for symptom monitoring implementation in SUD specialty care for our operational partners in OMHS and the Office of Mental Health Operations, (b) provide resources to facilitate local quality improvement and national technical assistance efforts, and (c) generate hypotheses for planned future research on this high-priority topic. The goal of promoting measurement-based care is to improve the quality of treatment for Veterans with SUD.

Practices developed by VHA SUD programs successfully implementing symptom monitoring are likely to be feasible, adaptable, and sustainable for dissemination in other VHA SUD programs. This project will help SUD programs implement symptom monitoring in order to provide effective, efficient, and patient-centered care.

PUBLICATIONS:

Journal Articles

  1. Cucciare MA, Simpson T, Hoggatt KJ, Gifford E, Timko C. Substance use among women veterans: epidemiology to evidence-based treatment. Journal of addictive diseases. 2013 Jan 1; 32(2):119-39.
Conference Presentations

  1. Gifford EV. Implementing Evidence-Based Practices in Substance Abuse Treatment for American Indians/Native Alaskans. Paper presented at: American Indian/Alaska Native Health Joint NIDA Work Group Meeting; 2013 May 16; Bethesda, MD.


DRA: Substance Abuse and Addiction
DRE: Treatment - Observational
Keywords: QUERI Implementation
MeSH Terms: none