Todd D. Molfenter, Ph.D. - US grants

DESCRIPTION (provided by applicant): A team of researchers from the University of Wisconsin-Madison College of Engineering and Oregon Health & Science University will test whether clinician training and the use of organizational change strategies are sufficient for disseminating an evidence-based practice (EBP), or if changes to both organizational systems and payer policy result in greater EBP use. Demonstrating the role of payment policy as a driver in the adoption of evidence-based practices could provide a contribution to dissemination and implementation science. This study will employ an intervention that was developed through the Robert Wood Johnson Foundation-funded Advancing Recovery (AR) program. In AR, payer/treatment organization partnerships in 12 states collaborated to remove systemic barriers to the adoption of EBPs such as medication-assisted treatment for substance abuse disorders. The resulting AR Framework of payer and organizational change strategies will be tested against its ability to increase the use of the addiction medication buprenorphine as compared to organizational change strategies alone. Buprenorphine is an EBP for treating people addicted to heroin or opioid-based pain medications for non-medical use. Buprenorphine has experienced low adoption rates and is not a standard part of addiction treatment. In Ohio, the location of the study, deaths to due to accidental opioid overdoses have increased by 304% over the past decade and surpassed auto accidents as the leading cause of accidental deaths in 2006. Ohio was selected for the study because of the public health significance of opioid abuse and because each county in Ohio acts as a stand-alone payer, offering 48 unique eligible payer environments. This trial will develop a deeper understanding of the role payers and treatment organizations play in implementing and disseminating EBPs and will focus on the public health issue of rising opioid abuse. PUBLIC HEALTH RELEVANCE: This trial will study the impact of Ohio counties (payers) and addiction treatment organizations working in partnership to remove systemic barriers to adoption of the evidence-based practice (EBP) buprenorphine, a medication for opioid dependence. While various implementation strategies have targeted clinicians and/or treatment provider organizations, we believe this to be among the first controlled studies to systematically study the impact payer and provider strategies have on the implementation and dissemination of an EBP.

? DESCRIPTION: A team of researchers from the Center for Health Enhancement System Studies (CHESS) at the University of Wisconsin-Madison College of Engineering will test the ability of a bundle of practices to increase physician capacity to prescribe buprenorphine for opioid misuse disorders in addiction treatment organizations. Overdoses, largely due to prescription and non-prescription opioids, are now the leading cause of accidental death in the United States. Buprenorphine pharmacotherapy is a promising evidence-based practice for treating opioid dependence in the specialty addiction treatment centers that provide 88% of opioid addiction treatment care. However, only 17% of these centers provide buprenorphine pharmacotherapy; the leading cause for not using this therapy is the lack of certified physician prescribers. Traditional physician recruitment practices have not been effective in the addiction treatment field, leading to a shortage of physicians in the addiction treatment workforce. This study will test, to our knowledge for the first time, a physician recruitment intervention called te Physician Recruitment Bundle (PRB). This bundle of practices was developed and field- tested in a buprenorphine implementation trial of n=40 organizations and resulted in improvements in physician prescribing capacity of 43.4-100% within organizations. The PRB includes proven physician recruiting practices and relies on the evidence-based NIATx organizational change model to implement the bundle elements. An eligibility determination phase for this 4-state (FL, MS, OH, & WI) trial will identify 20 addiction treatment programs per state that need to increase buprenorphine prescribing capacity. This should not be difficult, since a recent representative survey of addiction treatment organizations indicated 33% sought more buprenorphine prescribing capacity. The project will have two arms: 1) PRB bundle implemented with the NIATx model; and 2) treatment as usual (control). Organizations will be segmented by state, with 20 organizations per state, 10 per arm, for a total of 80 organizations. The mixed methods design will measure the ability of the PRB framework to influence a) the number of buprenorphine prescribing slots available to the organization by recruiting more physicians; and 2) organizational factors known to be related to successful physician recruiting. The qualitative methods will complement the quantitative methods by understanding what factors impact physician recruitment and the context and processes used to influence PRB adoption. This trial addresses a structural barrier to buprenorphine therapy: lack of buprenorphine prescribing capacity. By increasing access to buprenorphine pharmacotherapy capable of reducing the morbidity and mortality of opioid addiction, this trial could have significant public health impact on the opioid misuse epidemic. Should the PRB be successful, it could be used to recruit physicians to medically underserved areas or other areas where physician shortages exist.

Project Summary/Abstract A team of researchers from the Center for Health Enhancement Systems Studies (the Center) at University of Wisconsin?Madison College of Engineering and Marquette University School of Dentistry will test the effectiveness of an implementation science intervention called the NIATx Organizational Change Model (the NIATx model) in a multi-site study attempting to reduce dental appointment no-show rates. Our trial will be among the first RCTs to test a planned organizational strategy for instituting organizational change in dentistry. The NIATx model includes understanding and involving customers, flexibility to adapt, sensitivity to regulatory and payment considerations, just-in-time coaching, and leadership engagement within a multi-clinic learning community. We hypothesize that the NIATx model in dentistry will decrease appointment no-show rates as compared to the training alone approach that typically accompanies organizational changes in dentistry. The NIATx model has been applied in more than 3,300 organizations but has not yet been applied in or designed for dentistry. The systems engineering principles embedded in the NIATx model will attempt to reduce no- shows through the use of six evidence-based no-show practices in a two-arm trial (Arm 1 = Training Alone in the six targeted no-show practices & Arm 2 = NIATx + Training). The proposed study will measure the impact of the study arms on no-show rates in n=64 dental clinics (n=32 per arm) serving underserved populations in Illinois, New Mexico, Texas, and Wisconsin. We seek to understand whether the NIATx organizational intervention works (Aim 1) and specifically what organizational and no-show practices work best (Aim 2). We will conduct a staff debriefing to understand what helped or hindered organizational implementation of NIATx (Aim 3) and will then seek to quantify the magnitude of improvement in organizational efficiency associated with the intervention (Aim 4). The study will provide an evidence-based tool to reduce no-show rates and implement meaningful process change within dental care clinics, with the goal of helping the dental care field to become more adept at making organizational changes that support evidence-based care.

Project Summary/Abstract A team of researchers from the Center for Health Enhancement Systems Studies (the Center) at University of Wisconsin?Madison College of Engineering and the Iowa Department of Public Health will test the effectiveness of the Network for the Improvement of Addiction Treatment-Technology Implementation (NIATx- TI) framework in implementing the ACHESS substance use disorder (SUD) treatment and recovery app. ACHESS uses smartphone technology to provide continual access to SUD care and has improved treatment outcomes in a randomized trial as well as in real-world SUD treatment settings with patients with opioid and alcohol use disorders. Despite its evidence base and 74% of SUD treatment patients possessing a smartphone, ACHESS is currently used in <1% of settings that provide SUD treatment. ACHESS is not unique in this regard; health care, in general, has low patient-centered technology adoption rates. This low adoption highlights yet another implementation gap and the need for the dissemination and implementation field to develop approaches to facilitate adoption of the growing list of evidence-based e-health technologies. The two strategies to be tested in increasing ACHESS use are the NIATx-TI framework and product training, followed by ongoing technical support. The NIATx-TI framework developed by our Center builds on our experience in applying the NIATx organizational change model in more than 3,300 organizations. NIATx-TI combines the systems engineering principles embedded in the NIATx organizational model with validated technology adoption techniques. NIATx-TI was piloted successfully in our Center's 7-state project, ?Promoting the Use of Technology to Improve Treatment and Recovery Learning Collaborative,? and led to a 2-fold increase in clients receiving distance treatment during the pilot study. The RE-AIM framework will be used to measure the impact of the 2 interventions in n=16 SUD organizations in Iowa (with n=8 organizations per each arm). A qualitative and cost analysis will be used to develop a better understanding of the implementation process. Iowa was selected as a research setting because of its diverse population of service providers, high participation rates in other national projects, strong data reporting systems, and because the Iowa Consortium for Substance Abuse Research & Evaluation will provide strong local support for the study. SUD treatment providers in Iowa and across the country need the effective treatment supports that evidence-based mobile technologies can provide when successfully implemented. ACHESS and other promising evidence-based patient-centered technologies are positioned to alter SUD treatment and its outcomes. Through testing the NIATx-TI framework and typical product training, this trial will yield a deeper understanding of how to successfully implement ACHESS and other promising evidence-based technologies.

This supplement is for the Justice Community Opioid Innovation Network (JCOIN) Coordination and Translation Center (5U2CDA050097, Taxman) and is designed to accelerate Dr. TaLisa Carter?s career as an independent researcher. Dr. Carter is a trained criminologist with expertise in race and gender. This supplement and the mentors (Drs. Taxman, Rudes, and Gordon) are all part of JCOIN HEAL cooperative and Dr. Carter will have access to the opportunities afforded by nearly150 JCOIN researchers actively involved in health services and addiction research in justice settings. The research plan outlines a study that enhances the parent study, Fostering MAT Use in Justice Populations (PIs Molfenter & Taxman), by conducting two waves of interviews with 80 staff (total of 160 interviews or 200 hours of interviews) working on using MAT in jail and community-treatment programs. The interviews will focus on the understanding, acceptance, feasibility, and value of MAT from the perspectives of the staff that are part of this study. The staff sampling will ensure that interviewees are diverse in terms of race, gender, and class to garner how social position affects perception of MAT and innovations in their workplace. This is an understudied area of research on staff buy-in and acceptability. This fits within Dr. Carter?s long-term career goal: to conduct research that establishes her as an independent researcher focused on the impact of diversity of staff as it relates to health-oriented implementation strategies for innovations in the justice system. Dr. Carter desires to strengthen her research skills to work in justice settings and to implement mixed method studies. To achieve her goal, she has established the following objectives: 1) receive training in implementation science, mixed methods, addictions, and health services to understand how to study the implementation process and reforms in justice setting; 2) conduct an pilot study on system actors to examine how race, ethnicity, gender, and class affect the implementation of MAT and innovations in justice settings, and 3) enhance her research productivity through papers, presentations, and development of an R01 on staff diversity as it relates to their openness to innovations, buy-in, readiness for organizational change, and differential perceptions of organizational commitment, trust, and job satisfaction. For the parent study, Dr. Carter will use the quantitative data generated through this study and her interviews to understand staff receptivity to MAT and examine sustainability of MAT. This training plan will be accomplished through mentorship from leading researchers, participation in JCOIN activities, seminars, training programs, and completion of the proposed research study. Dr. Carter will participate in weekly research meetings for JCOIN protocols (including the parent study for this grant), the Qualitative and Implementation Science (and potentially others) workgroups, engage in mentorship meetings (biweekly with Dr. Taxman, monthly with Drs. Rudes and Gordon and quarterly meetings with teams of JCOIN researchers working on related studies), take related courses in related topics (outlined in her plan), and collaborate widely with JCOIN researchers. The dedicated time afforded by this supplement will connect Dr. Carter with esteemed researchers affiliated with JCOIN and advance her career.

Project Summary/Abstract Coronavirus (COVID-19) has disrupted the substance use disorder (SUD) treatment system, demanding an abrupt shift from in-person care to telehealth services. The transition to virtual care could permanently change SUD treatment delivery. This shift is coinciding with COVID-19-induced social isolation and anxiety, which could increase substance use and mental health disorder severity. A common refrain in the treatment and recovery field is that addiction is a disease of isolation; the cure is connection. To provide virtual treatment and the connection so essential to recovery, many SUD treatment centers are launching virtual services without a method for assessing how, where, and why virtual services are affecting their patients' quality of life and SUD recovery. The ACHESS smartphone app is currently being used at 40 Iowa treatment sites in the parent study, ?Test of a patient-centered e-health intervention in addiction treatment settings.? ACHESS offers a guide and a method for assessing use of virtual services and an unprecedented research opportunity. From 3/3/20 to 3/20/20, sign-ups for ACHESS in the parent study increased by 67% compared to the two prior weeks. Activity on the ACHESS app has nearly doubled in the same period! This supplement will address patient and organizational factors because of their integral roles in providing virtual care and adopting patient-centered technologies. The supplement will enhance ACHESS with new COVID-19 related features designed to help patients comply with social distancing guidelines, cope with unprecedented social isolation, and access virtual services and supports. The research will study how patients use ACHESS features, how organizations refer patients to the ACHESS, how they interact with patients in ACHESS, and the overall impact of the ACHESS features. The supplement's research aims are: Aim 1a: Refine ACHESS to provide information, support, and data on COVID-19, social distancing, adjusting to social isolation, and how to use virtual SUD services. Then, study how patients use existing ACHESS features before (for existing ACHESS services only), during, and after the announcement of social distancing guidelines. Aim 1b: Assess how the enhanced ACHESS APP affects anxiety, loneliness, and reported COVID-19 infections. Aim 2: Create ten case studies describing how agencies implemented and used COVID-19 enhanced ACHESS and how their patients used COVID-19 enhanced ACHESS. This supplement's projected outcomes will help us understand how to design virtual recovery systems to mitigate the effects of a pandemic and the resulting social isolation. The results will help design a virtual recovery system that can be used in future emergencies and to address the on-going challenges of social isolation in society post-COVID-19.