James H. Ford, Ph.D. - US grants

DESCRIPTION (provided by applicant): A healthcare quality improvement collaborative brings together multiple organizations in an effort to improve processes of care for clients in a specific organizational setting (e.g., substance misuse) or a particular disease (e.g., diabetes or asthma). Coaching, a key QIC component, involves a coach working with change or implementation leaders to teach quality improvement skills and thus helping participants learn skills to effect change in the organization. Understanding coach effectiveness and how the teacher-student relationship supports knowledge acquisition is a missing element in quality improvement research. In this study, we will adapt scales developed and validated in the field of educational research to assess individual learning and teaching styles and test their applicability in a quality improvement collaborative to identify learning styles of the implementation (i.e., change) leader and champion (i.e., executive sponsor) and teaching styles of the external change agent or coach. Study findings will lead to new potential prospective studies that match coaches and organizations or allow quality improvement or implementation science researchers to tailor the coaching intervention or the structure of a QI collaborative design based individual learning and teaching styles. Such studies would contribute to the fields of quality improvement and implementation research by exploring how change leader and executive sponsor learning styles and the teaching style of the coach improve expected patient and organizational outcomes.

DESCRIPTION (provided by applicant): A multi-organizational quality improvement collaborative is a proven strategy for implementing organizational change. Failure to sustain improvements is a direct waste of invested resources, has costs associated with missed opportunities, and may affect an organization's ability to implement change in the future. Research on the effectiveness of quality improvement collaborative to promote long-term sustainment of change is lacking, however. Moreover, we do not yet understand what attributes--organizational, innovation or environmental-are the most important contributors to the ability of organizations to successfully sustain change following participation in quality improvement collaborative. This application is the next logical step for our research program, and explores the sustainment of organizational change in substance abuse clinics after their participation in the NIATx200 initiative - a quality improvement collaborative designed to test the effectiveness of four different implementation strategies to improve access to and retention in treatment. In this study, we will seek to answer a fundamental research question: Are changes implemented using the NIATx implementation strategy sustainable? Using longitudinal administrative data and key informant interviews, we will explore whether improvements experienced by NIATx200 clinics located in Michigan, New York and Washington were sustained following participation in a quality improvement collaborative, and to identify the environmental, organizational and innovation-related factors that influenced sustained improvements. Our research team has extensive expertise in performing quality improvement and research in addiction treatment, sustainability and state policy, and qualitative research. The findings will contribute to implementation research by exploring sustainment of change after participation in a quality improvement collaborative and by providing a broader understanding of sustainability of organizational change within substance abuse clinics. The current project represents a foundational step in the field of implementation research by enabling researchers and practitioners to improve quality improvement collaborative to enhance sustainability of change.

DESCRIPTION (provided by applicant): The proposed implementation research addresses a longstanding and vexing problem in behavioral health care: Access to integrated services for persons with co-occurring substance use and mental health disorders. Despite decades of awareness of this problem, at present, less than 10% of treated patients with co-occurring disorders receive evidence-based integrated services. Implementation science holds to key to addressing this persistent gap. The present study unifies and operationalizes three major implementation research heuristics: the Consolidated Framework for Implementation Research, the Stages of Implementation Completion, and the Proctor et al (2011) taxonomy of implementation outcomes. Developed by industrial engineers, a multi-faceted implementation strategy, NIATx, has proven to be effective in implementing and sustaining simple interventions in behavioral health care services. The overarching goal of this project is to test whether NIATx strategies are effective in implementing a complex evidence-based intervention: Integrated services for persons with co-occurring disorders. Promising pilot data suggest that NIATx actually can integrate services, but a more rigorous study is needed. We now take this step and herein propose a cluster randomized wait-list control group design, in which a cohort of 23 agencies receive the active NIATx approach while the other cohort of 23 agencies are waitlisted. In the second phase, the wait-list group of 23 agencies participates in NIATx and the initial group enters a sustainment phase. Hypothesized to install and sustain integrated services, NIATx is examined for effectiveness on two core implementation outcomes: fidelity and penetration, as well as patient care outcomes (psychiatric and substance use symptom reduction). Variation in the extent of and fidelity to which NIATx strategies are delivered are evaluated using the NIATx Fidelity Scale, which embeds the Stages of Implementation Completion measure. Primary outcomes are assessed at pre- implementation, post-implementation and at sustainment follow-up periods. Qualitative and economic analyses augment the quantitative data, and add to the interpretation of organizational and social dynamics, as well as resource costs. We assemble a multi-disciplinary research team with considerable and complementary expertise and experience. Capitalizing on a technically sophisticated clinical management information capacity across a state system of care (Washington), the study engages representative outpatient programs across 20 counties. Consistent with US data, the participating agencies and their key stakeholders are highly motivated to improve services for patients with co-occurring disorders. Practical implementation strategies, including their associated costs, and the measurable impact on services and patient outcomes, will be definitive research products. Findings from this robust study are immediately applicable to improve clinical services, to advance implementation research, and ultimately, to guide future implementations with other behavioral health systems and settings.

PROJECT SUMMARY/ABSTRACT To combat the US opioid epidemic, massive efforts have been focused on expanding access to medications for opioid use disorder (MOUD). While there are indications of improved reach and adoption, an ironic gap persists?only about one-third of specialty addiction treatment organizations offer MOUD. This proposal, Stagewise Implementation-To-Target ? Medications for Addiction Treatment (SITT-MAT), not only advances the science of implementation, but advances our empirical understanding of how to best respond to a substance-related epidemic. This is a revised application in response to PAR-19-274: Dissemination and Implementation Research in Health? and aligned with the National Institute on Drug Abuse Strategic Plan ?ensuring the effective translation and implementation of scientific research findings to improve the prevention and treatment of substance use disorders.? Within an adaptive implementation strategy trial design, using an innovative stagewise implementation-to-target approach, 72 community addiction treatment programs will participate. The stagewise implementation-to-target, stepped ?care? type approach, deploys increasingly intensive strategies only if needed. The sequence of implementation strategies are: 1) Enhanced Monitoring and Feedback; 2) ?NIATx/MAT Academy,? a 2-day workshop on MOUD and NIATx (Network for Improvement of Addiction Treatment)?an evidence-based process improvement strategy; 3) Randomization to either NIATx Internal Facilitation or NIATx External Facilitation; and, 4) If outcome targets are not achieved in the NIATx Internal Facilitation arm, assignment to NIATx External Facilitation. We evaluate the relative impact of 5 possible paths of implementation strategies on RE-AIM target outcomes: reach, effectiveness, adoption, and implementation quality. Maintenance of outcomes is evaluated for sustainment. Measures of multi-level contextual determinants are rigorous and systematic. In opening the ?black box? of implementation strategies, we detail procedures, fidelity, participation and costs using standardized measures. The collective expertise of the research team, the established partnership with a state system of care and addiction treatment organizations, forecasts successful project execution. As we submit this application, the US is still coping with the COVID19 pandemic. The global health situation may rebound to relative normalcy in the months from December 2020. Meanwhile, the CDC, SAMHSA, CMS, and the State of Washington Health Care Authority have all made accommodations to continue the initiation and management of MOUD for patients receiving addiction treatment services. Therefore, even if the current quarantine restrictions persist, we do not anticipate major modifications to the study protocol, except in-person implementation support activities would be transitioned to videoconference formats. During this pandemic, it is even more critical for patients with opioid use disorders to access pharmacological interventions that require minimal physical contact with providers. This study has the potential to shift the paradigm in public health and implementation research.