<v ->Hello and welcome to today's webinar.</v> My name is Amy Campbell and I'm an associate professor of clinical psychiatric social work at Columbia University Irving Medical Center in the Department of Psychiatry Division on Substance Use Disorders. And today we're going to talk about improving implementation of substance use disorder services through the use of implementation science, first, I have no disclosures to make, and as a reminder, the overarching goal of PCSS or Providers Clinical Support System is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications as well as for the prevention and treatment of substance use disorders. So today's presentation has the following objectives. The first is to identify and define key elements that set the stage for why implementation science can be useful in improving substance use disorder services. Next, we'll review basic constructs from implementation science frameworks and implementation science outcomes to provide a foundation for later applied strategies that can be used across service settings. And lastly I'll describe ways that implementation science can inform our practice of integrating and sustaining best practice substance use disorder services and including the use of some case examples. The goal of today's presentation is to provide the rationale for using implementation science processes in daily practice and several pragmatic strategies to get you started. So let's first talk about why implementation science is needed, as I'm sure you're aware, despite many efforts best practices for preventing and treating substance use disorders and providing services for people who use substances is often unavailable, inaccessible, or not a good fit. Things that we know are helpful, like screening and early intervention for risky use and medications to treat alcohol and opioid use disorder are underutilized. According to data from the national survey on drug use and health in 2020, among those 12 and older, 41 million people likely needed substance use treatment, but only 4 million were receiving treatment and that's about 10% of those who express need. However, even for those who do access substance use treatment, it is estimated that upwards of 70% do not receive evidence-based care. A specific example of this is of the estimated 2.5 million people with opioid use disorder, only about 11% receive medications to treat that opioid use disorder and medications, of course, are considered the best available treatment for opioid use disorder. So some of this lack of accessible evidence based care is linked to what's been called the "Know-Do" divide or the Implementation Science Gap. So that is the gap in time between the addiction treatment field, knowing what to do and what works and actually delivering that service to the people who need it. So, a seminal Institute of Medicine report in 2001 estimated that the average "Know-Do" gap was 17 years. And likely this has changed little in the intervening years. Within the National Institution on drug abuse strategic plan in 2015, it was noted the bench to bedside gap is a failure of dissemination and adoption of effective interventions so that they can actually improve the lives of individuals, families, and communities, meaning that evidence-based practices are not reaching the folks who need them the most. And I would add that some of the "Know-Do" gap includes not contextualizing or not tailoring evidence-based practices to align with the values and culture of diverse communities across the country, making it hard to sustain those practices over time due to a lack of fit. So implementation science provides models and strategies with the goal of shortening that "Know-Do" gap. So first, let's review a common definition of implementation science, which is provided on this slide. So implementation science is the scientific study of methods to promote the systematic uptake of evidence-based practices into routine care with the ultimate goal of improving the quality and effectiveness of health services. So implementation science addresses the research to practice gap by identifying key facilitators and challenges to successful adoption and integration of evidence-based practices. And the ultimate goal of implementation science is of course to improve client and patient health outcomes. And so implementation science supports the translation of research into practice and into our communities. So this slide just shows a linear flow of research studies from basic research to testing interventions in highly controlled settings like research clinics in efficacy studies, to understanding if interventions work in community settings within effectiveness studies. And then finally to understanding how to scale up effective interventions through dissemination. And dissemination is really just getting the word out about interventions through different channels. And then finally, implementation towards the right hand side of this research continuum where we're actively supporting the use of evidence based practices. So we use implementation science to inform our implementation practice, which is really what we want to focus on today. And by practice that's actually doing the complex work of integrating evidence-based practices into routine care. So knowing about an effective evidence-based practice is certainly essential and necessary, but it's not sufficient to actually change the outcomes as we've seen in this "Know-Do" gap. So we've all had the experience of holding a manual for treatment in our hand and wondering what's next? How do we actually roll this out? How do we actually stand this up? As the figure in this slide demonstrates, effective practice on its own does not ensure health outcomes. We also need effective implementation strategies, which we'll be talking about a little later in this webinar, as well as supportive contextual factors, often at multiple levels to be part of that equation that is shown here. So we require effective interventions plus a well thought through implementation plan, plus the awareness of factors at the individual organizational and policy regulatory level that will result in the best possible outcomes for our patients and clients. We also know that the more passive an approach to implementing an evidence-based practice, the less likely it will be for that particular practice to be successfully stood up and sustained over time. And in fact, it's estimated that about two thirds of implementation efforts fail often because of a lack of systematic comprehensive implementation planning. So let's look at an example. This slide shows the outcomes from a study that looked at adding coaching, certification of skills and monitoring to support providers in using the Adolescent Community Reinforcement Approach and effective behavioral intervention. The researchers compared the more active implementation supports to standard training alone, and the graph shows the percentage change in abstinence among the participants in this study based on which training strategies were used by their providers. So as you can see from the blue bar compared to the yellow bar, the more intensive implementation strategies resulted in better client substance use outcomes. The more passive training only arm produced relatively little change overall. So just moving forward now and over the next several slides, I want to provide a brief overview of key constructs within implementation science that help us to conceptualize how it can inform practice. So this slide demonstrates the scientific foundation of implementation science, including the use of classic theories to inform the work as well as implementation specific theories. And today we're going to focus on what we call determinate frameworks, implementation process models, and how to think about evaluation of implementation efforts. And we'll talk about each one of those in a little more detail. So the first framework I want to mention is the consolidated framework for implementation research, or commonly known as CFIR which provides a structure for thinking about the context in which evidence-based practices are adopted and implemented. So that is which factors influence the success of our implementation work. So CFIR which was originally developed by Laura Damschroder and colleagues consists of five domains listed on this slide. And within each of the domains, our particular constructs that are associated with how successful the implementation of an evidence-based practice will be. So we're going to quickly walk through each of these domains just to give you a sense of some of the contextual and process factors that you might want to think about that have been shown to be important in our implementation practice. So first, the first domain is the intervention itself, the evidence-based practice and attributes associated with that intervention. So there are specific characteristics of evidence-based practice which research has demonstrated make them more or less likely to be adopted and successfully implemented. And we won't go through all of these today. You can take a look at those as we walk through a few of these on the slide. So for example, relative advantage, this means that the new practice, the new evidence based practice is seen as being advantageous or an improvement over current practice. So if staff perceive the new practice as being superior, they'll be more likely to want to adopt it and use it in their practice. If staff don't think the new practice is better than what they're currently doing, it will be more challenging to implement. So really understanding staff views of an intervention goes a long way in determining whether that intervention will ultimately be successfully rolled out within an organization. Another example, trialability means can we test on a small scale whether the new practice will work? So those evidence-based practices that allow for a trial run that don't require you to be all in to see whether it works are likely to have a better chance at being adopted and fully implemented. Other characteristics include whether we think the intervention is compatible with the needs of our clients, whether the intervention can be tailored to better fit specific populations or settings and how strong the evidence base is for the intervention. And not just the academic literature around the evidence, but whether that evidence really resonates with the staff that's going to be implementing it. So understanding the characteristics of the intervention and how they can influence implementation can really help us one, to develop better interventions and two, can help us with adoption decisions about what will work best for our organizations. The next domain are the knowledge, beliefs and attitudes of individuals. And those are both staff members, providers as well as clients. So how staff and clients view an evidence-based practice matters. For example, if the community we serve has specific beliefs or values related to the types of treatments that they find acceptable, we'll want to select an intervention that is in line with those values. Among providers, those who have higher self-efficacy around delivering a specific type of intervention will be more likely to do so. So if self-efficacy is low, meaning there's not a lot of confidence that they can actually deliver this intervention, we may want to select another intervention or develop a plan for how to increase self-efficacy with the new practice. Additional constructs in this domain include the level of commitment to an organization, so those who have greater alliance will be more open to trying new practices within that organization. And there are also certain personal attributes that lend themselves to openness to change, like motivation and tolerance for ambiguity. So the third domain of the consolidated framework for implementation research is the organizational setting. So this can be the individual clinic we work in or the large health system our clinic is a part of. Depending on how you're conceptualizing the organization. Characteristics of these organizational settings can influence how successful an implementation will be. So for example, is the organization well networked within the region? Are there high quality, is it high quality networking? Is there good interagency communications which can lead to better resourced organizations that are more likely to succeed at integrating new practices? The climate of an organization is also important. Is the organization generally open to trying new things? Have there been prior success at adopting and implementing new practices or is the organization really committed to kind of doing the same thing year after year? Other aspects for the organizational setting include readiness to engage in implementation, and this can be based on leadership support, having that buy-in, it can be based on resources that the organization has available as well as access to information. The fourth domain is the external environment. So outside the organization. So that is community characteristics, local and state regulations and policy and other resources within the region. So of course we know we operate within these larger systems and the way that policies are developed and deployed certainly have an impact on what is feasible within our organizations, in our individual organization, external characteristics can often be difficult to change, but it is good to be aware of exactly how these policies impact the work we do and in what ways we might be able to influence improvements for example, through professional organizations. Finally, the last domain of the consolidated framework refers to how the implementation process is structured. So we'll be getting into some of the details of this, but briefly, implementation efforts that involve systematic front end planning that pay attention to engaging relevant partners that track how the implementation effort is going, and provide opportunities for evaluation and reflection and modifications are usually more successful. So to think about these five domains in a more applied way, this side lists some of the challenges to implementing evidence based buprenorphine for opioid use disorder in healthcare settings. So this has been on the minds of many providers that provide services for substance use disorders more recently. So as you read through these challenges, and again these are challenges that have been documented in the research, consider which of the five CFIR domains these might fit within and they could fit within several of the domains. So are these intervention characteristics? Are these individual level factors? Are these organizational factors? External factors, or factors or characteristics related to the implementation process itself? We're just going to take a couple of examples here and you can kind of think through some of these others on your own. So lack of staff time, this is a very common challenge that's noted by providers in terms of thinking about whether to integrate buprenorphine into their primary care clinic and lack of staff time may be related to organizational factors. So how daily workflows are configured, how tasks and activities are distributed across provider time. Another example is limited training. So we don't have the expertise to be able to do this type of work within a primary care setting. And limited training may be a provider factor. Individual providers may experience that or have that perception, it can also be an organizational factor. And thinking about how to address this issue through our implementation process may include individual level training for individual providers, or it may be thinking through some of the organizational supports that might be needed to provide staff with the structure and resources they need to actually do this new type of work. The organization not having other ancillary services like behavioral health is also a very common challenge that's reported. And this could be related to organizational factors such as the need to network with other programs or increased capacity to provide the type of service. Or it could be related to external factors like the geographic region the organization is in or the resources provided to healthcare settings in their city or county. And the way in which we think about which particular domain that these challenges fall within, give us some sense of how we might go about addressing these challenges in our implementation work. So you can think through, again, some of these other noted challenges and where they might fall within our five domains of the consolidated frame for implementation research. So now I want to spend a few minutes talking more about the implementation process itself, one of the five CFIR domains. And that is how do we actually go about standing up a new evidence-based practice in our organization, in our program, in our clinic. So shown on this slide is a well known implementation process framework known as EPIS. And EPIS stands for exploration, preparation, implementation, and sustainment. And what this framework does is to help us think through distinct but integrated and iterative steps along the implementation process. So these steps break down what can be a complex and sometimes overwhelming task of successfully implementing a new evidence-based practice. So in the exploration phase, the organization or group explores the current landscape, the gaps or needs within an organization as well as resources and things that are working well related to the potential evidence-based practice that they're thinking about adopting and implementing. So really getting an understanding of what's currently going on within the organization. They may also engage relevant partners during the exploration phase and gather input from them. And during this time, the evidence-based practice is actually formally selected. We're going to move forward with the implementation of this and goals might be set around how we want to do that. In the preparation phase, the organization or group plans this new practice, plans how this new practice will be integrated into their system, what sorts of training may be needed, will new workflows need to be developed, and what additional resources need to be obtained. So they may develop an implementation map or blueprint to help organize the work and set feasible timelines and decide who might be in charge of doing each of those individual tasks. During the implementation phase, the third phase, the organization or group puts the practice into place. And they do this perhaps starting small in a triable way initially with one or two providers or with one or two clients. And monitoring is set up during this time to understand if the practice is going as planned. So is there a need to make modifications, make adaptations for it to better fit within the flow of the, of the clinic or program? And finally sustainment happens when the practice becomes part of routine care. The planning is needed to support that sustainability, it certainly doesn't happen on its own. And this includes thinking about funding, staffing, ongoing monitoring and training as new staff are onboarded. And we're going to talk in a bit more detail about some of these strategies used within each of these four phases of implementation. So the last framework I want to review in today's webinar focuses on evaluation. So how do we know our implementation efforts are working? So in practice, often this looks like quality improvement or ongoing monitoring that we might do in other aspects of our work. Evaluation can also ensure that we are considering and improving upon equity, that our improvements within the program as a whole, our adoption and implementation of evidence based practices are working equally for everyone. So the RE-AIM framework is commonly used and shows how to think about different types of implementation outcomes, the reach of implementation efforts, the effectiveness of those efforts, the level of adoption of the evidence-based practice, how it is being delivered or implemented and how well it is being sustained over time. As an example, reach is defined as the number of people receiving the evidence based practice. So who's actually getting the evidence based practice that we're implementing? So if we're introducing medications for opioid use disorder into our program, how many of our patients or clients with opioid use disorder are actually receiving, are actually receiving that medication. Further, are there differences in client characteristics for those who do receive the medication and those who are not receiving the medication? How do we think about those findings? Are there changes that might need to be made to ensure greater or more representative reach? The implementation outcome of this model looks at how the practice is actually being delivered. Is it how we planned for it to be delivered in our planning preparation? So perhaps there needs to be further tailoring to better fit our particular setting or to increase accessibility to clients we serve. So these outcomes can be tailored to fit the evidence-based practice selected and you can really think about them with equity in mind to make sure that when we do introduce improvements in our organizations, that they're equitability distributed across our patient populations. So we've covered some of the basics of implementation science and, and a little bit on how it can be applied to our practice. So now I want to focus on a few specific implementation strategies that will be used during different phases of the implementation process and that have been shown to be helpful. So these science-based strategies can help structure our implementation work, they can provide support and they can help us to understand how successful we are in our implementation efforts. So we all know even as individuals that change is hard and it's particularly challenging in a complex organizational setting. So implementation practice can help us to get to where we need to go. So first there's been work done to try and capture the range of implementation strategies that have been shown to be useful. Implementation strategies are how we seek to get evidence-based practices into routine practice in our healthcare settings. So over the last 10 years or so, the field has been identifying and categorizing science-based strategies to facilitate implementation practice. So this table shows six major categories of strategies and strategies should really be selected based on what has worked in similar settings. So learning by what has been done before, lessons learned from other groups, as well as what makes sense for your particular setting, especially considering specific goals that you have around implementing the evidence-based practices, the resources that you might have available and the challenges that might have been identified or the gaps that exist within your organization. The different categories of strategies include those focused on planning, educating relevant stakeholders, financial strategies to support or incentivize the new practice, organizational strategies, quality improvement to support evaluation, and policy related strategies such as advocacy through professional organizations. Next, we're going to walk through a few of these strategies using our ongoing example of implementation of medications for opioid use disorder in healthcare settings. So I want to start with facilitation. And facilitation can be internal to the organization or provided by external subject matter experts or external implementation facilitators. And facilitation is really a planning strategy and it can be particularly helpful in organizing an implementation team and the implementation process. So this is often called practice facilitation or implementation facilitation and facilitators really bring skills in problem solving, interpersonal relationship building, implementation strategy knowledge, and often with subject matter expertise in whatever the evidence-based practice might be grounded. So this slide identifies some of the skills and activities that facilitators may contribute to the overall implementation process. And facilitators can be identified through technical assistance programs like PCSS. Another planning strategy is identifying and engaging an implementation working group within an organization to help spearhead the work and keep each other accountable. So one of the most important roles within this team is what is called a champion. So a champion is one or two people within the organization that can help to drive the implementation effort. As noted on this slide, champions are responsible for keeping momentum going and may take a larger role in the planning process within the implementation effort. They're often recognized within the organization for their previous work in bringing about change or as a respected leader within the organization. So it's really that go-to person within the organization. People have a lot of respect for this person and they may turn to this person when there's challenges or when there's a particular initiative that they want to try to get off the ground. And I would just say that a strong champion is really key to an implementation effort. Leadership buy-in and ongoing support is also essential. So implementation efforts often need to be seen by leadership as a priority within the organization so that they can really make sure that sufficient effort is devoted to the implementation process and additional resources can be obtained as needed. Other team members within the working group should represent key constituents within the organization and this can include kind of diverse roles within the organization. So not just the clinical staff but the administrative staff that really often support the workflows being rolled out successfully. Other team members should provide diverse perspectives across all types of positions and consistently attend meetings to maintain that momentum as well. And so identifying, developing a successful work group can really go a long way in facilitating the implementation process. Another planning strategy, which I alluded to earlier when we were talking about the implementation process is used during, often used during the exploration phase and it's conducting a needs or asset assessment, sometimes a clinic health assessment is a term we might use. And it's really taking stock of what is working well within a program and where there may be gaps or areas of improvement related to the new practice that the team is wanting to implement. So in prior efforts to integrate buprenorphine into primary care settings, we developed a template which is shown here on this slide towards the bottom of various relevant areas for the implementation work group to think about, to address, to dialogue about. So for example, in this case we might include assessment around screening. How is that done? Is there a need to enhance screening services? Service provision, so what's actually provided within the clinic and how is that going? Pharmacy resources that are available. And even thinking about what are our provider and staff attitudes around this particular evidence-based practice. So this assessment can really be a useful tool to engage the implementation team, start a discussion and that discussion, you know, really leading to the identification of goals, gaps, and needed supports for implementation planning overall. Implementation blueprints or implementation plans can be used during the planning phase of the implementation process to really help guide the work. This is really the nuts and bolts, the activities and tasks, that are required to really stand up the evidence-based practice. So utilizing a blueprint like this can provide accountability, intentional planning, it can identify timelines that we can work towards and it can also identify additional needs and resources. So this slide just shows an, you know, a quick snapshot, an example of a few implementation steps, who's responsible, the deadline that we want to achieve that task by, as well as additional information that can be added as needed. So a commonly used evaluation strategy are improvement cycles. And on this slide is a common improvement cycle called the Plan Do Study Act, or PDSA. And these can be used during the implementation phase when the organization starts to think about actually standing up the evidence-based practice. So let's think about an example and how we might work through the PDSA around this example. So a common evidence based practice that primary care clinics often think about adding is a substance use disorder screening tool. So if a implementation work group came up with a plan for doing this work and initiating a screening tool, they may then want to evaluate how it's actually working. So in this example, maybe they find that two of their eight providers actually utilize the screen during this pilot phase representing about 20% of their patients screened using this tool during that time. So the work group may reconvene and they may decide to kind of go back to the planning phase to retool how the screening is done with the goal of increasing the number of providers that will actually use it. So throughout this process they may decide that they need to modify workflows. So where is the screening tool actually being inserted within the workflow, do we need to alter this? Do we need to automate the screening tool in some way? Or do we maybe need to have another staff person take responsibility for the screening getting done? And after making those decisions, putting it back into a workflow, they may go through this PDSA again to see if those modifications actually improved the number of providers that were actually using the screen or the number of patients that actually completed the screening during that pilot phase. So improvement cycles can really be used to understand how well our plan for the evidence based practice rollout is going and how we can make modifications and improvements. So as discussed earlier, the last implementation phase is sustainability and sustainability planning can be really be included from the start of any implementation process. So it really should be in the back of our mind as we're thinking about planning to implement an evidence based practice and actually doing that implementation work. So what types of mechanisms can we build into the planning that will ensure that the practice continues? So we want the new practice to become routine. That's the goal. So when someone new is hired at our program, we want them to feel like that particular practice has always been a part of what we do here. It's fully a part of the program. So planning ahead for potential bumps down the road can protect the implementation and sustainability of the evidence-based practice. So for example, I'm sure everyone has had or witnessed the situation when a key staff member leaves an organization, they take their institutional memory with them and sometimes practices can fall off or drift. So this side lists some of the things to consider during the implementation process that will help farther down the road. So one example, monitoring. Monitoring should continue at specific intervals even after the evidence-based practice is fully stood up. It's perhaps not as frequent as early in the implementation process, but often enough to identify drift or any staff that might need additional support. Another important way to support sustainability is to update staff with monitoring results. So share successes and engage staff when there are areas for improvement. So finally this slide integrates the implementation process. EPIS is what we use exploration, preparation, implementation, and sustainment, and also integrates some of the strategies we just discussed. So the blue boxes are the process steps with the purple arrow showing where specific implementation strategies may be useful. So as a reminder these implementation process models should be seen as iterative. So the team may go back to work in earlier phases as needed. For example, if a team discovers through monitoring that the evidence-based practice is not being delivered in the way they wanted, the team may want to go back to planning to modify workflow or identify additional training needs. So this brings us to the end of the formal presentation and I hope what you take away is that implementation science can help to integrate best practices into our work and that these strategies that we've talked about today can assist us in doing that with greater efficiency and hopefully, ultimately with better outcomes for the people we provide services, so as part of this takeaway, I wanted to reference a few key resources that might be helpful to you in your implementation journeys. So for implementation technical assistance on using medications for opioid use disorder, PCSS offers several options including a succession learning collaborative called PCSS-X and a more intensive implementation resource, PCSS-Implementation where individual programs can be linked to external facilitators who can work directly with you in your program. And links to information on these projects are listed on this slide, the first two bullets here. Other links on this slide are to websites with various types of implementation resources and tools covering a broader range of healthcare targets. And so I encourage you to check out some of those, including some that have short videos that talk about specific aspects of implementation. References to the information presented in this webinar are available in the slide deck. And I would also like to make you aware of two additional resources offered through PCSS, which may be of interest to you. First PCSS Mentoring Program is designed to offer mentoring assistance to those in need of more one-on-one interactions. And this is with one of our colleagues and they can help to address clinical questions. You have the option of requesting a mentor from our mentor directory or we're happy to pair you with one. And to find more about this mentoring program, please visit our website using the web link noted on this slide. Second, the PCSS offers a discussion forum, which is comprised of our PCSS mentors and other experts in the field who help provide prompt responses to clinical cases and questions. So we also have a mentor on call each month, and so again, these questions can be answered almost in real time. This person is available to address any submitted questions through the discussion forum. And you can also create a new login account by clicking the image on the slide to access the registration page. This slide simply notes the consortium of lead partner organizations that are a part of the PCSS project and who we want to acknowledge, and finally, please reference this slide for any contact information website and Twitter and Facebook handles, and to find out more about our resources and educational offerings. So thank you for joining and for your interest in implementation science and practice.

webinar

Amy Campbell

implementation science

substance use disorders

evidence-based practices

Providers Clinical Support System

phases

sustainability planning