Implementation in Community

Transcription

1 Medication-Assisted i t d Treatment t Implementation in Community Correctional Environments (MATICCE) CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA.

2 What is Medication-Assisted Treatment (MAT)? MAT is the use of medications in combination with counseling and behavioral therapies to provide a whole-patient t approach to the treatment t t of substance use disorders. Medications address withdrawal, craving & reinforcing euphoria. Research shows that when treating substance use disorders, a combination of medication and behavioral therapies is most successful. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 2

3 Why Focus on MAT in Community Corrections (Probation/Parole)? MAT Planning Survey RCs surveyed all potential CJ partner sites (N=50) Demonstrated several barriers to using MAT in CJ settings: Perceptions that MAT available in the community Security/Liability issues Cost/Regulatory issues Lack of knowledge about effectiveness ect e ess of MAT Philosophical opposition to MAT Parole/Probation sites: lowest current use of MAT most potential for initiating/expanding MAT CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 3

4 Specific Barriers to Implementing MAT in Community Corrections Community Corrections (CC) defers responsibility to existing community treatment providers but weak referral relationships exist Lack of knowledge about effectiveness Philosophical opposition to MAT Strategy for overcoming barriers: Address staff knowledge/perceptions and work to improve working relationship between CC and existing community treatment agencies (interorganizational linkages) CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 4

5 Specific Aims Aim 1: Improve service coordination between Community Corrections agencies and local MAT-providing tx agencies. Aim 2: Improve CC agents knowledge, perceptions, and information about referral resources and intent to refer appropriate clients to community-based MAT. Aim 3: Increase the number of CC clients linked with MAT. Aims will be accomplished by testing: a staff-level Knowledge, Perceptions, and Information (KPI) training intervention; and an interorganizational linkage intervention. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 5

6 bh3 Two-Part Implementation Strategy: Part 1 Knowledge, perception & information (KPI) Training of CC staff and selected staff from assessment & treatment agencies to address: lack of knowledge about effectiveness philosophical preference for abstinence-based treatment Information and understanding about local MAT resources Delivered by regional Addiction Technology Transfer Centers (ATTCs) based on NIDA/CSAT Blending Initiative materials CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 6

7 Slide 6 bh3 changed second check mark to specifically name the Blending Initiative bhall, 4/8/2010

8 KPI Outline Address Community Corrections (CC) perspectives on MAT through open discussion Basics of brain functioning in relation to MAT with features of special interest to those in CJ professions Medications used to treat alcoholism, evidence about effectiveness and side effects Medications used to treat opiates, evidence about effectiveness and side effects Examples of typical CC clients who could benefit from MAT Reasons that those under CC supervision with addiction histories might be good candidates for MAT Rapid re-addiction after release, opiate overdose, alcohol and violent crime CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 7

9 KPI Outline, cont d Advantages that MAT might offer the criminal justice system evidence-based practice reduced numbers of addicts going through repeated arrest-incarceration-release ti cycles would likely l result in decreased in crime associated with addiction and in lower public safety costs formal linkages with medication-assisted i t d treatment t t agencies could simplify supervision and lower parole/probation supervision costs How to decide if someone is a good candidate for referral to MAT Types of agencies where MAT is typically offered CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 8

10 Two-Part Implementation Strategy Part 2: Interorganizational linkage intervention (OLI) Incorporates 3 aspects of CMHS ACCESS intervention considered most effective Pharmacotherapy Exchange Councils (PEC) Representatives from relevant local agencies Co-chaired by directors of CC and local MAT providers (or designees) Charged to address linkage to MAT-enabled providers CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 9

11 Two-Part Implementation Strategy Organizational Linkage Intervention (OLI) Strategic Planning by PEC Facilitated by local research team Address factors influencing linkages to MAT Acknowledge complexity of system Connections Coordinator Position Coordinate PEC activities; liaison, foster consensus among agencies Key person, trusted by all participants CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 10

12 PEC Membership The PEC includes... Co-Chairs with the authority to change policy, or at least those who have direct communication to those with such authority Dedicated Connections Coordinator who works closely with members of the PEC in carrying out the OLI Supervisory and line staff familiar with issues and operations Researcher (usually affiliated with the research center) who will be called upon to provide technical, administrative, and logistical support to the PEC CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA

13 Overview of Phases for the Organizational Linkage Intervention(OLI) ti Phase Pre-PhasePhase 1. Needs Assessment Primary Outcome(s) Local PEC Team is formed and the MATICCE project is introduced PEC completes a Needs Assessment that identifies the relative strengths & weaknesses in the inter- organizational practices associated with MAT Duration (in weeks) Strategic Planning PEC develops and adopts a Strategic Plan that 8-12 identifies goals and objectives for improvements to increase the use of MAT 3. Implementation ti PEC works in a collaborative manner to implement the objectives and attain the goals identified in their Strategic Plan 4. Follow-Up PEC assesses the relative sustainability of both the process improvement targets achieved and the PEC method for facilitating process improvements

14 Jun -Nov 2010 (6 mo) Oct Dec 2010 (3 mo) Jan Feb 11 (2 mo) Study Design Pre-Intervention Pilot Phase Test chart data collection procedures Baseline Data Collection (all sites) Knowledge, Attitude, Information (KPI) Intervention (all sites) RANDOMIZATION PHASE 1 PHASE 2 Group 1 Linkage Intervention Feb 11-Dec 12 (12 mo) PEC Strategic Planning Connection Coordinator Group 2 No Linkage Intervention (KPI only ) PHASE 3 Jan Feb 12 (2 mo) End-of-Phase 3 Data Collection (all sites) Jun-Jul 12 (2 mo) After Jul 12 6-Month Follow-up Data Collection (all sites) If linkage intervention is effective, offer materials and training to Group 2 Analysis Phase

15 Nineteen Site Study Intervention based in community corrections (i.e., probation/parole) Each CC office would identify at least one local addiction pharmacotherapy-providing treatment agency to which client referrals can be made opioid treatment programs providing methadone or buprenorphine outpatient programs providing bup or naltrexone for opioid dep. or naltrexone, acamprosate or disulfiram for alcohol dependence Each RC would contribute at least 2 CJ sites to the protocol, preferably in distinct geographic catchment areas Catchment area distinction helps avoid contamination (especially of tx providers) in the delayed implementation group CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 14

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17 What: Sources of Data SURVEY QUALITATIVE AGENCY RECORDS INTERVIEWS -interorganizational relations (IOR) between criminal justice and treatment e agencies es participating in the study -knowledge perceptions and information (KPI) about MAT. Compliment and supplement the information o from the surveys. -Probation/parole and/or Tx agency records (electronic data, presentencing e evaluations, contact records, formal assessments, urinalysis results, etc.). -Abstract 200 client files with evidence of opioid or alcohol use. Who: Representative sample of -probation/parole personnel (director, supervisors, and POs) -treatment personnel (e.g., director, clinical supervisor, counselors, medical director). -All correctional staff with specialized substance abuse caseload Selected subsample of 4 survey respondents, 4 PEC members, and Connections Coordinator. -Researchers and trained assistants, with cooperation of participating agencies. -All procedures approved by RC Institutional Review Boards to ensure compliance with Human Subjects requirements.

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19 Hypothesis 1 CC units in the KPI+Linkage intervention will have greater relative to baseline in interorganizational tx svc coordination than those with KPI alone. Relates to Aim 1 (improve service coordination) Compares Groups 1 (KPI+Linkage) & 2 (KPI) at end of Phase 3 Outcomes Baseline Survey of Organizational Characteristics (BSOC) ACCESS measures (e.g., Morrissey et al., 2002) Interorg Relations Survey adapted from Van de Ven, 1980 Data sources Semi-structured interviews & CC staff surveys at baseline & end of Phase 3 CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 18

20 Hypothesis 2 After the KPI training, CC officers will have knowledge/perceptions re: evidence for MAT, use in treatment, and where to refer clients Relates to Aim 2 (staff knowledge & intent) Compares staff baseline-post KPI training in both groups Outcomes Opinions i about MAT Survey adapted d from Fitzgerald & McCarty, 2009; Springer & Bruce, 2008; Gjersing et al Data sources CC staff surveys at baseline and after KPI training CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 19

21 Hypothesis 3 Staff in KPI + Linkage group will have greater in intent to refer clients to MAT vs KPI alone Relates to Aim 2 (staff knowledge & intent to refer) Compares Group 1 vs. Group 2 staff baseline-post Phase 3. Outcomes Intent to refer on Likert-type scales (Varra et al., 2008) Data sources CC staff surveys at baseline & end of Phase 3 CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 20

22 Hypothesis 4 d interorganizational tx service coordination and staff knowledge / perceptions / referral practices will be sustained 6 months after intervention period. Relates to Aim 1 (service coordination) Compares Group 1 vs. Group 2 across all data collection periods Outcomes Interorganizational coordination measures per H1 KPI and intent to refer scales per H2, H3 Data sources CC staff surveys, semi-structured t interviews i at baseline, end of Phase 3 & 6-months later CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 21

23 Hypothesis 5 CC units in KPI+Linkage group will have a greater over baseline in % opioid/alcohol-using clients referred to MAT assessment than KPI only group. Relates to Aim 3 (increase client linkages) Compares Group 1 vs. Group 2 across all data collection periods Outcomes % opioid-/alcohol- using clients referred for assessment for MAT Data sources CC records for 6 mos prior to baseline, last 6 months of Phase 3, and 6 months after Phase 3* Monthly CC officer survey for month prior to baseline, last 6 months of Phase 3, and 6 months after Phase 3, reporting: # opioid/alcohol-using clients # clients referred for MAT assessment CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 22

24 Hypothesis 6 CC units in KPI + Linkage group will have a greater over baseline in clients assessed by a tx provider for MAT and who initiate MAT, vs. KPI only group Relates to Aim 3 (increase client linkages) Compares Group 1 vs. Group 2 staff baseline-phase 3 Outcomes # completed CJ referrals for assessment, MAT initiates, persondays on MAT Data sources Records abstract or report from substance abuse assessment provider and main MAT program for 6 mos prior to baseline & last 6 mos of Phase 3* CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 23

25 Hypothesis 7 CC units in KPI+Linkage group will have a larger relative to baseline in opioid/alcohol-using clients rearrested, re-incarcerated, & testing positive for substance use relative to KPI only group. Relates to Aim 3 (increase client linkages) Compares Group 1 vs. Group 2 staff baseline-phase 3. Outcomes: Of potentially MAT appropriate p CC clients i % arrested, reincarcerated, testing positive for drugs Data sources Records abstract or report from CC, CJ and drug-testing program for 6 mos prior to baseline, last 6 mos of Phase 3, & 6 mos after Phase 3. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 24

26 Challenges and Limitations If site cannot accept randomization assignment MATICCE SMS will recommend action, incl replacement if necessary. Protocol deviations Change in staff or level of cooperation Retraining Analyses by intent to treat Client Information Waiver IRB variability Unclear whether treatment programs will honor waiver Can still examine primary outcomes from CJ and survey data Extent, validity of record documentation reasonable from pilot Possible detection bias based on Group (hard to blind RAs) Self-report data Limited information on psychometrics of these reports Social desirability / Hawthorne effects CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 25

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28 Summary Addressing i staff knowledge/perceptions and interorganizational linkages could increase CC clients access to MAT MATICCE -- multi-site, cluster randomized study Compares KPI training alone to KPI training plus active linkage intervention ti Interorganizational Pharmacotherapy Exchange Council (PEC) Facilitated strategic planning Connections coordinator position Complex project that will attempt to address issues in implementation science (interorg. relationships; sustainability) HSR (structural influences on access, referral, and utilization) practical concerns of CJ agencies (facilitating interagency referrals; reducing relapse & arrest) Reproducible manual, training materials CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 27