Treffer: The System-Wide Medication for Opioid Use Disorder (SW-MOUD) program: A description of program implementation.
40D3SCR4GZ (Buprenorphine)
Weitere Informationen
Medication for opioid use disorder (MOUD) is an evidence-based treatment for opioid use disorder (OUD). However, only a small proportion of eligible patients receive MOUD, due in part to access barriers and the complex medical needs of this population. Provision of MOUD traditionally occurs in ambulatory opioid treatment programs that operate separately from other providers, making it difficult to address patient needs comprehensively during health care encounters. To alleviate these barriers to continuous care for individuals with OUD, The Ohio State Wexner Medical Center designed the System-Wide MOUD (SW-MOUD) program. The SW-MOUD program has two objectives, (a) expand access to MOUD across emergency, inpatient, and outpatient settings, and (b) coordinate care for patients across these settings using integrated program staff. This article describes the SW-MOUD program implementation in order to serve as a roadmap for the creation of similar care delivery mechanisms. In the program's first 4 years, there were a total of 4,908 MOUD initiations. The implementation tools presented in this article include a patient flow model with an overall program structure, a detailed multilevel implementation timeline, and a table of implementation strategies used across three broad phases: preparation, rollout, and sustainability. The transformation of evidence-based treatments into systematic delivery approaches offers the potential to improve patient outcomes. Our experience is informative not only for health systems seeking to increase access to MOUD in their communities but also for those looking to expand access to care for any treatment modality by coordinating care across existing system silos. (PsycInfo Database Record (c) 2025 APA, all rights reserved).
The System-Wide Medication for Opioid Use Disorder (SW-MOUD) Program: A Description of Program Implementation
<cn> <bold>By: Brian P. O’Rourke</bold>>
> <bold>Tory H. Hogan</bold>
>
> <bold>Alison Miller</bold>
>
> <bold>Martin Fried</bold>
>
> <bold>Margaret Williams</bold>
>
> <bold>Julie Teater</bold>
>
> <bold>Emily Kauffman</bold>
>
>
> <bold>Aaron D. Clark</bold>
>
> <bold>Orman Trent Hall</bold>
>
> <bold>Phuong Huynh</bold>
>
> <bold>Jennifer L. Hefner</bold>
>
>
<bold>Acknowledgement: </bold>Nazanin Bahraini served as action editor.This report was funded either in whole or in part through the Care Innovation and Community Improvement Program, a State Directed Payment program per 42 CFR 439.6(c). View stated in the publication are those of the researcher only and not to be attributed to health systems participating in Care Innovation and Community Improvement Program, to the Ohio Department of Medicaid, or to the federal Medicaid program. Brian P. O’Rourke played a lead role in formal analysis, visualization, writing–original draft, and writing–review and editing and an equal role in conceptualization and methodology. Tory H. Hogan played a supporting role in formal analysis, visualization, writing–original draft, and writing–review and editing and an equal role in conceptualization and methodology. Alison Miller played a lead role in project administration, a supporting role in conceptualization, writing–original draft, and writing–review and editing, and an equal role in funding acquisition. Martin Fried played a supporting role in conceptualization and writing–original draft and an equal role in funding acquisition. Margaret Williams played a supporting role in conceptualization and writing–original draft and an equal role in funding acquisition. Julie Teater played a supporting role in conceptualization and writing–original draft and an equal role in funding acquisition. Emily Kauffman played a supporting role in conceptualization and writing–original draft and an equal role in funding acquisition. Aaron D. Clark played a supporting role in conceptualization and writing–original draft and an equal role in funding acquisition. Orman Trent Hall played a supporting role in conceptualization and writing–original draft. Phuong Huynh played a supporting role in conceptualization and an equal role in funding acquisition. Jennifer L. Hefner played a supporting role in formal analysis, visualization, writing–original draft, and writing–review and editing and an equal role in methodology.
Opioid use disorder (OUD) is a public health crisis in the United States that is responsible for more than 100,000 deaths in each of the past 3 years (Tsai, 2024). The consequences of this epidemic are not distributed evenly: states in the Appalachian region experience an outsized impact, with Ohio reporting the third-highest incidence of fatal drug overdose in the country (Centers for Disease Control, 2022; Hall et al., 2020). Consequently, in 2020 alone, Ohio received $96 million in federal funding to fight the opioid crisis (Department of Mental Health and Addiction Services, 2020). The state has distributed this funding to both private and public sector organizations to help improve prevention, treatment, and recovery.
Medication for opioid use disorder (MOUD) is an evidence-based intervention that is the first-line treatment for OUD (Blanco & Volkow, 2019). Recent studies demonstrate that the effectiveness of MOUD at reducing overdoses and acute care utilization is superior to traditional approaches such as detoxification alone or behavioral therapy (Wakeman et al., 2020). Despite the strong evidence for the effectiveness of MOUD (Connery, 2015; Wakeman et al., 2020), multiple recent studies indicate that only a small proportion of eligible patients receive this treatment (Duber et al., 2018; Mauro et al., 2022). This disjuncture between MOUD as an evidence-based treatment and its low uptake points to the existence of substantial access and prescribing barriers. For example, patients seeking treatment for OUD face a variety of issues, ranging from societal stigma to psychiatric comorbidity (Sharma et al., 2017). Furthermore, while long-standing administrative barriers to prescribing MOUD were recently softened, clinicians still face a lack of comfort and professional support for prescribing medications like buprenorphine (Lanham et al., 2022). The current state of the opioid epidemic, alongside well-documented access and prescribing barriers for MOUD, necessitates the development of innovative care delivery approaches for patients with OUD.
There is increasing attention to the importance of understanding how to effectively design and implement optimal models for MOUD care delivery (Chou et al., 2016). Relatedly, delivery systems have recognized that MOUD can be initiated upon presentation to an emergency department (ED), during inpatient hospitalization for another health care episode, or integrated within the scope of primary care (Ahmed et al., 2019; Austin et al., 2023; Weimer et al., 2019). As individuals with OUD frequently have complex health care needs, incorporating MOUD more broadly across the spectrum of care (both inpatient and outpatient) may be critical to treatment success and meeting the health needs of this patient population. Despite these calls for comprehensive OUD care approaches, there are a variety of barriers to increasing MOUD access, ranging from the aforementioned individual- and clinical-level considerations like treatment stigma and clinician comfort to system-level issues such as organizational capacity and administrative commitment (Schmidt et al., 2012; Wyse et al., 2022). The successful implementation of novel care models can only occur by accounting for these notable barriers across all levels of the health care system.
The Ohio State Wexner Medical Center (a large urban health system) developed the “System-Wide MOUD Program” (SW-MOUD) in 2019 to address gaps in MOUD treatment delivery. The SW-MOUD program is a unique, coordinated approach to increasing the availability of MOUD and improving the health outcomes of patients with OUD through (a) the expansion of MOUD treatment across the medical center’s emergency departments, inpatient units, and ambulatory settings; and (b) coordinating care between treatment settings and specialties to support a comprehensive care team approach. Before 2019, several new and emerging clinical service lines provided MOUD initiations to patients. However, there was no coordinated MOUD strategy across these service lines. Each operated in a silo led by individual physicians with a passion for providing MOUD. As such, there was significant potential for a new coordinated care model to ensure that patients who receive MOUD within the health system remain connected to providers for long-term continuity of treatment.
In this article, we describe the implementation of the SW-MOUD program, in order to help inform the development of similar care delivery mechanisms for people with OUD in other health systems. First, we present the SW-MOUD care model, including characteristics of patients who have participated in the program as well as the patient flow diagram that the program team developed to ensure coordinated care across treatment sites. Next, we describe the program implementation process, including a timeline of key steps and notable challenges faced during program adoption as well as critical success factors. Last, we conceptualize the stages of the implementation process and outline the implementation strategies used during each of these stages. We mapped these strategies to the Expert Recommendations for Implementing Change (ERIC) implementation strategies (B. J. Powell et al., 2015) to support the continued understanding of implementation science in MOUD treatment programs. Our findings provide useful information for other health systems seeking to increase access to MOUD in their communities and promote retention in care by coordinating across existing care silos.
Method
> <h31 id="ser-22-4-761-d260e208">Site Context and Program Origins</h31>
This case study details the process of implementing the SW-MOUD program at the Ohio State Wexner Medical Center. The medical center spans seven hospitals with more than 1,500 beds, including two EDs, 22 primary care clinics, a clinic for pregnant women with OUD, and a facility dedicated to comprehensive drug and addiction recovery services. Medical center facilities are spread across the Columbus metropolitan area (which is composed of 10 central Ohio counties) but frequently serves patients across the state and even in some bordering states. Facilities are in a mix of high and low-socioeconomic status areas in the metropolitan region, with the seven hospitals and the drug and addiction recovery services building located near the urban center of Columbus.
Given the impact of the OUD epidemic in Ohio (Doogan et al., 2022), with the largest economic burden of all states in 2017 (Luo et al., 2021), health system leaders identified the need to develop a coordinated approach that ensured the widespread initiation of MOUD. Three departments within the health system originally submitted applications to a new quality improvement program funding mechanism through the state Medicaid program (IPRO, 2021). Health system leaders requested that these applications be combined into a single system-wide program. The specific program design and functions were developed by convening experts across clinical care for OUD, care delivery, and health administration into a SW-MOUD steering committee, which oversaw the entire program implementation process. At this point, the academic researchers who were involved in one of the three initial submissions joined the steering committee, bringing evaluation and health care delivery expertise to program development and serving as participant observers—an established qualitative method in implementation research (Hamilton & Finley, 2019). The academic researchers also led the evaluation of program uptake and its impacts on key inpatient outcomes. The SW-MOUD program officially began in early 2020. Originally, the program only included buprenorphine and naltrexone, with the incorporation of methadone for ED and inpatient settings occurring in late 2020.
<h31 id="ser-22-4-761-d260e226">SW-MOUD Program Care Model</h31>
Figure 1 displays the overall structure and organization of the SW-MOUD program, which operates across six service lines. The SW-MOUD implementation process included developing multiple new positions that operated across traditional areas, including care coordinators, MOUD social workers, and peer supporters. Patients enter the program after a provider identifies them as having OUD in any of the core service lines. Identification could occur from a variety of potential indications, including a patient’s primary complaints or reason for presenting, a prior diagnosis of OUD in the electronic health record, or from a referral for ongoing OUD care. By linking the service lines with coordinators and peer supporters, described below, the SW-MOUD program aligns continuous care for patients. For instance, a patient with OUD who presents at the ED (red/1st row in Figure 1) and is initiated for MOUD may receive a “warm handoff” at ED discharge to the inpatient withdrawal management facility for support during detoxification (orange/3rd row) or an ambulatory setting (dark blue/5th row) to achieve ongoing MOUD stabilization. Depending on the specific patient context, the specialty ambulatory care settings include (but are not limited to) a dedicated addiction medicine clinic, a palliative medicine clinic for people with OUD, or a program for individuals with OUD during pregnancy. This process is similar for a patient admitted to an inpatient medical hospital unit (light blue/2nd row): following MOUD initiation, the patient receives a warm handoff to program care coordinators who follow the patient across care settings. There may also be patients who present at an ED or inpatient setting in the process of withdrawal who would be eligible for admission to the inpatient withdrawal management facility to undergo detoxification and receive MOUD during their time at the unit. From there, program care coordinators can connect the patient to the same longer term stabilization options such as the addiction medicine treatment facility or the ambulatory addiction medicine clinic. Importantly, the rollout of these service lines did not occur simultaneously, due to a variety of program and system-level factors (see the Results section).
>
><anchor name="fig1"></anchor>
SW-MOUD program functions are achieved through both service line-specific staff such as clinicians and support workers in existing departments who work with MOUD and non-MOUD patients, as well as new program-specific staff who span service lines, including the peer supporters, MOUD social workers, and care coordinators represented in Figure 1 by shapes. Peer supporters (circles) provide emotional and relational support for patients undergoing treatment for OUD, serving as individuals who can provide a shared perspective on the recovery experience (Treitler et al., 2024). SW-MOUD peer supporters receive certification through the state mental health and addiction services agency. They work across the program’s main care settings, providing critical psychosocial support to individuals with OUD. MOUD social workers (diamonds) are often embedded in specific service lines but also work closely with the program to track patients and ensure proper handoffs between care sites. Finally, MOUD care coordinators (stars) focus on planning and executing patient transitions, working with both patients and clinicians to schedule follow-up appointments and address potential access limitations due to insurance, transportation, or other socioeconomic factors. MOUD care coordinators also guide patients across outpatient settings, for example, facilitating handoffs between primary care referrals (light blue/6th row) and MOUD services at the addiction medicine clinic (dark blue/5th row).
<h31 id="ser-22-4-761-d260e244">Data Collection and Analysis</h31>Using the methods of participant observation noted above, the academic researchers BPO, THH, and JLF took notes at weekly meetings on key decisions, issues, and programmatic changes. They also engaged in implementation planning with program leaders and staff to create program workflow documents and develop evaluation steps, which included periodic collection and analysis of electronic health record data to track inpatient outcomes among individuals with OUD. To have a more complete understanding of day-to-day program functions and the implementation trajectory, the academic researchers conducted interviews with five key program staff members: two care coordinators, one MOUD social worker, one peer supporter, and the program coordinator. We designed these interviews to provide insight into how the program was working on the front lines, to supplement our own accounts of how the program was intended to work. Interviews were semistructured and lasted between 30 minutes and an hour. The initial interview guide focused on the staff’s main day-to-day functions, how the job description aligned with their actual role, who each staff member tends to work the most with, difficulties that have arisen with aiding in the recovery of patients experiencing OUD, and perceptions on the main successes and difficulties of the program itself. While these questions were the main substance of the interviews, follow-ups and probing questions were also employed to clarify parts of responses or to elicit more detail on the day-to-day functioning of the program.
The first author conducted virtual interviews on Zoom in late 2022 and early 2023. After engaging in memo-writing during the interview (Birks et al., 2008), the memos were analyzed via rapid qualitative analysis (Lewinski et al., 2021; St George et al., 2023), in which answers to specific implementation questions were compared across interviewees using a visual matrix format to identify common themes. We then confirmed these themes with notes from the SW-MOUD program leadership team meetings and the authors’ own experiences with developing and implementing the SW-MOUD program. From this analysis, we identified core challenges and potential success factors for proper program design and functioning. These factors represent key insights from our own implementation experience that can serve as important guides for the start-up of similar organizational mechanisms in other health systems around the country.
Finally, we developed a table of implementation strategies that supported the program and the members of program leadership responsible for each component. Additionally, we mapped implementation strategies from the ERIC project onto these SW-MOUD implementation strategies utilized by the team (B. J. Powell et al., 2015). Two authors independently matched SW-MOUD implementation strategies within each phase to existing ERIC strategies. Following this, the authors met and discussed discrepancies. When the two authors did not agree on the applicable strategy, they reached consensus through extensive discussion.
Results
> <h31 id="ser-22-4-761-d260e266">Program Statistics</h31>
Between 2020 and 2023, a total of 4,908 initiations for MOUD occurred as part of the SW-MOUD program. The average age at time of initiation was 40.5 years. Patients were more commonly male (54.0%) than female (46.0%). Furthermore, 81.6% of patients were white, 14.7% were African American, and 3.2% identified as other races or multiracial. Only 1.5% were of Hispanic origin. Buprenorphine was the most common medication used (91.4%) followed by methadone (8.1%) and naltrexone (0.47%). 71.2% of patients who received initiations were current smokers, and another 18.3% were former smokers. There is variation in patient residence: 53.9% lived in the main urban county where the health system hospitals are located and 64.8% come from the overall metropolitan area (including the main urban county), meaning 35.2% of patients lived outside the metropolitan area where the health system is located. Finally, the most common insurance type during inpatient admissions for individuals who received MOUD during the study period was Medicaid (77.0% of admissions), followed by Medicare (16.6%). Only 4.7% of individuals used private insurance during their admissions, and 1.7% used other sources such as self-pay. The distribution of initiations across service lines was not even, with 10.0% occurring in the ED, 39.8% in the medical hospital inpatient units, 23.6% in the inpatient withdrawal management unit, 6.1% in the addiction medicine treatment facility, 17.1% in ambulatory settings (including 1.7% from the addiction medicine clinic specifically), and 1.7% from other system primary care providers. A total of 11 program staff were hired across the three key program roles as of 2023: four peer supporters, two care coordinators, and five MOUD social workers. Peer supporters and MOUD social workers were placed across various hospitals, emergency departments, and clinics within the health system, while care coordinators worked across the entire system. Peer supporters employed through the program had 1,828 patient contacts in 2023, up from 492 in 2022 when they were hired full-time around midyear. Additionally, MOUD care coordinators contacted 481 patients in 2023 to facilitate transitions between care sites and manage potential access barriers, up from 286 in 2022. Individual social worker contacts were not available at the time of this publication.
<h31 id="ser-22-4-761-d260e270">SW-MOUD Timeline, Challenges, and Success Factors</h31>
Figure 2 displays the overall implementation timeline, challenges, and success factors. This timeline details important program milestones, the accompanying evaluation process, and challenges and success factors that affected the rollout and functioning of the SW-MOUD program. Funding approval for the SW-MOUD program occurred in the Spring of 2020, though some components, such as the inpatient MOUD consult team, began earlier in 2019. Full-time care coordinators were hired in 2021. Peer supporters were originally contracted through an external organization starting in 2019, with the hiring of full-time peer supporters occurring in early 2022. The addiction medicine clinic opened in late 2021. The final expansion of the program occurred in 2022 when the main hospital ED was added. The other system ED, located at the same hospital as the addiction medicine treatment facility (see Figure 1), participated in the program at its inception because that location was initiating patients on MOUD before 2020. The bottom section of Figure 2 outlines the evaluation process over time. This includes tasks related to analyzing patient outcomes in the program, examining different care processes, and finding key areas for program improvement.
>
><anchor name="fig2"></anchor>
Red brackets in Figure 2 signify important periods within the implementation timeline where potential challenges to proper program functioning required management or mitigation by the program leadership team. First, as it did around the world, the COVID-19 public health emergency placed substantial stress on the health system, including staffing shortages and reallocation of hospital resources such as bed space. Even after the most acute stages of the pandemic, financial restrictions such as hiring freezes remained in place. These pandemic-related shifts in health system functioning impacted the implementation of the SW-MOUD program, resulting in at times modified functions (such as when inpatient withdrawal management floors were temporarily transformed into COVID-19 treatment units) and delays in hiring for key program roles.
On the program level, proper coordination and workflow were not immediate or inevitable. Specifically, central to proper program function was the integration of existing service line staff and functions with new program-specific staff and functions (Figure 2). Given this need for integration, we found that program functions were not immediately cohesive—a necessary developmental step was a period of “role specification” where program staff learned their tasks and how to interface with existing workflows. For example, optimizing the handoff between MOUD social workers, who help to address psychosocial needs and care plans during a patient’s stay, and care coordinators, whose main objective was to connect patients across different care settings, took time before coming together concordantly. A related challenge to program integration was resistance from some departments and clinicians to utilizing MOUD consult services, including peer support, as these program staff roles were new to their clinical workflows. On the evaluation component of program implementation, there were early difficulties in assessing the degree of program success and patient outcomes. This was partially attributable to the COVID-related rollout delays. While the evaluation plan began to assess the overall number of initiations occurring and potential impacts on inpatient outcomes, analyzing the more disparate benefits of the program continues to remain a challenge (see the Discussion section)
The green brackets in the implementation timeline highlight key successes that occurred across the entire rollout and sustainability periods of the program implementation (Figure 2). This includes having a consistent core program team that spans clinical, administration, and evaluation expertise, and the centering of specific site context when developing the SW-MOUD program. Given the health system challenges during the COVID-19 pandemic, and as program functions underwent integration with existing health system functions, program leaders recognized that a consistent core team was vital across all stages of implementation. Additionally, program staff frequently described during interviews that the ability to successfully coordinate MOUD treatment across different settings and specific patient situations required careful attention to the health system and the broader community’s available resources.
<h31 id="ser-22-4-761-d260e298">Tailoring Strategies to Support SW-MOUD</h31>The overarching development and implementation of a system-wide MOUD delivery approach required careful planning, organization, and adaptability. Recognizing the complexity of this implementation process and the inherent difficulties associated with the integration of new care functions with existing health system workflows, we provide a detailed description of the strategies used during the different phases of the implementation and an in-depth description of how they were tailored and operationalized within the team (Table 1). This was based on the experiences of the program leadership team as they navigated the entire implementation process and its (expected and unexpected) challenges. The program implementation consisted of three main stages:
>
><anchor name="tbl1"></anchor>
The
Discussion
>
The SW-MOUD program represents a novel care delivery model that can serve to alleviate the common barriers to coordinated MOUD delivery. In the first 4 years of the program, nearly 5,000 initiations of MOUD occurred across emergency, inpatient, and outpatient care settings. Although some embedded program staff, such as care coordinators and peer supporters, did not begin work until after the official program start date, the substantial number of patient contacts in 2022 and 2023, alongside the overall number of MOUD initiations, suggest rapid uptake of the program. Our timeline and implementation guide provide generalized information about the experience of developing, implementing, and adapting the SW-MOUD program over time. Our case study provides insight into the experience of a team of behavioral health, substance use disorder, internal medicine, and administrative experts during the implementation of a novel approach to providing treatment for OUD. While our study did not utilize traditional implementation science approaches to identifying barriers and facilitators, the team did experience and report challenges and critical success factors during the implementation of this program. As established in Figure 2 and Table 1, the SW-MOUD program implementation process was effective due to multiple key success factors. The existence of a consistent group of clinical and administrative leaders was central to the overall success of the SW-MOUD program. Existing accounts of implementation success in health care institutions frequently point to the necessity of high-quality leadership at multiple organizational levels (O’Reilly et al., 2010). The SW-MOUD program leadership team included clinicians from each service line, the program manager, and members of the evaluation team. This consistent steering committee ensured the coordination of program functions across existing units as they came into existence and mitigated potential challenges as they arose.
A second identified success factor was the emphasis on tailoring the program and implementation strategies to the specific considerations of the region and community. Without a proper understanding of the patient population’s particular needs and the resources available in the surrounding area, adequate care coordination would not be possible. For example, program leaders developed relationships with local skilled nursing facilities to ensure the continuation of MOUD for patients transitioning from acute to long-term care. While not necessarily generalizable beyond our program, these factors may provide valuable information for the development of other MOUD care delivery programs.
Our results (Figure 2) also identified the challenges our team faced during program implementation. These challenges did not inhibit the development of the program but did require a more flexible implementation process, including a more gradual adoption timeline than initially anticipated, and difficulties with assessing program outcomes early on. One of the significant challenges that the team faced was related to managing the pandemic-related resource constraints such as hiring freezes, funding limitations, and hospital capacity. While the team experienced these challenges within the context of the COVID-19 pandemic, they are common issues for health systems to face. Leaders interested in adopting a system like ours should anticipate facing such challenges and as a result should incorporate team members who can be flexible, manage uncertainty, and have the ability to activate nontraditional approaches to problem-solving. Similarly, the “role specification” period we describe in the results is not an uncommon phenomenon when implementing and going through organizational change, particularly as it refers to managing resistance to new care delivery functions among external departments and staff (Battilana & Casciaro, 2013). Resistance to change should be viewed as a normal component of program implementation that could be mitigated by strong leaders who attempt to work across all facets of the organization rather than focusing strictly on the new program functions (Battilana & Casciaro, 2013; DuBose & Mayo, 2020). Provider and staff education could represent one valuable mechanism to help disseminate information about the benefits of the program across the system and help break down existing stigma toward patients with OUD (Livingston et al., 2012). Additionally, there may be opportunities to continue refining program functions after integration into the existing workflows is complete, including improvements to OUD identification across all service lines.
Another challenge faced by the program team was difficulty assessing overarching program success and outcomes. The direct patient impacts of MOUD initiation were easily identifiable; a retrospective analysis using system electronic health records data demonstrated meaningful reductions in unplanned inpatient readmission rates among patients who received MOUD, relative to individuals with OUD who were not initiated for MOUD (O’Rourke et al., 2022). However, other program outcomes were more nuanced: changes to inpatient length of stay were inconsistent, a potential effect of increased treatment adherence among patients with OUD but not one that could be easily measured. Further, the “indirect” benefits of the program were even more difficult to assess. Patients who never received MOUD at the health system likely benefitted from care coordination functions as well as the availability of peer supporters. A recent study proposed that even the existence of an addiction consult service in a health system offers numerous disparate benefits that go beyond patient outcomes, including better staff recruitment and more robust education for clinician trainees (Terasaki et al., 2023). The widespread utilization of MOUD as part of the program, along with other modifications to existing service lines in order to enhance access, may have contributed to the gradual destigmatization of OUD care. Future evaluation work for this program can continue to comprehensively assess program impacts, including better understanding the proportion of patients with OUD in the system who do not receive MOUD. Additionally, as programs similar to the SW-MOUD program become more widely adopted, studies examining various cases may help conceptualize the barriers faced when approaching OUD treatment across the delivery system, and facilitators that ensure smooth implementation of programs. Our results highlight the challenges faced by our team and areas of success, but there is a need to systematically understand, across a variety of contexts, the experiences of clinicians and leaders when trying to implement innovations related to OUD treatment.
The incorporation of ERIC strategies within the implementation guide demonstrates that our generalized steps frequently align with the implementation science literature on the effective generation and sustainment of programs. We identified 22 different strategies utilized to implement the program. It is important to recognize that the system-wide nature of our intervention may create a unique implementation environment that cannot be entirely captured by ERIC strategies, which are more centered on single-site interventions or psychosocial strategies. Implementation science and behavioral health researchers have called for a more detailed understanding of how ERIC strategies are tailored to overcome barriers faced during implementation (Hynes & Thomas, 2023; B. J. Powell et al., 2019, 2021). Our study provides an in-depth description of the tailored implementation strategies, and how they were operationalized within the distinct stages of the implementation. Further studies can examine if different strategies are effective in supporting the implementation of evidence-based interventions, such as MOUD, across multiple departments/service lines within a health system.
One of the central components of implementation durability is the availability of a secure funding stream (Rapp et al., 2010). The SW-MOUD program is currently funded through the Care Innovation and Community Improvement Program, a Centers for Medicare and Medicaid Services-Ohio Department of Medicaid quality improvement funding mechanism, designed “to drive innovation in health care for Medicaid” with a particular focus on the treatment of OUD (IPRO, 2021). These funds were critical for securing the resources for programmatic success, such as hiring personnel and promoting overall institutional buy-in to the program. This is important to note for our case study, as traditional insurance reimbursement through both private payer and public insurance programs does not provide sufficient funding to support comprehensive programs to the full extent that we delivered. Policymakers interested in supporting MOUD in their communities should consider how to increase widespread funding opportunities so more health systems can consider our innovative care model.
Conclusions
>
The design and implementation of the SW-MOUD program can serve as a model for the development of improved approaches to provisioning care in a patient population with substantial access barriers. Leveraging evidence-based treatment practices such as MOUD to develop coordinated care delivery mechanisms is an ongoing opportunity for health systems to improve care for high-need patient populations, albeit one that comes with substantial challenges. While the specific, contextual needs of the patient population should always drive the design of these programs, there are important lessons to learn from our SW-MOUD program. Future work will continue to build on these outcomes, including a focus on medication adherence over time. Developing, implementing, and evaluating system-wide programs, while difficult, offers significant potential to ameliorate the outsized impacts of the opioid epidemic in the United States.
References
<anchor name="c1"></anchor>Ahmed, O. M., Mao, J. A., Holt, S. R., Hawk, K., D’Onofrio, G., Martel, S., & Melnick, E. R. (2019). A scalable, automated warm handoff from the emergency department to community sites offering continued medication for opioid use disorder: Lessons learned from the EMBED trial stakeholders.
Austin, E. J., Chen, J., Briggs, E. S., Ferro, L., Barry, P., Heald, A., Merrill, J. O., Curran, G. M., Saxon, A. J., Fortney, J. C., Ratzliff, A. D., & Williams, E. C. (2023). Integrating opioid use disorder treatment into primary care settings.
Battilana, J., & Casciaro, T. (2013). Overcoming resistance to organizational change: Strong ties and affective cooptation.
Birks, M., Chapman, Y., & Francis, K. (2008). Memoing in qualitative research: Probing data and processes.
Blanco, C., & Volkow, N. D. (2019). Management of opioid use disorder in the USA: Present status and future directions.
Centers for Disease Control. (2022, March1).
Chou, R., Korthuis, T. P., Weimer, M., Bougatsos, C., Blazina, I., Zakher, B., Grusing, S., Devine, B., & McCarty, D. (2016).
Connery, H. S. (2015). Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions.
Department of Mental Health and Addiction Services. (2020, August31).
Doogan, N. J., Mack, A., Wang, J., Crane, D., Jackson, R., Applegate, M., Villani, J., Chandler, R., & Barocas, J. A. (2022). Opioid use disorder among Ohio’s medicaid population: Prevalence estimates from 19 counties using a multiplier method.
Duber, H. C., Barata, I. A., Cioè-Peña, E., Liang, S. Y., Ketcham, E., Macias-Konstantopoulos, W., Ryan, S. A., Stavros, M., & Whiteside, L. K. (2018). Identification, management, and transition of care for patients with opioid use disorder in the emergency department.
DuBose, B. M., & Mayo, A. M. (2020). Resistance to change: A concept analysis.
Hall, O. T., Hall, O. E., Kolodny, A., Teater, J., & McGrath, R. P. (2020). Assessment of excess mortality associated with drug overdose in Ohio from 2009 to 2018.
Hamilton, A. B., & Finley, E. P. (2019). Qualitative methods in implementation research: An introduction.
Hynes, D. M., & Thomas, K. C. (2023). Realigning theory with evidence to understand the role of care coordination in mental health services research.
IPRO. (2021).
Lanham, H. J., Papac, J., Olmos, D. I., Heydemann, E. L., Simonetti, N., Schmidt, S., & Potter, J. S. (2022). Survey of barriers and facilitators to prescribing buprenorphine and clinician perceptions on the Drug Addiction Treatment Act of 2000 waiver.
Lewinski, A. A., Crowley, M. J., Miller, C., Bosworth, H. B., Jackson, G. L., Steinhauser, K., White-Clark, C., McCant, F., & Zullig, L. L. (2021). Applied rapid qualitative analysis to develop a contextually appropriate intervention and increase the likelihood of uptake.
Livingston, J. D., Milne, T., Fang, M. L., & Amari, E. (2012). The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review.
Luo, F., Li, M., & Florence, C. (2021). State-level economic costs of opioid use disorder and fatal opioid overdose—United States, 2017.
Mauro, P. M., Gutkind, S., Annunziato, E. M., & Samples, H. (2022). Use of medication for opioid use disorder among us adolescents and adults with need for opioid treatment, 2019.
O’Reilly, C. A., Caldwell, D. F., Chatman, J. A., Lapiz, M., & Self, W. (2010). How leadership matters: The effects of leaders’ alignment on strategy implementation.
O’Rourke, B. P., Hogan, T. H., Teater, J., Fried, M., Williams, M., Miller, A., Clark, A. D., Huynh, P., Kauffman, E., & Hefner, J. L. (2022). Initiation of medication for opioid use disorder across a health system: A retrospective analysis of patient characteristics and inpatient outcomes.
Powell, A.-L., Hinger, C., Marshall-Lee, E. D., Miller-Roberts, T., & Phillips, K. (2021). Implementing coordinated specialty care for first episode psychosis: A review of barriers and solutions.
Powell, B. J., Fernandez, M. E., Williams, N. J., Aarons, G. A., Beidas, R. S., Lewis, C. C., McHugh, S. M., & Weiner, B. J. (2019). Enhancing the impact of implementation strategies in healthcare: A research agenda.
Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project.
Rapp, C. A., Etzel-Wise, D., Marty, D., Coffman, M., Carlson, L., Asher, D., Callaghan, J., & Holter, M. (2010). Barriers to evidence-based practice implementation: Results of a qualitative study.
Schmidt, L. A., Rieckmann, T., Abraham, A., Molfenter, T., Capoccia, V., Roman, P., Gustafson, D. H., & McCarty, D. (2012). Advancing recovery: Implementing evidence-based treatment for substance use disorders at the systems level.
Sharma, A., Kelly, S. M., Mitchell, S. G., Gryczynski, J., O’Grady, K. E., & Schwartz, R. P. (2017). Update on barriers to pharmacotherapy for opioid use disorders.
St George, S. M., Harkness, A. R., Rodriguez-Diaz, C. E., Weinstein, E. R., Pavia, V., & Hamilton, A. B. (2023). Applying rapid qualitative analysis for health equity: Lessons learned using “EARS” with Latino communities.
Terasaki, D., Hanratty, R., & Thurstone, C. (2023). More than MAT: Lesser-known benefits of an inpatient addiction consult service.
Treitler, P., Crystal, S., Cantor, J., Chakravarty, S., Kline, A., Morton, C., Powell, K. G., Borys, S., & Cooperman, N. A. (2024). Emergency department peer support program and patient outcomes after opioid overdose.
Tsai, B. (2024, May15). U.S. overdose deaths decrease in 2023, first time since 2018
Wakeman, S. E., Larochelle, M. R., Ameli, O., Chaisson, C. E., McPheeters, J. T., Crown, W. H., Azocar, F., & Sanghavi, D. M. (2020). comparative effectiveness of different treatment pathways for opioid use disorder.
Weimer, M., Morford, K., & Donroe, J. (2019). Treatment of opioid use disorder in the acute hospital setting: A critical review of the literature (2014–2019).
Wyse, J. J., Mackey, K., Lovejoy, T. I., Kansagara, D., Tuepker, A., Gordon, A. J., Todd Korthuis, P., Herreid-O’Neill, A., Williams, B., & Morasco, B. J. (2022). Expanding access to medications for opioid use disorder through locally-initiated implementation.