CONDUIT

CONSORTIUM TO DISSEMINATE AND UNDERSTAND IMPLEMENTATION OF TREATMENT OF OPIOID USE DISORDER

The goal of CONDUIT-APEX, formerly known as “APEX”, was to address the “VA Priority Goal” of improving access to medication treatment for OUD (MOUD). In VISN19, our focus is to specifically improve access in VA primary care settings and community-based outpatient clinics (CBOC).

METHODOLOGY

CONDUIT-APEX investigators conducted several implementation strategies to improve access to medication-assisted therapy at the VA.

Individualized Physician Training Support
VA Care providers had the opportunity to access mentorship opportunities, attend buprenorphine wavier trainings (X-Waiver), and participate in OUD webinars and journal clubs.

Hub and Spoke MAT Implementation
The Hub-and-Spoke Model allows Community Based Outpatient Clinics (CBOC) primary care providers (the spoke) three different ways to personalize patient treatment. Providers were given the opportunity to...

Refer OUD patients to the Salt Lake City Veterans Administration Health Care System (SLCVAHCS) providers (the hub) for permanent empanelment,
Refer patient for to SLCVAHCS for stabilization and then resume providing treatment once the patient has been stabilized.
Receive personalized e-consultation from an addiction care specialist to assist in developing a treatment plan for specific patients being treated at local CBOC.

RESOURCES

The VISN19 CONDUIT-APEX implementation team provided several strategies for Primary Care Clinics and providers to improve access to medication treatment of opioid use disorder.

Prescriber Training and Education

The VISN19 CONDUIT-APEX team hosted monthly webinars and journal clubs on topics related to OUD care in collaboration with the national MAT-VA Initiative. The team also assisted prescribers in identifying buprenorphine waiver (“X waiver”) training opportunities and was able to provide this training in-person at VISN clinics upon request.

Individualized Prescriber Consultation

In addition to training and education, the VISN19 CONDUIT-APEX team staffed the VISN19 Opioid Safety Consultation Program. Prescribers or other VA healthcare providers could submit a brief consultation request and were contacted by an expert clinician within 24-48 hours for a telephone consultation.

Site Kick-off Facilitation

Site kick-off events can bring together key stakeholders in a VA system to address barriers and create action plans to improve access to OUD treatment. Using a combination of in-person and virtual meetings, the VISN19 CONDUIT-APEX team guided an interactive, productive kick-off meeting for VISN19 health systems. Sites were given the opportunity to receive personalized follow-up support after kick-off events if desired.

Hub and Spoke MOUD Implementation

Each of the strategies above was chosen to support an effective, sustainable, system-wide program using the Hub-and-Spoke Model, which allows primary care providers to care for Veterans with OUD while referring to and collaborating with specialty providers. The VISN19 CONDUIT team aims to work with key stakeholders at all levels to make progress toward the priority goal of improved access to OUD treatment.

PAST IMPACTS

CBOC Site Visits

VISN19 CONDUIT-APEX conducted six visits to CBOC’s located in VISN19. During these visits, over 62 practitioners received training and SUD instruction. Providers were also educated on how to use the three different “Hub and Spoke Models” that are now available in VISN 19. CBOC’s were also provided information about X-Waiver Training, information about monthly SUD webinars, and informed about mentorship opportunities available to assist PCPs in implementing SUD treatment.

MOUD Primary Care Conference

Knowledge taken from CBOC visits led to the planning and creation of a local SUD conference that was held twice in July of 2019 called “Addressing Addiction in Primary Care”. The conference provided local CBOC providers and staff an opportunity to more thoroughly learn how to better integrate Veteran-centered addiction care in their primary care setting. 49 CBOC providers and staff received specific training on…

The role of PC in addiction treatment
How to identify addicted patients in a provider’s panel
Addressing opioid use vs. opioid misuse vs. opioid use disorder
Pain management, chronic pain – The intersection of pain and addiction
OUD Medications and their proper use
Complex Patients-Hub & Spoke MAT Model

Attendees were provided with a packet of MAT/OUD informational materials as well as the presentation slides for future reference. Each participant was also eligible for 3.75 hours of CME provided by the University of Utah at no cost to participants.

Overall the response to the conference was very positive with 92% (12 out of 13) of the post-survey respondents stating that they would recommend the conference to other primary care providers and staff. 76% (10 out 13) of respondents also stated that they felt more empowered to treat OUD in a primary care setting. Respondents also expressed interest in a local X-wavier training and also asked that future conferences include more information on tapering, VA resources, and protocols.

Veteran Experiences with OUD Treatment in Primary Care

VISN19 CONDUIT in conjunction with Vulnerable Veteran Innovative Pact Team (VIP) completed interviews with 35 Veterans in Salt Lake City about their experience with MOUD in primary care settings at the VA. The interviews concluded that Veterans were generally pleased with the ORT they received. Veterans reported that the treatment was convenient, personalized, and that they felt like they were included in the decision-making process. Future efforts and studies are required to get a better understanding on the patient experience of having ORT transitioned to primary care.

VA Provider Experiences with OUD Treatment

Collecting primary care team member’s perspectives is to key to understand barriers and facilitators to implementing the medication treatment of OUDs; and key in understanding factors that influence successful implementation of medication treatment of OUD. Thus, we have been conducting in-depth qualitative interviews with VA primary care teams to understand their perspectives on implementing medication treatment of opioid use disorder at designated implementation sites. To date the VISN19 CONDUIT team has completed interviews with 10 VA healthcare providers with the goal to interview a total of 24 providers. When this work is complete CONDUIT-APEX will generate a summary of themes and highlight salient factors that impact MOUD implementation for dissemination to VISN 19 facilities and CBOCs.

MAT-VA Webinars Partnership

CONDUIT-APEX developed a partnership with the Medication Assisted Treatment-In the VA (MAT-VA) program in 2018. Since that time over 70 webinars have been hosted in conjunction with MAT-VA on a variety of OUD and SUD topics. Over 7500 attendees have participated, and each webinar has been recorded and made available on the MAT-VA SharePoint page.

PROGRAM EFFORTS

CBOC Site Kick off Conferences

CONDUIT-APEX would like to offer an expanded version of the July 2019 Addiction in Primary Care Conference to all the CBOC’s and facilities in VISN19. CONDUIT-APEX set aside funds to visit facilities over the next 2 years to offer this educational service. Conferences would include:

*Workshop on Pain*	The goal of this workshop is to expose providers and staff to some of the basics of OUD care in primary care settings. The Stepped Care Model of Pain Management, developed by the SCOUTT program, will be highlighted in detail. Foundational topics such as pain, non-opioid based treatments, and current research will be covered.
*Workshop on Addiction and Primary Care*	The goal of this workshop is to improve Veteran access to medication treatment outside the confines of specialty addiction care and move such treatment to primary care as much as possible. As such, the objectives of this workshop are to reduce barriers to OUD treatment implementation via training on: The role of primary care in addiction treatment How to identify patients at risk of OUD in a provider’s panel Addressing opioid use vs. opioid misuse vs. opioid use disorder Pain management, chronic pain – The intersection of pain and addiction OUD Medications and their proper use Complex Patients-Hub & Spoke MAT Model Review the BUP Notice
*X-Waiver Training (If requested)*	Adam Gordon, a co-PI of this project, is a registered Providers Clinical Support System (PCSS) instructor. This allowed Dr. Gordon the opportunity to offer X-Waiver Training to clinical providers. These trainings could be held in two formats: an 8-hour in-person course or a “Half and Half” course where the in-person portion lasts 4 hours and is followed up with a 4-hour online portion. This course was offered at no charge.
*Resource Presentations*	This workshop covered some of the resources available to VA providers. The MAT-VA Journal Club, BUP Volunteer Listing, VIP Chats, Catalog of SUD/OUD Webinars will be shared. The MAT-VA, VIP, SCOUTT SharePoint pages, and Opioid Safety Warmline (When Operational) were introduced as important MOUD resources.

*These workshops were developed so that any VA staff member can join. Facilities are encouraged to permit all staff who wish to attend an opportunity to do so.

Outreach to more VISN19 CBOCs

In conjunction with the Site Kick Off Conferences CONDUIT-APEX has developed a weekly office hour program for each facility that participates in the conference. This office hour program would last roughly one year for each site and would act as a sounding board for issues and questions the CBOC sites and facilities may encounter while implementing MOUD treatment in Primary Care. The office hour is staffed with MOUD subject matter experts and coordinating staff to help empower CBOC providers and staff to offer the best MOUD care possible.

Denver, CO -Corresponding PI:

Salt Lake City, UT -Corresponding PI:

Operational Partners:

Research Team:

Joseph Frank, MD, MPH

Adam Gordon, MD, MPH,

VISN19, Rocky Mountain VA Network.

Matthew Dungan, MPH, CPH

Mary Nunnery, MPH (Colorado VA)