Patient and pharmacist perspectives on opioid misuse screening and brief interventions in community pharmacies.

BACKGROUND: Pharmacy-based screening and brief interventions (SBI) offer opportunities to identify opioid misuse and opioid safety risks and provide brief interventions that do not overly burden pharmacists. Currently, such interventions are being developed without patient input and in-depth contextual data and insufficient translation into practice. The purpose of this study is to qualitatively explore and compare patient and pharmacist perceptions and needs regarding a pharmacy-based opioid misuse SBI and to identify relevant SBI features and future implementation strategies. METHODS: Using the Consolidated Framework for Implementation Research, we conducted semi-structured interviews with 8 patients and 11 pharmacists, to explore needs and barriers to participating in a pharmacy-based SBI. We recruited a purposive sample of English-speaking patients prescribed opioids for chronic or acute pain and pharmacists practicing in varied pharmacies (small independent, large-chain, specialty retail) settings. We used an inductive content analysis approach to analyze patient interview data. Then through a template analysis approach involving comparison of pharmacist and patient themes, we developed strategies for SBI implementation. RESULTS: Most patient participants were white, older, described living in suburban areas, and were long-term opioid users. We identified template themes related to individual, interpersonal, intervention, and implementation factors and inferred applications for SBI design or potential SBI implementation strategies. We found that patients needed education on opioid safety and general opioid use, regardless of opioid use behaviors. Pharmacists described needing patient-centered training, protocols, and scripts to provide SBI. A short-self-reported screening and brief interventions including counseling, naloxone, and involving prescribers were discussed by both groups. CONCLUSIONS: Through this implementation-focused qualitative study, we identified patient needs such as opioid safety education delivered in a private and convenient format and pharmacist needs including training, workflow integration, protocols, and a time-efficient intervention for effective pharmacy-based SBI. Alternate formats of SBI using digital health technologies may be needed for effective implementation. Our findings can be used to develop patient-centered pharmacy-based SBI that can be implemented within actual pharmacy practice.

An Implementation-Focused Qualitative Exploration of Pharmacist Needs Regarding an Opioid Use Disorder Screening and Brief Intervention.

BACKGROUND: Screening and brief interventions (SBI) can help identify opioid safety risks and healthcare professionals can accordingly intervene without a significant increase in workload. Pharmacists, one of the most accessible healthcare professionals, are uniquely positioned to offer SBI. To design an effective intervention with high potential for implementation, we explored pharmacist needs and barriers regarding SBI for opioid use disorders. METHODS: Using the Consolidated Framework for Implementation Research (CFIR), we conducted 11 semi-structured 60-minute interviews with community pharmacists. We used a purposeful sample of English-speaking pharmacists practicing in varied pharmacies (small independent, large-chain, specialty-retail) and positions (managers, owners, full-time/part-time pharmacists). Transcriptions were analyzed using deductive content analysis based on CFIR constructs, followed by inductive open coding. Utilizing a theoretical framework for data collection and analysis, a diverse sample of pharmacist roles, peer debriefing, and 2 independent coders for each transcript, altogether increased the credibility and transferability of our research. Data collection and analysis continued until data saturation was achieved. RESULTS: Pharmacists described good working relationships with colleagues, organization cultures that were open to new initiatives, and believed the SBI to be compatible with their organization goals and pharmacy structure, which are facilitators for future SBI implementation. Pharmacists were motivated by improved patient outcomes, more patient interaction and clinical roles, representing facilitators at the individual level. They also described stigma toward patients, mixed need for change, and lack of knowledge regarding SBI, which are potential barriers to be addressed. Pharmacists believed that the SBI model was adaptable, not complicated, and benefits outweighed implementation costs. CONCLUSIONS: We addressed current SBI literature gaps-mainly lack of focus on implementation and contextual data, through rigorous implementation-focused qualitative research. Our exploratory findings have direct implications on future pharmacy-based SBI implementation.

Moving behavioral interventions in nursing homes from planning to action: a work system evaluation of a urinary tract infection toolkit implementation.

BACKGROUND: Implementation evaluations based on a hybrid deductive-inductive approach provide a detailed understanding of organizational choices to introduce and implement complex interventions and may help explain implementation success or failure. However, such evaluations may not be feasible due to resource constraints. Qualitative analyses of artifacts collected for other purposes during implementation may represent a cost-effective method to understand program implementation when robust evaluations are not feasible. This study used a work systems evaluation of how nursing homes (NHs) implemented a urinary tract infection (UTI) recognition and management improvement toolkit. METHODS: Thirty NHs participated in a randomized control trial in which intervention NHs (n = 12) were assigned a clinical coach who employed a standard template to structure coach calls with the NH champion. A hybrid inductive-deductive approach, using the Systems Engineering Initiative for Patient Safety (SEIPS) model, characterized three action domains related to (1) engagement of staff and providers, (2) distribution of toolkit elements, and (3) toolkit use. RESULTS: A total of 369 coded segments from 148 coach notes generated by three coaches working with 18 NH champions were examined. Planned changes (n = 203) were more frequent compared to actual changes (n = 169). While most NHs quickly engaged staff and providers, which leadership appeared to support, engagement actions were hindered in some NHs due to champion instability or extended champion or medical director absences. Dissemination of materials to family and providers and distribution of tools to staff occurred quickly in 75% of NHs, although delays were encountered in some NHs, usually because of champion instability. CONCLUSIONS: Implementing NH practice change is challenging, and studies examining actions to support planned versus actual change in this setting are limited. The application of the SEIPS model to coach notes collected during the implementation of a structured behavioral intervention to improve the recognition and management of UTI in NHs generated unique insights into the work system and how staff attempted to implement changes. This study identified several factors that interfered with progression from planning to actual change. Future studies are needed to better understand how to best support change interventions in NHs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03520010 , Registered May 9, 2018.

Adapting the stages of implementation completion to an evidence-based implementation strategy: The development of the NIATx stages of implementation completion.

Background: Dissemination and implementation frameworks provide the scaffolding to explore the effectiveness of evidence-based practices (EBPs) targeting process of care and organizational outcomes. Few instruments, like the stages of implementation completion (SIC) examine implementation fidelity to EBP adoption and how organizations differ in their approach to implementation. Instruments to measure organizational competency in the utilization of implementation strategies are lacking. Method: An iterative process was utilized to adapt the SIC to the NIATx implementation strategies. The new instrument, NIATx-SIC, was applied in a randomized controlled trial involving 53 addiction treatment agencies in Washington state to improve agency co-occurring capacity. NIATx-SIC data were reported by state staff and external facilitators and through participating agency documentation. Proportion and duration scores for each stage and phase of the NIATx-SIC were calculated for each agency. Competency was assessed using the NIATx fidelity tool. Comparisons of proportion, duration, and NIATx activities completed were determined using independent sample t-tests by agency competency level. Results: The NIATx-SIC distinguished between agencies achieving competency (n = 23) and those not achieving competency (n = 26). Agencies achieving competency completed a greater proportion of implementation phase activities and had a significantly longer Stage 7 duration. These agencies participated in significantly more individual and group coaching calls, attended more in-person meetings, implemented more change projects, and spent approximately 64 more days, on average, engaging in all NIATx activities. Conclusions: Organizational participation in dissemination and implementation research requires a significant investment of staff resources. The inability of an organization to achieve competency when utilizing a set of implementation strategies waste an opportunity to institutionalize knowledge of how to apply implementation strategies to future change efforts. The NIATx-SIC provides evidence that competency is not an attribute of the organization but rather a result of the application of the NIATx implementation strategies to improve agency co-occurring capacity. Trial Registration: ClinicalTrials.gov, NCT03007940. Registered January 2, 2017, https://clinicaltrials.gov/ct2/show/NCT03007940.

Access to integrated services for persons with co-occurring substance use and mental health disorders is a long-standing behavioral health problem. Evidence-based practices (EBPs) that focus on patient needs are effective in improving care for persons with co-occurring disorders. The stages of implementation completion (SIC) is a measure that assesses the process that organizations go through when implementing a new EBP and can be used to compare differences between organizations in their fidelity to recommended processes. To implement, organizations use specified strategies to integrate EBP into the care process. These strategies require a significant investment of staff resources. When organizations struggle to achieve competency with a set of implementation strategies, resources are wasted impacting the ability to use the strategies in future change efforts. As such, it is critical to measure organizational efforts to achieve competency, but instruments to do so are lacking. The SIC was adapted for a proven implementation strategy, NIATx, to address this gap. The NIATx strategy provides outside support and coaching to facilitate the implementation of a new EBP. Results from this study indicated that the NIATx-SIC could distinguish between addiction treatment agencies that applied NIATx implementation strategies with competency, versus those that did not, in the context of a multilevel randomized control trial. Study results provide evidence for the utility of adapting the SIC to specific implementation strategies and the benefit that the NIATx-SIC could provide for similar studies involving the use of NIATx to implement EBPs.

Piloting an opioid callback program in community pharmacies.

BACKGROUND: Although opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription. OBJECTIVES: This study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies. METHODS: The opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement. RESULTS: Forty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients' willingness to answer questions and appreciation for the extra attention and care. CONCLUSION: Community pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.

Sociotechnical Work System Approach to Occupational Fatigue.

INTRODUCTION TO THE PROBLEM: Occupational fatigue is a characteristic of excessive workload and depicts the limited capacity to complete demands. The impact of occupational fatigue has been studied outside of health care in fields such as transportation and heavy industry. Research in health care professionals such as physicians, medical residents, and nurses has demonstrated the potential for occupational fatigue to affect patient, employee, and organizational outcomes. A conceptual framework of occupational fatigue that is informed by a sociotechnical systems approach is needed to (1) describe the multidimensional facets of occupational fatigue, (2) explore individual and work system factors that may affect occupational fatigue, and (3) anticipate downstream implications of occupational fatigue on employee well-being, patient safety, and organizational outcomes. CONCEPTUAL FRAMEWORK OF OCCUPATIONAL FATIGUE: The health care professional occupational fatigue conceptual framework is outlined following the Systems Engineering Initiative for Patient Safety (SEIPS) model and adapted from the Conceptual Model of Occupational Fatigue in Nursing. Future research may apply this conceptual framework to health care professionals as a tool to describe occupational fatigue, identify the causes, and generate solutions. Interventions to mitigate and resolve occupational fatigue must address the entire sociotechnical system, not just individual or employee changes.

A scoping literature review of pharmacy-based opioid misuse screening and brief interventions.

BACKGROUND: Although prescription opioid dispensing rates have continued to decrease, overdose deaths involving prescription opioids have increased during the COVID-19 pandemic. Screening and brief interventions (SBI) are an effective prevention strategy to identify and address opioid misuse and safety risks. Emerging literature on pharmacy-based SBI needs to be systematically appraised to develop robust interventions. OBJECTIVE: Our objective was to conduct a scoping review of the literature regarding pharmacy-based opioid misuse SBI to identify relevant literature that explore the topic, evaluate the patient-centeredness of included studies, and explore the use of dissemination and implementation science in the literature. METHODS: The review was conducted according to Preferred Reporting of Systematic Reviews and Meta-analyses -Scoping reviews (PRISMA-Sc) guidelines. We searched PubMed, CINHAL, PsychInfo, and Scopus for studies regarding pharmacy-based SBI, published in the last 20 years. We also conducted a separate grey literature search. Two of three total reviewers screened each abstract individually and identified eligible full-texts for inclusion. We critically appraised quality of included studies and qualitatively synthesized the relevant information. RESULTS: The search resulted in 21 studies (categorized as intervention, descriptive, and observational research) and 3 grey literature reports. Of the recently published 21 studies, 11 were observational research, with six interventions in the pilot stages. Screening tools varied but naloxone was the brief intervention in 15 of the 24 results. Only eight studies had high validity, reliability, and applicability and only five were patient-centered. Implementation science principles were addressed in eight studies (mainly interventions). Overall, the findings suggest high potential for evidence-based SBI to be successful. CONCLUSIONS: Overall, the review suggested a strong lack of a patient-centered and implementation science-focused approach to designing pharmacy-based opioid misuse SBI. Findings suggest that a patient-centered, implementation focused approach is needed for effective and sustained pharmacy-based opioid misuse SBI.

Characteristics of telemedicine workflows in nursing homes during the COVID-19 pandemic.

BACKGROUND: The use of telemedicine increased dramatically in nursing homes (NHs) during the COVID-19 pandemic. However, little is known about the actual process of conducting a telemedicine encounter in NHs. The objective of this study was to identify and document the work processes associated with different types of telemedicine encounters conducted in NHs during the COVID-19 pandemic. METHODS: A mixed methods convergent study was utilized. The study was conducted in a convenience sample of two NHs that had newly adopted telemedicine during the COVID-19 pandemic. Participants included NH staff and providers involved in telemedicine encounters conducted in the study NHs. The study involved semi-structured interviews and direct observation of telemedicine encounters and post-encounter interviews with staff and providers involved in telemedicine encounters observed by research staff. The semi-structured interviews were structured using the Systems Engineering Initiative for Patient Safety (SEIPS) model to collect information about telemedicine workflows. A structured checklist was utilized to document steps performed during direct observations of telemedicine encounters. Information from interviews and observations informed the creation of a process map of the NH telemedicine encounter. RESULTS: A total of 17 individuals participated in semi-structured interviews. Fifteen unique telemedicine encounters were observed. A total of 18 post-encounter interviews with 7 unique providers (15 interviews in total) and three NH staff were performed. A 9-step process map of the telemedicine encounter, along with two microprocess maps related to encounter preparation and activities within the telemedicine encounter, were created. Six main processes were identified: encounter planning, family or healthcare authority notification, pre-encounter preparation, pre-encounter huddle, conducting the encounter, and post-encounter follow-up. CONCLUSION: The COVID-19 pandemic changed the delivery of care in NHs and increased reliance on telemedicine services in these facilities. Workflow mapping using the SEIPS model revealed that the NH telemedicine encounter is a complex multi-step process and identified weaknesses related to scheduling, electronic health record interoperability, pre-encounter planning, and post-encounter information exchange, which represent opportunities to improve and enhance the telemedicine encounter process in NHs. Given public acceptance of telemedicine as a care delivery model, expanding the use of telemedicine beyond the COVID-19 pandemic, especially for certain NH telemedicine encounters, could improve quality of care.

Characteristics of U.S. older adult medicare beneficiaries receiving the influenza vaccination at retail pharmacies.

Background: Pharmacy-provided influenza vaccination services have become more prevalent among the older adult population. However, little is known about the characteristics of older adults associated with receiving the influenza vaccination at retail pharmacies and how these associated characteristics have changed. Objective: To examine characteristics of older adults associated with use of retail pharmacy-provided influenza vaccination services and how the characteristics changed between 2009 and 2015. Methods: The study used a retrospective, cross-sectional design with data from the 2009 and 2015 Medicare Current Beneficiary Survey. Older adults aged 65 and older who completed a community questionnaire and received the influenza vaccination during the previous winter were identified. Andersen's Behavioral Model of Health Services Use was the conceptual framework for inclusion of the population characteristics. A multivariable log-binomial regression was performed to estimate the association between the population characteristics and use of pharmacy-provided vaccination service, and the relative change in associations between 2009 and 2015. Survey weights were applied in all analyses. Results: The results showed older adults who were non-Hispanic black (compared to non-Hispanic white), who did not have secondary private insurance (compared to those who had), who did not have physician office visit (compared to those who had) and who lived in non-metro area (compared to those who lived in metro area) had become more likely to use pharmacy-provided influenza vaccination services in 2015 than in 2009. Conclusions: Pharmacy-provided influenza vaccination services appear to reduce access barriers for racially and socioeconomically disadvantaged older adults. Findings could help inform not only the retail pharmacies that provide vaccination services to better outreach to potential target populations but also policy makers about the disadvantaged populations that would benefit from the vaccination services provided by retail pharmacies.

Stepped implementation-to-target: a study protocol of an adaptive trial to expand access to addiction medications.

BACKGROUND: In response to the US opioid epidemic, significant national campaigns have been launched to expand access to `opioid use disorder (MOUD). While adoption has increased in general medical care settings, specialty addiction programs have lagged in both reach and adoption. Elevating the quality of implementation strategy, research requires more precise methods in tailoring strategies rather than a one-size-fits-all-approach, documenting participant engagement and fidelity to the delivery of the strategy, and conducting an economic analysis to inform decision making and policy. Research has yet to incorporate all three of these recommendations to address the challenges of implementing and sustaining MOUD in specialty addiction programs. METHODS: This project seeks to recruit 72 specialty addiction programs in partnership with the Washington State Health Care Authority and employs a measurement-based stepped implementation-to-target approach within an adaptive trial design. Programs will be exposed to a sequence of implementation strategies of increasing intensity and cost: (1) enhanced monitoring and feedback (EMF), (2) 2-day workshop, and then, if outcome targets are not achieved, randomization to either internal facilitation or external facilitation. The study has three aims: (1) evaluate the sequential impact of implementation strategies on target outcomes, (2) examine contextual moderators and mediators of outcomes in response to the strategies, and (3) document and model costs per implementation strategy. Target outcomes are organized by the RE-AIM framework and the Addiction Care Cascade. DISCUSSION: This implementation project includes elements of a sequential multiple assignment randomized trial (SMART) design and a criterion-based design. An innovative and efficient approach, participating programs only receive the implementation strategies they need to achieve target outcomes. Findings have the potential to inform implementation research and provide key decision-makers with evidence on how to address the opioid epidemic at a systems level. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov (NCT05343793) on April 25, 2022.

Assessing the use of an infographic on pre-exposure prophylaxis for Wisconsin community pharmacists.

BACKGROUND: Pre-exposure prophylaxis (PrEP) treatments reduce the risk of contracting human immunodeficiency virus (HIV). However, despite proven effectiveness, PrEP use remains low among populations at risk of contracting HIV. Successful PrEP uptake includes developing partnerships with health care providers to implement PrEP-related tools and interventions. Pharmacists are uniquely positioned health professionals who can provide PrEP services in the community, such as pharmacy-led PrEP clinics, to increase uptake, adherence, and retention. Unfortunately, prior evidence shows that not all pharmacists have enough knowledge about PrEP to provide effective care, resulting in low confidence and discomfort in PrEP-related patient consultations. OBJECTIVES: This study aimed to assess Wisconsin community pharmacists' intentions of utilizing an infographic on PrEP for HIV prevention to educate themselves on PrEP and in consultations with patients starting PrEP. METHODS: An adaptative survey, using the Theory of Planned Behavior, was conducted to assess pharmacists' intentions by measuring their attitudes, subjective norms, and perceived behavioral control. The Fisher exact tests were performed to examine associations between the 3 theoretical constructs against intentions. RESULTS: Pharmacists reported high intentions of utilizing the infographic to educate themselves (62%) and counsel patients starting PrEP (54%). Their attitudes, subjective norms, and perceived behavioral controls were all significantly associated with their intentions. However, their intentions were reported lower than their attitudes, subjective norms, and perceived behavioral control, suggesting that additional factors may influence intentions that were not measured in this study. CONCLUSION: The results from this study demonstrate Wisconsin community pharmacists' intentions of using an infographic on PrEP for HIV prevention in practice while measuring their attitudes, subjective norms, and perceived behavioral control. Future research is warranted to explore adapting and using the infographic to better understand its influence in improving pharmacy care among HIV-negative individuals.

There and back again: the shape of telemedicine in U.S. nursing homes following COVID-19.

INTRODUCTION: Telemedicine use in nursing homes (NHs) expanded during the COVID-19 pandemic. The objectives of this study were to characterize plans to continue telemedicine among newly adopting NHs and identify factors limiting its use after COVID-19. METHODS: Key informants from 9 Wisconsin NHs that adopted telemedicine during COVID-19 were recruited. Semi-structured interviews and surveys were employed to identify participant perceptions about the value of telemedicine, implementation challenges encountered, and plans and barriers to sustaining its delivery after COVID-19. Directed content analysis and a deductive thematic approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model was used during analyses. Quantitative and qualitative data were integrated to identify participant views on the value of telemedicine and the tools and work system enhancements needed to make telemedicine easier and more effective. RESULTS: All participating NHs indicated a preference to continue telemedicine after COVID-19. Urgent assessments of resident change-in-condition and cognitively based sub-specialty consultations were identified as the encounter types most amenable to telemedicine. Reductions in resident off-site encounters and minimization of resident therapy interruptions were identified as major benefits of telemedicine. Twelve work system enhancements needed to better sustain telemedicine were identified, including improvements to: 1) equipment/IT infrastructure; 2) scheduling; 3) information exchange; and 4) telemedicine facilitators. DISCUSSION: NHs that adopted telemedicine during COVID-19 wish to continue its use. However, interventions that enhance the integration of telemedicine into NH and off-site clinic work systems require changes to existing regulations and reimbursement models to sustain its utilization after COVID-19.

Wait No Longer: Reducing Medication Wait-Times for Individuals with Co-Occurring Disorders.

Objective: Community addiction treatment agencies have utilized Network for the Improvement of Addiction Treatment (NIATx), a proven implementation strategy, to reduce appointment wait-times. However, its effectiveness at reducing medication access wait-times has not been explored. Thus, we conducted an exploratory analysis to evaluate the impact of the NIATx implementation strategies on reduced wait-times to addiction, psychotropic or both medications for individuals with co-occurring disorders (COD). Methods: In a cluster-randomized waitlist control group design, community addiction treatment agencies (n = 49) were randomized to receive the NIATx strategy (Cohort 1, n = 25) or to a Waitlist control (Cohort 2, n = 24). All agencies had a 12-month active intervention period. The primary outcome was the medication encounter wait-time. A univariate general linear model analysis utilizing a logarithmic (log10) transformation examined medication wait-times improvements. Results: The intent-to-treat analysis for psychotropic medications and both medications (reflecting integrated treatment) showed significant main effects for intervention and time, especially comparing Baseline and Year 1 to Year 2. Conversely, only the main effect for time was significant for addiction medications. Wait-time reductions in Cohort 1 agencies was delayed and occurred in the sustainment phase. Wait-times to a psychotropic, addiction, or both medications encounter declined by 3 days, 4.9 days, and 6.8 days, respectively. For Cohort 2 agencies, reduced wait-times were seen for psychotropic (3.4 days), addiction (6 days), and both medications (4.9 days) during their active implementation period. Same- or next-day medication access also improved. Conclusions: NIATx implementation strategies reduced medication encounter wait-times but timing of agency improvements varied. Despite a significant improvement, a three-week wait-time to receive integrated pharmacological interventions is clinically suboptimal for individuals with a COD in need of immediate intervention. Community addiction treatment agencies should identify barriers and implement changes to improve medication access so that their patients "wait no longer" to receive integrated treatment and medications for their COD.

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living.

OBJECTIVES: Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living. DESIGN: We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs). SETTING AND PARTICIPANTS: The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 residents. METHODS: The model was codesigned iteratively 2009-2012 by a public-private multistakeholder advisory group. Using system usage statistics and project records, we evaluated implementation outcomes: appropriateness, acceptability, adoption, feasibility, fidelity, penetration, and sustainability. RESULTS: Implementation for ≥1 quarter was feasible for 92% of the 810 ALCs that enrolled. The model has been deemed appropriate and acceptable by public-private stakeholders representing residents, providers, regulators, and payers, and appropriateness for ALCs serving different populations has been iteratively improved through targeted workgroups. The model is currently adopted in Wisconsin by 31% of the 1573 ALCs in provider associations. Among adopters, 88% on average implemented the model with fidelity to key membership rules per quarter. The model achieved demographic and institutional penetration by currently reaching 24% of Wisconsin ALC residents and by leveraging initial grant funding to become integrated in Wisconsin's annual Medicaid budget and being central to Wisconsin's incentive program to managed care organizations. Model implementation for 8 years has been sustained by member enrollment for nearly 4 years on average, with 71% of members enrolled >2 years and sustained early adopters representing 37% that have been enrolled >5 years. CONCLUSIONS AND IMPLICATIONS: This is the first implementation study of large-scale data-driven quality improvement in assisted living, despite its demonstrated value in other health care sectors. The article proposes a model with core components and implementation strategies drawing on a decade-long public-private collaboration. The implementation study findings establish a promising path and future directions for wider implementation.

Sustainment of Integrated Care in Addiction Treatment Settings: Primary Outcomes From a Cluster-Randomized Controlled Trial.

OBJECTIVE: Integrated treatment services are the gold standard for addressing co-occurring mental and substance use disorders, yet they are not readily available. The Network for the Improvement of Addiction Treatment (NIATx) was hypothesized to be an effective strategy to implement and sustain integrated mental health and substance use care in addiction treatment programs. This study examined sustainment of integrated services for up to 2 years after the active implementation phase. METHODS: The effectiveness of NIATx strategies to implement and sustain integrated services was evaluated by using a cluster-randomized, waitlist control group design. Forty-nine addiction treatment organizations were randomly assigned to either NIATx1 (active implementation strategy) or NIATx2 (waitlist control). The Dual Diagnosis Capability in Addiction Treatment Index was used to evaluate organizations' capability to provide integrated care. The NIATx Stages of Implementation Completion scale was used to assess participation in and adherence to the NIATx implementation process. Linear mixed-effects modeling was used to evaluate changes from baseline to end of the sustainment period. RESULTS: Both cohorts sustained their capability to provide integrated treatment services. Both groups achieved successful implementation and sustained integrated services to a similar degree, regardless of sustainment year. Sustainment did not vary as a function of NIATx adherence. CONCLUSIONS: The delivery of integrated treatment services was sustained for 2 years after receipt of active implementation support. Future research should consider how contextual factors may predict, mediate, and moderate sustainment outcomes.

Pilot testing a tool to determine the costs and time associated with community pharmacy-based administration of injectable naltrexone.

BACKGROUND: Medications for opioid use disorder (MOUD), including injectable naltrexone (IN), are part of evidence-based OUD treatments. MOUD access often is limited, especially in rural communities. When authorized to administer non-vaccination injections, pharmacists can increase IN accessibility. However, inadequate reimbursement for pharmacist-administered IN can hinder widespread adoption. OBJECTIVES: To pilot test a process to obtain a preliminary estimate of the total costs and time associated with community-pharmacist administered IN. METHODS: A purposively-selected sample of key informants at community pharmacies administering IN were surveyed about time and cost for best practice IN activities. Respondents estimated the time to perform activities and average pharmacist/pharmacy technician hourly salary, which were used to calculate administration costs. RESULTS: The approach to estimate time and costs was feasible. Administrative costs (mean = $93, range: $48-$164) and time (mean = 123 min., range: 63-220 min.) to administer IN varied widely. Pharmacists'/pharmacy technicians' roles varied by pharmacy. CONCLUSIONS: Pharmacists allocate significant time and resources to administer IN. Insufficient reimbursement may disincentivize pharmacy-involved OUD treatment and ultimately slow needed expansion of MOUD services. Increasing IN services requires engaging pharmacies to expand their practice through educational campaigns, along with a commitment to reimburse the cost of medications and related administration activities.

A peek behind the curtain: exploring coaching styles within the implementation and sustainment facilitation (ISF) strategy in the substance abuse treatment to HIV care study.

BACKGROUND: The Grasha-Riechmann teaching styles, which includes three didactic and two prescriptive styles, have been shown to help enhance learning within educational settings. Although an adaption of the Grasha-Riechmann style classification has enabled coaching styles to be identified for use as part of quality improvement (QI) initiatives, research has not examined the styles actually utilized by coaches within a QI initiative or how the styles change overtime when the coach is guiding an organization through change implementation. Interactions between coaches and HIV service organization (HSO) staff participating in a large implementation research experiment called the Substance Abuse Treatment to HIV care (SAT2HIV) Project were evaluated to begin building an evidence base to address this gap in implementation research. METHODS: Implementation & Sustainment Facilitation (ISF) Strategy meetings (n = 137) between coaches and HSO staff were recorded and professionally transcribed. Thematic coding classifications were developed from the Grasha-Riechmann framework and applied to a purposively selected sample of transcripts (n = 66). Four coders independently coded transcripts using NVivo to facilitate text identification, organization, and retrieval for analysis. Coaching style use and changes across the three ISF phases were explored. RESULTS: Facilitator and formal authority were the two coaching styles predominately used. Facilitator sub-themes shifted from asking questions and providing support to supporting independent action over time. Coaches' use of formal authority sub-styles shifted notably across time from setting expectations or ensuring preparation to offering affirmation or feedback about changes that the HSO's were implementing. The use of the delegator or personal model coaching styles occurred infrequently. CONCLUSIONS: The current research extends implementation research's understanding of coaching. More specifically, findings indicate it is feasible to use the Grasha-Riechmann framework to qualitatively identify coaching styles utilized in a facilitation-based implementation strategy. More importantly, results provide insights into how different coaching styles were utilized to implement an evidence-based practice. Further research is needed to examine how coaching styles differ by organization, impact implementation fidelity, and influence both implementation outcomes and client outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02495402 . Registered on July 6, 2015.

Novel Integration of Administrative Pharmacy Residents in a Management Course.

BACKGROUND: Management skills are an essential component of a pharmacy graduate's abilities for successful practice. Although pharmacy education standards require that students have a working knowledge of management principles, students often do not see the value in management and business courses. One innovative approach is restructuring course content using case examples and real-world experiences to improve student understanding of finance and management principles. INNOVATION: Two specific changes were implemented in a second year (P2) management and finance course to improve the relevance of business principles. Course content was organized around current pharmacy service cases from a variety of practice settings and supported by the value of problem-based learning. Post-graduate year 1 (PGY-1) administrative pharmacy residents were engaged as course teaching assistants (TAs) who brought real-world experiences into the class. An analysis of pre- and post-course voluntary surveys, course evaluations, and TA evaluations assessed the impact of the course redesign. FINDINGS: The course redesign achieved its intended goal of improving student-perceived course relevance. This was shown through statistically significant improvements in course evaluations that were intended to measure student perception of pharmacy management and its relevance in their future career. Student completed TA evaluations showed that those who reported their TA shared real-world applications had higher confidence in applying course concepts and greater understanding of course materials. CONCLUSIONS: Administrative pharmacy residents were successfully integrated into a pharmacy management course redesign, resulting in improved student perceptions of course relevance.