Integrated Collaborative Care for Substance Use Disorders

Study Overview
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Brief Summary
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Primary care settings (PCS) are a missed opportunity for delivering evidence-based treatments for opiate and alcohol-use disorders (OAUD). The investigators propose to evaluate the costs and effectiveness of two strategies to increase the delivery of OAUD treatments in PCS, integrated collaborative care (ICC) and education and resources (E&R). The investigators hypothesize that ICC will be more effective than E&R in promoting A. Implementation outcomes B. Service system outcomes and C. Patient outcomes. Results from our study will help providers choose between two different strategies and advance the field of implementation research.

Detailed Description
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Most individuals with opiate and alcohol-use disorders (OAUD) do not receive treatment. Primary care is an ideal setting in which to deliver OAUD treatment, yet evidence-based OAUD treatment is rarely provided. Barriers to delivery include insufficient organizational support and lack of provider role models and clinical support. The investigators propose to evaluate the effectiveness of two strategies for increasing use of evidence-based treatment for OAUD within primary care: integrated collaborative care (ICC) and education and resources (E&R). While both strategies provide primary care practices with the same clinical information, ICC addresses these barriers by including organizational and technical support for delivering evidence-based care. ICC is grounded in the chronic care model and includes a behavioral health provider working as part of the care team. Essential elements of ICC strategy include a decision support component to help providers with complex patients, and a restructuring of the delivery and clinical information systems to support the delivery of evidence-based care. Our approach to implementing ICC is based on the organizational transformation model and quality improvement. The investigators define the E&R strategy as providing printed educational materials and access to resources along with provider education. Both strategies are designed to increase the delivery of two evidence-based practices: motivational enhancement therapy and medication assisted therapy. The investigators propose a 5-year mixed methods study and will conduct a RCT, with randomization occurring at the level of the care team and patient. The investigators partner with 5 Venice Family Clinic (VFC) clinics, two hospitals in LA County, and COPE Health Solutions. VFC is a large federally qualified health center (FQHC) and the largest free clinic in the United States. Our approach includes document review, focus groups, interviews, and surveys for obtaining data on the adoption process and implementation outcomes; analysis of patient records and patient surveys on service system and patient outcomes; and analysis of provider financial records and patient records and surveys for estimating costs. The investigators will enroll 400 patients with an OAUD diagnosis and follow them at 3 and 12 months. Our specific aims are: 1) To measure the process and extent of ICC and E&R implementation; 2) To test the effectiveness of ICC compared to an E&R strategy in promoting A. Implementation outcomes B. Service system outcomes and C. Patient outcomes; and 3) To estimate provider costs for each strategy. The investigators define implementation outcomes as measures of the acceptability, adoption, appropriateness, feasibility, and sustainability of evidence-based OAUD treatment. The investigators define service system outcomes as 1) process measures of treatment quality and 2) treatment co-morbidities. The investigators define patient outcomes as hospital readmissions, OAUD outcomes, patient functioning, negative consequences from substance use, and unmet need. The investigators define cost outcomes as start-up costs, operating costs and medical/psychiatric cost offsets.

Official Title
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Integrated Collaborative Care for Substance Use Disorders

Conditions
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Substance Use Disorders

Intervention / Treatment
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* Other: Integrated collaborative care
* Other: Education and Resources


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: opiate or alcohol use disorder not currently in substance use disorder treatment past 30 day use of alcohol or opioids English or Spanish speaking Exclusion Criteria: co-morbid severe mental illness medically unstable

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: ICC<br>Integrated collaborative care | Other: Integrated collaborative care<br> <br> |
| Active Comparator: E&R<br>Education and Resources--enhanced usual care | Other: Education and Resources<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| unmet need | Of those identified as screening positive for an opiate or alcohol use disorder, proportion who did not receive treatment for their substance use | past 6 months | 
| abstinent from alcohol and opioid use, past 30 days | change in abstinence from alcohol and opioid use between baseline and 6 month follow up | past 30 days | 
| negative consequences related to substance use | SIP-AD frequency questionnaire | past 3 months | 
| Functioning | change in SF-12 between baseline and follow up | past 4 weeks | 
| Engagement | Proportion with at least 2 SUD-related visits within 30 days of initiation, Washington Circle | 30 days of initiation | 
| initiation | Washington Circle initiation indicator--at least one SUD-related visit within 14 days of index visit | Within 14 days of index visit | 
| heavy alcohol use | among people at baseline with heavy alcohol use, proportion with heavy alcohol use in past 30 days | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion initiating Brief therapy | Proportion initiating brief therapy within 6 months | 6 months | 
| Proportion initiating MAT | Proportion initiating MAT within 6 months, among those eligible for MAT, and if N's are large enough, stratified by type of MAT | 6 months | 
| abstinence from alcohol, opioids and all other drugs in the previous 30 days | abstinence from alcohol, opioids and all other drugs in the past 30 days | collected at six months at the past 30 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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substance use disorders, implementation science, collaborative care, opiate disorders, alcohol disorders