Systems analysis and improvement to optimize opioid use disorder care quality and continuity for patients exiting jail (SAIA-MOUD).

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Opioid-related overdose deaths in the United States are skyrocketing, including in Washington State (WA) where overdose deaths rose 37% from 2021-2022. Estimates suggest that over 50% of people with opioid use disorder (OUD) pass through WA jails each year. Jail incarceration causes a dramatic increase in overdose risk following release, in addition to compounding marginalization that hinders management of OUD. Treatment with evidence- based Medications for Opioid Use Disorder (MOUD) effectively manages OUD, reduces patients’ overdose risk, and reduces rates of recidivism. WA has prioritized improving access to MOUD, including for individuals incarcerated in jails, however systemic weaknesses exist in the handoff of care from jail to clinical referral sites and there is little focus on developing strategies that foster linkages between services. Low-cost, systems-level interventions are effective and efficient approaches to improve linked cascade services and may improve linkages between jails and referral clinical services, improve flow through the MOUD cascade, address barriers to holistic OUD care, and ultimately reduce unmanaged OUD, recidivism, and mortality. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based implementation strategy of bundled systems engineering tools designed to optimize complex healthcare delivery systems and improve linkages between clinical and community providers. The SAIA-MOUD study aims to strengthen the quality and continuity of MOUD care, and linkages to social services, across jail and referral clinics in King County, WA. We will implement the SAIA for three years—including a two-year intensive phase and one year of sustainment—at one jail based MOUD program and two referral MOUD clinics. We will then evaluate the effectiveness of SAIA on improving MOUD cascade quality and continuity for patients receiving care in jail and exiting to referral clinics, determining the effect on linkage to care within 14 days of release. A secondary outcome of retention (those who return for a second MOUD pick up within a month of initial linkage) will be considered. We will describe—and explore determinants of—adoption, implementation, and sustainment of SAIA-MOUD via qualitative inquiry with jail and clinic staff. Analysis will be guided by the Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modification to Evidence-based Implementation Strategies (FRAME- IS) will be used to document implementation strategy adaptations. We will estimate the cost and cost- effectiveness of SAIA-MOUD using the cost per additional client linked to MOUD referral clinics upon release from jail as well as quality-adjusted life year gained from the county government, healthcare sector, and societal perspectives. Using a micro-costing approach, we will estimate the incremental costs per additional patient passing through the MOUD cascade. The results of this implementation research are expected to develop the evidence base on how a systems-focused intervention applied to a novel clinical cascade can lead to measurable improvements in cascade functioning and patient-level outcomes for a significant, national public health threat.