Implementing a patient navigation intervention across a health system to address treatment entry inequities

项目摘要/摘要 阿片类激动剂治疗(OAT)对过量用药有保护作用，但只有不到20%的阿片类药物使用者 失调症从事这样的治疗。医院利用率在有尿毒症的人中很高，可能是 “触手可及的时刻”来发起燕麦片。然而，大多数医院缺乏对患者进行事后随访的能力 出院。基于理论、经验支持的医院后患者导航仪(PN)干预 出院通过帮助患者在复杂的系统中导航来减少获得基于社区的OAT的不平等 关爱。然而，如所需，在大规模实施个人卫生干预措施方面仍然存在挑战 跨机构协调、数据共享、专职人员和社区资源。这是 尤其是在触及多元化、资源匮乏的社区的环境中。将这些干预措施带到 需要规模、策略来评估影响医院实施PN的因素以增加 可行性、覆盖范围和可持续性。测试PN干预的创新实施战略具有 可能产生重大影响，因为这将表明干预措施的实施成功， 解决现实世界中阿片类药物的流行问题，缩小研究与实践之间的翻译差距。这个 拟议的研究是一项第二类混合实施-导航服务有效性试验，以避免 再次住院(Navstar)。我们的研究团队在一项单一地点的随机试验中显示， 与会者表示，Navstar显著增加了燕麦片的入院人数，减少了再入院人数，并且成本高昂- 与常规治疗相比有效。本研究将测试执行便利化(IF) 遵循普罗科特概念模型的战略，使用外部促进者和内部本地临床 冠军提供培训、资源和绩效反馈，以便在四家医院实施Navstar。 我们假设在IF中让利益相关者(包括患者、临床医生和社区领袖)参与进来 战略将创建并测试可行、可接受且在扩展方面有效的实施流程 出院后获取燕麦片的途径。R61阶段将进行流程映射，以确定现有医院 工作流程，然后通过在4个医院站点进行顺序试点试验来细化IF策略，为 R33期。该小组的Navstar操作手册将根据这些地点进行调整，以培训现有工作人员。R61 里程碑包括创建执行工具包和数据共享协议。在R33期间 阶段，我们将进行Navstar的第二类混合实施有效性试验(N=720)，使用 增加逆概率加权的随机步进楔形设计比较治疗前结果 和实施后。这项研究将制定有效的IF战略，以扩大覆盖范围并 Navstar的可持续性，并提供了一条扩大这一干预措施以应对阿片类药物流行的途径。

Project Summary/Abstract Opioid agonist treatment (OAT) is protective against overdose, yet less than 20% of people with opioid use disorder (OUD) engage in such treatment. Hospital utilization is high among people with OUD and can be a ‘reachable moment’ to initiate OAT. However, most hospitals lack the capacity to follow up with patients after discharge. Theory-based, empirically supported patient navigator (PN) interventions following hospital discharge reduce inequities in accessing community-based OAT by helping patients navigate complex systems of care. However, challenges persist in implementing PN interventions on a wide scale, as they require coordination across institutions, data sharing, dedicated personnel, and community resources. This is especially true in settings that reach diverse, resource-challenged communities. To bring these interventions to scale, strategies are needed to assess factors that influence PN implementation in hospitals to increase feasibility, reach, and sustainability. Testing innovative implementation strategies for PN interventions has the potential for significant impact, as it will demonstrate implementation success of an intervention that can address the opioid epidemic in real-world settings and close the research-to-practice translation gap. The proposed study is a type II hybrid implementation-effectiveness trial of Navigation Services To Avoid Rehospitalization (NavSTAR). Our research team showed in a single-site randomized trial with 400 participants that NavSTAR significantly increased OAT entry, reduced readmissions, and was highly cost- effective compared to treatment as usual. The present study will test an Implementation Facilitation (IF) strategy following Proctor’s conceptual model using an external facilitator and an internal local clinical champion to provide training, resources, and performance feedback to implement NavSTAR in four hospitals. We hypothesize that engaging stakeholders (including patients, clinicians, and community leaders) in an IF strategy will create and test an implementation process that is feasible, acceptable, and effective in expanding access to OAT post-discharge. The R61 phase will conduct process mapping to identify existing hospital workflow and then refine an IF strategy through sequential pilot trials at 4 hospital sites in preparation for the R33 phase. The team’s NavSTAR operations manual will be adapted to the sites to train the existing staff. R61 milestones include the creation of an implementation toolkit and data sharing agreements. During the R33 phase, we will conduct a type II hybrid-implementation-effectiveness trial (N=720) of NavSTAR using a randomized stepped-wedge design with augmented inverse probability weighting to compare outcomes pre- and post-implementation. This study will develop an effective IF strategy to increase the reach and sustainability of NavSTAR and provide a path to scale-up this intervention to address the opioid epidemic.