Integrated Collaborative Care for Substance Use Disorders

描述（由申请人提供）：大多数患有阿片类药物和酒精使用障碍（OAUD）的人没有接受治疗。初级保健是提供OAUD治疗的理想环境，但很少提供循证OAUD治疗。提供服务的障碍包括组织支持不足以及缺乏提供者的榜样和临床支持。我们建议评估两种策略的有效性，以增加在初级保健中使用循证治疗OAUD：综合协作护理（ICC）和教育和资源（E&R）。虽然这两种战略为初级保健实践提供了相同的临床信息，但ICC通过为提供循证护理提供组织和技术支持来解决这些障碍。ICC以慢性护理模式为基础，包括作为护理团队一部分的行为健康提供者。国际商会战略的基本要素包括决策支持部分，以帮助处理复杂患者的提供者，以及重组交付和临床信息系统，以支持提供循证护理。我们实施ICC的方法是基于组织转型模型和质量改进。我们将E&R策略定义为提供印刷的教育材料和访问资源以及提供者教育。这两种策略都旨在增加两种循证实践的交付：动机增强疗法和药物辅助疗法。我们建议进行一项为期5年的混合方法研究，并将进行一项随机对照试验，在护理团队和患者的水平上进行随机化。我们与5家威尼斯家庭诊所（VFC）诊所，洛杉矶县的两家医院和COPE健康解决方案合作。VFC是一家大型联邦合格医疗中心（FQHC），也是美国最大的免费诊所。我们的方法包括文件审查、焦点小组、访谈和调查，以获取有关采用过程和实施结果的数据；病历和患者调查对服务体系和患者结果的分析；分析医疗服务提供者的财务记录和病人的记录以及估算成本的调查。我们将招募400名诊断为OAUD的患者，并在3个月和12个月时对他们进行随访。我们的具体目标是：1)衡量ICC和E&R实施的过程和程度；2)测试ICC与E&R策略在促进A.实施结果B.服务系统结果和C.患者结果方面的有效性；3)估算每种策略的供应商成本。我们将实施结果定义为基于证据的OAUD治疗的可接受性、采用性、适当性、可行性和可持续性的衡量标准。我们将服务系统结果定义为1)治疗质量的过程测量和2)治疗合并症。我们将患者结局定义为再入院、OAUD结局、患者功能、药物使用的负面后果和未满足的需求。我们将成本结果定义为启动成本、运营成本和医疗/精神病学成本抵消。

DESCRIPTION (provided by applicant): 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. We 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. We 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. We propose a 5-year mixed methods study and will conduct a RCT, with randomization occurring at the level of the care team and patient. We 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. We 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. We define implementation outcomes as measures of the acceptability, adoption, appropriateness, feasibility, and sustainability of evidence-based OAUD treatment. We define service system outcomes as 1) process measures of treatment quality and 2) treatment co-morbidities. We define patient outcomes as hospital readmissions, OAUD outcomes, patient functioning, negative consequences from substance use, and unmet need. We define cost outcomes as start-up costs, operating costs and medical/psychiatric cost offsets. PUBLIC HEALTH RELEVANCE: Primary care settings (PCS) are a missed opportunity for delivering evidence-based treatments for opiate and alcohol-use disorders (OAUD). We propose to evaluate the costs and effectiveness of two strategies to increase the delivery of OAUD treatments in PCS, integrated collaborative care and education and resources. Results from our study will help providers choose between two different strategies and advance the field of implementation research.