Models for Medication-Assisted Treatment for Opioid Use Disorder, Retention, and Continuity of Care. APPENDIX 3: Site Interview Protocol

07/09/2020

APPENDIX 3. SITE INTERVIEW PROTOCOL

IBM Watson Health

July 2020

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on March 29, 2019.

 

TABLE OF CONTENTS

ACRONYMS

OVERVIEW

  • Purpose
  • How to Use

LOGISTICS

  • Site Visit Cover
  • Site Visit Agenda
  • Contact Information

DISCUSSION GUIDE

  • Key Points Checklists
  • Warm-Up Questions
    • Topic 1. Discussion Questions: Site and Environment Description
    • Topic 2. Discussion Questions: Treatment Design
    • Topic 3. Discussion Questions: Patient Retention and Continuity of Care
    • Topic 4. Discussion Questions: Patient Outcomes
    • Topic 4. Discussion Questions: Patient Outcomes
    • Topic 5. Discussion Questions: Models/State or Local Authorities

APPENDIX A: INTERVIEW/NOTE-TAKING PROCESSRESEARCH FINDINGS

APPENDIX B: TEMPLATE FOR SITE VISIT NOTES

 

ACRONYMS

The following acronyms are mentioned in this appendix.

ASPE HHS Office of the Assistant Secretary for Planning and Evaluation
AUD Alcohol Use Disorder
 
CEO Chief Executive Officer
CMO Chief Marketing Officer
COO Chief Operating Officer
 
MAT Medication-Assisted Treatment
 
OUD Opioid Use Disorder
 
SUD Substance Use Disorder

 

OVERVIEW

Purpose

This Site Visit Protocol is for use in the research study, Models for Medication-Assisted Treatment for Opioid Use Disorder, Retention, and Continuity of Care. This study is funded by ASPE.

The purpose of this Protocol is to establish a semistructured discussion guide that will be used when interviewing substance use disorder (SUD) specialty treatment sites or models (hereinafter Sites) that show promise in retaining individuals in Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD). In addition, it will be used to organize background information about the organization.

How to Use

The Logistics section of this Protocol is a template that will be tailored to each of site visit. Tailored Protocols will include logistics specific to the site visit including an agenda for the visit and contact information for the interviewees and research team.

The Discussion Guide included in this resource provides both a quick reference checklist of the key topics to be discussed and the discussion guide by topic. The research team anticipates that the guide will be modified for each site to include site-specific profile and background information. The research team will decide which topics will be covered for each meeting arranged during the site visit. The interviewer can use the checklist to ensure that major topics are covered during the site visit. The Discussion Guide will provide primary and probing questions for each topic area. Additionally, the team anticipates that the guide will be modified based on lessons learned or new focal areas discovered in the course of conducting the site visits. Any changes to the guide will be discussed with, reviewed, and approved by ASPE prior to implementation in subsequent site visits.

The Site Background section should be included, tailored to each site visit based on information gathered about the site prior to the site visit. This section provides useful background information on the site and the context in which it is operating.

Appendix A offers a brief eight-step overview of the interview and note-taking process that the researchers will review prior to each site visit. Finally, Appendix B is the note-taking template that the researchers will use to document each interview.

 

LOGISTICS

Site Visit Cover

Site Visit Protocol: SITE NAME

Site Visit Date: DATE

Site Visit Agenda

 

Site Name
Site Visit Agenda
Day One: MONTH DD, YYYY Task Location
HH:HH AM – HH:HH PM Meet and Greet: NAMES  
HH:HH AM – HH:HH PM Meeting: NAMES
Topics:
 
HH:HH AM – HH:HH PM Tour: NAMES
Topics:
 
HH:HH AM – HH:HH PM Lunch [NAMES]  
HH:HH AM – HH:HH PM Meeting: NAMES
Topics:
 
HH:HH AM – HH:HH PM Meeting: NAMES
Topics:
 
HH:HH AM – HH:HH PM Day 1 Wrap-Up [NAMES]  

Contact Information

Interviewees at Site Visit (this will be tailored to the visit)

  • NAME, Chief Executive Officer, ###-###-####, email

  • NAME, Chief Medical Officer, ###-###-####, email

  • NAME, Clinical Director, ###-###-####, email

  • NAME, Clinical Staff, ###-###-####, email

  • NAME, Case Manager, ###-###-####, email

  • NAME, Outreach Coordinator, ###-###-####, email

  • NAME, #####, ###-###-####, email

  • NAME, Patient, ###-###-####, email

  • NAME, #####, ###-###-####, email

  • NAME, #####, ###-###-####, email

Interviewers Traveling for Site Visit

  • Peggy O'Brien, 339-927-1064, marbrien@us.ibm.com

  • Kristin Schrader, 301-547-4692, kschrader@us.ibm.com

 

DISCUSSION GUIDE

Key Points Checklists

Purpose: Use these checklists to ensure that all major subtopics are covered during the Site visit. Phrasing of questions will be based on questions described in the sections that follow this checklist; this checklist is simply a topic area reminder tool for the interviewers. Each checklist is specified to the interviewee's role.

Site Description

  1. Organization

  2. Partners

  3. Local Population

  4. Policies

  5. Data

Treatment Design

  1. Treatment focus

  2. Types of SUD treatment

  3. Care integration/coordination

  4. Case management

  5. Staff training

Retention and Continuity of Care

  1. Duration of treatment

  2. Retention initiatives

  3. Retention measurement

  4. Barriers and solutions to retention

  5. Continuity of care

Patient Outcomes

  1. Relation of retention to outcomes

  2. Data

Models/State or Local Authorities

  1. State model

  2. Relationship to retention

  3. Relationship to continuity

Warm-Up Questions

  • Discuss goals of this research. Do you have any additional questions about this project before we get started?

  • How long have you been with [Site]?

  • What are the major responsibilities in your current position?

Topic 1. Discussion Questions: Site and Environment Description

Discussion Goals: To understand the site's organizational design and management and local environmental factors influencing operations.

Key Points That Need to Be Clarified by Discussion's Close:

Treatment facility structure and payments sources, partners, local population demographics and substance use patterns, other local and state context such as rurality and employment (some of which can be gathered before the site visit), and state or local policies affecting the facility's operation and provision of treatment.

Key Words: organizational structure, management, funding, reimbursement, value-based payments, partners, demographics, SUD patterns, state policy, local policy

Site and Environment Description Discussion Questions
(If already know answer, use questions to confirm)

INTRODUCTION: This group of questions looks at the big picture of your organization and the setting in which you are located.

  • At a high level, how is your organization structured?
    PROBES:

    • For-profit, non-profit, government owned or operated, academic medical setting

    • Organizational structure

    • Do you bill Medicaid or other insurance?

    • What other funding sources do you rely on?

    • Do you participate in any value-based purchasing (pay-for-performance) initiatives (either incentives or payment withholds) based on how services are provided, retention in treatment, continuity of care, or patient outcomes?

      • Follow-up on what they answer as it relates to this research.

  • Do you have any major partners in the community?
    PROBES:

    • Hospitals, withdrawal management facilities, residential facilities, sobering centers, other substance use treatment organizations, housing entities, other social services organizations, governmental or community organizations, others?

    • What is the nature of these partnerships?

    • Are there referrals between your organization and theirs? (We will discuss care coordination and integration in more detail later.)

  • What are the local population demographics and SUD patterns in your treatment area?
    PROBES:

    • Demographics

    • SUD use and change over time (be sure to address OUD specifically (pills, heroin, fentanyl)).

    • Urban vs. rural nature of the treatment area?

    • Can you discuss the general employment trends in your treatment area?

    • How do most of your patients pay for care? (Medicaid, uninsured, private.)

  • Are there state or local policies that closely affect your facility operations or provision of SUD treatment?

  • How does your program make use of data?
    PROBES:

    • Electronic health records?

    • Reporting of performance metrics?

    • Retention and outcomes.

 

Topic 2. Discussion Questions: Treatment Design

Discussion Goals: To understand the site's SUD treatment program structure and design.

Key Points That Need to Be Clarified by Discussion's Close:

Program's focus and composition, treatments offered, approach to care coordination, approach to care integration, approach to provision of MAT and psychosocial supports, staffing and staff training, and related challenges and solutions.

Key Words: provider type, population, treatment approaches, psychosocial, MAT, integration, coordination, staffing

Treatment Design Discussion Questions
(If already know answer, use questions to confirm)

INTRODUCTION: This group of questions looks at your approach to SUD treatment.

  • Describe [the Site's] SUD treatment focus and composition?
    PROBES:

    • What substances do you address?

    • What levels of SUD treatment do you offer?

    • Do you have a specific approach or treatment model you use?

      • Can you describe it please?

    • Do you have requirements regarding ongoing substance use while in treatment? Opioids, alcohol, other substances?

      • If yes, can people stay in treatment or are they discharged?

      • Has this policy changed over time?

      • What do you do when someone has a positive drug screen?

    • Do you provide SUD treatment for specific populations?

      • Gender-specific.

      • Age-focused.

      • Dual diagnosis.

      • Pregnant and parenting women.

      • Adolescents.

      • Others.

    • Have there been changes to your program that reflect a need to address the opioid crisis?

      • Follow-up on the reply.

  • What types of SUD treatment do you offer?
    PROBES:

    • Describe [the Site's] use of MAT in SUD treatment (be specific (for OUD and AUD)).

      • Which medications do you use?

      • How long have you offered each?

      • What is the uptake as an estimated percent of your patient population?

        • Has that changed over time? Why?

    • Describe [the Site's] use of psychosocial services and supports in SUD treatment.

      • What approaches do you use?

        • If motivational interviewing is used, when is it used?

      • Is use of psychosocial services mandatory, encouraged, up to the patient?

      • What is your history of using these approaches? Has there been change over time? Why?

  • Describe [the Site's] approach to care integration and care coordination.
    PROBES:

    • Integration or coordination of mental health screening or treatment?

    • Integration or coordination of physical health screening or treatment?

    • What challenges do you encounter in providing either integrated or coordinated care?

  • Describe the role of case management at [the Site].
    PROBES:

    • Follow-up on what they state.

    • Can you elaborate as it relates to efforts to retain people in treatment?

    • Are there specific approaches you take when someone fails to appear for expected treatment?

    • Has [the Site's] approach to case management changed over time in an effort to address retention?

  • Describe your staff training and education protocols.
    PROBES:

    • Staff composition.

    • Education and credentialing requirements.

    • Continuing training requirements.

  • Are there specific challenges and solutions you would like to share with us related to the services you provide or would like to provide?
    PROBES:

    • Follow-up on what they identify.

    • Workforce or treatment availability limitations?

      • Access to waivered prescribers?

        • Use of nurse practitioners or physician assistants to prescribe buprenorphine?

      • Access to methadone treatment?

 

Topic 3. Discussion Questions: Patient Retention and Continuity of Care

Discussion Goals: To understand how the site addresses patient retention and continuity.

Key Points That Need to Be Clarified by Discussion's Close:

Duration of retention in treatment, challenges and solutions to improve retention, approaches to monitoring retention, access barriers, motivational barriers, approaches to assuring and monitoring continuity of care.

Key Words: retention, follow-up, continuity of care, access, motivation

Patient Retention Discussion Questions
(If already know answer, use questions to confirm)

INTRODUCTION: This group of questions looks at issues related to retention and continuity of care.

  • Describe the expected and typical duration in treatment for patients at [the Site].
    PROBES:

    • Do you have an objective for the length of time you would hope to see someone remain in treatment with you?

    • What it the typical or average length of treatment?

    • What is the range of retention in treatment?

    • Has your site's retention duration changed over time?

      • If changed: What caused this change in retention?

  • Has [the Site] taken steps to improve retention in treatment, for example quality improvement initiatives?
    PROBES:

    • What actions were taken?

    • What were the effects of those actions?

    • Were there any unintended effects (good or bad)?

    • What challenges and solutions did you encounter in trying to improve retention?

  • What approaches do you use to monitor retention?
    PROBES:

    • Do you have any data that you would be willing to share regarding treatment retention?

  • What are the primary barriers to retaining patients in treatment?
    PROBES:

    • Follow-up on what they identify, including their attempts to solve the problems and degree of success.

  • Describe [the Site's] approach to alleviating access burdens for patients.
    PROBES:

    • Insurance or payment ability (Problem? Attempted solutions? Effect?)

    • Transportation services (Problem? Attempted solutions? Effect?)

    • Childcare (Problem? Attempted solutions? Effect?)

    • Access to pharmacy to fill buprenorphine prescriptions (Problem? Attempted solutions? Effect?)

    • Other geographic barriers (Problem? Attempted solutions? Effect?)

    • Other (Problem? Attempted solutions? Effect?)

    • Telehealth

      • If used: How do you use it? (Prescribing and medication management, psychosocial, consults, etc.)

      • How long have you used it?

      • What percentage of the patient population uses it?

      • What effect on retention?

  • Describe [the Site's] approach to addressing patient motivation to engage and remain in treatment.
    PROBES:

    • How do you address patient motivational challenges?

    • When do you find this to be successful?

    • Discuss your approach to re-engaging patients you haven't seen in a while.

    • Do you do outreach? What outreach strategies do you use?

    • What continued barriers do you encounter?

  • I am going to ask you some specific questions related to other items that might or might not enhance retention and would like your feedback on these:

    • Are there specific clinical approaches related to either MAT or psychosocial services that may improve retention?

      • Ongoing motivational interviewing?

    • Are there specific social supports that may improve retention?

    • Are there structural approaches regarding how care is organized that may improve retention?

    • Are there other specific changes to how you conduct SUD treatment that might improve retention?

      • Are there specific governmental (federal, state, or local) policies that might be changed that could enhance retention?

    • Are there differences in what affects retention for OUD compared to other SUDs?

  • Describe [the Site's] approach to coordinating follow-up or ongoing care for SUD for your patients?
    PROBES:

    • What methods are used?

    • Level of success?

    • How long have you been doing this? Has it changed over time? Why?

    • What other barriers are there to assuring continuity of care when someone leaves your site?

    • What methods do you use to monitor continuity of care after someone leaves your site?

  • Is there anything else we should know related to retention and continuity of care?

 

Topic 4. Discussion Questions: Patient Outcomes

Discussion Goals: To understand retention and patient outcomes of treatment.

Key Points That Need to Be Clarified by Discussion's Close:

Relationship of retention to treatment outcomes such as abstinence, overdose rates, employment, criminal justice involvement, and level of child welfare involvement.

Key Words: outcomes, abstinence, overdose, employment, child welfare, criminal justice

Patient Outcomes Discussion Questions
(If already know answer, use questions to confirm)

INTRODUCTION: These questions are about the relationship between retention and outcomes.

  • Based on your experience at [the Site], is there a relationship between retention in treatment and patient outcomes of treatment?
    PROBES:

  • Follow-up on what they offer

  • Do you see differences in the following outcomes:

    • Substance use, abstinence

    • Mental health

    • Overall functioning

    • Overdose rates

    • Employment

    • Level of child welfare involvement

    • Level of criminal justice involvement

    • Other important outcomes

  • Do you have data that you can share related to outcomes?

 

Topic 5. Discussion Questions: Models/State or Local Authorities

Discussion Goals: To understand how the state's model of treatment and/or reimbursement relate to retention and patient outcomes.

Key Points That Need to Be Clarified by Discussion's Close:

Relationship of state model of treatment or reimbursement to retention and continuity of care.

Key Words: model, reimbursement, retention

State Treatment Model Discussion Questions
(If already know answer, use questions to confirm)

INTRODUCTION: These questions are about the relationship between the state's treatment or reimbursement model and patient retention and outcomes.

  • Describe the [treatment/reimbursement] model.
    PROBES:

    • Follow-up on what they offer.

    • Structure.

    • Reimbursement approach.

    • Relationship to aspects of treatment in the state.

  • How does the design of the [treatment/reimbursement] model affect retention in treatment?
    PROBES:

    • Organization:

      • Model structure.

      • Ability to provide office-based MAT and how to handle when acuity increases.

      • Cross-system collaboration.

      • Value-based payment (incentives and withholds).

    • Treatment design:

      • Policies on substance use while in treatment.

      • MAT (availability and whether mandated or not).

      • Psychosocial services (availability and whether mandated or not).

      • Care integration and coordination.

      • Case management.

    • Access:

      • Geographic issues (rural, other shortage areas, pharmacy or OTP availability).

      • Social supports and removal of access barriers.

      • Insurance and ability to pay.

      • Telehealth.

      • Wait time and low-threshold treatment access.

    • Follow-up and continuity between settings.

  • Are there other things we should know about this model and how it relates to retention or continuity of care?

  • Do you have data that you can share related to retention in treatment, continuity of treatment, and/or patient outcomes?

 

APPENDIX A. INTERVIEW/NOTE-TAKING PROCESSRESEARCH FINDINGS

  1. Review Discussion Guide questions, site information, including notes from preliminary outreach calls with the site, and interviewee background prior to the interview.

  2. The lead interviewer and note-taker will pre-select key discussion topics based on the interviewee's position. They will designate pre-determined timing for each topic area based on interviewee's position and keep track of time to assure coverage of all key topics.

  3. Inform the interviewee that specific interviewee names will not be revealed to ASPE or published. Sites will be identified by name in reports or publications unless the site objects. Results of interviews with patients (if any) will only be discussed if it can be done in a way that does not reveal who said what to their programs.

  4. Provide a project overview (e.g., major goals) and an overview of the topics that will be covered during the interview.

  5. Ask warm-up questions to start the interview and create a comfortable environment with the interviewee.

  6. Conduct interview.

  7. Close interview by asking "is there anything else you would like to share"?

  8. Review notes at the end of the interview day to fill in any gaps and record impressions and other useful observations.

 

APPENDIX B. TEMPLATE FOR SITE VISIT NOTES

Interview Information
Date & Time MM/DD/YYYY, HH:MM AP/M
Interviewer Name  
Note Taker Name  
Participant Information
Site Name  
Site Location  
Interviewee(s) Name(s) & Titles  
Participant Types
Executives (i.e. CEO, CMO, COO) [# interviewed]
Managers (i.e. Directors of Quality, Behavioral Health, Contracting, Care Management) [# interviewed]
Affiliated Case Managers [# interviewed]
Key Providers [describe role, # interviewed]
Other Site-Related Stakeholders [describe role, # interviewed]
State or Local-Level Officials [describe role, # interviewed]
Topics Covered in Interview
[cross out topics not covered]
  • Topic 1
  • Topic 2
  • Topic 3
  • Topic 4
  • Topic 5
  • Topic 6
Discussion