Incentives and Support for MOUD (ISM) is an initiative with the objectives to increase access to MOUD for patients in the primary care setting and build the confidence of waivered physicians to successfully support patients eligible for MOUD in primary care.

PTO will be eligible to receive up to $9600/practice ($300/month for 12 months, plus up to $6000 for meeting specified benchmarks across 12 months). 

Practice facilitators that have taken the Train the Trainer Training and is currently employed by PTO.  

Recruitment of practices will begin in October 2021, and practices can begin receiving support in January 2022. Practices will have until December 2022 to complete the training. 

ISM Implementation Guide

Milestone 1.1: The leadership in this clinic is committed to providing Medications for Opioid Use Disorder (MOUD) and communicates consistently its aims within meetings, case conferences, emails, internal communications, and celebrations of success.

Action Items:

1. Practice leadership understands clinical approaches to providing MOUD
2. MOUD leadership creates a vision and aims to meet MOUD needs of patients that is refined by MOUD team and communicated to staff
3. Leadership recognizes and rewards innovation and improvement related to providing MOUD.

Resources:
California Improvement Network Webinar — E ngaging Providers in
 Substance Use Disorder Treatment
 
California Improvement Network Toolkit – T hree Strategies to Help
 Primary Care Teams Treat Substance Use Disorder
 
National Council for Mental Wellbeing - M edications for Addiction
  Treatment (MAT) Readiness and Implementation Checklist

Milestone 1.2: Practice identifies champions (ie. RN, Provider, MA, etc.) responsible for practice change related to MOUD. Practice has dedicated resources (protected time, EHR, functionality, etc.) to meet and engage in practice change.

Action Items:

1. Identify MOUD practice champions; individuals that will lead process change to support MOUD.
2. Develop quality improvement (QI) capability within the practice and empower staff/providers to participate in MOUD related QI activities, including:
   1. Identify multidisciplinary MOUD quality improvement team.
   2. Protect time for MOUD team meetings by blocking patient care responsibilities where necessary.

Consider what time and resources may be required for MOUD team work outside of regular meetings.

Resources:

 Institute for Healthcare Improvement – Science of Improvement:

 Forming the Team

 AHRQ Primary Care Practice Facilitation Curriculum - Creating Quality

 Improvement Teams and QI Plans

Milestone 1.3: Eligible providers have obtained their DEA X-waiver allowing them to prescribe buprenorphine for treatment of OUD.

Action Items:

1. Compile a list of all prescribers in the practice. Document that participating providers complete the Buprenorphine Waiver Notification.
2. Develop processes for new providers in the practice to obtain their waiver during their onboarding.

 
Resources:
SAMHSA DATA Waiver Completion

SAMSHA Become a Buprenorphine Waivered Practitioner

ASAM e-learning Center

Practice Innovation Program at CU Provider Training Opportunities

        

Milestone 1.4: Providers and staff have received training in the last two years on patient-centered, empathic communication emphasizing patient safety, de-stigmatization, and harm reduction.

Action Items:

1. Identify and prioritize staff knowledge gaps and prioritize areas for training.
2. Pick resources that address knowledge gaps.
3. Participate in monthly ISM calls with addiction specialist.
4. Develop processes for new providers and staff to be trained on MOUD, emphasizing patient safety, de-stigmatization, and harm reduction during their onboarding.

Resources:
MOUD Learning Forum

March of Dimes Beyond Labels Stigma Training

Philosophy of Harm Reduction (National Harm Reduction Coalition)

Harm Reduction Action Center

Comparisons to Medications Used to Treat Opioid Use Disorder: Appendix
XI (Page 143)

MOUD Training Video - By David Mendez, MD

 

Trainings:

DESCRIPTION	TARGET AUDIENCE	TIME REQUIREMENT
Education Symposium:  Fentanyl in Colorado and  the U.S.: Current Trends  and Perspectives	Patients, medical providers, care managers, social workers, clinic staff, public health, pharmacy, community coalitions, LEO	5 hours of pre- recorded content. Learn at your own pace.
Primary care and behavioral health practices play a key role in increasing access to medication assisted treatment (MAT) for opioid dependence and use disorder (OUD). The ITMATTTRs TM Practice Team Training helps create a cohesive, supportive clinical environment where the entire team plays a role. Make sure your team is ready! IT MATTTRs Team Training Sign-Up	Clinic Practice Teams	Five 45-minute modules - details available on the IT MATTTRs Team Training web- page

             

Milestone 1.5: Comprehensive policies regarding MOUD that reflect evidence-based guidelines exist, have been recently updated, and have been discussed with all clinicians and staff.

Action Items:

1. Create/edit/update policies regarding MOUD and build consensus across team about important aspects of MOUD care, such as establishing diagnosis, labs, urine drug testing, establishing routine follow up, routinely checking PDMP, and managing refills. Document and distribute policies to staff.
2. Establish or review current workflow to support implementation of practice established policies.  

Resources:
Urine drug screening: A guide to monitoring Treatment with controlled
substances (requires free Medscape login)

VA/DoD Clinical Practice Guideline for the Management of Substance
Use Disorders – modules A and B provide good workflow examples

SAMSHA Buprenorphine Quick Start Guide

Comparisons to Medications Used to Treat Opioid Use Disorder: Appendix
XI (Page 143)

            

Milestone 1.6: Formal signed patient agreements regarding MOUD exist, align with current policies, and are consistently used with all patients on MOUD.

Action Items:

1. Develop or revise current patient agreement identifying areas of improvement with emphasis on patient centered versus punitive language.

Resources:
National Alliance of Advocates for Buprenorphine Treatment – The
Words We Use Matter. Reducing Stigma through Language

ITMATTTRs Patient Consent Form

Sample Patient Agreement

         

Milestone 1.7: Practice uses a registry or other system to pro-actively track & monitor patients prescribed MOUD to ensure their safety.

Action Items:

1. Practice maintains a registry of patients eligible for MOUD that tracks newly prescribed MOUD, maintenance refills of medications, patients lost to follow up, patients referred out of the practice, and patients that have stopped MOUD.
2. Practice creates a strategy to follow up and outreach to newly induced patients and/or patients lost to follow up.

Resources:
MOUD registry example

ISM MOUD Data Collection Table

    

Milestone 2.1: Care plan documentation templates align with current policies and are consistently used for people on MOUD.

 

Action Items:

1. Practice identifies documentation templates for MOUD patients.
2. Practice staff is trained on where to find and how to use MOUD documentation templates.

Resources:
CU College of Nursing and ITMATTTRs Induction Note Example

History of Present Illness (HPI) Assessment and Plan Template

ITMATTTRs Induction Day Care Plan

ITMATTTRs Maintenance Care Plan

 

Milestone 2.2: Practice communicates to its patients about the benefits of MOUD through flyers, posters and other appropriate outreach.

Action Items:

1. Practice identifies and circulates patient-facing materials demonstrating MOUD treatment options and outlining benefits of MOUD.

Resources:
Practice Innovation Program at CU Resources for your Practice and
 Patients

Prescription Drug Safety Starts With You | Take Meds Seriously

Providers Clinical Support System, Common Questions and Concerns
 about Medications for Opioid Use Disorder (MOUD): A Handout for
 Ambivalent Patients

Have you Met MAT? - ITMATTTRs

 MAT for OUD in SLV – ITMATTTRs

     

Milestone 2.3: Practice consistently uses screening tools and other workflows to identify opioid misuse, diversion, and addiction.

Action Items:

1. Identify patients meeting DSM-V criteria for opioid use disorder.
2. If the patient meets criteria for OUD, offer MOUD.
3. Providers should check PDMP prior to every visit or refill.
4. Practice implements universal screening to identify patients at risk for SUD (opioids, stimulants, benzodiazepines, alcohol, etc).
5. Establish frequency of urine drug testing – may vary depending on stability of use disorder. Consider referral to higher level of care for continued positive urine drug tests.

Resources:
 ITMATTTRs DSM-V criteria for diagnosis of opioid use disorder

 Drug Abuse Screening Test (DAST-10)

 Opioid Risk Tool (ORT): patients on chronic opioid pain medications at risk for developing a use disorder

 CRAFFT Screening Interview

 AUDIT-C for Alcohol Use Screening

 Example MOUD Workflow

      

Milestone 2.4: Workflows exist and are used to provide prompt access to patients for MOUD inductions and routine maintenance appointments. Practice prescribes MOUD for at least 10 new patients since the start of the project.

Action Items:

1. MOUD team creates/tests/modifies workflow to support MOUD induction in practice.
2. Identify patients using illicitly manufactured fentanyl, as this will change the home induction process. Consider a slower buprenorphine induction to avoid precipitated withdrawal.

Resources:
 ITMATTTRs Side Effect Management Protocol
 Example MOUD Workflow
 ITMATTTRs Buprenorphine Initiation Checklist for Clinics
 ITMATTTRs Office Induction Protocol
 Clinical Opioid Withdrawal Scale (COWS)
 ITMATTTRs Patient Drug Relapse Flowchart
 SAMSHA Buprenorphine Quick Start Guide (The last page has home induction protocol)
 Patients using fentanyl (Start from section titled “the fourth wave” about 29 minutes into the video)
 Home Induction Protocol (from David)
 ITMATTTRs Home induction patient guide
 National Clinical Consultation Warm Line - Clinically supported advice warm line on substance use management for healthcare providers

 

Milestone 2.5: Harm reduction strategies are identified, implemented and tracked as a part of the routine care for patients with an Opioid Use Disorder.

Action Items:

1. Routinely check infectious disease labs:
   1. Consider annual recheck: HIV, Hep C, Hep B/A.
   2. As needed depending on risks identified (every 3-6 months): Treponema ab, GC/CT.
2. Prescribe Narcan with all patients prescribed buprenorphine/opioids.
3. Identify harm reduction centers and/or syringe exchanges in your community and compile hand out for patients.
4. Provide information about and access to fentanyl test strips.

Resources:

 Syringe access sites in CO flyer

 Harm Reduction Action Center

DESCRIPTION	TARGET AUDIENCE
Reducing health-related stigma among moms and babies  https://beyondlabels.marchofdimes.org/	Designed for people who work in health-related fields, this interactive site will help you learn how stigma can impact the healthcare and support women need, seek and receive.
Committed to Public Health: The Harm Reduction Action Center promotes public health by ensuring that people who inject drugs are educated and equipped with the tools to reduce the spread of communicable diseases such as HIV and Hepatitis C and to eliminate the proliferation of fatal overdoses  https://www.harmreductionactioncenter.org/	Patients, medical providers, care managers, social workers, other clinic staff. *Located in Denver

 

Milestone 3.1: Practice communicates with at least 3 local professional organizations about the availability of MOUD services in the clinic.

Action Items:

1. Identify and reach out to local professional organizations to raise awareness and visibility of available services. 

Resources:

 MAT Communications Guide from the Practice Innovation Program

Milestone 3.2: Policies and workflows are implemented to identify people who may benefit from higher levels of care for their Opioid Use Disorder or other mental and behavioral health needs. Hand offs to appropriate specialists and treatment facilities are coordinated and tracked.

Action Items:

1. Identify co-morbid diagnoses that would trigger an automatic referral, including significant mental health illness, HIV+, Hep C+, and suicidal ideation.
2. Consider referral for ongoing benzodiazepine and/or alcohol use.
3. Identify nearby treatment facilities and addiction specialists that can provide care for diagnoses above.

Resources:
 OpiRescue’s treatment locator

 SAMHSA’s treatment locators

 ITMATTTRs Drug Screening Treatment Referral Form

 Medical Management Strategies for Patients Taking OUD Medications in
 Office-Based Settings

    

Milestone 3.3: Patients are provided information about community resources for recovery services, including both in-person or virtual, where available,

Action Items:

1. Practice identifies community resources for recovery services.
2. Practice maintains up to date list of community recovery services for patient referral.

Resources:
 Colorado Community Recovery Organizations

 ITMATTTRs blank local resources log

 Regional Health Connectors - can make introductions to community organizations that provide recovery support services as well as organizations to address social needs

   

Milestone 3.4: Practice defines and implements workflows to assess social needs of those on MOUD (housing, transportation, food insecurity, etc.) and to refer patients to appropriate resources to address identified needs.

Action Items:

1. Choose and implement a method for initial assessment of patient population's social needs, including screening patients for existing social needs screening and speaking with social workers, care managers, or other personnel at practice or in community who are currently assisting patients with social needs.
2. Practice maintains, or has access to, up to date list of community services and resources for patient referral. 

Resources:

AF Williams Social Determinants of Health Screening Tool

Three tools for screening for social determinants of health from the AAFP

A Practical Approach to Screening for Social Determinants of Health 

The Feasibility of Screening for Social Determinants of Health: Seven

 Lessons Learned