University of Louisville, Kent School of Social Work & Family Science, 2217 S 3rd St, Louisville, KY, USA.
I-Lead Institute, Research to End Healthcare Disparities Corp, 150 Ocean Park Blvd, 418, Santa Monica, CA, USA.
Int J Drug Policy. 2024 Oct;132:104567. doi: 10.1016/j.drugpo.2024.104567. Epub 2024 Sep 5.
Enhancing care integration and coordination to improve patient outcomes in opioid use disorder treatment is a growing focus in the field. Understanding of how the treatment system implements coordination and integration, particularly in the aftermath of the COVID-19 pandemic, remains limited. In this study, we explored the implementation of medications for opioid use disorder (MOUD) and the evolution of service delivery toward a more comprehensive approach. We examined providers' perspectives from high-achieving programs in Los Angeles County, the largest and most diverse U.S. county, including barriers to integrating and coordinating care and strategies for integrating MOUD service delivery.
We gathered qualitative interview data from 30 high-performing programs in Los Angeles County, each represented by a manager or supervisor. High performance was defined by empirical indicators of access, retention, and program completion. Our data collection and analysis followed the constructivist grounded theory approach, explicating the social processes used by participating managers during the pandemic and subsequent organizational shifts. This approach yielded 14 major and six minor codes. Interrater reliability tests yielded a pooled Cohen's kappa statistic of 93%.
Expert providers exhibited a strong commitment to destigmatizing MOUD and worked to overcome obstacles in delivering care to clients by advocating its efficacy to fellow health care providers. Along with their endorsement of MOUD, they identified challenges in integrating and coordinating MOUD care. Barriers included stigma at both patient and provider levels, inadequate education about MOUD, limited access to MOUD, and the complexities of operating in a fragmented health care framework. Despite these challenges, high-performing providers used strategies to harmonize and align MOUD service delivery with health and social services. These included establishing service colocation, adopting a multidisciplinary team-based approach, forming partnerships with the community, offering telehealth services, integrating and sharing data, and embracing a harm reduction philosophy.
Through the adoption of these strategies, providers enhanced care accessibility, boosted patient engagement, sustained retention in treatment, and enhanced treatment outcomes. Even among highly skilled treatment providers in Los Angeles County, barriers to integrating and coordinating care using MOUD remain intricate and multifaceted. Addressing these challenges necessitates a comprehensive strategy involving provider education and training, increased availability of MOUD, enhanced coordination and communication among health care providers, resolution of regulatory hurdles, and addressing patient hesitancy toward MOUD.
加强医疗服务整合与协调以改善阿片类药物使用障碍治疗的患者结局是该领域日益关注的焦点。然而，人们对于治疗系统如何实施协调和整合，尤其是在 COVID-19 大流行之后，仍然知之甚少。在这项研究中，我们探讨了美沙酮等药物在阿片类药物使用障碍（MOUD）治疗中的应用以及服务提供方式向更全面方法的演变。我们研究了洛杉矶县高绩效项目的提供者的观点，这些项目包括美国最大和最多样化的县的提供者观点，包括整合和协调护理的障碍以及整合 MOUD 服务提供的策略。
我们从洛杉矶县 30 个高绩效项目中收集了定性访谈数据，每个项目都由一名经理或主管代表。高绩效是通过可获得性、保留率和项目完成的经验指标来定义的。我们的数据收集和分析遵循建构主义扎根理论方法，详细阐述了参与管理在大流行期间和随后的组织转变期间使用的社会过程。这一方法产生了 14 个主要和 6 个次要代码。评分者间可靠性测试产生了 93%的 pooled Cohen's kappa 统计量。
专家提供者表现出强烈的承诺，将 MOUD 去污名化，并通过向其他医疗保健提供者倡导其疗效，努力克服向客户提供护理的障碍。除了对 MOUD 的认可外，他们还发现了整合和协调 MOUD 护理方面的挑战。障碍包括患者和提供者层面的污名化、对 MOUD 的教育不足、MOUD 的可获得性有限，以及在支离破碎的医疗保健框架中运作的复杂性。尽管存在这些挑战，但高绩效提供者使用了策略来协调和调整 MOUD 服务提供与健康和社会服务。这些策略包括建立服务协作、采用多学科团队方法、与社区建立合作伙伴关系、提供远程医疗服务、整合和共享数据，以及采用减少伤害的理念。
通过采用这些策略，提供者提高了护理的可及性、增强了患者的参与度、维持了治疗的保留率，并改善了治疗结果。即使在洛杉矶县技能熟练的治疗提供者中，使用 MOUD 整合和协调护理的障碍仍然复杂和多方面的。解决这些挑战需要一个综合的策略，包括提供者的教育和培训、增加 MOUD 的可获得性、加强医疗保健提供者之间的协调和沟通、解决监管障碍，以及解决患者对 MOUD 的犹豫。
