Table 2 Operational factors influencing MAT implementation and sustainment
Screening Aim: Employ an initial screen for opioid use disorder at intake for 100% of new admissions | ||
Category | Barriers: | Solutions and Innovations: (bold = innovation) |
Facility | Space at intake not conducive to screening | Self-administered screen with tablet at intake |
Culture and Change Management | Inconsistent screening due to custody vs. medical priorities | Aligned custody and medical leadership |
Policy/Procedure | Lack of standardized procedure for screening and assessment | Develop a comprehensive screen to be completed by Day 2 |
Education | Lack of education on medication assisted treatment options and recovery treatment | Video education at intake about treatment program |
Staffing & Training | Insufficient staff to screen consistently | Train interdisciplinary staff to screen; temporary increase in staffing during busy times |
IT/EMR | Use tablet technology for screening linked to EMR | |
Treatment Aim: To offer system-approved treatment to all individuals diagnosed with opioid use disorder unless treatment is contraindicated | ||
Category | Barriers | Solutions and Innovations: (bold = innovation) |
Culture & Change Management | Lack of buy-in from Security and Nursing; Judgement that patient is “poor candidate” for treatment or terminate treatment due to “bad behavior”; contraband concerns of custody | Alignment of custody and medical priorities through training and open dialogue policy to continue all FDA approved treatment at time of incarceration |
Staffing | Medical services not 24/7; insufficient staff for treatment induction | Increase capacity to treat 24–7; add staff during peak days; contract with community-based provider to assist with treatment onsite; train staff to be flexible |
Policy/Procedure | No standard process for treatment induction | Create comprehensive treatment procedures |
Patient knowledge & education | At jails providing agonist treatment, many patients express lack of interest in treatment | Focus groups to explore lack of interest in treatment and group education visits to address concerns |
Facility | Space not conducive to treatment | Site expansion; medication line customization; designated housing units for treatment |
Contraindication | Medical conditions preclude treatment; e.g. liver disease; medication side effects intolerable | Provide alternative medication |
Safety Concern/Procedure | Inmate movement and transfers | |
Spread and expand treatment | Criminal justice collaborations: pre-trial, drug court, work release populations | |
Practice transformation | Add CBT; interdisciplinary team approach; structure improvement efforts into smaller functional work groups; treatment integrated into standard operating procedures | |
Community coordination for post-release care Aim: 100% of treated patients will receive an appointment for treatment at time of release and all appointments will be kept | ||
Category | Barriers | Solutions and Innovations |
Community Access | Large geographic catchment for return to home post-release | Develop a community/county reentry council |
Patient tracking | Data not available from community agency; lose patients to follow-up | Contract with community-based treatment provider for onsite treatment; identify liaison with community-based providers; recovery specialist or coach follows patient post-release; close coordination with courts and probation |
Insurance | Lack of access to post-release treatment or transportation issues; lack of health insurance at time of release; | Work with state to suspend public insurance and reactivate at time of release; expand state Medicaid enrollment; work with community providers willing to provide ‘bridge’ services |
Staffing | Insufficient staff for discharge planning | Develop follow-up process for patients released on treatment; Cross-train all discharge planners to coordinate post-release treatment; addition of recovery coaches; CMS waver for 30-day pre-release planning |
Post-release programming | Aftercare group for released population on treatment; job placement in recovery friendly environment; open step-down unit run by prison or jail | |
Data collection systems: develop system for tracking patients screened with OUD, those treated and untreated as well as community referral tracking | ||
Category | Barriers | Solutions and Innovations |
Data collection and reporting | Manual data collection with data entry in Excel; errors in secondary data entry; status revision requires repeated data input already entered | Fully integrated EMR with MAT assessment and treatment information and reporting capacity |
Staffing | Limited staff for data collection and reporting | Peer navigators assist with intake and referral data entry |
Culture and Change Management | Data collection and reporting not a priority | Prioritize value of data across public safety and coordinate with all agencies |