NIATx in New Places: Empowering Teams in Recovery Community Organizations with NIATx

 By Kris Kelly, PR COE and Great Lakes ATTC, MHTTC, PTTC Project Manager, and Maureen Fitzgerald, Great Lakes ATTC, MHTTC, and PTTC Communications Manager

For recovery advocate Kris Kelly, the NIATx model helps tackle a long-standing question: 

“How can we support grassroots recovery organizations that are typically underfunded, under resourced, but continuously over-delivering?”

Kris joined the team at the Great Lakes ATTC, MHTTC, and PTTC in 2018 as a project coordinator, bringing experience in helping people discover and maintain recovery as director of programs for the Minnesota Recovery Connection, Minnesota’s most longstanding recovery community organization (RCO). In 2020, she became the team lead for the Recovery Community Organization Capacity Building Arm of the Peer Recovery Center of Excellence (PR-CoE). 

After attending her first NIATx Change Leader Academy, Kris quickly saw the potential for NIATx tools to help RCOs drive positive change, improve processes, and empower individuals and teams. 

A tool for empowerment

For Kris, the true power of the NIATx approach lies in empowering teams.

“The NIATx approach doesn’t  involve an authority figure swooping in to do something for you,” adds Kris. “Instead, it teaches teams to use a process like flowcharting that helps them understand what it’s like to be a customer in their organization.The flowchart tool can uncover both the strengths in a process and surprises about what’s not working well—like asking someone the same question four times!”

The NIATx walk-through also helps teams understand the challenges people face when seeking services from an RCO. “The walk-through exercise is easy and approachable and makes complete sense once you give it a try,” adds Kris.

Another participatory process that RCOs find valuable is the Nominal Group Technique (NGT). “We can use the NGT in staff meetings to decide on practically anything,” comments Kris. “The NGT brings in all voices to decide on a way to move forward. This really aligns with the RCO philosophy.”

Validating lived experience

“RCOS are frequently staffed by people who come into the work because of their lived experiences navigating the confusing and complex system of care for people with substance use challenges,” explains Kris. “They come to the field with a passion to expand and change the available options and provide care that authentically meets the wants and needs of the recovery community.”

Many employees of RCOs come from outside the clinical addiction treatment field. While learning about the work of an RCO, people may be hesitant to bring forth their ideas.

"This is where NIATx steps in as an empowerment tool for people who may not yet see themselves as leaders and changemakers," says Kris. "It shows people that there is a process for trying out their ideas, and that it’s perfectly OK to abandon a change if it doesn’t work. In the end, you have some data that supports your reason for continuing with a change in a process.”

What’s more, says Kris, NIATx also mimics how recovery coaches work with people new to recovery.

"Recovery coaching can be similar to doing a flowchart of your life and doing a walk-through of your recovery journey," explains Kris. In recovery, we follow Plan-Do-Study-Act cycles, trying out different strategies and refining our approaches— for example, finding a mutual support meeting that works best for you. A coach might tell someone to try one meeting for a few sessions, then decide to continue or try a different one that works better.”

Building the peer recovery support workforce

An exciting prospect for Kris is the potential impact of the NIATx model on the future of RCOs and the peer recovery workforce. 

“What really interests me is the idea of moving NIATx upstream,” says Kris. “By including NIATx in program planning, organizations can ensure that they assess whether a program is working as intended. It provides a way to constantly evaluate and improve upon initiatives.”

The PR CoE will provide two NIATx CLAs focused on recruitment, retention, and leadership in RCOs in the coming year.

“The field of peer support is rapidly evolving, and for RCOs seeking funding to embed peers, including the NIATx approach can make a winning proposal,” she adds. “NIATx provides a blueprint for incorporating peers into organizations and with a built-in tool for collecting valuable data to showcase the success of a project.”

Kris Kelly is a Project Manager for the Peer Recovery Center of Excellence and Great Lakes ATTC, MHTTC, and PTTC, at the University of Wisconsin–Madison,  and a subject matter expert on peer recovery support services. Kris has developed best practices for integrating peer recovery supports into a wide variety of systems and services.

ATTC/NIATx’s Top 10 Posts From Our First Decade

 Compiled by ATTC/NIATx staff and directors

This month marks a decade of partnership and collaboration between the ATTC Network and NIATx on our shared blog. In that time, we’ve published more than 300 articles, including multiple series, from the pearls of wisdom we’ve learned over the years, to all the many new places you can implement the NIATx process.

Together we have compiled a list of 10 of our favorite posts from the last 10 years.

November 2022: Embracing Change: Providing Program Specific Harm Reduction Technical Assistance

The goal of the Embracing Change series was to showcase the ways each of the regional and population-specific ATTCs had found to survive, adapt, and thrive during COVID-19.

June 2021: The Treatment Challenge in Jail Settings: Detox and Withdrawal or Continuing Medication?

The ATTC/NIATx blog is a place where we sometimes invite our friends and collaborators to share their thoughts on issues affecting our industry, like this guest editorial from the Justice Community Opioid Innovation Network (JCOIN).

July 2020: Addressing the Syndemic of Addiction, COVID-19, and Structural Racism by Strengthening the Workforce

Our Tech Transfer In Action series focused on ways the ATTC Network delivers to the communities we serve. This article looks at the syndemic approach deployed by the New England ATTC to address addiction, COVID-19, and structural racism.

May 2019: Great Lakes ATTC: Process Improvement Focus Helps Organizations Implement Evidence-Based Practices

“A fundamental tool in the Great Lakes ATTC’s effort to accelerate EPB implementation is the NIATx model, developed in 2003 as a demonstration project supported by the Robert Wood Johnson Foundation and SAMHSA… Since then, more than 50 peer-reviewed articles have documented the use of the NIATx model in adopting evidence-based practices in addiction treatment, mental health, HIV treatment, child welfare, criminal justice, and other human services settings.”

December 2018: Building Rural and Technology Literacy Skills

The Mountain Plains ATTC provides an update on its efforts to strengthen the behavioral health workforce in rural communities.

February 2017: PPW Project Echo: Building capacity to provide care for pregnant and postpartum women with substance use disorders

The ATTC Network often gets TA requests for materials and resources targeted to specific populations, like this effort to utilize Project ECHO to provide care for pregnant and postpartum women with substance use disorders.

June 2016: Are we leveraging digital technology in addiction treatment?

Then-NIATx director David H. Gustafson provides an update on their A-CHESS app, a smartphone app for recovery support.  

November 2015: A Seminal Study Asks: Should our paradigm for treatment be expanded? Are we doing enough?

Another guest post, this time from a quartet of researchers who published “An Interpretive Phenomenological Analysis of Secular, Spiritual, and Religious Pathways of Long-Term Addiction Recovery” in Alcoholism Treatment Quarterly. The study explores 64 shared themes over three distinct stages of recovery.

October 2014: Integrating SUD Services with Health Care: the ATTC Network's Role

Here’s a post about the ATTC Network’s role in integrating behavioral and physical health care services.

August 2013: Better Together: Welcome to the ATTC/NIATx Service Improvement Blog!

The post that started it all!

NIATx in New Places: Implementing MOUD Programming in Criminal Justice Settings

By: Jessica Vechinski, MSW, Client-Based Researcher & Project Manager, Justice Community Opioid Innovation Network (JCOIN),Center for Health Enhancement Systems Studies, UW–Madison, and Kristina Spannbauer, MA, Communications Specialist, Great Lakes ATTC, MHTTC, PTTC Center for Health Enhancement Systems Studies, UW–Madison

Coaching is a favored strategy for the implementation of medications for opioid use disorder (MOUD), yet research has not adequately tested or assessed coaching dosages and mediums for overall effectiveness, nor has coaching been widely used or studied within criminal justice settings (CJS).

The University of Wisconsin’s Center for Health Enhancement and Systems Studies (CHESS) in partnership with the Justice Community Opioid Innovation Network (JCOIN) funded by the National Institute on Drug Abuse (NIDA) was provided the opportunity to implement a pilot program and research study using the NIATx learning collaborative model within jails and community treatment provider sites around the country where recent policy mandates for the provision of MOUD have been handed down to jails. 

Over the last three years, 50 sites in 14 states have participated in the study and utilized NIATx coaching in their jail systems. As of July 2023, 32 sites have completed the two-year study and the remaining 18 sites will be completing the study by January 2024.

In the initial steps of the pilot, a NIATx coach worked with each site to identify one or more process improvement aims to focus on during the 12-month intervention phase by flow-charting and conducting a walk-through of their MOUD processes. These steps not only provided NIATx coaches with a greater understanding of the operational environment of CJS, but a few reoccurring themes related to the existing barriers of offering MOUD treatment presented themselves. One theme was the stigmatization of providing MOUD to incarcerated individuals. This was a monumental barrier that needed to be addressed before any changes could effectively be made. Another predominant theme was that each correctional setting is a complex system with processes that are structured around standard operational procedures as well as guidance from multiple different key stakeholders—and there is often little direct correlation or communication between the two!

The Role of Stigma

The stigmatization of MOUD in CJS is the greatest barrier preventing many of the sites from implementing a successful MOUD program. For some sites, leadership was in support of MOUD; however, the staff was not, and protocols would be skipped. On the flip side, other sites would have medical teams pushing for change and the leadership would be resistant. These examples highlight the importance following the NIATx principles, because if staff and leadership are not on board with the MOUD programming, change cannot occur. This unique dynamic created the ultimate barrier for NIATx coaches and was ultimately addressed by dedicating multiple coaching sessions to educating staff and leadership about the benefits of MOUD and how MOUD programs improve CJS conditions and outcomes.

Interprofessional Communication Gaps

Conducting the CJS walkthroughs were “eye-opening” experiences for everyone involved. Sites asked a variety of different staff and stakeholders to describe their current processes—from intake, to screening, to the administration of medication, and the warm-community handoff. For many of the sites, it was the first time their staff had sat down together and created a process flowchart based on input from a diverse cross-section of site staff and leadership, and they discovered that often the processes were not occurring as described by their team. The NIATx coaches used team coaching calls to help the participating sites improve gaps in communication that may be affecting the follow-through of their processes. As the study progressed, many of the sites commented on the helpfulness of the NIATx coaching calls in keeping them on track, bringing key players to the table, facilitating fruitful discussions, and maintaining accountability. There was also the added bonus of having a coach to guide them through MOUD process improvement! 

NIATx Keeps Evolving

This pilot program and study is not only testing the efficacy of the NIATx model in CJS, but also assessing the optimal amount of coaching needed to successfully implement or increase MOUD programming. Although the jails enjoyed the coaching calls, most of them stated that they wish they would have had more one-on-one coaching time. Some sites received four hours of coaching while others received twelve hours of coaching of the course of a year. Based on preliminary findings, there was a need for more communication between the sites and the coach. A small pilot is underway to develop and test a web based NIATx Coaching Extender Platform (CEP) that will allow asynchronous communication between the coach and jail staff. The platform will include a running agenda, all rapid-cycle PDSAs, MOUD data, a message board, and an "ask the expert" feature. All these features will include email and/or phone notifications so that communication can happen in a quick, timely matter.

We've learned so much from this unique and intensive pilot. Although the study has concluded for many of the participating sites, several of those facilities have continued their monthly team meetings and remain committed to maintaining MOUD programming in their facilities.

Want to learn more?

Read Jessica's 2021 blog post, The Treatment Challenge in Jail Settings: Detox and Withdrawal or Continuing Medication? for additional insight on JCOIN's research and the aims of this pilot program during the early stages of the study.

Discover additional evidence-based information about medications for OUD by downloading SAMHSA's TIP 63: Medications for Opioid Use Disorder.

Stay tuned for updates on the NIATx CEP next year!

Jessica Vechinski is a member of Center for Health Enhancement System Studies (CHESS) at the University of Wisconsin. She serves as a client-based researcher and project manager for a five-year study with the Justice Community Opioid Innovation Network (JCOIN), an initiative funded by NIDA/NIH. The study is testing the combination and dosages of two evidence-based strategies to implement or improve medications for opioid use disorder (MOUD) programming within justice settings around the country. You can reach Jessica at jvechinski@wisc.edu.

ATTC & NIATx: After 10 years – Still Better Together!

By Todd Molfenter, director of Great Lakes ATTC & director, NIATx, Laurie Krom – ATTC NCO co-director, and Maxine Henry, ATTC NCO co-director

In August 2013, the ATTC Network and NIATx launched the ATTC/NIATx Service Improvement blog with a welcome post by Laurie Krom and Kim Johnson, aptly titled "Better Together." The inaugural post celebrated the ATTC Network and NIATx collaboration and shared vision for the behavioral health field. Ten years and more than 300 blog posts later, we’re even better together!

Our "Better Together" collaboration continues to evolve and grow. The ATTC Network was established 30 years ago to promote technology transfer and bridge the gap between research and real-world application. NIATx entered the scene 20 years ago, focused on evidence-based process improvement and systems change practice. The magical combination of technology transfer and process improvement has helped to fuel transformative change in prevention, treatment, and recovery practices—now more important than ever as we face the intersecting epidemics of HIV, hepatitis, substance use disorders, mental health issues, and pregnancy-related morbidity and mortality.

The ATTC/NIATx approach that has emerged from combining technology transfer (or translational science), process improvement, and implementation science offers several guiding practices that can help tackle health challenges and drive the adoption of effective, evidence-based solutions:

1.      Identifying implementation brokers: Both NIATx and ATTC recognize the importance of key individuals in scaling up practices. The NIATx model includes the key roles of Executive Sponsor and Change Leader. The ATTC Network’s seminal product, The Change Book, also promotes the use of a Change Leader. These roles are implementation brokers. They can help accelerate the implementation process. For example, in implementing medications for opioid use disorder (MOUD), we’ve learned that payers, administrators, clinical champions, and recovery community leaders play integral roles.

2.      Translating knowledge: A key element of the ATTC Network’s Continuum of the Diffusion of an Innovation is translation. ATTC’s define translation as “explaining the essential elements and relevance of an innovation, then packaging it to facilitate dissemination.” Examples could include lay-language newsletter articles describing an innovation or training curricula. In the NIATx model, the voice of the customer highlights the importance of translating research into accessible, culturally responsive language for people outside the scientific community. Incorporating input from those receiving services has long been part of ATTC and NIATx practice, resulting in numerous products and technical assistance knowledge translations.

3.      Aligning implementation strategies: Leveraging implementation science, NIATx tools such as the PDSA cycle, and the practical experience of ATTCs, we understand the value of selecting strategies to enhance the implementation process. For example, in community health or criminal justice settings with multiple systems components, a learning collaborative with coaching may be the perfect solution for building MOUD capacity. In contrast, implementing Narcan distribution at ED discharge may require a less intensive strategy, such as step-by-step instructions provided in a quick podcast or YouTube video.

4.      Leveraging partners: Scaling up evidence-based practices requires collaboration and coordination. Our long-standing relationships with regional partners create effective channels for disseminating implementation products and services. For example, each ATTC Regional Center utilizes a robust Advisory Board comprised of key partners and SAMHSA and state officials.

As the ATTC Network and NIATx grow better together, we look forward to sharing our successes in the ATTC/NIATx Service Improvement Blog. Stay tuned for more inspiring stories as we shine a spotlight on the incredible innovations and achievements of our colleagues. Here's to another 10 years of transformative change as we address today’s most pressing healthcare challenges together. 

ATTC’s Pearls of Wisdom: Using the Science to Service Laboratory to bridge the gap between research and practice

 By Rosemarie Martin, PhD and Sara Becker, PhD, New England ATTC

The New England ATTC at the Center for Alcohol and Addiction Studies of Brown University has been continuously funded since the ATTC network’s inception in 1993. The mission of the Center for Alcohol and Addiction Studies is to promote the identification, prevention and effective treatment of addiction and its problems through research, education, training, and advocacy.  Having a home in a world-class addiction research center, the New England ATTC fills a unique niche that sets us apart. Our role as technical assistance purveyors, paired with our home in a center dedicated to advancing science, makes us ideally suited to advance the study of implementation science. We are well poised to close the lengthy gap between the development of research-based addiction health services and their adoption to clinical practice. 

The New England ATTC has leveraged our academic partnerships with community providers to improve the standard in the field for rolling out evidence-based practices (EBPs).  The centerpiece of the New England ATTC’s training efforts for the past two decades has been the Science to Service Laboratory. The SSL is a comprehensive, state-of-the-art multi-component implementation strategy that facilitates technology transfer. 

What is unique about the SSL is the inclusion of three key implementation strategies designed to better support the broad process of technology transfer: didactic workshop, performance feedback, and external facilitation. 

The SSL has strengthened the New England ATTC’s capacity for providing intensive technical assistance through ongoing immersive experiences that help infuse EBPs into real world settings.  As a result, the New England ATTC provides a higher proportion of intensive technical assistance relative to the rest of the network: a network-wide analysis in 2020 suggested that 4% of TTC events were classified as intensive technical assistance during COVID, whereas for the New England ATTC this proportion was 30% over the same time period. Early evaluation of the SSL showed that 96% of agencies that completed all of the SSL components ultimately adopted an EBP.

Using contingency management as test case, our ATTC first applied for funding in 2008 to evaluate the SSL strategy compared to the standard at the time, didactic workshop delivered by a national expert, Nancy Petry. 

We offered the SSL multi-component implementation strategy to seven opioid treatment programs within our region and compared that to 11 opioid treatment programs outside of our region that received a didactic workshop. Opioid treatment program staff in both conditions reported on their delivery of contingency management every two weeks for a year. We found that those organizations trained with the SSL model had higher odds of adoption (odds ratios up to times higher than the didactic workshop), higher speed of adoption, and higher overall frequency of adoption.

Still, we thought there was room for improvement. Could we help accelerate the uptake of contingency management in clinics?  Could we help sustain its use? We asked opioid treatment providers from 11 programs in our region how we could more effectively help them to integrate contingency management into their treatment approach and used their feedback to enhance the SSL. With R01 funding from the National Institute on Drug Abuse, our ATTC is partnering on a large-scale cluster randomized trial with 28 opioid treatment programs throughout the region to test our standard SSL strategy versus an enhanced SSL strategy that layers in provider incentives and external facilitation targeting sustainment. 

This five-year project is wrapping up and we are excited to share the results soon.

In the meantime, we are using the lessons learned to partner with the Rhode Island Department of Health to help them rollout contingency management to opioid treatment programs state-wide. Our SSL model has also informed the multi-component implementation strategy currently being used across California in their rollout of contingency management as a Medicaid-reimbursable service.

The SSL continues to evolve as we integrate new scientific findings in behavior change at both individual and organizational levels.  The science to service influence is bidirectional: we learn from scientific research to improve our technical assistance, and we learn from our work in the field providing technical assistance to improve our science.

In recent years, the most popular EBPs for which the New England ATTC receives intensive technical assistance requests include contingency management, motivational interviewing, and Screening, Brief Intervention, and Referral to Treatment. We look forward to continuing to apply the SSL to help organizations implement EBPs and improve the quality of care offered to persons with or in recovery from substance use disorders.

About the authors:

Rosemarie A. Martin, PhD, is Director of the New England ATTC.  Dr. Martin is an Associate Professor at the Center for Alcohol and Addiction Studies at  the BRown University School of Public Health.  

Sara J. Becker, PhD is Co-Director of New England ATTC.  Dr. Becker is the Inaugural Director of the Center for Dissemination and Implementation Science at the Northwestern Feinberg School of Medicine.