NIATx: The Intersection of Behavioral Health and Systems Engineering — A Conversation with David H. Gustafson

By David H. Gustafson, PhD, Director, Center for Health Enhancement Systems Studies, and Maureen Fitzgerald, Communications Manager, Great Lakes ATTC, MHTTC, and PTTC

Update: In Memoriam

It is with deep sadness that we acknowledge the passing of Don Holloway, who made significant contributions to the NIATx model. 

Learn more about Don’s legacy.

Dave Gustafson

Dave Gustafson directs the University of Wisconsin−Madison’s Center for Health Enhancement Systems Studies, which includes the Great Lakes ATTC, MHTTC, PTTC, NIATx, and several research projects that focus on using systems engineering tools to support sustainable individual and organizational improvement. His individual and systems change research develops and tests technology to help people deal with issues affecting quality of life, including addiction, cancer, and aging.

In this post, Dave reflects on the enduring impact of the NIATx model.

When NIATx launched in 2003, did you envision it expanding and continuing to grow 20 years later?

"No, it was not a long-term view at all. The Robert Wood Johnson Foundation (RWJF) was interested in whether systems engineering could help in the addiction space. Victor Capoccia, a project officer with RWJF, contacted me and asked if I wanted to run a national program focused on improving addiction treatment. I knew nothing about addiction treatment, so I played the role of someone with an SUD and tried to get myself admitted for treatment in a couple of places. I wanted to make sure that the program we set up with RWJF would make a difference. Our vision was very short-term — what we could do in the 3 or 4 years of the funding period. We did not expect the project to have an extended life beyond the initial funding in 2003.”

What was something that surprised you in the NIATx evolution?

“The biggest surprise was recognizing how little I knew about what it takes for your work to have a broad impact. Victor Capoccia was always thinking about NIATx at a much broader level and set the direction for us. He'd call me and say, "OK, I've set up a meeting with Congress so we can talk about this," or, "I think we can hold a national conference."

Other things came up, but I wouldn’t refer to them as surprises—more like accidental discoveries. Some of the changes we made came about just from conversations. One that stands out is a conversation I had with Dean Lea, one of our NIATx coaches for the first project. Dean and I were driving back from a visit to a treatment center in Maine that Lynn Madden (a current NIATx coach) was directing. We’d been looking at appointment books from a lot of agencies and could see from the packed schedules that there was no room for new patients. But we could also see how many appointments were canceled or no-shows. While the field as a whole was saying they could not meet demand, agencies often had 35% unused space. Dean said, "I don't know why people even bother to schedule appointments because nobody shows up.”

So, we went back to Lynn and talked about not scheduling appointments. This turned into trying out the idea of (what Lynn called) on-demand appointments. That solution just took off. So that's one solution we came up with by accident, not planning. 51% of innovations come up by accident, not by planning. It was an Aha! moment that made a tremendous difference in treatment access. As Einstein said, "If we knew what we were doing, it wouldn't be research." It’s the stumbling along that brings about great ideas.”

What do you think has contributed to NIATx expansion?

“Many things contributed to NIATx expansion. A top factor was staying focused on our original four aims: reducing waiting time, reducing no-shows, increasing admissions, and increasing continuation. Don Holloway, who was part of the team that launched NIATx, told me to really drive that message whenever I got in front of a group to talk about what NIATx was and was not. Staying focused on just those four aims  (and nothing else) at a time made the change projects manageable for our providers versus feeling overwhelmed by the idea of having to overhaul their systems completely. Maintaining that single focus was important.

I also think that the simplicity of the NIATx change model is what makes it so powerful. We told providers that they only had to follow five principles—not 10 or 15—and that they only had to try a change for a very short time. If it worked, great. But if didn’t, then stop and try something else. The idea was to keep NIATx simple and fast-moving enough so people could easily adopt it.

Another factor in our success was the doors that Victor Capoccia and Fran Cotter from SAMHSA opened and their commitment to the project. SAMHSA-funded projects led from a focus on individual treatment agencies to the role of state agencies and the tremendous impact they can have on treatment delivery.

I would add research as another factor contributing to the NIATx trajectory, with work by Todd Molfenter, Jay Ford, and others helping drive widespread implementation and testing in new spaces. Plus, the NIATx Change Leader Academy (CLA) that we launched in 2006 has played a huge role in dissemination efforts and has trained hundreds nationwide.  Mat Roosa and Scott Gatzke continue to refine the CLA to respond to the field’s evolving needs, including work with Alfredo Cerrato on applying NIATx tools to foster cultural responsiveness. That’s really exciting. 

And then, the stories. How many times have I told the story of creating a persona of someone with a heroin addiction and then trying to get my persona admitted for treatment? How I was told to call back for seven weeks in a row to find out if a bed was available when my persona was ready for (and needed) treatment that day! While the science is there, it’s anemic compared to a great story. And, of course, the ATTC/NIATx Service Improvement Blog has been a great way for sharing these stories over the past decade.”

Are you using NIATx tools in your current research?

“The NIATx approach is embedded in the way I think about things and continue to integrate into everything I do. One project that’s been a great interest of mine for some time is the idea of automating addiction treatment, or in other words, finding ways to explore how technology, and that includes AI, can play a role in prevention, treatment, and recovery. The NIATx model of rapid cycle improvement is playing a fundamental role in that effort right now.”

What aspects of your current research are you most excited about?

“One of our current initiatives involves weekly Zoom meetups with around 60 older adults. We kick things off by having participants break into small groups to share something positive or challenging that’s happened in the previous week. We spend the initial 10 minutes in open conversation, then shift gears—assigning someone to lead a discussion on a weekly theme. It could be something as straightforward as dietary choices for older adults, a shared concern for everyone. Then, a member of our research team will give a brief but informative lecture on the topic, followed by a wrap-up 30-minute discussion where everyone pitches in with their thoughts. Towards the end, we summarize the key takeaways and wrap up with a movement exercise.

The impact has been astounding. I initially thought the idea of bringing people together on Zoom was good, but it turns out it's a great idea! I've never experienced such a profound response before. People are emotionally moved, and some have even teared up when they learn that the intervention is coming to an end. That leads us to ask what the next step is. What's the message here, and where is this taking us? It's been a powerful journey, and the participants' emotional response speaks volumes about this project's impact.”

Guest Post — Still Reaching: The Syndemics that Complicate and Characterize How Drugs and HIV Intersect in People’s Lives

 (Editor's note: This post originally appeared on the National Institute on Drug Abuse blog. It is reprinted here with permission from NIDA.)

By Dr. Nora Volkow

Imag

Nearly 42 years ago, the Centers for Disease Control and Prevention (CDC) reported a rare pneumonia in five gay men, marking the recognized start of the HIV/AIDS epidemic. While we often hear about those men’s sexuality, we hear less often about their substance use. As the 1981 report notes, one of those five men injected drugs, and all five used drugs.

The history of HIV has long been entwined with substance use. In the United States today, more than 30,000 people acquire HIV every year while the drug overdose crisis cost the lives of nearly 107,000 people in 2021. Research shows people with HIV are more vulnerable to drug overdose than are those without HIV.

Because substance use plays such a significant role in HIV transmission and in health outcomes for people living with HIV, the National Institute on Drug Abuse (NIDA) is one of the largest funders of HIV research at the National Institutes of Health (NIH). We highlight the stories behind this essential research in the video series, “At the Intersection: Stories of Research, Compassion, and HIV Services for People Who Use Drugs.”

What is a syndemic?

Syndemics happen when two or more diseases interact to amplify each other—leading to an excess burden of disease and perpetuating health disparities. In a syndemic, environmental and social factors, like lack of quality healthcare, can make people more likely to be exposed to and experience worse outcomes from diseases. Having one health condition can also make people biologically or behaviorally more likely to acquire another illness.  However, science shows that when we address syndemic diseases together, outcomes for both can improve—especially when we integrate a variety of medical and social services with community support programs.

Approaching HIV, substance use, and other health issues through this lens can identify new opportunities to intervene that are invisible when we look at each issue alone.

Methamphetamine use, HIV, and mental health issues

A 2020 NIDA-supported study showed that as many as one in three new HIV transmissions among sexual and gender minorities who have sex with men were in people who regularly use methamphetamine. Many participants reported using methamphetamine to enhance sexual experiences, sometimes called “partying and playing.” Other NIDA-funded research shows that individuals who use methamphetamine are more likely to have sex without HIV prevention; to have mental health issues like depression, anxiety, or bipolar disorder; and are more likely to have detectable HIV viral loads and less likely to take HIV treatment and prevention medication. Fortunately, approaches that emphasize compassion and flexibility over judgement show promise in helping people who use meth achieve their health goals, take medication, and reduce their drug use or stay safer when they are using.

Substance use, HIV, and syringe sharing

Since 2014, there have been at least nine HIV outbreaks associated with the sharing and reusing of syringes in communities of people who inject drugs. CDC- and NIDA-funded researchers have identified factors associated with such outbreaks, including higher rates of hepatitis C and drug overdose, poverty, and lower levels of education. Fortunately, decades of research show that syringe services programs are safe, effective ways to reduce syringe sharing—and with it, the risk of acquiring HIV. Today, many syringe services programs also offer the overdose antidote naloxone and medications for opioid use disorder (MOUD), as well as HIV testing, prevention tools and treatment.

Substance use, HIV, and stigma, criminalization, and violence

People with HIV and substance use disorder (SUD) struggle to access quality, evidence-based healthcare. Racism, homophobia, transphobia, and HIV- and SUD-related stigma in healthcare are serious problems. Policies that punish drug use and criminalize HIV status can lead to time in jails and prisons, where access to HIV and SUD services may be limited. Immediately after incarceration, people are at greater risk of overdose and of leaving HIV care.

These factors—plus high rates of intimate-partner violence (especially among transgender and cisgender women living with HIV), childhood abuse, and other trauma—mean many people face intersectional factors leading to poor HIV and substance use outcomes. But NIDA-funded research shows promising ways forward, including integrated care that addresses the totality of people’s lives. For example, “one-stop” clinics—like the mobile health units in the NIDA-supported INTEGRA trial—test the impact of offering comprehensive services delivered by trained peer navigators who can connect with participants’ diverse experiences.

Bottom Line

Meeting people where they are to provide harm reduction and healthcare without stigma and treating the totality of people’s lives offers hope. And that hope is essential to ending the HIV epidemic.

NIATx in New Places: RHRP

By: Mat Roosa, LCSW-R

“How can we improve our workforce?”

In a human service environment filled with open positions, understaffed programs a low rates of worker retention this seems like a perfectly reasonable question. 

As NIATx has continued to explore new places, we have turned our attention to trying to support the workforce challenges of health and human service organizations. The critical need for this support emerged from the experience of attempting to support programs in implementing NIATx based change projects, but finding that the change leader supervisors were struggling to keep enough staff to operate the program, and had little energy for improvement. Some consultants and providers of technical assistance have been struck by the level of stress related to workforce concerns that supervisors are experiencing. Too many supervisors express a high level of stress and moral injury, as they find themselves unable to pursue the mission that they care deeply about, because they do not have the staff to do it. 

So, we decided to use our improvement model to help organizations to answer that question: “How can we improve our workforce?”  And upon further inspection we found that this might not be the right question to ask.

One of our NIATx principles is to get ideas from other industries, and so we found ourselves thinking about how a similar question might play out in another environment. What if a customer went into a grocery store and asked the front-end manager, “Where can I find the dinner food?” We all know why this would not be an appropriate question. It is just too generic to be meaningful. The response would likely be some version of “It depends on what you want to eat.”  

The work of Deming teaches us that everything we do can be defined as a process. And workforce issues are no exception. It became clear that any effort to support workforce improvements needed to use our NIATx tools to break down the issue into the specific processes. These included recruitment, hiring, retention, and promotion (RHRP). The NIATx tools of the walk through and flow charting could then be used to understand the potential applicant or interviewee’s experience associated with that specific process. Nominal group technique brainstorming could then help to define specific strategies for recruitment, or hiring that could be tested using the PDSA (plan, do, study, act) change model. 

We have begun to use this approach to train supervisors and managers to make specific changes and to measure the results to see if they can recruit more diverse candidates, get more people to apply for positions, enhance the interview experience, etc. In addition to the NIATx model, we have also included other key factors, including cultural responsiveness, wellness, and coaching/ mentoring to provide additional support to the workforce improvement effort.

There is certainly no single fix to the complex economic drivers of workforce challenges. But the use of focused data driven change projects can help an organization or a broader system, to find strategies that can make a difference. Harnessing the wisdom of a change team to find new paths forward is a key part of NIATx. Using PDSA change cycles is helping leaders to impact these workforce challenges in simple and powerful ways. 

Mat Roosa, LCSW-R

Mat Roosa is a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant and trainer in the areas of process improvement, evidence-based practices implementation, and organizational development and planning. Mat’s experience also includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human services agency administration.

Addiction Technology Transfer Center (ATTC) Network: Celebrating 30 Years of Empowering Professionals

By Greg Grisolano, for the ATTC Network

Technology transfer is in our name, but do you really know what it is?

 

Even though the Addiction Technology Transfer Center (ATTC) Network has been a leading expert in the field of substance use disorders since 1993, we realize there are still some folks who don’t know who we are and what we do.

 

We provide professionals with free training, tools, and support to help those in recovery and facing substance use disorders. The ATTC Network offers evidence-informed education, technical assistance, and custom resources aimed at strengthening the skills of practitioners. By listening to the needs of local, regional, and national partners, the ATTC ensures it stays relevant and effective, working to empower professionals and foster a thriving, recovery-oriented system of care.

Recently, we launched a new series of explainer videos that provide an overview of the organization’s mission and services. The videos are available in both English and Spanish and are designed to be accessible to a wide range of audiences.

What is the Addiction Technology Transfer Center (ATTC) Network? - Full Length from ATTC Network on Vimeo.

In addition to these explainer videos, the ATTC Network recently celebrated its 30th anniversary. As part of this celebration, we released a timeline highlighting significant accomplishments over the past 30 years. The timeline includes information about how the organization has grown over time and how it has adapted to meet changing needs in the field of substance use disorders.

Our 30th anniversary celebration also included a virtual event that featured remarks from SAMHSA Assistant Secretary Dr. Miriam Delphin-Rittmon and Dr. Yngvild Olsen, director for the Center for Substance Abuse Treatment (CSAT). During this event, attendees had the opportunity to learn more about the organization’s history and its plans for the future.

Watch the ATTC Network’s 30^th Anniversary Celebration

 

The ATTC Network is helping to empower practitioners and foster a thriving, recovery-oriented system of care. 

NIATx in New Places: Insights on Using NIATx in Prevention

By Erin Ficker, Prevention Manager, Great Lakes PTTC, and Maureen Fitzgerald, Communications Manager Great Lakes ATTC, MHTTC, PTTC

Erin Ficker, CPRS, MPAff, has over 18 years of experience in substance use prevention, helping communities adopt evidence-based strategies and data-driven processes for prevention planning and execution. Since 2019, Erin has teamed up with NIATx coach Scott Gatzke to conduct NIATx Change Leader Academies for prevention professionals. An August 2023 CLA for prevention included four 90-minute weekly virtual sessions over four weeks.

According to Erin, prevention has always involved elements of process improvement. “During the implementation phase of prevention programs, it’s very common to review data and make  mid-course corrections," says Erin. “But a structured approach to this process has been the missing piece. NIATx provides a great framework for addressing this gap."

In the August prevention CLA, Erin and Scott revamped the language and presentation to resonate with the prevention audience. For example, NIATx Principle #1: “Understand and involve the customer,” was fine-tuned to “Understand and involve the participant,” with prevention participants identified in multiple settings: community, schools, government, and families.

Erin and Scott also work to reframe the concept of  “process” within the context of prevention work. "Prevention professionals don’t typically view their work as process-driven. We used the flowcharting tool to help participants identify their prevention work as processes, while integrating quality improvement concepts."

She continues, "Processes in prevention are less obvious than, say, the daily routines in hospitals dealing with new mothers and babies, which are straightforward to define. In areas such as recruiting coalitions and implementing policy, it may not always be apparent that there are well-defined processes at play.”

NIATx Tools

Erin cites the Plan-Do-Study-Act (PDSA) cycle as one of her favorite tools for streamlining the change process. She explains, "Prevention efforts often require ongoing adjustments and enhancements. The PDSA cycle enables a coalition to make gradual, incremental changes to their strategies and interventions and then assess the impact of those changes.” 

The training offered sample prevention-focused aim statements to guide a prevention-focused PDSA Cycle:

• Increase number of schools using Project Towards No Drug Abuse program from 7 to 11 by April 
• Increase number of parents completing 80% or more of Strengthening Families sessions from 20 to 50% by May
• Increase coalition meeting attendance from 50 to 85% by March

Another favorite NIATx tool for Erin is the Nominal Group Technique (NGT). "The NGT has been a game-changer for engaging participants in structured idea generation,” she says.

“Aha!” Moments

“Participants saw the potential for these tools to enhance their work, even though they had not yet identified a specific change project,” says Erin.

“For the next iteration of the prevention CLA, we’re planning to embed activities in the sessions that will give attendees the skills to apply what they’ve learned immediately.”

The Great Lakes PTTC will offer a NIATx Change Leader Academy for Prevention Professionals again in 2024.

Erin Ficker, CPRS, MPAff, serves as a prevention manager for the Great Lakes PTTC. She has worked in substance use prevention for more than 18 years, supporting communities to use evidence-based strategies and data-driven processes in substance abuse prevention planning and implementation. Erin works with community-level prevention practitioners and schools to develop, implement, evaluate, and sustain prevention interventions.

 

 

 

 

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.