RAPID PROCEDURE BRIEF IMPLEMENTATION GUIDE

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Implementing a new intervention requires an openness to change and creating a shared vision across your organization. It’s important to understand that implementing the Rapid Procedure will require changes to your clinical practices and organizational processes. The Rapid Procedure involves additional medical monitoring compared to routine clinical practices at community detoxification centers. Clinical staff may be tasked with additional responsibilities and leadership may consider adapting staffing and workflow to support the implementation of this new intervention. Although change can be uncomfortable at first, we are confident that your team can be successful in implementing this new intervention and we are here to support you in this process!

IMPLEMENTATION OVERVIEW

Before implementing the Rapid Procedure for Vivitrol® induction, your site will need time to prepare and train staff for the new intervention. You must first understand your current clinical practices in order to identify and prioritize the changes needed to support the Rapid Procedure. This process is called “Site Mapping” which helps to understand your current clinical workflow and organizational processes. We recommend key stakeholders and clinical staff at your organization meet regularly to ensure preparedness for the Rapid Procedure.

Changing clinical practice is multifaceted and often involves staff across various organizational levels. In an effort to simplify the implementation process, we have broken this down to 5 general steps.

STEP 1: IDENTIFY YOUR CHAMPIONS

IDENTIFY ADMINISTRATIVE AND CLINICAL LEADERS

Effective implementation of a new clinical intervention starts with identifying your champions and forming a clinical Implementation Team. It’s important that your Implementation Team is available for weekly meetings with the Lead Node team and can assist with pre-launch planning activities, coordinate trainings, and facilitate and monitor the implementation of the Rapid Procedure. We recommend that you first identify a team leader such as your Chief Medical Officer (CMO), Chief Operating Officer (COO), medical director, other clinical director, or another staff member in a leadership position that has a strong influence within your organization and can directly facilitate the changes needed for the rapid intervention.

In addition to this champion, we recommend a clinical champion that can be on site and available for supervising clinical staff during the initial implementation of the Rapid Procedure. For instance, other sites that have been successful in implementation had a CMO or CCO as the team leader and a clinical champion to provide direct supervision and support to the clinical teams on site.

These champions are critical to the success of the Rapid Procedure, so spend time deciding who may best fit these roles. When thinking about who best suits these roles, leadership must also consider these staff members’ current work responsibilities, general availability, and if there is flexibility in their current schedule to take on additional responsibilities for the Rapid Procedure implementation.

BUILD YOUR IMPLEMENTATION TEAM

Now that you have identified your champions, it’s time to build your Implementation Team! Leadership must consider other key members for the Implementation Team. The team should consist of individuals that are available to adapt internal processes and clinical workflow on the detoxification unit for the Rapid Procedure. Examples of other team members include physicians, physician assistants, nurse practitioners, nurses, or inpatient counselors.

STEP 2: CREATE A SHARED VISION

FACILITATE BUY-IN WITHIN YOUR ORGANIZATION

A crucial step in implementing any new intervention is facilitating buy-in and creating a shared vision within the organization. The Rapid Procedure is more involved than usual detoxification procedures and staff will be tasked with intensive training and additional work responsibilities. It’s important for leadership to understand those demands upfront and consider what changes may be needed to support the clinical staff in implementing this new intervention. There are many ways to facilitate buy-in across staff within your organization. A few examples are listed here:

• Develop strong advocacy among leadership and your clinical team.
• Create a unified vision for the Rapid Procedure with respect to the organization’s overall mission and quality improvement efforts.
• Ensure that staff understand the evidence supporting the Rapid Procedure for Vivitrol® induction and benefits to patients with opioid use disorder.

TIP: Regular luncheons when discussing these clinical practice changes can’t hurt!

STEP 3: PLAN FOR CLINICAL PRACTICE CHANGE

ASSESS CURRENT CLINICAL PRACTICES

The next step is to assess the current clinical workflow on the detoxification unit and determine what changes are needed to implement the Rapid Procedure. This can be a great opportunity to examine practices and make changes otherwise to workflow or staffing at your site. For instance, a previous site discovered that their nurses were doing various tasks that could be completed by medical assistants or other staff. Their leadership made changes, hired additional medical assistants, and distributed these tasks differently which ultimately lessened the burden on their nursing staff. Nurses then had more time to engage with patients and manage clinical care (not only for the Rapid Procedure but for all patient care). Your Implementation Team should meet early on and identify what needs to change for the adoption and implementation of the Rapid Procedure. This process is called “Site Mapping” and can be carried out across several meetings. An example “Site Mapping Guide” is available to help identify clinical processes and changes needed for implementing the Rapid Procedure for Vivitrol® induction. We expect that your site leadership and key stakeholders will have additional internal meetings to prepare and discuss changes within your organization.

While assessing your current clinical practices, we encourage you to think about the strengths and weaknesses at your site.

• What works well on your detoxification unit? What doesn’t work well?
• Are staff ready to implement a new intervention or do they need additional training in certain areas?
• Do you have adequate staffing and resources to implement the Rapid Procedure?

TIP: We encourage your leadership to pave the way for the changes needed. Again, this can be a great opportunity to examine clinical practices on your detox unit and make other changes to optimize general workflow.

PLAN FOR CHANGE

Now that you have mapped out what’s needed for the implementation of the Rapid Procedure, it’s time to put it into action. Your site’s Implementation Team can help prioritize and carry out these action items. An example list of action items is available here.

ESTABLISH PLAN FOR MONITORING AND PERFORMANCE

It’s important to think about how this intervention can fold into your current quality improvement practices and monitoring. Leadership at your site can help to establish a plan for monitoring and tracking performance with the Rapid Procedure.

STEP 4: TRAINING

STANDARD TRAININGS

We highly recommend that all key clinical staff participate in trainings. Various training modules are available on this website and we have included a rapid overview option for those who have less time and cannot complete all training modules upfront.

INTERNAL TRAININGS

In addition to these standard trainings, your team may wish to conduct supplemental trainings. For instance, other sites have led their own trainings for nurses and other staff on the detoxification unit to prepare them for the Rapid Procedure. Additional training and supervision will be needed during the initial implementation of the Rapid Procedure and treatment teams should prepare for this.

STEP 5: LAUNCH THE RAPID PROCEDURE

INITIAL IMPLEMENTATION OF THE RAPID PROCEDURE

Now that you have done all that hard work and training for the Rapid Procedure, the fun part begins…implementing the Rapid Procedure! As with any new practice, you will learn the most by carrying out these procedures on the ground. Expert clinicians through learning collaboratives will be available for coaching during the initial implementation of the Rapid Procedure.

ADDRESS BARRIERS OR CHALLENGES

You may encounter other challenges or find additional adjustments are needed to support implementation of this new intervention. We recommend that site leadership communicates a clear plan to monitor the Rapid Procedure and maintains an open channel of communication across site staff. Leadership can help refine internal processes and adjust staffing to support the Rapid Procedure.

TIP: If your clinical team has less experience with OUD patients that use fentanyl, please reference the clinical tools that provide recommendations on how best to manage these patients (i.e., start with a lower dose of buprenorphine).

MAINTENANCE AND SUSTAINABILITY OF THE INTERVENTION

It’s important to think about what’s needed to maintain the Rapid Procedure. Ideally, discussions around sustainability are held early in the implementation process. Ensuring adequate staffing and funding for the intervention are essential. Your organization may be eligible for national grants and other funding that can support efforts around the Rapid Procedure (i.e., Substance Abuse Mental Health Services Administration (SAMHSA) grants or other initiatives).

APPENDIX

SITE MAPPING MEETING FACILITATOR’S GUIDE

Instructions: This document serves as a guide for Site Mapping meetings that will help to identify potential challenges/barriers or strengths/facilitators to implementing the Rapid Procedure for Vivitrol® induction. This is a guide for meeting facilitators, and we encourage the facilitator to exercise judgment and incorporate other relevant questions that may provide additional valuable information.

Questions for Meetings

Implementation and Learning Climate

• Can you share an example of a recent quality improvement project or an experience implementing a new intervention or program?
• What was most important in making the changes necessary for [example(s) given]?
• Were staff resistant to these changes, and what helped to facilitate buy-in?
• How receptive are staff currently to implementing this new Rapid Procedure for Vivitrol® induction? Has anyone expressed concerns? Do you all have specific concerns?

Screening and Intake Process

• What is the current intake and admissions process for new patients seeking treatment for opioid use disorder at your detoxification program?
  • Where are patients referred from for admissions?
  • Admissions criteria? (i.e., must be admitted in opioid withdrawal?, sent to nearby medical facility if concurrent alcohol or benzodiazepine dependency?)
  • Who conducts the initial assessment?
  • What’s involved in this initial assessment? (i.e., H&P, COWS, vitals, urine toxicology, COVID-19 testing, labs)
  • Who first discusses medication options for opioid use disorder with the patient?
  • When does the medical clinician meet with the patient (in-person or virtual)? What is the latest that the patient is seen by a medical clinician?
  • When are medications first started? Buprenorphine? Ancillary medications?
  • How are these procedures different overnight? On the weekends?

Standard Clinical Practices

• Describe the MOUD decision-making process between the clinician and patient.
  • Who is involved in the discussions about MOUD for patients?
  • Are there tools to help facilitate this discussion (i.e., patient handout)?
  • Are staff trained in how to have these discussions or educated on MOUD options and differences?
• Describe the standard procedures on your unit for buprenorphine induction and taper (if applicable to site) and Vivitrol® induction.
  • Refer to the Site Needs Assessment document under the section “Standard Clinical Practices” for information on buprenorphine dose, criteria for initiating induction, average total daily dose of buprenorphine on induction day, and ancillary medications.
  • What are the criteria before giving the first dose of buprenorphine (i.e., COWS > 12)?
  • What is the average first dose of buprenorphine given?
  • How is subsequent dosing done?
  • What is the average total daily dose given to most patients for buprenorphine induction?
  • What ancillary medications are given to help manage opioid withdrawal symptoms? Clonidine? Benzodiazepines? PRN or standing? When are these first administered?
• Are patients inducted onto buprenorphine over the weekend? Overnight?
• How are medications ordered and stored on site? For instance, are medications ordered for each patient and delivered by the pharmacy? Are there delays in receiving these medications?
• If medications are delivered (and not stored on-site), would it be possible to change practices and keep medications on-site (i.e., buprenorphine, clonazepam, low-dose naltrexone)? How might you go about this?
• How are medication doses generally logged, documented, and communicated between clinicians and nurses?
• Describe the planned workflow for acquiring low-dose naltrexone from an outside compounding pharmacy.
• How do you envision the process for low-dose naltrexone administration on the unit?
  • How will medication be stored and accessed?
  • Low-dose naltrexone is only administered after certain COWS parameters, who will be overseeing the COWS and administration of low-dose naltrexone?
  • How are these orders communicated between clinicians and nursing staff?
• Are staff comfortable with Vivitrol® and who administers the injections typically?

Clinical Monitoring and Psychosocial Support

• How often are patients seen by a clinician (MD/DO/PA/NP) during inpatient detoxification? Overnight? Weekends?
• How often are patients seen by a counselor/therapist? Peer support?
• How frequently are COWS and vitals done on the unit?
• Describe falls risk assessments and precautions on your detox unit.
• How frequently does staff meet to discuss patient care? What is the process for nurses contacting the clinician if needed?
• The Rapid Procedure requires increased clinical monitoring compared to most standard procedures on detox units. For instance, q4h medication administration, q4h vitals, increased PO fluid intake, falls precautions, more frequent COWS, and dosing based on COWS parameters.
  • Who will oversee these processes on-the-ground?
  • Who are the key clinical staff needed for these procedures?
  • Do you think there is adequate staffing for what we are describing? If not, who can you communicate these concerns to?
  • Are there other changes that may be needed to support this increased monitoring? Other things to consider?
• In addition to increased clinical monitoring, this procedure requires additional support and counseling.
  • Is there potential to increase counseling interventions on your unit? Who will oversee these processes?
  • Will counseling be done with in-person or virtual/audio-only visits?
  • Who will primarily provide counseling and support to these patients?
  • Do you think there is adequate staffing for what we are describing? If not, who can you communicate these concerns to?
  • Are there other changes that may be needed to support this increased monitoring? Other things to consider?

Discharge and Linkages to Care

• Describe your process for routine discharges of patients with opioid use disorder.
  • Are there current length-of-stay goals/limitations that influence how long a patient stays on the detox unit?
  • Who meets with the patient before discharge?
  • What’s included in their discharge instructions typically?
  • How are treatment referrals set up? What do you do for patients who decline MOUD while on the detoxification unit? Are they discharged with a short-term prescription for BUP-NX and referrals?
  • Are patients discharged with ancillary medications like clonidine and benzodiazepines for protracted withdrawal symptoms?
  • Overdose prevention training?

• Describe the process when a patient requests to leave the inpatient setting before completing opioid detoxification.
  • Who meets with the patient? Do clinicians evaluate all patients requesting to leave the unit early?
  • What is typically reviewed with the patient if they request to leave early (i.e., management of opioid withdrawal symptoms, nicotine replacement therapy, etc)?
  • Can you give an example of counseling/encouragement that you would provide to a patient requesting to leave the unit early?
  • Treatment referrals and short-term BUP-NX script?
  • Overdose prevention training?

• Where are most patients discharged to after completing detoxification?
• Describe your access and relationship with outpatient treatment facilities.

Readiness/Preparedness for Rapid Procedure

• Now that we have completed the Site Mapping and trainings, how ready do you feel to implement the RP intervention? Anything else needed?
• What changes or preparations have you made in this planning phase for the RP intervention that we have not discussed here? For example, reduced work responsibilities of medical clinician to increase availability/time for RP intervention, or hired additional staff, etc.
• Other than those of you here on the Implementation Team, are there other people on the detoxification unit who are likely to help champion this intervention that should be included in our upcoming Coaching Sessions during the initial rollout of the RP intervention? These calls will be primarily clinical and troubleshooting logistical issues around the RP intervention.
• Are there any other potential barriers or facilitators to RP implementation that we should be aware of?

Considerations for Maintenance of Rapid Procedure

• To what extent has your unit set-up internal measures or processes that supports the sustainability of this intervention post-study? Or, what processes are already in place that might align with RP maintenance?
• Are there incentives in place to implement the RP intervention? What are these?

Case Examples for Zoom Breakout Sessions

Case Example 1) Your site has started implementing the Rapid Procedure. A couple of your nurses/champions are very invested in the success of this intervention and helping patients get onto treatment sooner. They start working overtime and training additional nurses/respective staff in the steps of the Rapid Procedure. They are having difficulty getting other nurses/staff trained, and these staff report already being busy just completing their routine work responsibilities. These nurses/champions are also exhausted after working overtime for consecutive days.

What is the process for communicating these concerns to supervisors/administrative staff? Has this happened before and what did your leadership do to accommodate these training and staffing needs?

Case Example 2) A 35-year-old male with severe OUD presents as a walk-in overnight on Saturday for detoxification. He is insistent on getting “off of everything for good” and only wants “Vivitrol” because he thinks buprenorphine maintenance is just replacing one addiction with another. His COWS is 8.

[Clinicians/Nurses] Can you walk us through how this patient would be managed (i.e., screened, admitted, evaluated, and initiated on medication)? Are there different procedures for patients admitted on the weekend (i.e., they can only see physician on weekday and must wait to start buprenorphine)?

[Counselors/Peers/Other Staff] Can you walk us through what your role would be in managing this patient upfront? How does this change on weekends/overnight compared to daytime shift?