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Identifying unique barriers to implementing rural emergency department-based peer services for opioid use disorder through qualitative comparison with urban sites

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Abstract

Background In an effort to address the current opioid epidemic, a number of hospitals across the United States have implemented emergency department-based interventions for engaging patients presenting with opioid use disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such interventions, emergency department-based peer support services, in rural areas by comparing implementation of rural and urban programs that participated in Indiana’s Recovery Coach and Peer Support Initiative (RCPSI). Methods We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with representatives from each program at 3 time points over the course of the first year of implementation. Our deductive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external context taxonomy. Results We identified key differences for rural programs corresponding to each of the 5 primary constructs in the coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficulties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time identifying external partners and abandoned more components of their initial implementation plans. Conclusions Findings demonstrate how rural programs faced greater challenges implementing emergency department-based peer services over time. These challenges required flexible adaptations to originally intended plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure success considering local contextual constraints that were identified by our analysis.
Watsonetal.
Addiction Science & Clinical Practice (2022) 17:41
https://doi.org/10.1186/s13722-022-00324-3
RESEARCH
Identifying unique barriers toimplementing
rural emergency department-based
peer services foropioid use disorder
throughqualitative comparison withurban sites
Dennis P. Watson1,2* , Monte D. Staton2 and Nicole Gastala3
Abstract
Background: In an effort to address the current opioid epidemic, a number of hospitals across the United States
have implemented emergency department-based interventions for engaging patients presenting with opioid use
disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such inter-
ventions, emergency department-based peer support services, in rural areas by comparing implementation of rural
and urban programs that participated in Indiana’s Recovery Coach and Peer Support Initiative (RCPSI).
Methods: We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as
part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with
representatives from each program at 3 time points over the course of the first year of implementation. Our deduc-
tive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external
context taxonomy.
Results: We identified key differences for rural programs corresponding to each of the 5 primary constructs in the
coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required
more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed
to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient
transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficul-
ties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted
working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time
identifying external partners and abandoned more components of their initial implementation plans.
Conclusions: Findings demonstrate how rural programs faced greater challenges implementing emergency
department-based peer services over time. These challenges required flexible adaptations to originally intended
plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure
success considering local contextual constraints that were identified by our analysis.
Keywords: Peer services, Overdose, Substance use disorder, Behavioral health services, Program implementation,
Implementation context
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Background
With 446,032 overdose deaths attributed to opioids from
1999 to 2018 [1], the opioid epidemic is one of the most
Open Access
Addiction Science &
Clinical Practice
*Correspondence: dpwatson@chestnut.org
1 Chestnut Health Systems, 221 W. Walton St, Chicago, IL 60610, USA
Full list of author information is available at the end of the article
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Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
serious public health issues facing the United States.
While a national problem, some researchers have argued
the burden of the epidemic is much greater in rural com-
munities [2], which is partially due to rural areas hav-
ing fewer and less easily accessible opioid use disorder
(OUD) treatment options [3]. Despite a recognized need
to improve understanding of rural opioid use and treat-
ment [4], a recent scoping review identified relatively few
studies on this topic [2]. e study described in this arti-
cle identifies implementation differences across 4 rural
and 6 urban hospital systems participating in Indiana’s
Recovery Coach and Peer Support Initiative (RCPSI),
which supported delivery of novel emergency depart-
ment (ED)-based peer support services. Identifying dif-
ferences in implementation for ED-based peer supports
is timely considering the recent national proliferationof
similar interventions [5, 6].
e RCPSI was a federally funded initiative that sup-
ported the integration of peer services to engage ED
patients presenting with OUD and link them to treat-
ment and services [7]. e initial idea for the RCPSI was
partially inspired by peer support programs developed
for patients presenting with OUD in urban EDs [8, 9].
While a small but developing body of research supports
the potential effectiveness of ED-based peer supports
for improving outcomes for people with OUD [810], no
recognized standard for the implementation of these
programs currently exists. However, prior research has
identified three core functions of such programs [6]: (1)
peers are somehow integrated into the ED environment;
(2) patients presenting with OUD are identified and con-
nected with peer supports; and (3) peers connect patients
with medication for opioid use disorder (MOUD) or
other treatment services and supports. Implementation
of these three core functions vary depending on the ED
context [6]. However, the ways in which these contex-
tual differences impact implementation have not been
explored in detail. Furthermore, we are aware of only
two studies of ED-based OUD interventions that have
focused on the rural ED context [11,12] andboth were
focused on buprenorphine induction, rather than peer
supports. More rural studies of ED-based OUD interven-
tions, including peer-facilitated ones, would be useful
considering prior work has demonstrated that barriers
unique to rural settings can limit the effectiveness of
a variety of OUD interventions [1317]. For instance,
one of the most pervasive rural barriers likely to impact
peers’ linkage function is a lack of MOUD treatment
options [1822]. Proactive identification of such barriers
and their impacts on implementation success can lead to
adaptations that can make an intervention more viable
than if it was directly translated from an urban setting
[23].
e current qualitative study addresses existing gaps
in knowledge related to implementation of ED-based
peer supports for OUD in rural areas. e primary ques-
tions guiding this study were: (1) what determinants (i.e.,
barriers and facilitators) most impacted ED-based peer
service implementation?; and (2) how did these determi-
nants differ between rural and urban sites over the course
of implementation?
Methods
We conducted a secondary analysis of data originally col-
lected to evaluate Indiana’s RCPSI. Indiana University’s
institutional review board determined the project did not
require review because the data were originally collected
for quality assurance purposes and were de-identified
prior to secondary analysis.
Description oftheRCPSI andits funded sites
Indiana’s Division of Mental Health and Addiction sup-
ported the RCPSI from September 2017 to May 2020
with funds from the U.S. Substance Abuse and Mental
Health Services Administration. e RCPSI’s goal was
to implement the peer position within EDs, rather than
implement a defined program model. is is because no
robustly defined evidence-based model for ED-based
peer linkage programming existed at the time programs
were funded and because the state authority recognized
the need for agencies to have latitude during imple-
mentation due to their differing contexts. As such, the
only specific requirements were that the peer (a) com-
pleted state-level peer recovery coach certification, (b)
engaged OUD patients who presented to the ED, and (c)
attempted to link those patients with MOUD or other
appropriate treatments and supports.
Ten hospital systems participated in the RCPSI. ese
systems varied in size and number of participating EDs
within them. e state provided funding directly to one
primary vendor for each program, which could either be
the hospital system itself or an external behavioral health
provider who offered peer services (we refer to vendors
rather than hospitals when discussing the involved sys-
tems moving forward, as this was the term used by the
state agency that supported the RCPSI). Four of the ven-
dors exclusively focused their RCPSI programming in
hospitals with a rural critical access designation. While
some of the larger systems served both rural and urban
EDs, the implementation data focused considerably, if not
exclusively, on their hospital sites located within cities.
We therefore consider those vendors to be urban-serving
for the purpose of this study. Regarding the 3 functions of
ED-based peer supports discussed previously [6], (1) peer
integration varied according to their physical location in
relation to the ED, with only three programs having some
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Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
sort of space within the ED for peers to work. (2) Identi-
fication of patients with OUD and activation of peer sup-
ports relied largely on ED staff; however, peers for four
of the vendors could scan for appropriate patients using
the electronic health record. (3) e goal of all programs
was to connect patients to MOUD or other treatment,
but supportive services were offered to those who were
not yet ready. Table1 displays characteristics of the ven-
dors’ hospital systems and the acronyms used to identify
them. It is important to note that, while they participated
in evaluation activities, RV4 did not follow-through with
implementation of the program; though, they were able
to speak to the barriers influencing this result.
Data collection
Data collection occurred between April 16, 2018 and
March 8, 2019. Each vendor participated in three semi-
structured interviews that occurred at the beginning
(T1), mid-point (T2; 4–6 months depending on ven-
dor) and near the end of the first year (T3; 9–11 months
depending on vendor) of implementation respectively.
Vendors provided the name and contact information of
a primary evaluation liaison to help arrange interviews.
e number of interview participants ranged from 1 to
3 depending on the vendor and time point; however,
interviews always included the primary person leading
implementation at the site. Additional interview partici-
pants were typically supervisors of the vendor’s peers.
Peers were only involved in meetings at UV3 & UV4. In
the case of UV3, the peer took over as the primary imple-
mentation lead after the original person in this role left
the organization. While UV3’s peers joined T2 & T3
meetings, the main contributor to the conversation was
the implementation lead.
Evaluation data collection was led by the first author
who is a trained qualitative researcher and implementa-
tion scientist with experience working on several opioid
treatment studies. He was assisted by two staff research-
ers with advanced training in qualitative methods and
program evaluation. Questions were adapted from those
developed from the Consolidated Framework for Imple-
mentation Research (CFIR), which organizes 37 con-
structs reflective of implementation determinants across
five domains [24]: (1) the intervention’s defining charac-
teristics, (2) the inner setting (i.e., environment in which
the intervention is being implemented), (3) the outer set-
ting (i.e., the environment existing outside of the imple-
menting organization), (4) characteristics of individuals
involved in the implementation, and (5) the process that
facilitated the implementation. erefore, each vendor
was asked the same series of questions related to the 5
CFIR domains. e first interviews occurred in person at
vendors’ sites to establish familiarity between evaluations
and local leaders, and subsequent interviews occurred
over conference call. All interviews were recorded and
lasted between 16 and 63min. As funding for the project
supported interview participants’ time involved in evalu-
ation activities, they were not separately compensated for
interview participation.
Analysis
We followed a case study approach [25, 26] to analy-
sis with the vendors being the main unit of analysis
(i.e., cases). e number of cases exceeds the minimum
Table 1 RCPSI vendor identifiers and characteristics
*Detail related to the exact number of EDs served is not shown to limit the degree to which vendors could be identied
Vendor identier Vendor relationship
to the hospital system
served
Single or
multiple ED(s)
served*
Peer physical location Identication and activation of
peers
Rural Vendor 1 (RV1) Same Single On-site office outside ED ED staff initiate
Rural Vendor 2 (RV2) Same Single On-site office outside ED ED staff initiate
Rural Vendor 3 (RV3) Same Single Off-site with no on-site space ED staff initiate
Rural Vendor 4 (RV4) Same Single n/a n/a
Urban Vendor 1 (UV1) External provider Multiple Primarily off-site but have on-site ED
space to work ED staff initiate
Urban Vendor 2 (UV2) Same Multiple On-site office in ED ED staff initiate & peer monitoring of
electronic health record
Urban Vendor 3 (UV3) Same Multiple Off-site with no on-site space ED staff initiate & peer monitoring of
electronic health record
Urban Vendor 4 (UV4) External provider Single Off-site but have on-site ED space to
work ED staff initiate & peer monitoring of
electronic health record
Urban Vendor 5 (UV5) Same Multiple On-site office outside ED or off-site
depending on hospital ED staff initiate & peer monitoring of
electronic health record
Urban Vendor 6 (UV6) Same Multiple Off-site with no on-site space ED staff initiate
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Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
of four recommended for such analyses [25]. While the
data demonstrate valuable information related to imple-
mentation in both rural and urban contexts, the analysis
concentrated on understanding how rural sites differed.
is decision was based on the need to focus the analysis
given (a) rural vendors’ discussions suggested more diffi-
culties with implementation and (b) the lack of attention
to rural sites in the existing literature.
Analysis was organized with MAXQDA software [27].
e first part of the process was deductive and used an
a priori coding structure developed from two sources
(see Hanna et al. [28] for a prior example of such an
approach). e first source was the CIFR [29]. e sec-
ond was a taxonomy of external context constructs [30],
which comprises 8 constructs and was substituted for the
CFIR’s outer setting domain. e reason for this substi-
tution is because the CFIR was developed within a rela-
tively closed clinical setting, while the external context
taxonomy pulled from a variety of clinical and public
health interventions. erefore, the taxonomy provides
more nuances related to the context outside of a hospi-
tal’s walls, which was important given the RCPSI vendors
relied heavily on state and local resources and because
our goal to compare rural and urban programs requires
a detailed look at the community context they are set
within.
A second analyst, a medical doctor with expertise
in rural MOUD implementation, reviewed the codes,
indicating areas of disagreement, while also applying a
second-level code indicating whether the construct rep-
resented an implementation barrier or facilitator. e
lead analyst then reviewed the codes again and discussed
areas of disagreement with the second analyst until 100%
consensus was met. In the second part of the analysis, the
lead analyst attributed each hospital system with a rural
or urban destination. He then used MAXQDA’s interac-
tive quote matrix function to explore codes (1) within
and across cases and then (2) within and across rural
and urban hospital groups.1 Because of the large num-
ber of codes and to ensure determinants identified were
associated with a rural context, rather than just a single
hospital, the analysts focused on only those constructs
reflecting data from at least two rural hospitals. e final
step in the analysis was inductive, with two analysts iden-
tifying and establishing themes within the CFIR con-
structs through a consensus process and identifying how
they differed between the urban and rural vendor groups
over the course of the implementation (e.g., T1, T2, & T3
data). We determined saturation to be at the point when
no additional insights were gained through further itera-
tions between data and developing themes because add-
ing new cases or interviews was not possible [25].
Results
Findings demonstrating differences between rural
and urban EDs are presented below by 4 of the CFIR
domains, with the external context taxonomy substituted
for the CFIR’s outer setting domain. Specific constructs
are italicized within the paragraphs. Table2 displays the
themes categorized by domain and construct, which are
also defined.
Intervention characteristics
e perceived evidence supporting peer services and
the source of pre-existing ED-based peer programs was
an important facilitator of adoption discussed at T1
interviews. Vendors described awareness of research on
peer supports as influencing their decisions to apply for
RCPSI funding. For instance, a representative from RV1
spoke about research they looked to when considering
applying:
I did a little research on it [peer services], and
it made a lot of sense. It works for AA [Alcohol-
ics Anonymous] and NA [Narcotics Anonymous]
to get people who’ve been through it [12-step pro-
gramming] to be your coach and support [i.e., spon-
sor]. But, then this [peer services in the ED] takes
it to another level because they’re [the peers are]
more involved with connecting to the [treatment]
resources around you [in the community]. (T1)
While the above statement applies logic from other
types of peer supports to the decision to implement ED-
based peers, other vendors directly discussed knowledge
of early successes of ED-based peer support programs
they had learned about as influencing their decisions.
While urban vendors discussed similar reasons for apply-
ing for the RCPSI funding at T1, a key difference was that
some urban vendors (e.g., UV3, UV4, and UV6) physi-
cally visited sites that had implemented ED-based peers
to learn directly from them. While all vendors were aware
of early successes of other ED-based peer programs,
rural vendors were the only ones that displayed skepti-
cism about the ability to translate these services directly
to their settings. As noted by one rural vendor, “[a] lot of
this research [on ED-based peers] is only hypothetically
applicable to rural [areas]…” (RV2; T1).
Across vendors, the addition of peer services was
viewed as having a relative advantage compared to usual
care provided to OUD patients presenting in their EDs.
is is because most hospitals did very little for these
1 Instances where urban vendors discussed issues with rural sites were easy to
identify and excluded from the analysis because the information provided was
too few and far between to add substantially to the understanding of rural-
urban differences.
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Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
patients after ED discharge: “Honestly…[prior to apply-
ing for RCPSI funding] we do not do anything post ED
[discharge]” (RV4; T1). As such, vendors viewed peer
supports as a valuable resource for patients that would
provide needed relief to ED staff: “at this point [T1], the
physicians and nurses do what they can. ey just see it
[treating OUD patients] as too much for them, so they
are eager to get additional resources [from the peers]”
(UV2). However, as the implementation progressed,
urban vendors continued to discuss relative advantage
as it related to the ED environment, while rural vendor
discussions shifted to described how the advantage of
peer services extended beyond the ED’s boundaries. For
instance, data from RV2 demonstrated they were using
the peer to fill a need for outpatient services: “We had a
great need for peer recovery coaching in the outpatient
side. So, [the peer has] actually been helping with our
outpatient addictions program too, and then just coming
over here [to the ED] when called” (T3).
Interviews also demonstrate the high degree of adapt-
ability of peer services. While all vendors discussed ways
in which the peer position was different from those on
which the RCPSI was partially based and how the peer
role evolved over time, rural vendors’ discussions dem-
onstrated they made more considerable modifications
to the scope of peer services in an effort to address the
fact that peers had very little work due to low numbers
of OUD patients being admitted to the ED. e previous
quote from RV2 demonstrates how their peer’s scope was
extended to include outpatient services, and an earlier
interview also showed how the peer was working with
other departments: “[our peer] also does [work in] the
OB [obstetrics department], and she also is involved with
our court program [for justice-involved patients]” (T2).
Table 2 Definitions and source for implementation domain and construct names identified in the analysis
a Source: Consolidated Framework for Implementation Research [29]
b Source: External context taxonomy [30]
Domain Construct Primary issues identied
Intervention Characteristicsa
Evidence, strength, and quality Awareness of successful pre-existing ED-peer influenced adoption decisions for all
vendors, but rural vendors were skeptical about applicability to their settings.
Intervention source
Relative advantage Rural vendors saw advantages of peers outside of the ED, where urban vendor solely
focused on peer advantage in the ED.
Adaptability Rural sites made more adaptations over time to address peers’ low work volume.
Cost Rural vendors had greater concerns regarding costs.
External contextb
Target population Rural vendors did not have resources to fully staff peak overdose admission times or
the ability to engage with transferred patients. Patients in rural areas also tended to use
drugs other than opioids.
Relational climate Rural vendor slacked protocols to follow-up with transferred patients.
Policy and legal climate Privacy laws limited rural vendors’ ability to share information with other hospitals
where patients were transferred.
Local infrastructure Rural areas lacked treatment providers for patient referral and options for transportation
to referrals were limited.
Inner settinga
Networks and communication Rural vendors lacked strong mechanisms for communication between ED staff and
peers. Rural providers were often reluctant to have peers see patients.
Culture Rural peers frequently encountered lack of respect for their lived experience and nega-
tive attitudes toward addiction on the part of ED staff.
Implementation climate Rural vendor experienced difficulties justifying integration of peer services into ED
systems and workflows due to low volume of patients eligible for peer services.
Characteristics of individualsa
Knowledge and beliefs Rural providers resisted working with peers and patients they served due to pre-exist-
ing beliefs.
Implementation processa
Engaging Rural vendors had to spend more time identifying external providers to refer patient
to. They also spent more time engaging local law enforcement in order to create more
work for peers.
Executing Rural vendors abandoned more components of their initial implementation plans
because of staff resistance and low patient volume.
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Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
In another example, RV3 contracted with a local off-site
mental health provider that designated a peer to respond
to the ED when needed since it did not have enough
patients presenting with OUD to justify employing a full-
time ED-based peer.
Rural vendors found the costs related to peer services
to be a greater barrier at all interview points. Early in the
implementation, RV1 and RV4 both expressed concerns
for how they would support peers because they did not
have enough target patient volume to cover the salaries.
However, this was demonstrated to be resolved at T2
when the funding model was changed from service reim-
bursement to one that directly covered peer salaries. At
T1, RV2 had concerns about the costs getting “completely
out of control” because their hospital had only one part-
time, on-call psychiatrist available who warned they were
overwhelmed with their peer’s referrals. It was noted in
later interviews that the administration hired a full-time
psychiatrist to address this issue, which was an unex-
pected cost at the time they applied for RCPSI funding.
e cost of technology also later derailed RV2’s original
plans to implement telehealth-based peer services as an
addition to their program, as they had no monies left to
do this after using RCPSI funds to update their electronic
health record to document peer service contacts. In con-
trast, urban vendors directly stated they had no or very
little concerns regarding implementation costs, and they
did not discuss any unexpected costs to have occurred
over the course of implementation.
External context
Target population needs greatly impacted peer service
feasibility at some rural sites. Specifically, OUD patients’
needs that were not anticipated at baseline resulted in
missed engagement opportunities and low peer case-
loads. One aspect of this was that rural vendors did not
have resources to cover evening hours when many over-
doses presented to the ED. As an example, RV2 and RV3
peers missed patients due to restricted hours, with RV3
stating in their final interview that no overdose patients
had been admitted to the ED when a peer was avail-
able. Another unexpected issue was that rural hospitals
often transported overdose patients to urban hospitals
that could provide services for which rural vendors were
unequipped to handle. Because these patients were
often unconscious prior to transfer, peers were unable
to engage them or obtain a release required to speak
about their case to staff at the hospital to which they
were transported: “For what we see in our emergency
room, [overdose patients are] either very ill, intubated,
[or] transported to a higher level of care [at another loca-
tion]” (RV3; T3). Finally, rural vendors also expressed in
later interviews that the majority of patients who could
benefit from peer services had other substance use dis-
orders, which were outside of the RCPSI’s scope: “We
have a strong uptick in stimulants here in this part of the
world…I suspect that’s a big reason why we’re not see-
ing a lot of [opioid overdoses]” (RV2; T3). While urban
vendors also noted the need to serve patients with other
substance use disorders, enough OUD patients presented
to the ED to make up a considerable portion of peer
caseloads.
Connected to the above issue of patient transportation
to urban hospitals are factors associated with the external
relational climate, which includes the quality of relation-
ships with other hospitals and providers. Despite rural
hospitals having relationships and procedures necessary
to transport patients to urban hospitals, they had not
developed protocols that would allow peers to follow-
up regarding a patient’s status. is lack of information
sharing was a major barrier to implementation for rural
hospitals because peers needed to communicate with
patients to link them with treatment and services. As an
example, RV3 expressed how their peers had no way of
knowing if the patient was transferred to another hospi-
tal or if they are “gonna come back in our community”
(T2) where they should be connected to local resources
by the peer. Information sharing with other health pro-
viders is also a matter of the policy and legal climate, as
this sharing is governed by external regulations, includ-
ing rules, policies, and laws, that impact implementation.
is was not an issue in urban hospitals, which had the
resources necessary to address most OUD patients’ care
needs internally.
Rural vendors also described their local infrastructure
as lacking needed OUD services and resources. While
urban vendors also described such issues, it was far more
detrimental for rural ones. For instance, where urban
vendors discussed issues finding transportation assis-
tance to help patients attend referral appointments, rural
vendors did not even have sufficient providers in their
local areas to which they could refer patients. Indeed
mostrural vendors had to rely on a single MOUD pre-
scriber, and this was a concern for themover the entire
course of implementation. For instance, at T1 RV3
expressed concern about their sole MOUD prescriber
who they felt was already overwhelmed with referrals.
In the most extreme case, RV4 was not able to find any
MOUD provider to work with them: “that was my big-
gest hurdle because I did not have access to a nurse prac-
titioner or anyone [to prescribe MOUD]” (T3). is was a
major factor leading to RV4’s not following through with
RCPSI implementation.
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Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
Inner setting
Networks and communication among inner setting actors
were key to implementation for all sites, with the funda-
mentally important line of communication demonstrated
to be the one existing among peers and the ED’s medi-
cal staff. It is through this communication that peers are
notified if and when they can approach an ED patient.
All vendors had some growing pains establishing initial
lines of communication; however urban vendors describe
minimal issues or had largely solved any recognized
problems by their final interview. For instance, at base-
line, UV1 discussed their plan for integrating peers in the
ED but described difficulties getting ED staff to under-
stand that communicating with the off-site peers was not
a violation of patient confidentiality at T2. However, this
issue was largely solved by T3. Regarding communication
issues at rural sites, RV1’s ED staff were supposed to call
the peer when an appropriate patient presented. ough,
they never identified a mechanism to ensure the peer
was alerted. is resulted in the peer needing to “make
more of an effort” (T2) to identify patients without ED
staff assistance. Likewise, RV2 interviews demonstrated
difficulty developing effective lines of communication
between the ED staff and peer: “they [ED staff] would
kind of just stare at her [the peer] and not talk to her”
(T2). It was further explained that RV2’s ED staff would
contact the social workers when OUD patients presented
instead of alerting the peer. For all three rural vendors
who carried through with implementation, they dis-
cussed these communication issues as persisting through
their final interviews.
Differences in ED culture were highly noticeable when
comparing rural and urban vendors. is was most
apparent when it came to attitudes and actions of ED
staff toward behavioral health care workers, including
the peer. RV2 explained “[e ED staff] like things a cer-
tain way, and it’s hard to fit behavioral health into that
box sometimes…is has been a historical thing for the
hospital” (T2). RV3 also described a “bias of [i.e., against]
addiction” (T3) among ED staff in which they hesitate to
contact the peer because they do not believe there is any-
thing that can be done to benefit overdose patients. By
contrast, site leaders of urban vendors largely reported
more welcoming ED staff attitudes, with the largest issue
being the introduction of the peer role and its fit within
the current ED hierarchy: “in the medical realm, the more
initials you have behind your name, the higher status you
have…Many of them [peers] don’t have any letters behind
their names…but I feel like they’ve gained and earned
respect within our health system” (UV5, T3).
e implementation climate was another important
factor. Shared receptivity for RCPSI programming was
lacking at RV2, where implementation leaders struggled
to put necessary processes in place with the finance
department and ED because there was a “resistance to
behavioral health” (T2) that resulted in difficulties inte-
grating peer services into pre-existing systems and work-
flows, and this issue was not fully solved by T3. RV3
attribute ED staff implementation resistance to the fact
that they could not “hardwire” (T3) peer services into
the pre-existing workflow since OUD patient volume was
too low to justify a need for change among ED staff. In
contrast, urban vendors and hospitals displayed more
capacity for change (particularly regarding technological
change), receptivity to peer services, and positive expec-
tations about them among administration, ED staff, and
behavioral health staff of involved organizations. As an
example, UV2’s ED physicians were stated to be “very
eager to hear [about the program]. ey were interested
in Narcan [the opioid overdose reversing drug] being
used, they were very happy to hear about the [MOUD]
clinic opening up and then, to hear about actually hav-
ing a coach [i.e., peer] on site” (T1) from time they first
learned about the peer services.
Characteristics ofindividuals
ED staff members’ knowledge and beliefs about peer ser-
vices resulted in barriers to implementation initially for
two urban (UV4 and UV6) and two rural (RV2 & RV3)
vendors. In the case of the two urban sites, individual-
level resistance receded over time. One interview with
UV4 provides an example of something a physician said
that highlights this: “[a physician said] I was really against
this [peer supports] at first, but I kind of see this working,
so I think I’m gonna try this with some of my patients”
(T2). In contrast, individual-level physician resistance at
the two rural sites persisted. At T2, an RV3 physician was
described as being “reluctant to open up just to anybody
and say that [he can prescribe] Suboxone [a band name
formulation of the MOUD buprenorphine]” because he
did not think he could meet the potential demand that
would be created by the peer services. Additionally, RV2
“never could really get the [ED] staff on board with why
you would call a peer recovery coach [i.e., peer] over
an LCSW [Licensed Clinical Social Worker] when the
LCSW has more training” (T3), suggesting they did not
believe a peer could provide services of a similar quality.
Implementation process
Both rural and urban vendors recognized the impor-
tance of engaging health providers in various roles,
including ED staff and local MOUD providers. One
already discussed difference for rural sites was that
they lacked MOUD providers in their communities
to whom they could refer patients. Due to this lack of
physicians, RV3 and RV4 sought out providers who
Page 8 of 12
Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
they could support to obtain training necessary to pre-
scribe MOUD, something no urban vendors needed to
do. Although both rural and urban vendors described
a process of engaging with and winning over the ED
staff, mainly nurses, rural vendors experienced more
difficulty with this over the course of implementation:
“ [the peer service program] hasn’t been accepted [by
ED frontline staff] quite as well as I thought it would be
in the beginning” (RV2; T2). Engaging external organi-
zations was also important for peer implementation.
Both rural and urban vendors disseminated informa-
tion about their peer services to local physicians, law
enforcement agencies, and community organizations;
however, rural vendors were much more focused on
law enforcement. For instance, RV2 and RV3 devel-
oped relationships with local drug courts and probation
departments, with RV2 using this as a means of pro-
viding more work for their peer given the low patient
volume in the EDpreviously discussed: “she [the peer]
also does some case management for our people in our
court program” (T2).
In executing the implementation, both rural and
urban vendors described peer hiring challenges and
difficulties incorporating them into the ED workflow,
but overall, rural vendors were less successful following
through, with RV4 discontinuing and RV2 still trying
to gain ED staff cooperation by the end of the first year
of programming. As previously stated, rural vendors
experienced greater difficulty getting ED staff to alert
peers when patients presented who were eligible for
their services, as with RV3: “[for] My [ED staff], still,
[the peer is] not top-of-mind there yet, and she’s gone
down there and spoken to them, and shadowed them
for a shift, a couple different things, but yeah, if any-
body has any ideas on how to get more buy in from your
[ED staff], I’d be interested” (T3). RV2 described great
difficulty setting the electronic health record system up
to track peer services, which was not a problem for any
of the urban vendors who discussed requiring similar
technological adaptations. While urban vendors also
described some challenges executing the implementa-
tion, these discussions focused more on successes and
their underlying facilitators, as they indicated having
more support from ED staff, more helpful technology
departments with better resources, and an easier time
integrating peer services into the pre-existing work-
flow. A typical example of the smoother execution of
the implementation plan among urban vendors is dem-
onstrated by a selection from in UV4’s T3 interview
where participants listed barriers they had encountered
and overcome:
e first barrier was training up a group of recov-
ery coaches [i.e., peers] that we could look at to
hire. We overcame that barrier…a few times we
had some issue with ‘Oh my gosh how’s the per-
son [patient] gonna get their medication?’…but we
were able to utilize [our foundation] and different
things to help….
Such discussions of successful resolutions to major
implementation barriers were not a feature of later rural
vendor interviews.
Discussion
Our secondary analysis of implementation interviews
from the evaluation of the RCPSI identified a number of
differences between rural and urban locations. In some
instances, issues raised were completely unique to rural
sites, such as the concern that peers might not be com-
pletely adaptable to the local context. is was likely
rooted in the fact that the RCPSI, like most substance
use interventions, was developed without explicit con-
sideration of the rural healthcare context [31]. In other
instances, similar issues impacted sites but differed in the
degree of their perceived effect over time. For instance,
all vendors viewed peers as filling a gap in both setting
types, but rural vendors viewed them as filling this gap
beyond the confines of the ED, largely due to their need
to make adaptations in response to challenges encoun-
tered. e rest of this discussion focuses on the most sali-
ent and actionable themes identified.
One of the most unique and pressing issues for rural
sites was the lack of patient referrals to peers, which is
one of the core functions of such programs [6]. One una-
voidable reason for this was the low volume of service-
eligible ED patients. Compounding this issue, was the
fact that peers did not work evenings when most eligible
ED patients were likely to present. e data do not pro-
vide an exact reason for these restricted hours, but rural
vendors did have smaller budgets that prevented hiring
peers to provide more extensive coverage and schedul-
ing peer shifts during normal business hours was likely
to attract more potential hires in rural areas where the
applicant pool was likely smaller. One potential solution
to low patient volume and incompatible staffing coverage
would be to partner with an external peer telehealth hub
that operates 24h a day, as use of telehealth for substance
use disorder and specialist services in the ED is becoming
more common [32, 33].
Rural ED providers were reluctant to refer eligible
patients to RCPSI peers. While there was no discus-
sion of the specific reasons, prior work has noted diffi-
culties adapting interventions to rural areas when they
are incompatible with provider experience [31]. Addi-
tionally, incompatibilities between peers’ workflow and
Page 9 of 12
Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
established and longstanding processes within the ED
without appropriate information and technology to sup-
port integration likely had some negative impact on
implementation of the referral process [34]. Reluctance
to initiate referrals could also be rooted in high levels of
individual stigma toward substance users and services
designed to assist them, which prior research has demon-
strated to be common in rural communities [3537]. For
instance, Richard etal.’s [38] analysis of semi structured
interviews conducted with rural Appalachian stakehold-
ers, including healthcare professionals, demonstrated
conservative abstinence-focused attitudes that stood in
opposition to MOUD. It is possible stigmatizing attitudes
influenced rural providers’ willingness to communicate
with and make referrals to non-peer behavioral health
staff, since peers were known by providers to be in recov-
ery from a substance use disorder. More research should
seek to understand peers as both recipients and potential
mediators of stigmatizing attitudes among the provid-
ers they work alongside and how this might differ by the
greater health services context. Regardless of the reason,
the lack of patients resulted in the need to expand the
role of some rural peers to ensure they were utilized. is
meant assigning them to serve OUD patients in other
hospital departments and through collaboration with
community programs.
Despite low patient volume, rural vendors still expressed
concern regarding inaccessibility of MOUD treatment for
patients with whom peers worked. While not documented
in the data, it is possible this concern reflected referrals for
patients whom peers saw through their expanded job duties
given ED referrals were low. Regardless, this resulted in a bot-
tleneck for rural peers’ work that negatively impacted their
ability to meet the third core function of ED-based peers
[6]—connecting patients with MOUD or other treat-
ment. Prior research has identified barriers to MOUD
implementation and access as common in rural areas
[39, 40]. Greater discomfort treating OUD patients is one
possible reason for this shortage, and prior research com-
paring rural and urban physician attitudes toward treat-
ing OUD patients has demonstrated this likely has more
to do with lower levels of training and experience among
rural physicians [41]. Fortunately, there are interventions
demonstrated to educate and support rural physicians,
which hospitals could use to improve MOUD access in
their areas. e Extensions for Community Healthcare
Outcomes (ECHO) model offers education over a dis-
tance through video to facilitate case-based learning, and
it has been shown to be a feasible model for expanding
MOUD and other substance use treatments in rural com-
munities [42, 43]. Another option, the hub-and-spoke
approach, utilizes a network with a central anchor estab-
lishment (hub) with a full service array that supports
secondary providers (spokes) with more limited services.
e approach can improve provider confidence and has
documented success improving rural system’s MOUD
treatment capacity [44]; however, this does require the
identification of a hub, which can be difficult in some
rural communities [45]. If these two approaches are not
feasible, rural hospitals can also consider developing
internal MOUD capacity, as RV2 did.
e difficulty some rural peers experienced following-
up with patients transported to urban hospitals was likely
rooted in federal laws prohibiting the sharing of indi-
vidual-level health information between providers with-
out patient consent. e most well-known of these laws
is the Health Insurance Portability and Accountability
Act (HIPAA). However, Title 42 of the Code of Federal
Regulations Part 2 (42 CFR Part 2) is a less known regu-
lation among general healthcare providers that applies
specifically to the release of information for behavioral
health treatment. Prior work has demonstrated provider
confusion related to 42 CRF Part 2 that is perceived to
inhibit communication between providers, and this can
in turn negatively impact care coordination [46]. While
not documented in the data represented in this article,
discussions from an informal learning collaborative in
which RCPSI vendors participated [47] demonstrated 42
CFR Part 2 was a sticking point of confusion that limited
communication between rural and urban hospitals. For-
tunately, one of the main urban hospitals to which rural
vendors transported patients participated in the collab-
orative, and they were able to work together to address
some of the issues around 42 CFR Part 2.
At the RCPSI’s start, the state contractually required ven-
dors to limit peer work to ED patients presenting with OUD.
To ensure this, the state was initially only supporting peer
work through cost reimbursement for services provided to
eligible patients. is requirement limited rural hospitals
because they did not not have the patient volume to sup-
port peer work under those terms. In recognition of this and
other issues, the state changed the terms of the contracts to
directly support peer salaries. Rural vendors were then able
to adapt and allow peer work to expand beyond the confines
of the ED. is highlights the need for state-wide initiatives
to recognize contextual differences between rural and urban
locations when initiating contracts, as well as understand-
ing that rural programs should likely not be evaluated on
the exact same terms as their urban counterparts [31]. Also
connected to funding, rural vendors faced more unexpected
costs over time related to the need to support MOUD pro-
viders and implement needed technology, and prior research
has identified similar barriers to rural substance use disorder
treatment [39].
Regarding limitations, interview data only represent
three snapshots in time for each vendor. However, the
Page 10 of 12
Watsonetal. Addiction Science & Clinical Practice (2022) 17:41
data do provide a longitudinal picture of the first year of
implementation and were conducted at key time points
for the project. As such, the analysis demonstrates how
implementation determinants evolved over time and
how rural vendors were faced with greater challenges
despite expectations similar to those of urban vendors
at T1 interviews. e focus on 10 sites, only 4 of which
were rural, has implications for applicability of thefind-
ings to other contexts; however, the sample is larger
than the minimum recommended for making strong
comparisons between cases [25, 26]. Additionally, the
compatibility of findings with the broader rural-focused
OUD literature strengthens their transferability [25, 26,
48] to other situations and thus their potential ability to
inform implementation of similar programs. While the
potential change in interview participants across time
points for some sites might have impacted data reliabil-
ity, the inclusion of primary designated implementation
leaders in each interview provided some consistency,
making it likely key issues were discussed. Many of the
issues discussed in interviews cut across constructs. For
instance, lack of appropriate technology to support the
intervention could cut across intervention characteris-
tics, inner setting climate, and unexpected costs related
to the implementation process depending on how the
issue is framed. While this could have led to difficulties
tracing the exact nature of a particular implementation
challenge, the longitudinal nature of the data helped us
to better understand the nature of specific issues raised
by tracing how they unfolded over time. Finally, it is
important to note that the absence of the discussion of a
particular determinant within a site or among a group of
sites (e.g., urban, rural) does not mean it was necessarily
absent; however, it does mean it was unlikely to have had
as influential of an impact as those that were the focus of
interview participants’ discussions.
Conclusions
Secondary analysis of interviews from the RCPSI eval-
uation identified several issues related to program
implementation that differed between rural and urban
contexts. Such information is important given the major-
ity of research on ED-based OUD interventions has been
urban-focused to date. Most notably, findings demon-
strate how rural hospitals were faced with greater chal-
lenges implementing ED-based peers that required
flexible adaptations to originally intended plans. Funders
should allow rural programs to have such flexibility when
interventions they are implementing were developed
inor for urban settings.
Abbreviations
CFIR: Consolidated Framework for Implementation Research; ED: Emergen-
cydepartment; MOUD: Medicationsfor opioid use disorder; OUD: Opioiduse
disorder; RCPSI: RecoveryCoach and Peer Support Initiative.
Acknowledgements
The authors would like to thank Dr. Brad Ray for engaging Dr. Watson in the
original evaluation for which the data analyzed for this paper were collected
and Lisa Taylor for assisting in the data collection process for the evaluation.
We would also like to thank Becky Buhner, our primary state partner at the
Indiana Division of Mental Health and Addiction and all of the representatives
from the evaluation sites who participated in the interviews.
Author contributions
DW was the primary evaluator for the RCPSI program and is Multiple Principal
Investigator of the grant that supported analysis for this study. As such, he led
all data collection and analysis activities described. MS assisted substantially
with the analysis and writing of the manuscript. NG provided a needed per-
spective to the analysis process and development of the manuscript as a phy-
sician with substantial experience implementing OUD services in both urban
and rural environments. All authors read and approved the final manuscript.
Funding
Data collection was supported by the Indiana Family and Social Services
Administration (FSSA), Division of Mental Health and Addiction (DMAH), the
U.S. Substance Abuse and Mental Health Services Administration [TI080233].
Secondary analysis of the data were supported by the National Institutes of
Health/National Institute on Drug Abuse [R33DA045850]. The content of this
article is solely the responsibility of the authors and does not represent the
official view of any of the funding agencies listed.
Availability of data and materials
Qualitative data are not available due to confidentiality concerns related to
such a small sample.
Declarations
Ethics approval and consent to participate
The primary designated single Institutional Review Board of Indiana University
determined this study did not require human subjects ethics review because
it was a secondary analysis of de-identified evaluation data.
Consent for publication
Not applicable.
Competing interests
The authors have no competing interests to declare.
Author details
1 Chestnut Health Systems, 221 W. Walton St, Chicago, IL 60610, USA. 2 Center
for Dissemination and Implementation Science, Department of Medicine,
University of Illinois College of Medicine at Chicago, Chicago, IL, USA. 3 Mile
Square Health Centers, Department of Family Medicine, University of Illinois
College of Medicine at Chicago, Chicago, IL, USA.
Received: 9 December 2021 Accepted: 15 July 2022
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The Recovery Coach and Peer Support Initiative (RCPSI) in Indiana focused on implementing peer recovery coaches (PRCs) to engage opioid overdose patients in emergency department (ED) settings and promote entry into recovery services. State workers and researchers organized an informal learning collaborative primarily through teleconference meetings with representatives of 11 health service vendors to support implementation. This study presents qualitative analysis of the teleconference meeting discussions that guided RCPSI implementation to display how the informal learning collaborative functioned to support implementation. This informal learning collaborative model can be applied in similar situations where there is limited guidance available for a practice being implemented by multidisciplinary teams. Authors conducted a thematic analysis of data from 32 stakeholder teleconference meetings held between February 2018 and April 2020. The analysis explored the function of these collaborative teleconferences for stakeholders. Major themes representing functions of the meetings for stakeholders include: social networking; executing the implementation plan; identifying and addressing barriers and facilitators; educating on peer recovery services and target population; and working through data collection. During the last 2 months of meetings, stakeholders discussed how the COVID-19 pandemic created multiple barriers but increased use of telehealth for recovery services. Teleconference meetings served as the main component of an informal learning collaborative for the RCPSI through which the vendor representatives could speak with each other and with organizers as they implemented the use of PRCs in EDs.
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Background In recent years, a number of emergency department (ED)-based interventions have been developed to provide supports and/or treatment linkage for people who use opioids. However, there is limited research supporting the effectiveness of the majority of these interventions. Project POINT is an ED-based intervention aimed at providing opioid overdose survivors with naloxone and recovery supports and connecting them to evidence-based medications for opioid use disorder (MOUD). An evaluation of POINT was conducted. Methods A difference-in-difference analysis of electronic health record data was completed to understand the difference in outcomes for patients admitted to the ED when a POINT staff member was working versus times when they were not. The observation window was January 1, 2012 to July 6, 2019, which included N = 1462 unique individuals, of which 802 were in the POINT arm. Outcomes of focus include MOUD opioid prescriptions dispensed, active non-MOUD opioid prescriptions dispensed, naloxone access, and drug poisonings. Results The POINT arm had a significant increase in MOUD prescriptions dispensed, non-MOUD prescriptions dispensed, and naloxone access (all p-values < 0.001). There was no significant effect related to subsequent drug poisoning-related hospital admissions. Conclusions The results support the assertion that POINT is meeting its two primary goals related to increasing naloxone access and connecting patients to MOUD. Generalization of these results is limited; however, the evaluation contributes to a nascent area of research and can serve a foundation for future work.
Technical Report
Project POINT (Planned Outreach, Intervention, Naloxone, and Treatment (hereafter referred to simply as POINT) is a quality improvement initiative of Eskenazi Hospital’s emergency department (ED) and Indianapolis Emergency Medical Services (IEMS) that emerged in 2015 as a response to the City’s opioid epidemic. POINT started with two simple goals: (1) provide patients revived from a non-fatal overdose with access to the opioid overdose reversing drug naloxone (also known by the brand name Narcan®) and (2) connect those same patients with long-term substance use disorder treatment—with the ideal being evidence-based medication for addiction treatment (MAT; also referred to as medication assisted treatment). In January of 2017, the Richard M. Fairbanks Foundation funded POINT to expand services and evaluate results. Most notable to this expansion was the addition of two peer recovery coaches (PRC; i.e., individuals with lived experience of recovery who provide support for individuals living with SUD). This report provides evaluation results related to this foundation-supported expansion.
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Background In the United States, methadone provision for opioid use disorder (OUD) occurs at opioid treatment programs (OTPs). Ohio recently enacted a policy to expand methadone administration to Federally Qualified Health Centers (FQHC). We compared how the provision of methadone at current OTPs or the proposed expansion to FQHCs and pharmacies meets the urban and rural need for OUD treatment. Methods Cross-sectional geospatial analysis of zip codes within Ohio with at least one 2017 opioid overdose death stratified by Rural-Urban Commuting Area codes. Our primary outcome was the proportion of need by zip code (using opioid overdose deaths as a proxy for need) within a 15- or 30- minute drive time of an OTP Results Among 581 zip codes, sixty four percent of treatment need was within a 15-minute drive time and 81%, within a 30-minute drive time. The proportion of need within a 15-minute drive decreased with increasing rural classification (urban 78%, suburban 20%, large rural 9%, and small rural 1%;p<.001). The portion of need within a 15-minute drive time increased with the addition of FQHCs (96%) and the addition of chain pharmacies (99%) relative to OTPs alone among all zip codes and for all urban-rural strata (p<.001). Conclusion Over one-third of OUD treatment need was not covered by existing OTPs and coverage decreased with rural classification of zip codes. Most of the gap between supply and need could be mitigated with FQHC methadone provision, which would expand both urban and rural access.
Article
Objectives To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States. Methods Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis. Results Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns. Conclusions The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems.