Using the Cascade of Care to Increase Use of Medication for Opioid Use Disorder in Criminal Justice Populations
Todd Molfenter, Ph.D.
Director, Great Lakes ATTC, MHTTC, and PTTC
Principal Investigator, Justice Community Opioid Innovation Network’s (JCOIN) Implementational and Translational Research Core
Jessica Vechinski, M.S.W
Project Coordinator, Justice Community Opioid Innovation Network's (JCOIN) Implementational and Translational Research Core
The opioid epidemic has had a disproportionate impact on the nation’s criminal justice (CJ) population. Justice-involved individuals with opioid use disorders (OUD) desperately need evidence-based translational practices to implement medication for opioid use disorder (MOUD), a clinical practice that is underused in CJ settings. As part of the Justice Community Opioid Innovation Network’s (JCOIN) Implementational and Translational Research Core (I/Trans Core), the Center for Health Enhancement Systems Studies (CHESS) is working with jails and their community-treatment providers across the country to improve their cascade of care in supporting justice-involved populations with OUD.
JCOIN’s Implementation and Translational Research Core
The purpose of the JCOIN I/Trans Core is to study the effectiveness of Dissemination and Implementation (D/I) strategies to facilitate use and uptake of JCOIN scientific findings into widespread practice in criminal justice (CJ) and health settings. Just as in clinical settings, the CJ system experiences a significant lag in adopting research evidence and adoption into practice. With few rigorous, prospective studies examining mechanisms of implementation strategies in CJ settings, now is the time to examine mechanisms of D/I strategies to advance the adoption, implementation, and maintenance of behavioral health evidence-informed practice, treatments, and policy in CJ health. The I/Trans Core, led by Drs. Todd Molfenter (University of Wisconsin-Madison) and Faye Taxman (George Mason University) is grounded in Implementation Science theory and principles and the HIV/OUD Cascade of Care (Williams et al., 2019). The JCOIN I/Trans Core is conducting a randomized control trial (RCT) Fostering MOUD Use in Justice Populations. The trial will determine the optimal approach to low-cost interventions of NIATx coaching and Extension for Community Healthcare Outcomes (ECHO) with 48 jails and community treatments providers across the country to improve MOUD use in justice-involved populations by enhancing the Cascade of Care. (Molfenter et al., 2021).
NIATx is an organizational change approach aimed at improving performance, increasing efficiency, and informing process improvement. In the JCOIN study, each participating CJ site is assigned a NIATx coach who works with a site’s change team to review the current practice, identify process change opportunities, help implement changes, and monitor performance.
Extension for Community Healthcare Outcomes (ECHO)
The ECHO model is focused on MOUD prescribers and clinical staff in the jail and community-based treatment provider sites to improve their competence in using MOUD with justice-involved individuals. ECHO uses telemedicine through monthly videoconferences for case-based, peer-to-peer counseling. Experienced prescribers address counseling strategies, complex medical needs, medication storage and diversion, and transitioning pharmacotherapy between buprenorphine, naltrexone, and methadone.
What is the Cascade of Care, and how is It being used to measure system change?
Cascade of Care was initially introduced as a strategic measurement to assess the quality of HIV care delivery to improve survival and reduce HIV transmission. The HIV Cascade provides a framework to consider how screening and assessment influence engagement and retention in care. This approach has since been applied to other diseases, including opioid use disorder, that Williams et al. adapted to measure systems outcomes. The OUD Cascade of Care model, as applied to use of the NIATx and ECHO technical assistance models, encompasses the following Cascade of Care Domains: Identification of OUD as individuals enter jail settings, followed by Treatment to continue existing MOUD regimens or MOUD initiation for those not on an existing regimen, and followed MOUD Treatment retention within the jail setting and extending in post-incarceration community care.
MOUD cascade of care enhancement activities occurring in the study
Jails and community-provider sites within the trial focus primarily on two of the four domains of the OUD Cascade of Care framework: Identification (screening/diagnosis) and Treatment (engagement in care/MOUD initiation/retention). To assist in identifying gaps in service delivery, sites complete table-top walk-through exercises with their NIATx coaches to flowchart their site’s processes for each domain of the cascade framework. Then, with the support of their coach, sites use the information and data to guide process improvement project(s).
For example, the trial has many sites that identified an aim to improve or implement screening measures to identify individuals with OUD upon entry. One jail aimed to increase eligibility screening for MOUD at intake from 0% to 75% in four months. Another jail had only been maintaining justice-involved individuals upon entry already receiving buprenorphine. Many CJ sites are aware of the high incidence of OUD in their populations. They are now identifying selection criteria and screening measures to put in place for identifying and inducting individuals as they enter the jail. A third jail in the study is focusing on increasing access to MOUD by offering additional forms of medication. This jail has been providing naltrexone successfully but is now conducting a small pilot providing buprenorphine with three justice-involved individuals.
Approximately half the jails in the study are also working with a community treatment provider to improve continuity of care (retention) when a justice-involved individual is released. For example, one site has coordinated monthly interdisciplinary team meetings with jail and community provider staff to plan a “warm handoff” for justice-involved individuals. A second jail has increased its case management services. In addition, this site has reassigned a jail staff member to provide care coordination and referrals to community-based providers for justice-involved individuals who request MOUD upon release.
Although sites are just eight months in to the 24-month study and little data is available, study sites have reported improvements in their overall cascade of care and delivery of MOUD through the use of NIATx Coaching and ECHO.
Where we are in the study
The study has enrolled two cohorts with a total of 32 sites (20 jails/12 community treatment providers) since January 2021. Participating sites range in size, location (urban vs. rural), and the number of medications offered (injectable naltrexone, buprenorphine, and/or methadone). The study team is now recruiting 16 additional sites to create a third and final cohort that will kick off in January 2022.
Molfenter, T., Vechinski, J., Taxman, F. S., Breno, A. J., Shaw, C. C., & Perez, H. A. (2021). Fostering MOUD use in justice populations: Assessing the comparative effectiveness of two favored implementation strategies to increase MOUD use. Journal of Substance Abuse Treatment, 108370.
Williams, A. R., Nunes, E. V., Bisaga, A., Levin, F. R., & Olfson, M. (2019). Development of a Cascade of Care for responding to the opioid epidemic. The American journal of drug and alcohol abuse, 45(1), 1–10. https://doi.org/10.1080/00952990.2018.1546862