By Dennis McCarty
Implementation science is emerging from Rogers’ (2003) foundational text and a systematic review of implementation research and model for the implementation of innovation (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). The ATTC technology transfer model provides a focused framework to examine the process of developing, disseminating, and implementing new interventions for the prevention and treatment of alcohol and drug use disorders. The ATTC workgroup generalized models proposed for the adoption of psychosocial (Simpson, 2002; Simpson & Flynn, 2007) and pharmaceutical (Thomas, Wallack, Lee, McCarty, & Swift, 2003; Thomas et al., 2008) innovations for treating alcohol and drug addiction.
The model will be more useful as it is operationalized for specific stakeholders interested in the adoption and implementation of addiction treatment innovations. One key stakeholder is the Single State Authority for Prevention and Treatment of Alcohol and Drugs (Single State Authority or SSA). Since the early 1970s, federal legislation requires states to designate a state agency to coordinate service development and to receive and manage federal funds for addiction prevention and treatment services. The SSA may purchase services through direct grants and contracts with treatment organizations or through county or sub-state regional entities. Regulations and contracts specify requirements for service delivery. State authorities may also license or certify treatment centers and practitioners. They play leadership roles in setting standards of care and, if they use their authority to its full extent, they can facilitate or inhibit the adoption of innovations. Advancing Recovery illustrates how states can promote the adoption of treatment innovations.
Advancing Recovery was a Robert Wood Johnson Foundation initiative designed to promote the use of addiction treatment medications and/or new models of care for addiction treatment. The project began in 2007 and came to a conclusion in 2010. Twelve states (or local authorities) participated in partnership with selected addiction treatment centers: Alabama, Arkansas, Baltimore, Colorado, Dallas, Delaware, Florida, Kentucky, Maine, Missouri, Rhode Island, and West Virginia. The state and local authorities were encouraged to use levers to accelerate implementation.
The state authority and providers in Maine worked with the legislature to secure an appropriation of $500,000 specifically to purchase medications. The state authority used its close relationship with Medicaid to prevent requirements for pre-authorization prior to placing patients on addiction medications. Using financing and inter-organizational levers, the Maine state authority stimulated a substantial increase in the number of patients receiving buprenorphine to treat opioid dependence.
Missouri, conversely, was unable to access new funds to support the use of alcohol treatment medications. Instead, they modified contract language to permit treatment centers to use existing funds to purchase medications and physician time. The state authority also encouraged the development and use of a standardized screening tool so that every patient was evaluated for appropriate use of medications. The state director in Missouri made an impact when he explained that treatment centers in the “Show Me” state would support use of medications or they would not receive state contracts. Use of these regulatory and contract levers led to increased use of alcohol medications throughout the Missouri.
In Rhode Island, the state authority and its providers fostered the development of a continuing care process to permit treatment centers to maintain a long-term, low intensity contact with patients though periodic telephone follow-ups. Without new resources, the state and providers negotiated a translation of outpatient slots into continuing care slots and permit providers to be reimbursed for continuing care contacts. Billing codes were developed and approved to facilitate the reimbursement process.
Arkansas adopted a similar procedure. Implementation was challenging, however, because counselor turnover was high. The state authority learned that to sustain the model they needed to over-train – train more counselors than needed. Thus, to promote continuing care, the state authorities not only had to use financing and contracting levers, but also had to provide staff training and monitor the process to assure that it was sustained.
Toward an Implementation Science
The ATTC technology transfer model can help the addiction prevention and treatment field stimulate the development of implementation science. Addiction treatment and prevention services are evolving rapidly in response to emerging findings from neuroscience and behavioral science. By using addiction treatment as a platform for testing implementation strategies, we can facilitate the development and articulation of comprehensive models for technology transfer and implementation. The next iteration of the ATTC model will include testable mechanisms for moving an innovation through each step in the technology transfer process and to determine when a product has been developed and transferred.
Oregon Health & Science University