Increasing Buprenorphine access for Veterans with Opioid use Disorder in Rural Clinics using Telemedicine

Abstract

Background: Having prescribers use clinical video teleconferencing (telemedicine) to prescribe buprenorphine to people with opioid use disorder (OUD) has shown promise but its implementation is challenging. We describe barriers, facilitators and lessons learned while implementing a system to remotely prescribe buprenorphine to Veterans in rural settings. Methods: We conducted a quality improvement project aimed at increasing the availability of medications for OUD (MOUD) to Veterans. This project focused on tele-prescribing buprenorphine to rural sites via a hub (centralized prescribers) and spoke (rural clinics) model. After soliciting a wide-range of inputs from site visits, qualitative interviews of key stakeholders at rural sites, and review of preliminary cases, a “how-to” toolkit was developed and iteratively refined to guide tele-prescribing of buprenorphine. After internal and external facilitation strategies were employed, Veterans with OUD at three clinics were transitioned to buprenorphine treatment via telemedicine. Results: Factors impacting adoption of the tele-prescribing intervention were mapped to the Consolidated Framework for Implementation Research (CFIR) constructs. Barriers to adoption included concerns about legality of tele-prescribing a controlled substance, conflicting interests between different stakeholders, and coordination with an existing buprenorphine program requiring more attendance and abstinence from Veterans than the tele-prescribing program required. Factors facilitating adoption included a sense of mission around combating the opioid epidemic, preexisting use of and comfort with tele-prescribing, and rural sites’ control over Veterans referred to tele-prescribers. A total of 12 patients from rural areas were successfully transitioned onto buprenorphine, of whom 9 remained on buprenorphine 6 months after initiation of treatment. Conclusions: Implementing tele-prescribing was negotiated with stakeholders at the target clinics and operationalized in a toolkit to guide future efforts. Implementation issues can be addressed by activities that foster collaboration between hubs (centralized prescribers) and spokes (rural clinics) and by a toolkit that operationalizes tele-prescribing procedures.

Barriers and facilitators in implementing a pilot, pragmatic, telemedicine-delivered healthy lifestyle program for obesity management in a rural, academic obesity clinic

“…Technology-delivered care can be helpful in scaling interventions for rural adults with obesity residing in remote areas Policymakers can enhance reimbursement and incentives to promote telemedicine-delivered care to adults Enhancing patient/staff engagement and culture can overcome organizational stress and enhance reach of the intervention the Consolidated Framework for Implementation Research (CFIR) and RE-AIM [5]. These frameworks have previously been applied in the context of telemedicine and have found that patient and leadership engagement, comfort levels with the technology, and a need to have similar efficacy and workflows to in-person visits were important factors [6][7][8]. As such, the purpose of this analysis was to apply these established implementation frameworks to refine our intervention for a future, large-scale trial that could ensure its long-term success and program sustainability in rural areas.…”

Low Barrier Tele-Buprenorphine in the Time of COVID-19: A Case Report

“…10 Prescribing buprenorphine via telemedicine in nonrandomized studies appears to be safe and likely increases access in rural communities. 11 On March 6, 2020, the Centers for Medicare and Medicaid Services agreed to pay for telemedicine encounters during the COVID-19 public health emergency. 12 The Office for Civil Rights stipulated that providers who serve patients in good faith through everyday communication technologies, such as FaceTime or Skype, during the COVID-19 pandemic are protected from Health Insurance Portability and Accountability Act (HIPAA) enforcement.…”

A Pilot Study on the Impact of the COVID-19 Pandemic on the Physical Activity and Well-Being of United States Military Veterans in Alaska

“…The results also indicated that participants in this study were statistically significantly less satisfied with their health during the compulsory stay-at-home order in Alaska as compared to prior to the compulsory stay-at-home order. Telemedicine for veterans in the US has increased in recent years for a variety of health services, including sleep (e.g., Sarmiento et al, 2019), drug use (e.g., Brunet et al, 2020), and PTSD (e.g., Campbell et al, 2020). Additional telemedicine services for veterans have also emerged as a result of the COVID-19 pandemic, including, for example, an increase in behavioral health telemedicine (e.g., Shelton et al, 2020); however, additional research has noted the need for even more telemedicine services during the COVID-19 pandemic (Egede et al, 2020).…”