Addictions treatment organizational response to 2020 public health policy changes: impact on quality of care

New York University School Of Medicine, New York NY

Investigators

Abstract

Public health policies instituted in 2020 gave an extraordinary exogenous shock to substance use disorder (SUD) treatment organizations, forcing rapid changes in how they provide care. Before 2020, the treatment model relied heavily on brick-and-mortar clinics to provide in-person medical care and psychosocial treatment, including specialty outpatient addictions treatment (SOAT) and pharmacotherapy provided through medical office-based addictions treatment (OBAT). Due to government mandates for physical distancing and relaxation of restrictions for using telehealth, both SOAT and OBAT providers quickly and fundamentally changed their workflows, including: new forms of medical screening and medication management; greater flexibility in allowing patient self-dosing of medication at home; treatment through individualized and group meetings via telehealth; reduced reliance on drug use screening; and new strategies for treatment engagement. These changes will have unknown effects on treatment retention, use of pharmacotherapy for addictions, and longer-term outcomes. The outpatient treatment system responses—both temporary and enduring—to these external shocks will take many forms depending on the organizational and environmental context in which programs operate. There are fundamental questions about how these systemic changes will affect access and quality of care. We will employ a social-ecological framework to examine the conditions under which outpatient treatment across New York State adapted to the exogenous shock and analyze relationships between new clinical practices (e.g., use of telehealth) and proximal (e.g., retention, use of pharmacotherapy) and distal (e.g., overdoses, emergency department visits) markers of patient outcomes. Further, we will explore geographic, provider, and patient level characteristics that account for variation in patient access and outcomes. We propose an explanatory sequential mixed-methods design to study both short term and longer-term changes to treatment services and outcomes. We will first use administrative data—joining a state registry of SUD treatment episodes with Medicaid—to study variation in treatment practices across 545 SOAT clinics and 3100 OBAT providers. We will examine changes to treatment practice: clinical delivery (e.g., use of telehealth, mix of group versus individual counseling), use of pharmacotherapy (e.g., remote induction, greater flexibility in methadone self-administration), and retention. We will then examine the association between these practice changes and treatment outcomes, such as overdoses, substance-related emergency department visits, and hospitalizations. We will employ qualitative methods to develop an understanding of the quantitative findings by examining organizational characteristics of programs representative of those that have best retention and treatment outcomes as well as programs that performed worst on these measures. The findings will inform clinical and policy decisions on treatment system reforms.