# Using a quality improvement framework to evaluate the feasibility of implementing a patient-reported outcome measure for recovery in an office-based treatment setting for opioid use disorder

## TL;DR

This study evaluates the feasibility of using a patient-reported outcome measure for recovery in an opioid use disorder treatment setting, highlighting cultural and workflow barriers to implementation.

## Contribution

The study provides insights into the specific challenges of implementing PROMs in addiction treatment, emphasizing the need for cultural and systemic changes.

## Key findings

- The R2AR PROM faced barriers including the need for a champion, education to disrupt cultural norms, and the right care team member for implementation.
- NCMs had limited time and the PROM's psychosocial focus conflicted with their medication management emphasis.
- PROM adoption requires a culture of patient-centered care and systems like EHRs must mandate PROM use for workflow integration.

## Abstract

Patient-reported outcome measures (PROMs) offer a way to track patient recovery from substance use disorder (SUD) and make clinical decisions more effective and efficient. PROM implementation in the context of the SUD population is not yet well understood, but recovery is the type of outcome that requires self-report. While studies have found PROM implementation feasible, an abundance of literature conveys the complexities of implementing PROMs in routine clinical care. We report here on the feasibility of incorporating a PROM for SUD recovery within a buprenorphine program for people with opioid use disorders at a federally qualified health center.

We describe the challenges and distill learnings gained from the feasibility study of the Response to Addiction Recovery (R2AR) PROM instrument that was tested for validity and feasibility with staff (nurse care managers; NCMs) and clients of an office-based addiction treatment program. We assessed the R2AR in terms of clinical workflow and value to clients and clinicians within a fully remote research study which influenced the findings regarding workflow and value. We used the IHI root cause analysis framework to organize results, capturing learning relating to culture, systems, process, people, and environment.

The three most significant barriers to implementing R2AR included the need to identify a champion and change agent, educate clients and providers to disrupt cultural norms, and use the right care team member to implement the intervention. These barriers were amplified by the limited time that NCMs had available to engage with clients and the fact that R2AR’s psychosocial perspective was outside of their medication management emphasis.

Implementing a clinically-based PROM requires clients and providers to alter the way in which they currently behave. A new tool alone cannot change the culture that ascribes provider and client roles within healthcare. The culture of patient-centered care must precede PROM adoption for effective changes to occur. Systems, such as the EHR, must mandate PROM administration to allow workflows to adjust to new processes, and to convey its import as part of clinical care. Until systems are updated, and large-scale PROM adoption becomes ubiquitous, PROMs can also play an important role in supporting self-management and shared decision making.

This study is registered at ClinicalTrials.gov (https://clinicaltrials.gov/, NCT05388045, registered April 14, 2022).

1. Successful adoption and use of patient-reported outcome measures (PROMs) in clinical workflows (i.e., cancer treatment, knee replacement) requires a culture of shared decision making and mutual respect, whereas people with substance use disorders are traditionally disempowered as providers drive what happens in formal addiction treatment.

2. While patients and providers conceptually agreed that the addiction recovery PROM, Response to Addiction Recovery (R2AR), was a benefit for recovery planning and patient centeredness, actual adoption was thwarted by implementation barriers that are common to other change management efforts in quality improvement.

3. The findings suggest that more time spent during the study design phase focused upon culture, including roles and responsibilities of patients and providers, is necessary for PROM adoption, as are the systems and processes that facilitate adoption as part of best practices.