Table 2.

Operational factors influencing MAT implementation and sustainment

Screening Aim: Employ an initial screen for opioid use disorder at intake for 100% of new admissions
Category	Barriers:	Solutions and Innovations: (bold = innovation)
Facility	Space at intake not conducive to screening	Self-administered screen with tablet at intake
Culture and Change Management	Inconsistent screening due to custody vs. medical priorities	Aligned custody and medical leadership
Policy/Procedure	Lack of standardized procedure for screening and assessment	Develop a comprehensive screen to be completed by Day 2
Education	Lack of education on medication assisted treatment options and recovery treatment	Video education at intake about treatment program
Staffing & Training	Insufficient staff to screen consistently	Train interdisciplinary staff to screen; temporary increase in staffing during busy times
IT/EMR		Use tablet technology for screening linked to EMR
Treatment Aim: To offer system-approved treatment to all individuals diagnosed with opioid use disorder unless treatment is contraindicated
Category	Barriers	Solutions and Innovations: (bold = innovation)
Culture & Change Management	Lack of buy-in from Security and Nursing; Judgement that patient is “poor candidate” for treatment or terminate treatment due to “bad behavior”; contraband concerns of custody	Alignment of custody and medical priorities through training and open dialogue policy to continue all FDA approved treatment at time of incarceration
Staffing	Medical services not 24/7; insufficient staff for treatment induction	Increase capacity to treat 24–7; add staff during peak days; contract with community-based provider to assist with treatment onsite; train staff to be flexible
Policy/Procedure	No standard process for treatment induction	Create comprehensive treatment procedures
Patient knowledge & education	At jails providing agonist treatment, many patients express lack of interest in treatment	Focus groups to explore lack of interest in treatment and group education visits to address concerns
Facility	Space not conducive to treatment	Site expansion; medication line customization; designated housing units for treatment
Contraindication	Medical conditions preclude treatment; e.g. liver disease; medication side effects intolerable	Provide alternative medication
Safety Concern/Procedure	Inmate movement and transfers
Spread and expand treatment		Criminal justice collaborations: pre-trial, drug court, work release populations
Practice transformation		Add CBT; interdisciplinary team approach; structure improvement efforts into smaller functional work groups; treatment integrated into standard operating procedures
Community coordination for post-release care Aim: 100% of treated patients will receive an appointment for treatment at time of release and all appointments will be kept
Category	Barriers	Solutions and Innovations
Community Access	Large geographic catchment for return to home post-release	Develop a community/county reentry council
Patient tracking	Data not available from community agency; lose patients to follow-up	Contract with community-based treatment provider for onsite treatment; identify liaison with community-based providers; recovery specialist or coach follows patient post-release; close coordination with courts and probation
Insurance	Lack of access to post-release treatment or transportation issues; lack of health insurance at time of release;	Work with state to suspend public insurance and reactivate at time of release; expand state Medicaid enrollment; work with community providers willing to provide ‘bridge’ services
Staffing	Insufficient staff for discharge planning	Develop follow-up process for patients released on treatment; Cross-train all discharge planners to coordinate post-release treatment; addition of recovery coaches; CMS waver for 30-day pre-release planning
Post-release programming		Aftercare group for released population on treatment; job placement in recovery friendly environment; open step-down unit run by prison or jail
Data collection systems: develop system for tracking patients screened with OUD, those treated and untreated as well as community referral tracking
Category	Barriers	Solutions and Innovations
Data collection and reporting	Manual data collection with data entry in Excel; errors in secondary data entry; status revision requires repeated data input already entered	Fully integrated EMR with MAT assessment and treatment information and reporting capacity
Staffing	Limited staff for data collection and reporting	Peer navigators assist with intake and referral data entry
Culture and Change Management	Data collection and reporting not a priority	Prioritize value of data across public safety and coordinate with all agencies