Using structured analysis and design technique to characterize barriers and facilitators to outpatient care coordination after emergency department-initiated buprenorphine.

INTRODUCTION: Emergency department (ED)-initiated buprenorphine is an evidence-based strategy for treating opioid use disorder, but reducing overdose requires patients to stay on buprenorphine after they leave the ED. This study used the structured analysis and design technique to identify key activities for successful ED-outpatient care coordination; characterize variation in care coordination across ED-clinic pairs, and identify barriers and facilitators to connecting patients to outpatient buprenorphine.

METHODS: Group interviews with core clinical teams, direct observation of care coordination, and patient interviews were conducted at two EDs and four associated clinics (two per ED) in Northern California. Using the structured analysis and design technique, we identified activities that were necessary and sufficient to "transform" ED patients with opioid use disorder into patients with opioid use disorder maintained on outpatient buprenorphine and constructed four sets of maps to depict care coordination workflows. Using a multiteam systems framework lens, we qualitatively analyzed data to identify barriers and facilitators for each activity and crosscutting themes.

RESULTS: Five common activities were identified: identify ED patients with opioid use disorder, initiate treatment and follow-up plan, obtain buprenorphine, establish outpatient treatment, and maintain buprenorphine treatment. We found that care coordination for ED patients starting opioid use disorder treatment with buprenorphine is complex and not standardized (including within the same ED). Themes identified were: 1) activities often depend on a single individual for success; 2) EHR-based referral and scheduling processes are not fast or reliable enough to avoid gaps in buprenorphine access; 3) EDs and clinics have conflicting incentives that complicate care coordination; and 4) ED patients who get buprenorphine have substantial social instability and require additional support to establish and maintain outpatient treatment.

CONCLUSIONS: The common sequence of care coordination activities we identified can help advance OUD research by providing a framework for comparing and contrasting care coordination across heterogeneous ED-clinic pairs. The SADT method and multiteam systems framework may be useful for characterizing care coordination in addiction research generally. Strategies to improve care coordination should include facilitating HIPAA-compliant communication across ED-clinic pairs, ensuring ED and clinic team members know one another and can communicate efficiently, encouraging OUD-specific workflows that prioritize rapid buprenorphine access and reduce barriers to scheduling, and making it easier for patients to contact ED and clinic teams.