Of the sixteen leaders who were interviewed, the majority (68.7%) were female. The leaders most commonly led from Census designated Southern states (5) followed by the Northeast (4), Southwest (3), West (2), and Midwest (2). The majority (87.5%) of both leadership groups were housed in Medicaid expansion states, which adjusted eligibility to uninsured individuals at or below 138% of the federal poverty level. This is slightly over-representative of the national Medicaid expansion proportion of 74% of states (35). Seventy-five percent of the current leaders were housed within their states’ department of health, with 50% of those within divisions of behavioral and mental health and 25% in substance use departments, exclusively. The remaining two leaders led from within departments of child welfare and human services, respectively. The leaders had an average of 5.34 years of experience in the role of state agency authority and an average of 12.85 years in the substance use field. Seven of the eight current leaders reported directly to an appointee of the governor or legislature and half were also appointees themselves.
Emergent themes from the responses to the a priori questions on barriers and facilitators to sustaining federal programs are listed in alignment with the EPIS framework (Table 1).
Table 1
Emergent themes: Barriers and Facilitators categorized within EPIS framework.
|
Theme responses by leader type
|
|
Current (n= 8)
|
Former (n = 8)
|
|
n (%)
|
n (%)
|
SUSTAINMENT BARRIERS
|
|
|
Outer Context
|
|
|
Service-Environment
|
|
|
Medicaid coverage & reimbursement
|
4 (50.0)
|
4 (50.0)
|
Rely on continued funding
|
3 (37.5)
|
X
|
Infrastructure
|
2 (25.0)
|
3 (37.5)
|
Inter-organizational
|
|
|
Reduced timeframes
|
4 (50.0)
|
X
|
Opioid-specific funding cliff
|
3 (37.5)
|
X
|
Opioid-specific data collection
|
2 (25.0)
|
X
|
Inner Context
|
|
|
Intra-organizational
|
|
|
Costs to integrate services
|
3 (37.5)
|
4 (50.0)
|
Lack of adequate workforce
|
2 (25.0)
|
3 (37.5)
|
Individual† Adopter Characteristics
|
|
|
Competing priorities
|
3 (37.5)
|
5 (62.5)
|
Shifting priorities
|
X
|
2 (25.0)
|
SUSTAINMENT FACILITIATORS
|
|
|
Outer Context
|
|
|
Inter-organizational
|
|
|
Positioning within the state
|
8 (100.0)
|
4 (50.0)
|
Access to governor office
|
3 (37.5)
|
X
|
Access to Medicaid office
|
6 (75.0)
|
X
|
Professional networks
|
X
|
3 (37.5)
|
Consumer Support/Advocacy
|
|
|
External pressure/public support
|
2 (25.0)
|
3 (37.5)
|
Service-Environment
|
|
|
Flexibility in spending
|
2 (25.0)
|
2 (25.0)
|
Technical assistance
|
3 (37.5)
|
1 (12.5)
|
Inner Context
|
|
|
Intra-organizational
|
|
|
Strategic planning
|
6 (75.0)
|
4 (50.0)
|
Demonstration of outcomes
|
1 (12.5)
|
X
|
X: Not identified as a theme among interviewees in this group.
Note. This table only reflects responses to the barrier and facilitators prompt, in-text citation may differ when referencing separate prompt.
†“Individual” within the inner context of the EPIS framework is interpreted as unit-level factors influencing adoption of a practice within a system. For our analysis, the inner context unit is at the organizational-level.
Emergent Themes: Barriers
Outer Context: Service Environment
Outer context barriers included Medicaid and reimbursement challenges for programs requiring continued funding beyond the allocated period. Half of the current (n=4) and former (n=4) leaders interviewed identified reimbursement, both within and outside of Medicaid expansion, as one of the most prominent barriers to sustaining grant-funded programs. Former leader 2 (Medicaid expansion state) described their experience attempting to get a Screening, Brief Intervention, and Referral to Treatment (SBIRT) program “reimburs[ed] through Medicaid and Medicaid commercial insurance” and their inability to “sustain that by making it kind of [a] billable insurance service.” Some leaders acknowledged this was particularly true for differential reimbursements across formularies of addiction medication (medications for addiction treatment [MAT]). Current leader 1 (Medicaid expansion state) described an inability to “have Medicaid coverage for MAT in our state…particularly for Methadone”, while current leader 8, also from an expansion state, experienced similar difficulty “[on] the injectable Naltrexone side … getting that medication paid for patients.” Current leaders (n=3) pointed out that certain treatment-based programs which relied on additional funding inherently posed challenges to sustainment beyond the life of the grant. One reported:
“So, for those initiatives that are new like sober living… or recovery support services through… the discretionary grants [make] sense. But, treatment is largely funded now in this country like healthcare is funded and if we're going to look at expansions and treatment services - providers need sustainable payer resources… When the money's gone. It's gone.”
- Current leader 5, Medicaid expansion state
A major non-funding related barrier that emerged among both current (n=2) and former (n=3) leaders was lack of ability or allocation by the grant itself to support projects that develop infrastructure. Former leader 3 described this difficulty to “build infrastructure on funding that’s going to go away… what was most badly needed is to expand both our treatment and prevention infrastructure.” Leaders often followed this up with an example of a project that addressed an “immediate” need – such as Naloxone kits (current leader 5) – in the absence of developing treatment capacity.
Outer Context: Inter-organizational
Another major theme identified by half of the current leaders (n=4) interviewed was the impact of condensed grant timelines on project selection and ability to integrate sustainability planning. Current leader 8 questioned, “When do you have time to build in the sustainability” for projects with time-limits when it “potentially loses the sustainability factor if you aren’t given the time to plan.” Current leader 2 touched on how shorter time to implement a project can make agencies “a little more cautious and risk adverse if you know you only have two years to do something – [which] also impacts sustainability.”
Current leadership recognized that the limited period of grant funding was immediately
impactful on projects funded through the opioid response grant mechanisms. Many current leaders (n=3) described concerns that as the impending funding cliff was at odds with the non-fleeting nature of the epidemic. For example, current leader 3 described substance use disorders as “[a] chronic illness, it’s not like this is an epidemic that’s going to end” and that without continuation of funding for “some of these services I see people returning back to illicit opioids.” One quarter of current leaders (n=2) also expressed concerns about data collection and the inability to create infrastructure within the time limit. Current leader 4 said, “the only way I can do that is I can build something internally. This is two-year money … I'm still probably a year away from having a system to actually gather this information.”
Inner Context: Intra-organizational
There was high recognition among current (n=3) and former leaders (n= 4) that the impending grant end would leave certain programs unfunded, a cost that would have to be subsumed and integrated with other entities in order to continue. Current leader 6 questioned - in relation to the community behavioral clinics they served - “what is going to be billable, do they have the staff resources they need to keep things going?”. This concern was often mentioned in the context of integrated care between service entities. Current leader 8 mentioned the particular need within “hospital settings… if they [could] bill … services to Medicaid and find a way to absorb the costs of some of the ancillary services.” Former leaders also highlighted addressing the barrier of dis-integrated care in order to sustain programs past the funding period. Former leader 8 referenced a need to replicate the accomplishments during the HIV epidemic, when “agencies came together and … every funding stream [paid] for what they can pay for.” Former leader 4 also highlighted the lack of joint care prioritized in the grants themselves “as we see more and more focus on just integration in general, whether it’s integration of state agencies… integration of behavioral health with physical health… there should be this focus on integration of the funding.”
Many former (n=3) and current (n=2) leaders discussed lack of adequate workforce, both with the skillsets and availability, to continue projects started within grant funding. Current leader 4 described this impact on system capabilities as “the lack of workforce, that’s really what constrains the expanding [sic] provider capacity.” Another, former leader 8, introduced that even if funding may exist to continue a program past the grant period, “the fact that we had so few people who were specifically qualified to treat adolescents and young adults, that was a problem for other funders.” Specific workforce challenges related to substance use, such as provider stigma, were also presented when current leader 4 described “everything from bias within the practice setting against this population and fear that it’s going to alienate their other patients.” Capacity, qualifications, and stigma were all workforce components that were acknowledged by leaders as prohibitive factors in sustaining grant funded programs.
Inner Context: Individual Adopter Characteristics
Competing priorities between funded projects was overwhelmingly identified by both the former (n=5) and current leaders (n=3) as the most prominent barrier to sustaining programs; spanning time, resources, and projects. Current leader 2 discussed this strain on time and staffing, saying “there’s a competition between my time… I didn’t get extra staff to implement these grants, and they’re so fast.” Former leader 4 contextualized this as their agencies’ differential “attention [paid] to the fast block grants rather than some of the smaller ones.” Current leaders (4 and 7) noted differences that exist between state and federal agency priorities as some “organizations will get funding from SAMHSA, and create a whole new program that may not be on the state priority list” in which later on the project may “not make the cut and thing[s] will not continue.” A small number of former leaders (n=2) contextualized a shift in prioritization as the substance use landscape transitions from one substance to another, creating a “moving target” of different approaches and resources:
“I would also add the moving target of problems –for example the opioid money … as the problem shifts to cocaine or methamphetamine or marijuana, whatever works for one thing doesn’t always work for another.”
Emergent Themes: Facilitators
Outer Context: Inter-organizational
Across both leaders, the most commonly cited outer context facilitator was one’s political positioning within the state. All current leaders (n = 8) and half of the former leaders (n = 4) discussed how their standing within state government either contributed to, or hampered, their efforts to enact change. They noted that there was a “political reality” (current leader 5) which officials felt obliged to operate within. One, former leader 6, indicated that support “from above… makes it more likely that the work can continue” after a grant has ended.
Furthermore, respondents pointed to multiple players they felt required to negotiate and collaborate with, including Medicaid, the governor’s office, and others. As a sub-theme of positioning within the state, collaboration with the governor’s office was mentioned by some current leaders (n = 3). Current leader 6 pointed out the importance of the governor’s support, saying “I certainly think that having people buy in at every level… from the governor's office, all the way down, we have an absolute buy-in about the need for this kind of work.” More noticeably however, current leaders (n = 6) endorsed that their relationship with the Medicaid office was an important facilitator. Those leaders who enjoyed a “good relationship” (current leader 8) were able to collaborate by virtue of state bureaucratic infrastructure. As current leader 7 noted: “we have a really strong partnership with our Medicaid agency…some of that is the fact that this is a separate state agency that's part of the governor's cabinet that works on addiction issues and that it's not merged together with mental health and/or with health, generally.” These kinds of bureaucratic structures seemed to matter insofar as they also impacted the ability of officials to work seamlessly. For example,
“The further removed you are from the Office of Medicaid, the harder it is to influence Medicaid policy. So being in the same department, having the director of Medicaid as a peer… facilitates being able to integrate the benefit in meaningful ways.”
Similarly, some former leaders (n = 3) also cited professional networks more broadly, not necessarily solely within government, as being important outside facilitators. As one former leader reported:
“One thing that helped me accomplish one of the goals in the state ... was that I knew who to contact… So I called a colleague in public health who then figured out who I could access that was external to government [who] helped us… [So] getting people that are external – that’s the facilitator. Having a leader, having someone in the leadership team that has good connections with people outside of the state… getting expertise from outside of the industry, this was definitely something that I encouraged.”
Outer Context: Consumer Support/Advocacy
Current (n=2) and former (n=3) leaders pointed to public support and external pressure as outer facilitators as they put pressure on governments to increase resources. According to former leader 7, “getting that public support is important…particularly if what you wanted to do with that public funding… is going to require new funds to continue things moving forward.” Former leader 4 also agreed, noting that this is critical given the scope and heightened public awareness of the opioid crisis:
“We all have, I think, recognized now that the opioid epidemic has gotten everyone’s attention, which, I think we can use to our advantage as a substance use disorder treatment community. We’ve been wanting for years for others to recognize the chronic… nature of addiction… there’s a lot of pressure for providers to demonstrate quality, to demonstrate outcomes, and to position themselves within the true healthcare community, if you will.”
Outer Context: Service-Environment
Some current leaders (n = 2) identified flexibility in spending as a facilitator. Current leader 2 noted that “traditionally funding services [are] so siloed” but – in relation to the opioid response grants - “this type of funding [opioid response grants] that is so flexible, umm you know, I think, ultimately, it really does help with removing silos.” Current leaders (n = 3) also reported that knowledge retention, sometimes in the form of technical assistance from outside contractors, was a helpful resource.
Inner Context: Intra-organizational
Among former leaders (n=4), strategic planning was the most frequently mentioned facilitator. Former leader 7 created and continually adapted a strategic plan “with the goal that within our resources, [the program] was already something we were going to maintain,” thus bringing sustainment into the conversation earlier. Another added that strategic planning involved viewing time-limited grants not as isolated initiatives, but as “pilot or demonstration projects” (former leader 9) whose results could be collected and built upon for future endeavors. Current leaders (n=6) also reported that strategic planning was helpful in past sustainment efforts, although none identified planning as a facilitator of current project sustainment. Four of the six who acknowledged planning as important cited the benefits gap or needs analyses. One, current leader 2, said because of gap analysis, “we [already] knew where we wanted to go. So when the funding came… it was just like, ‘Okay, we know that we have an issue in this area, so we’re going to put funding over here’.” Preemptively gaining an understanding of the most urgent needs, pre-existing coverage, and the “policy landscape and… infrastructure,” current leader 5 added, enabled leaders to “try to build and grow and sustain and create good policy… [even] if the funding goes away.”
When asked about program sustainment supports, both former and current leaders also discussed the importance of a program’s ability to demonstrate outcomes, with current leader 6 characterizing demonstration of outcomes as “building a business case for return on investment… pushing agendas and making sure that people see… return on investment exists.” Although only one current leader explicitly identified demonstration of outcomes as a facilitator, several current leaders (n=3) expressed interest in receiving training on it and many former leaders (n=4) recommended discussing the topic with current leaders (not listed in Table 1). Commonly cited was the need to collect and present program data in formats understandable by state legislatures. Current leader 6, who identified this as a facilitator, said they intentionally use of data showing “impact and… [returns on investment]” to potentially catch the attention of “an interested lawmaker who looks to us for… the newest, latest, and greatest thing that needs to be supported and sustained.”
Emergent Themes: Sustainment Strategies
When prompted to discuss strategies taken to sustain current or former programs within their tenure, leaders often highlighted initiatives that directly addressed the aforementioned barriers, which are listed in alignment with the EPIS framework (Table 2).
Table 2
Emergent Themes: Strategies categorized within EPIS framework
|
Theme responses by leader type
|
|
Current (n= 8)
|
Former (n = 8)
|
|
n (%)
|
n (%)
|
Outer Context
|
|
|
Inter-organizational
|
|
|
Involving stakeholders
|
6 (75.0)
|
X
|
Technical assistance
|
3 (37.5)
|
X
|
Creating buy-in
|
2 (25.0)
|
X
|
Selecting champions
|
1 (12.5)
|
X
|
Engaging leadership
|
3 (37.5)
|
8 (100.0)
|
Enacting policy change
|
1 (12.5)
|
2 (25.0)
|
Consumer Support/Advocacy
|
|
|
Raising awareness
|
4 (50.0)
|
X
|
Inner Context
|
|
|
Intra-organizational
|
|
|
Workforce/credentialing
|
5 (62.5)
|
3 (37.5)
|
Capacity development
|
6 (75.0)
|
1 (12.5)
|
Demonstrating outcomes
|
2 (25.0)
|
X
|
Primary prevention initiatives
|
2 (25.0)
|
X
|
X: Not identified as a theme among interviewees in this group
Outer Context: Service Environment
Financing was a major strategy employed among the current leaders (n=5) and ranged from “working with our legislature to get them to approve funding for putting methadone on the formulary, for Medicaid” (current leader 1) to “[writing] a new 1115 waiver that included … behavioral health advancements” (current leader 2) to adding “Medicaid as a reimbursement structure for peer support” (current leader 4). Current leader 2 specifically mentioned financial reimbursement strategies’ increased impact on sustaining programs in that “with some of the other short-term funding … the sustainability is really impacted because you’re not going to do projects necessarily increasing access.” Although not a stated strategy, there was also a high recognition among current leaders (n=3) of wanting to receive training or content knowledge on healthcare financing, a separate question.
Outer Context: Inter-organizational
A major strategy employed by the current leaders (n=6) included involving stakeholders early on in discussions and initiatives to create ownership for sustaining programs. For many who noted this, it included technical assistance activities (n=3), creating buy-in (n=2), and selecting champions (n=1). Current leader 2 described the importance of creating this buy-in by “talking about sustainability … as we’re reaching across silos of different systems – how do we get them to understand and own the problem, too?”
A related strategy strongly employed by both current (n=3) and all former (n=8) leaders was engaging other state department leaders and offices and using one’s position to partner with and advocate for policy and funding changes. Former leader 3 described this inter-agency connectivity “…as a Cabinet-level official, I was able to work with the Physician General, and we called health insurers all over the state, and raised a half a million dollars for naloxone for police.” Another described this role positioning as a key component of change as “the biggest thing … where they [the leader] are in the hierarchy and where their sphere of influence actually is” (former leader 7).
Enacting policy changes was another avenue employed by leaders [former (n=2), current (n=1)]. Former leader 7 described their plan to change licensing policies as “one of the plans to sustain was to change the contract language or changing … the rules and regulations.” Another, former leader 5, explicitly described rewriting “bundle payments differently for OTPs… so even though this money will go away, their rate for all other state and federal money will support the program.” Another strategy acknowledged by current leaders (n=4) was raising awareness through information campaigns –categorized within the “consumer support/advocacy” subdomain of the outer context (Table 2).
Inner Context: Intra-organizational
Several strategies were stated by former (n=3) and current leaders (n=5), respectively, to address barriers related to workforce capacity. This included prioritizing “co-location models” (current leader 8) to “hiring people in government [with] business experiences,” because “learning about insurance and about how the healthcare world works … never used to be so essential as it is now” (former leader 6). Former leader 8 even discussed the intentionality of workforce capacity as a key component of sustainability, providing an example of “credentialing over 300 folks to be peer specialists … purposefully put into both the [opioid response] grants to encourage that sustainability.”
The majority of current leaders (n=6) and one former leader mentioned employment of capacity development initiatives to build content knowledge among practitioners, lasting beyond the grant-funding period. This included training initiatives on diversion and medication-assisted therapy within jail settings (current leader 2), hospital training collaboratives, and telehealth technology among primary care providers (current leader 4). Current leader 8 contextualized using these grant funds as an opportunity to “to be paying for activities that put things in place like … a good knowledge basis and some training … that they can build from any kind of workforce development.”
Other minor strategies listed by current leaders included the importance of demonstrating outcomes (n=2) and engaging in primary prevention initiatives (n=2).