This study found CFIR to be a useful framework for understanding implementation uptake and barriers. The framework was particularly valuable in reinforcing the use of implementation research as a means for continuous process improvement. CFIR is a comprehensive and flexible framework that may be adopted in future cross-system evaluations.

The process evaluation showed that adaptability of the clinical model and staff flexibility were critical to implementation. Cultural and procedural differences across correctional facilities and community-based treatment programs required frequent and structured forums for cross-system communication. Challenges related to recruitment and enrollment, staffing, MAT, and data collection were addressed through the collaborative development and continuous review of policies and procedures.

Given the interrelated nature of opioid use, criminal justice interaction, and mental health issues, the current opioid crisis has created an urgent need for treatment, including medication assisted treatment, among justice-involved populations. Implementation research plays an important role in improving systems of care and integration of evidence-based practices within and outside of criminal justice institutions. The current study is a formative qualitative evaluation of the implementation of a cross-system (corrections and community-based) opioid use treatment initiative supported by Opioid State Targeted Response (STR) funding. The purpose of the study is to assess the fit of the Consolidated Framework for Implementation Research (CFIR) to a cross-system initiative, and to identify key barriers and facilitators to implementation.

Although previous studies have used the CFIR to evaluate implementation of singular substance use, MAT, and criminal justice programs, the present study will be the first to use the CFIR in relation to a cross-system (criminal justice and community-based behavioral health treatment systems) implementation of an opioid use treatment initiative with an MAT option. This paper focuses on a formative qualitative evaluation of the implementation of the MISSION-CJ model in two correctional facilities. The purpose of the evaluation is two-fold: 1) to assess the fit of the CFIR to a cross-system (corrections and community-based) opioid use treatment initiative, and 2) to identify key barriers and facilitators to the implementation of this cross-system initiative.

MISSION-CJ services begin inside the correctional facilities and then continue after release to the community, involving a number of correctional and community-based systems to coordinate re-entry planning, housing, insurance coverage, and parole stipulations to name a few. Because the initiative requires careful attention to interdependent interactions within and across delivery organizations, the initiative includes a university team that acts as both evaluator and system broker, asnote, “Research teams often take on the role of an external change agent in the context of randomized implementation trials running in multiple sites.” (p.197). The university team conducts evaluation and provides ongoing feedback in accordance with the plan-do-study-act (PDSA) approach to process improvements ().

A recent application of the CFIR framework to a Patient-Centered Care “cultural transformation” in the Department of Veterans Affairs (VA) found that the CFIR was a useful starting point but that adapted definitions and a mixed deductive-inductive approach were needed to accommodate the complexity of a broad-scale implementation (). With the adaptations, key findings helped the researchers to understand the individual and organizational factors, barriers and facilitators, and the impact on implementation (). Furthermore, the researchers were able to turn the findings into an easily understood and actionable set of findings and recommendations for stakeholders ().

The Consolidated Framework for Implementation Research (CFIR;) was selected given its flexibility for use in the current initiative across multiple systems, each with their own distinct policies, procedures, and cultures. The CFIR framework has been used most often to examine discrete health interventions in community or health service settings. A 2017 implementation study of 39 commercial and state health insurance plans in seven regions across the United States found the application of CFIR useful for generating actionable findings relevant to the implementation of a primary health care initiative (). The timely, actionable findings allowed for a rapid-cycle approach to evaluation in which ongoing feedback was provided to program stakeholders to support learning, adaptation, and continuous quality improvement (). The framework has also been used to study the implementation of substance use treatment programs () and HIV programming for women in community corrections (). Another study applied the framework to categorize and interpret the processes involved in the adoption of the XR-NTX injection at nine addiction treatment centers contracted with a singular health plan and found that it effectively captured relevant issues related to authorization processes, provider networks, and organizational culture ().

The current initiative was implemented in 2017 with funding from SAMHSA's State Targeted Response to the Opioid Crisis (STR). The initiative goals are to expand the service array for individuals with co-occurring opioid use and mental health disorders by increasing access to psychosocial supports and MAT, to reduce OODs, and to reduce recidivism among the target population. This initiative utilizes the evidence-based MISSION-CJ (Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking – Criminal Justice) model to address the unique needs of justice-involved individuals with co-occurring mental health and substance use disorders (). MISSION-CJ services are provided by a case manager and peer support specialist for up to three months pre-release and six months post-release from incarceration. Case managers and peer support specialists connect participants with mental health and substance use disorder providers in the community to assist in the continuity of care. MISSION-CJ includes six components: Critical Time Intervention case management (); Dual Recovery Therapy (); peer support; vocational and educational supports; and trauma-informed care. MISSION-CJ also includes comprehensive risk-need assessment and treatment planning modeled after the Risk-Need-Responsivity (RNR) framework (). This initiative is a cross-system collaboration among the Michigan Department of Health and Human Services (MDHHS), the Michigan Department of Corrections (MDOC), and two university partners (one for evaluation and system brokerage; one for model consultation and fidelity) and is currently being offered in two state correctional facilities for men and women being released to the three largest counties in the state. Studies on collaboration and service integration across mental health, substance use and justice systems have shown that challenges such as organizational culture and philosophy are barriers that must be addressed for successful implementation (). Including MAT as a treatment option presents additional layers of complexity. The current study was therefore undertaken to evaluate the implementation process in the context of an intervention involving not only multiple systems but multiple levels within those systems and different cultures across systems.

An increased focus on evidence-based practices (EBPs) has yielded the benefits of practices that are standardized and manualized. However, the ‘research-to-practice’ question remains i.e., How do we tailor and apply researched interventions such as MAT in a way that is most relevant to a specific population? Inconsistent adoption of EBPs across these complex settings has contributed to a growing focus on implementation science (). Implementation studies examine a breadth of process outcome variables, factors effecting implementation, and implementation strategies (). The purpose of implementation research is to understand “what, why, and how interventions work in ‘real world’ settings and to test approaches to improve them” (, p. 1).

The environments in which public health programs are implemented are increasingly complex, involving interdependent interactions across multiple service delivery systems (). Adding to the complexity is the degree to which these systems differ in organizational characteristics and culture. The National Criminal Justice Treatment Practice Survey (NCJTPS) was conducted to assess substance use treatment services in the criminal justice system and found a need for “better systems of care and integration of services inside and outside the institutions” (, S92). An entire issue of Drug and Alcohol Dependence in 2009 (103S) was dedicated to examining the role of systems relationships across correctional and community-based substance use treatment systems, with a key recommendation being establishment of cross-system relationships at policy and program levels ().

A recent meta-analysis examining the effectiveness of MAT delivered in prisons and jails found promising results with methadone treatment (). There were not enough studies of buprenorphine or naltrexone to meta-analyze, but data from trials in which methadone was provided during incarceration demonstrated increased community treatment engagement and reduction in illicit opioid and injection drug use (). In a randomized control trial of individuals recently released from prison, XR-NTX plus counseling showed improved relapse outcomes compared to counseling or treatment referrals alone (). These differences disappeared one year after treatment ended, demonstrating the need for ongoing community-based treatment. In 2016, Rhode Island became the first state to implement a full MAT program in prison, offering all three forms of MAT in conjunction with psychosocial supports. Twelve-months following program implementation, OODs have decreased by 61% among re-entering citizens ().

Despite MAT's effectiveness in treating opioid use disorders, discrepancies exist in the rates of use across the three types (i.e., methadone; naltrexone available in oral form or extended-release injectable form with the generic label “XR-NTX”; and buprenorphine products). Barriers to receiving MAT include stigma (the idea of “replacing one drug with another”) and limited availability among community substance use treatment providers. The 2017 National Survey for Substance Abuse Treatment Services (N-SSATS) reports that only 10%, 29%, and 24% of substance use treatment providers offer methadone, buprenorphine and XR-NTX, respectively (). These barriers are exacerbated in justice settings, leading to extremely limited MAT availability in jails and prisons. One such obstacle in implementing MAT in justice settings is the need for complex cross-system collaboration among justice and community-based treatment systems at the state and county levels, including creation of policies, provision of intensive training, establishing cross-system networks, and ensuring ongoing monitoring to proactively address public safety concerns ().

Both the World Health Organization's Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence and the U.S. Surgeon General () recommend that a variety of psychosocial and medical services be offered to individuals regardless of incarceration status. Research shows that individuals who receive medication assisted treatment (MAT) prior to release have improved outcomes such as increased enrollment in community-based substance use treatment, improvements in medical and mental health, and decreased rates of substance use and recidivism ().

A recent study in North Carolina showed that the risk for OOD among inmates within two-weeks post-release from prison was 40 times higher than that of the general population; heroin carried an even greater risk, with recently released individuals being 74 times more likely than the general population to die from a heroin overdose (). Furthermore, those receiving mental health services while incarcerated had almost twice the risk of OOD during the study period compared to those who did not receive mental health services (). The increased vulnerability of this population demonstrates the importance of connection to community-based services, specifically substance use treatment, prior to reentry into the community.

Analysis of the National Survey on Drug Use and Health data (NSDUH) showed that criminal justice involvement increases as intensity of opioid use increases (). Additionally, about half of those with higher intensities of opioid usage (i.e., prescription opioid misuse, prescription opioid use disorder, or heroin use) also have co-occurring mental health issues (). People who have co-occurring disorders and are also incarcerated present a unique set of needs for accessing appropriate treatment and for successful reentry to the community (). Managing behavioral health needs as well as securing housing, transportation, and employment upon release are all challenging. This population has high rates of recidivism and homelessness and tends to have limited social and financial supports ().

Between 1999 and 2017, nearly 400,000 opioid overdose deaths (OODs) occurred in the U.S., with nearly 50,000 OODs occurring in 2017 alone (). The Centers for Disease Control and Prevention (CDC) outlines three waves in the rise of OOD: prescription OODs starting in 1999, heroin overdose deaths starting in 2010, and synthetic OODs starting in 2013 (). By 2017, the federal government had declared the opioid crisis a public emergency ().

After common themes were identified across all data sources, three members of the evaluation team independently coded the themes within the CFIR framework and reached 93% agreement. The team members then discussed to come to consensus. Based on this approach, at least one element from each of the five CFIR domains is included. Table 2 shows the five domains along with the elements in each domain that emerged as part of the findings.

Responses from graduate interviews were coded individually by two team members who conducted interviews. Themes around the importance of relationships with staff and the unique experience of this program emerged prominently. A third team member verified coding and confirmed 100% agreement.

Participant focus groups were coded by two members of the system broker/evaluation team who were present at the focus group; Verification by a third team member showed initial agreement of 96%. Findings were used to inform the interview guide for individual interviews with graduates.

Field notes and meeting notes were coded collaboratively by members of the system broker/evaluation team in sessions immediately following the observation. Common themes began to appear regularly such as staffing, enrollment and retention, communication, facility logistics, post-release networks/services, and evaluation process issues/questions. After field notes were taken, two team members coded their own notes and then came together for interactive discussion around categories and any changes needed in coding to reach 100% agreement.

During the staff focus groups, individual responses were coded into categories decided upon collaboratively between the evaluation team/group facilitators and the focus group participants. For example, responses about improvements in communication between provider teams, parole, and facility staff, as well as responses about the benefits of discussions at newly established meetings were coded during the meeting as communication. After the focus groups, the three group facilitators reviewed the coding collaboratively and came to 100% agreement.

We used a mixed inductive-deductive approach to first identify themes that emerged from the data and second to determine if/where they fit within the CFIR framework. Percent agreement was used to determine interrater reliability in the second level of coding i.e. in the CFIR (). Themes were identified using constant comparison analysis in which an item is coded into a category while comparing it to other items in the category (). This method was used to analyze each data source.

Multiple methods were used to assess implementation of the initiative. As part of the ongoing formative evaluation, the evaluation team collected observational field notes; documented notes from 28 structured meetings and discussions with stakeholders; conducted four focus groups with provider staff, facility staff, and policymakers; and conducted two focus groups with current participants and ten individual interviews with program graduates. Observational field notes were collected during site visits to the facilities as well as during ongoing discussions and meetings with stakeholders. Structured meetings and discussions with stakeholders yielded an abundance of information organized in meeting minutes and shared with stakeholders for feedback. Standing meetings with stakeholders were used as a forum for focus groups; interview guides were followed to get feedback on questions related to communication and collaboration, assessment processes, what was going well, and what areas needed improvement. The evaluation team facilitated these meetings and utilized interactive methods such as participants writing responses on small pieces of paper and sticking the pieces of paper on poster board. The group then discussed and coded responses collaboratively into themes. Focus groups were also held with participants inside the facilities to gather perceptions about what was going well, what areas were in need of improvement, and insights into enrollment or lack thereof. Finally, individual phone interviews were conducted by trained evaluation team members with graduates to obtain feedback on their overall experience. In addition to qualitative data, basic quantitative data on enrollment and attrition contributed to the implementation evaluation.

The inclusion of process measures within evaluation is becoming more prevalent, but the use of theories to guide the assessment of implementation processes is still limited (). The CFIR offers a guideline for the systematic analysis and organization of findings from implementation studies (). Its developers reviewed hundreds of empirical studies and 19 published implementation theories to identify the primary factors associated with effective implementation (). The overarching framework is comprised of five major domains: Two domains (Intervention Characteristics and Implementation Processes) relate to the program and the implementation generally, and the other three domains (Outer Setting, Inner Setting, and Characteristics of the Individual) are concerned with context (). Each domain consists of a number of constructs – 39 in total – that reflect the evidence base of factors most likely to influence implementation of interventions (). Because of the breadth and flexibility of the framework, the literature shows that researchers apply different domains and constructs depending on the particular implementation study.

Provider team members, supervisors, and administrators were trained in various aspects of MISSION-CJ, with training content being tailored to their role. Model experts provided ongoing clinical support, advice, and training as well as assessment of model fidelity.

Clinical teams were hired through the regional community mental health organization to provide MISSION-CJ services. See Table 1 for depiction of the systems; levels within those systems; key pre- and post-release services; and the role of each system in development, implementation, and evaluation of those tasks. As Table 1 shows, the collaboration across and within systems is complex considering the variation across each factor. Pre- and post-release services were coordinated among the regional MDHHS office, local community mental health providers, MDOC re-entry specialists and parole staff. Facility wardens were instrumental in working with the university teams and MISSION-CJ teams to implement services inside the facility around the facility logistics, limitations/requirements, and current programming. Services in the facilities include screening for eligibility, enrollment in MISSION-CJ, enrollment in XR-NTX, and re-entry planning. Post-release services include meeting with parole regularly and enrolling in community-based mental health and/or substance use services including MAT.

A few months prior to the STR initiative's implementation, the MDOC began a pilot MAT program at two facilities – the only women's facility and a men's parole center in the state's largest county – to offer one XR-NTX injection prior to release and connect the individual to a provider in the community after release. MISSION-CJ was funded through STR to augment the use of MAT, and individuals could enroll in MISSION-CJ services with or without the facility-based MAT with the hope that individuals would elect MAT in the community upon release. During the STR proposal phase, state-level administrators from MDOC provided data on the number of individuals with documented mental health and substance use issues being housed in each of the XR-NTX pilot facilities as well as the number of individuals being released to each county. Working with state-level administrators from MDHHS and the university partners, and based on the MDOC data, the two facilities (one men's and one women's) and three counties of release were selected for MISSION-CJ.

In addition, adverse events in this population are expected, though the goal is to augment services to decrease the likelihood and frequency of adverse events for the population compared to services as usual. Nevertheless, the evaluation and cross-system collaboration required adverse event reviews and sharing of information about aspects of the provision of services to help continuously inform practices. Issues identified that tapped into barriers within reentry and community opioid use disorder “treatment as usual” for releasing inmates were also reviewed in these processes, such that benefits extended beyond the scope of this particular initiative.

The evaluation team has worked with clinical and MDOC leaders to establish ongoing sessions dedicated to providing feedback based on findings from evaluation. Some of the sessions have been ad hoc meetings and some have been scheduled around key events such as state site visits. The evaluation team conducted a one-year evaluation and shared the findings with all stakeholder groups. The evaluation team director, MDOC substance abuse treatment services manager, and one of the peer support specialists presented on the initiative at the state's annual co-occurring conference.

Processes for collecting and transmitting data were streamlined early in implementation so that a point person was identified per team for sending the documents. During ongoing implementation as participant status changes became more prevalent (e.g., release from facility to community, change in release date, transfer to other facilities, graduation) the evaluation team created an additional form for teams to submit weekly that documented all of these transitions.

Challenges occurred early in implementation with staff not completing the referral/screening/assessment forms correctly i.e., skipping items or providing invalid responses. The evaluation team established a weekly process for a quick turnaround of reviewing, entering, and summarizing the data from the forms and providing a weekly tracking sheet to teams as a tool for tracking participant status and documentation status. This tracking sheet along with the service fidelity logs became the basis of discussions during the weekly tracking calls with teams. Ongoing discussions were held about the purpose of the documents as clinical planning tools as well as providing the basis for evaluation. Focus groups were held with provider staff around eight months into enrollment to get feedback on forms; changes were made accordingly, which staff reported helped with ease and clarity.

Based on data reviewed during the proposal phase, the expected enrollment was much higher than the actual. Interviews with participants revealed common barriers to enrollment, primarily lack of recognition and the misperception that enrollment would postpone one's release dates. To address these issues, teams provided assertive in-reach and marketing e.g., the system broker/evaluation team designed and printed new fliers and posters for staff to use within the facilities and specified on the marketing materials that enrollment would not impact length of parole. As mentioned above, peer support specialists became more involved in educating potential participants about the program. Staff also hung sign-up sheets in the facility for individuals to indicate that they were interested in speaking with a facility coordinator about the program. Participants and graduates reported that many were interested in the psychosocial supports but not XR-NTX simply because “They're not serious about recovery.” Staff has been trained in motivational enhancement strategies to help individuals progress in their stage of change and reflect on the possibility of MAT.

The XR-NTX pilot was implemented just a few months before the STR-funded initiative began. As such, education on XR-NTX was still underway for staff and inmates when the STR initiative began, and the concurrent implementations initially caused confusion regarding eligibility and referrals. The XR-NTX pilot is open to anyone in the two pilot facilities who has an alcohol use or opioid use disorder and is releasing to one of four counties (i.e., the three included in the STR initiative plus one more). The STR-funded initiative's eligibility is more limited because individuals must be reentering to one of the three designated counties and must have a co-occurring opioid use and mental health disorder. To provide clarification, the evaluation team worked with MDOC to develop a singular screening tool to be used for both initiatives and created a process map that helped to differentiate eligibility criteria. The university teams provided ongoing education and training on the eligibility criteria, from which staff reported an increase in their confidence and ability to refer individuals to the appropriate initiative. To support education of staff and potential participants, the evaluation team revised print materials and worked with facility staff to ensure that brochures were being distributed electronically and in person and that posters were displayed in common areas. Based on feedback from participants about the importance of the peer's role, the evaluation team worked with the facility staff to establish a schedule for peer support specialists to provide an overview of the initiative to all individuals during their orientation to other programming.

As an initiative in start-up, there is the need for staff to be flexible and willing to share information for process improvements. Staff feedback showed that those experiencing the greatest frustration were those who wanted rigid guidelines. Ongoing training and discussions around the expectation that procedures were open to modification was helpful for some.

All systems and stakeholders were invested in the initiative and expressed support for the goals of the initiative. During the planning phase, it became apparent that the resources needed such as private space for sessions and the logistics of scheduling sessions were much more difficult to arrange inside a correctional facility than in a community setting. The Deputy Wardens at the facilities worked closely with the provider teams to designate specific days/times and space for sessions. Additionally, the facility coordinator staff play an instrumental role in scheduling sessions and ensuring that individuals receive their daily schedule, which shows when they have a session with the provider team.

MDOC leadership have played a crucial role in lessening cultural differences around MAT. Leaders at all levels actively participate in stakeholder meetings and reinforce the message that the department supports MAT. The implementation of the XR-NTX pilot demonstrated that MDOC has a vested interest in treatment of opioid use disorders, including MAT. With the success seen with XR-NTX, the MDOC has reported that it is considering piloting a more expansive array of MAT services upon entry into the facility. In addition, MDOC recently created a policy explicitly stating that all types of MAT are permissible for individuals under parole supervision and use of prescribed medications for opioid use disorder (i.e., any form of MAT) will not result in parole violations. MDOC leadership actively participate in all meetings.

Organizational culture differences across the corrections system and community mental health/substance use treatment system were expected. These cultural differences were displayed most prominently in views toward MAT (specifically methadone and buprenorphine) from a public safety perspective because diversion of MAT in the facility and misuse of MAT under community supervision are legitimate concerns. Despite the differences, stakeholder discussions across both systems revealed a common goal of providing treatment to help individuals with their reentry into the community, to maintain sobriety, and to remain out of the criminal justice system. As relationships developed, similarities became more apparent than differences, and staff across systems began to see themselves as more of a multi-disciplinary team, with one clinician reporting that “parole agents have been very accessible and helpful in the process.” These cross-system relationships were also recognized by participants, as one stated, “The relationship [the provider team] had with the parole agent made things much easier for me.”

In establishing networks, the provider teams reported that relationships with parole were inconsistent e.g., teams did not always know who the designated parole agent was and/or know how to best communicate with the agent. Trainings were held with parole leadership and agents, and parole agents began attending the bi-weekly facility meetings, which staff reported greatly improved opportunities for working collaboratively.

In the early phases of implementation, stakeholders expressed issues in communication across systems either because of a lack of established relationships and sometimes tension between roles. The system broker/evaluation team began facilitating monthly meetings with all stakeholders to establish relationships and lines of communication. The system broker/evaluation team was key during this time as a neutral entity that could mediate concerns that had been raised either in the meeting or in communications outside of the meeting. The system brokers emphasized that these discussions were to examine processes not individuals. One method used by the team was to stick large pieces of paper on the wall with a topic on it (e.g., “What is working/What is not working with the referral process?”); staff wrote their responses on small pieces of paper, which they stuck on the topic sheet. This facilitated non-confrontational and productive discussions. After a few months, staff reported significant improvements in relationships and communication. Meeting frequency was decreased from monthly to quarterly, and facility-provider teams began to schedule their own check-ins every other week.

Because of the involvement of multiple systems and multiple levels within those systems, communication emerged very early as one of the most critical components of successful initiative implementation. Table 3 displays the multiple systems, multiple levels, and multiple roles and responsibilities along the implementation continuum for key initiative components pre-release and post-release. Ongoing trainings and meetings have helped with role clarification as well as organizational cultural differences that may impact implementation. Observation and feedback revealed that stakeholders did not clearly understand the different roles of the two university partners. As a result, the university teams worked together to develop and disseminate organizational charts and process maps. They explained roles at established meetings and took the opportunity to redirect questions/communications as needed.

Although the two facilities are both part of the MDOC, they have distinct differences because one is a prison and one is a parole center, so guidelines and decisions are not always the same. The basic protocols for entering the facility and scheduling sessions with participants are different. Program requirements at the parole center are greater than at the prison, with the majority of the men already participating in substance abuse treatment services. As protocols were planned (e.g., provider teams' daily visits to the facilities), the requirements of each facility were considered separately.

Related to staff turnover is the need to establish processes for quick hiring and onboarding. MDOC has a multi-step process for clearance and orientation to the facilities. During the implementation process as hiring occurred more frequently, MDOC leadership instituted written procedures and a manual to assist new hires and their supervisors in moving through this process.

All of the systems and organizations involved in the initiative are mature and well-established. This was helpful for having staff at the leadership levels who tended to be long-standing, invested, and well-informed on the systems. At the provider-team level, however, all staff were newly hired specifically for this initiative. This comes with advantages like a high degree of enthusiasm and excitement around the new teams and roles. It also comes with challenges such as hiring, maintaining staffing, and filling positions that have been vacated. Filling the peer support specialist positions has proven to be difficult; one of the preferred qualifications is that the peer has a criminal justice history, but depending on the circumstances (particularly the length of time since incarceration/community supervision), the applicant may be denied clearance to enter the correctional facility. This has been seen in other states and programs as well. Working with the MDOC has been helpful in terms of providing some level of flexibility in clearance. Still, processes among multiple stakeholders can create some delays in hiring. In those instances, or when there are staff vacancies in general, teams adapt to continue to provide the services but may feel stretched. Fidelity tracking has been helpful to review participant contact with staff and maintain the intended level of service intensity. Participants have reported that the peer is a critical component of services, and future analyses will examine the possible relationship with individual-level outcomes.

In a multi-system initiative such as this one, cosmopolitanism is a complex construct: ‘Outer setting’ networks exist, but the need for strengthening of connections across networks was revealed; for example, the corrections system contracts with a limited number of community-based residential providers, which are not always practical options for parolees because of distance or a waitlist. Corrections leadership and community provider team leadership have collaborated to improve the knowledge of and use of available treatment centers. The university system broker/evaluation team facilitated ongoing discussions between corrections leadership and community providers so that both sides gained an understanding of the barriers and resources. Current policies were not prohibitive but merely required an explanation of the process through which parole agents and provider teams could work together to facilitate treatment in a setting other than the corrections-contracted treatment providers.

Determining the specific level of opioid use treatment needs was initially not possible because the MDOC had no opioid screening tool in place. MDOC collaborated with the evaluation team to create and implement a brief screen to identify potential participants for the XR-NTX pilot and/or the STR-funded initiative. Facility staff use this tool to screen individuals and initiate discussions about the initiative's offerings. Next steps will be for MDOC to institute the screen or something comparable in its current intake process. The provider teams also administer a series of bio-psychosocial assessments at three points during enrollment. Assessments include questions on medical status, mental health, substance use, previous use of medication assisted treatment, employment, housing, and other standard assessment sections. The teams have been trained on the Risk-Needs-Responsivity (RNR) framework () and utilize risk-needs assessment and an RNR treatment support planning tool to develop treatment plans consistent with RNR principles, which have been found to reduce violent recidivism () and general recidivism (). Examples of criminogenic risks that are assessed include antisocial behaviors, antisocial cognition, and antisocial personality patterns. All of the information gathered is used as the foundation for the clinician to develop the individual's ongoing treatment plan.

Another adaptation is related to mental health status. Although current enrollment in correctional mental health services was initially required as evidence of a co-occurring mental health disorder facility staff noted that individuals who were not currently receiving mental health services were expressing interest in enrolling. As a result, questions were added to expand on the possibilities for eligibility i.e., “Have you ever received a mental health diagnosis in the community?”, “Have you ever received mental health services in the community?”, “Have you ever experienced any form of trauma?”, and “Do you ever experience anxiety, depression or other symptoms of mental health difficulties?”

Although the MISSION-CJ model is an evidence-based model with manualized components, it is also adaptable to the particular setting. The model's co-developers and implementation experts (Pinals, Smelson, and Gaba) have played an integral role in collaborating with the evaluation team and local stakeholders in this implementation, providing guidance on ways that the model can be adapted based on ongoing observations. One of the key adaptations was related to the number of days of in-reach services provided before release from the facility. The program initially called for 90 days of in-reach service; however, identifying potential participants three months prior to release proved to be difficult especially in the early phases of implementation, as providers were unable to gain access to client release dates. MDOC addressed this issue by beginning to run a report on a monthly basis that identifies potential participants with up to 9 months to release. In addition, adaptations were made such that 75–90 days is considered the ideal, 60–75 days is allowed, and less than 60 days is allowed after review by implementation leadership and confirmation from the provider team that they can provide services at a higher frequency/intensity. This change proved to be key to increasing enrollment; in the early phases of implementation, 40% of enrolled participants were referred with less than 90 days to release. As staff formalized strategies for identifying and engaging eligible participants sooner, this number decreased. Still, by the end of year one, about 30% of enrolled participants had been referred to the program with less than 90 days until their scheduled release to the community.

4. Discussion

Damschroder and Hagedorn (2011) Damschroder L.J.

Hagedorn H.J. A guiding framework and approach for implementation research in substance use disorders treatment. Oser, Knudsen, Staton-Tindall, Taxman, & Leukefeld, 2009 Oser C.B.

Knudsen H.K.

Staton-Tindall M.

Taxman F.

Leukefeld C. Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions. Taxman & Kitsantas, 2009 Taxman F.S.

Kitsantas P. Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis. Taxman & Kitsantas, 2009 Taxman F.S.

Kitsantas P. Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis. Taxman et al. (2009) Taxman F.

Henderson C.

Belenko S. Organizational context, systems change, and adopting treatment delivery systems in the criminal justice system. Applying the CFIR to the implementation evaluation of this STR-funded initiative proved to be useful in examining implementation across various levels of the involved systems. Using an inductive-deductive approach, we were able to identify the themes that emerged naturally and found that they fit well into the elements of the CFIR framework. Like, we found that the Inner Setting was the most difficult domain to evaluate not only because of the complexities within organizations but in this case also because of the complexities across the several involved systems. Delivering substance use treatment in correctional settings can be a complex and even controversial process: the primary goal of correctional institutions is to detain criminal offenders and to protect society, whereas rehabilitation is often a secondary goal (). Historically, correctional agencies have operated under a brokerage model of referring offenders to treatment or allowing outside programs to operate within their facilities (). Treatment services that are integrated within criminal justice settings are challenged by the culture of correctional practices and therefore have a diminished impact on outcomes ().recommend that all levels of staff be involved in the development and implementation processes.

Chinman, McCarthy, Hannah, Bryne, & Smelson, 2017 Chinman M.

McCarthy S.

Hannah G.

Bryne T.H.

Smelson D.A. Using getting to outcomes to facilitate the use of an evidence-based practice in VA homeless programs: A cluster-randomized trial of an implementation support strategy. Henderson et al., 2009 Henderson C.E.

Young D.W.

Farrell J.

Taxman F.S. Associations among state and local organizational contexts: Use of evidence-based practices in the criminal justice system. Although the CFIR has been previously used to examine implementation across systems (), the complexity of the implementation of this initiative not only crossed systems, but levels within systems (see Table 1 ). Perhaps surprising to all involved was that communication within systems often presented its own challenges. For example, although high level administrators in MDOC were in support of the model, parole agents in the field may not have been trained or well versed on how to interpret or act upon positive drug screens that reflected MAT involvement. Similarly, although state level MDHHS administrators were supportive of integrated co-occurring disorders treatment, regional level community mental health provider programs usually bifurcated such services. Therefore, the implementation of this intervention required initial and ongoing communication involving three levels of staff within and across the MDOC and MDHHS systems (high- and mid-level administrators as well as direct service providers). This often required separate within-system meetings (all levels within MDOC or MDHHS), as well as meetings across systems at a particular level (i.e., parole officers talking to local mental health providers) or across all levels. The university teams facilitated and participated in these communications that sometimes required daily communications. Our findings support existing research, which suggests the adoption of evidence-based programming within correctional settings is most successful when programs are supported with policies and practices that create opportunities for shared activities and frequent cross-system contact (). It is imperative that federal and state funding organizations recognize and compensate for the intense level of communication and cross system training required to successfully implement these cross-system interventions.

Alanis-Hirsch et al. (2016) Alanis-Hirsch K.

Croff R.

Ford II, J.H.

Johnson K.

Chalk M.

Schmidt L.

McCarty D. Extended-release naltrexone: A qualitative analysis of barriers to routine use. There were many similarities in the barriers to implementing XR-NTX in this cross-system corrections initiative to those presented byin implementing MAT in community treatment centers. Participants and staff had varying degrees of knowledge of XR-NTX (especially compared to methadone or buprenorphine), thereby causing hesitance to receive it or encourage it. Cost or insurance coverage were not issues in our evaluation because the first injection is covered inside the facility, and injections in the community are covered by Medicaid, which is the insurer of the vast majority of the participants.

Henderson et al., 2009 Henderson C.E.

Young D.W.

Farrell J.

Taxman F.S. Associations among state and local organizational contexts: Use of evidence-based practices in the criminal justice system. Henderson & Taxman, 2009 Henderson C.E.

Taxman F.S. Competing values among criminal justice administrators: The importance of substance abuse treatment. Taxman et al., 2009 Taxman F.

Henderson C.

Belenko S. Organizational context, systems change, and adopting treatment delivery systems in the criminal justice system. The evaluation findings have been used to provide ongoing feedback and improvements in the current implementation and also to support expansion of the initiative to additional counties with State Opioid Response (SOR) funding. In the current implementation, it was encouraging to find that despite the different cultures and purposes of the CMH/SUD system and criminal justice system, all of the staff are working toward the same goals around recovery, preventing recidivism, preventing overdose and increasing time in the community. Much of the success of the program's implementation across multiple facilities may be attributed to executive level administrators' perspectives regarding the importance of corrections-based substance use treatment. Research demonstrates that criminal justice system administrators who place high importance on substance use treatment tend to oversee facilities that use more EBPs (). Staff have collaborated well to work through systemic barriers and build rapport to the extent that participants feel comfortable openly disclosing to MISSION-CJ staff and parole agents if they have relapsed. This is moving toward the “reframing of the correctional system as a service provider” with the purpose of not only public safety but also public health (). Conversely, the provider teams became trained in RNR and versed in criminogenic risk factors, which aided in their abilities to provide comprehensive services. This has come because of a great deal of time and resources allocated at all levels of all involved systems to improve care delivery. Many of the stakeholders admitted that the initiative has required a much higher degree of time than originally anticipated.

Oser et al., 2009 Oser C.B.

Knudsen H.K.

Staton-Tindall M.

Taxman F.

Leukefeld C. Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions. As the initiative moves through different phases of implementation, some issues remain (e.g., staff turnover and continued efforts to build and maintain communication), and other issues are specific to the implementation phase (e.g., related to participants moving into the post-release phase). As the first wave of participants moved into the transition-to-community phase, issues related to MAT emerged. Provider teams had to build relationships with MAT providers in the community. Questions arose requiring training on MAT (and its side effects, impact on drug screens, acceptance by MDOC, etc). Policy issues emerged related to MDOC's MAT policy, which resulted in creating a policy in support of MAT and discussions about piloting a wider array of MAT inside a correctional facility. This outcome supports the assertion that collaborations between researchers, treatment providers, and correction staff may provide the type of forum necessary for innovative service delivery and progressive policy change (). The evaluation has shown that funding for MAT has not been an issue since the injection inside the facility is covered by the pharmaceutical company and facility and provider staff have been making sure that Medicaid benefits are activated when the individual is released.

Because of the lessons learned and the continuous discussions about the implementation a broader and more innovative public health approach to the opioid crisis is emerging within the state. This includes using the county as the focal point and seeing the criminal justice system as a continuum that includes the county-level jail, as well as those on court-level probation and returning to the county on state-level parole. The next SOR funded project will include a mobile health component to increase initiative and MAT engagement and exploring the possibility of the recently-approved buprenorphine injectable. Using a combination of implementation evaluation findings, preliminary outcomes, and published research, stakeholders have made decisions specifically around increasing MAT i.e., improving name recognition of XR-NTX, educating individuals on side effects and drug screen results, understanding concerns about receiving an injection that requires a 30-day commitment, creating a MDOC policy on MAT and parole, becoming networked with providers of XR-NTX and other MAT in community, and understanding the importance of word-of-mouth of other individuals enrolling in the initiative and opting for MAT.

Despite some implementation challenges and the high level of risks known to exist among the participant group, the initiative has seen successes and positive outcomes. After one year of enrollment, the target enrollment was surpassed with 153 persons served; sixteen participants had graduated, and 42% of those released to the community were enrolled in MAT. Participants report that the support they have received has been “more than [they] could have wished for” and that, “MI-REP staff really care about you, they want you to succeed… I was so scared to be released from prison, but knowing that people would be there for me, and that they really cared about me – that gave me some peace of mind… it made a big difference”.