From: Methadone Maintenance Treatment: A Community Planning Guide (© 2009 CAMH)
An implementation plan will assist you in moving the project from development to service provision. Implementation plans will vary from community to community. Use your implementation plan to:
- determine a time line for implementation
- train and educate service providers
- define roles and responsibilities of service providers
- develop written protocols for referrals
- develop communication protocols among service providers and the working group
- develop policies and procedures (See Policies and procedures.)
- confirm performance indicators based on your logic model.
Before receiving clients, ensure that all members of the MMT program team (the service providers and working group):
- have received MMT-specific training and education
- agree to and understand the policies, protocols and procedures of the program
- are prepared and equipped to take on clients.
“Talking about starting a methadone clinic is one thing…actual bricks and mortar are another thing altogether. Continue to involve the community in this process and stay proactive rather than reactive in this phase.” — CAMH program consultant
Time lines, roles and responsibilities
Determine essential milestones and establish a clear time line to ensure that all members of the team are ready to receive clients when the program opens. Some physicians and other service providers may only want to take on a limited number of clients when the program first opens. In this case, establish expected time lines and a review of the services to decide how and when the program will be fully operational and able to meet capacity.
Clearly define the roles and responsibilities of the service providers, partner agencies, clients, the working group and the community advisory committee (if applicable). Sharing these descriptions with the entire team will help build a cohesive program in which team members respect and recognize the contributions of their colleagues.
Training for service providers
All MMT service providers should receive MMT-specific training and education before the program starts. The Opiate Dependence Treatment Interprofessional Education Program offered by CAMH is required for physicians and pharmacists and recommended for nurses and counsellors. Physicians are also required to get special exemption under the federal Controlled Drugs and Substances Act to be able to prescribe methadone.
The CAMH education program prepares MMT health care professionals to provide a comprehensive range of services for people who are dependent on opioids. These services include assessment for opioid dependence, methadone or buprenorphine maintenance treatments when appropriate, counselling, case management and referral to withdrawal management services, if appropriate.
You can help plan and organize local education opportunities for service providers. For example, experienced MMT physicians and other service providers can give workshops, presentations and consultation support specifically tailored to the team and service delivery model of the program. Education workshops should also include informing team members of the policies, procedures and protocols of the program.
Additionally, all service providers should be aware of other available education resources, such as:
- Best Practices: Methadone Maintenance Treatment (Health Canada) 2002
- Methadone Maintenance Guidelines (CPSO) 2005
- Methadone Maintenance Treatment: Best Practices in Case Management (CAMH) 2009 (in press)
- Methadone Maintenance: A Counsellor’s Guide to Treatment (CAMH) 2003
- Methadone Maintenance: A Pharmacist’s Guide to Treatment, 2nd Edition (CAMH) 2004
- Methadone Maintenance: A Physician’s Guide to Treatment, 2nd Edition (CAMH) 2008.
- Methadone Maintenance Treatment: Client Handbook (CAMH) 2008.
For a full listing, see Resources.
Policies and procedures
Developing written policies and procedures can help avoid potential problems when service begins. A program policy manual provides a set of guidelines to help the team manage the day-to-day care of clients.
Kingston’s Street Health Centre — a harm reduction health centre — developed a comprehensive policy manual for its methadone treatment clinic in 2004 and revised it in 2008. It includes information about the centre’s program design, policies and procedures, eligibility criteria, MMT client agreement and medical directives. Street Health Centre’s Policy Manual provides an excellent template that you can adapt to reflect your own program and client base. For a copy of the manual, contact the Street Health Centre at firstname.lastname@example.org.
Successful implementation relies on clearly defined systems of referral, especially when the services are not provided at one site. Outline a protocol to assist in the referral of clients to the MMT program. Make sure everyone (i.e., MMT providers, clients and partners) are aware of the referral process to avoid any unnecessary delays or confusion.
A well-articulated communication protocol among the program team members and between the service providers and the working group is equally important as a strong system of referral. The communication protocol should outline the need for ongoing communication between team members, while respecting the need for client confidentiality.
A reliable communication link between the team and the working group helps address any problems or areas that need attention in a timely manner. It also provides an avenue to discuss opportunities to enhance service delivery.
Certain elements of your service delivery model may require establishing a procedure to ensure consistency among service providers and to help manage the needs and expectations of clients. For example, in its 2008 revised Policy Manual, the Street Health Centre outlined procedures for:
- methadone overdose
- recording missed methadone doses
- dispensing fentanyl patches
- detention centre transfers
- pharmacy transfers.
For your implementation plan, draft those procedures for which you anticipate a need. Once the program is running, you can review and revise your draft procedures and create new ones where appropriate.
Clear program policies are associated with longer retention in treatment and improved treatment outcomes. The policies you develop should be tailored to meet the needs of your program model, client base and health care provider needs. Develop policies that promote ease of access to a client-centred model of care. Health Canada’s Best Practices: Methadone Maintenance Treatment (2002a) identified the following treatment policy areas as key:
- open admission
- timely assessment
- adequate, individualized dosage
- methadone dosage during pregnancy
- unlimited duration of treatment
- clear discharge criteria
- non-punitive approach to drug use during treatment
- client-centred management of tapering.
The Street Health Centre (2008) established policies in the following areas for their MMT program:
- use of opioid medications
- use of benzodiazepines
- vomited doses of methadone
- missed doses of methadone
- missed appointments
- carry privileges
- urine toxicology and collection protocol
- client conduct/onsite violence
- criminal activity at the centre
- cash payment for methadone
- duplicate names.
Whatever policies you choose to develop, it is important that program rules are clearly outlined and that they are applied consistently. To help ensure client understanding and agreement with the policies, develop a client–provider treatment and confidentiality agreement. This agreement should outline the conditions under which clients are typically admitted to treatment, the rules they are generally required to adhere to and what they can expect. Review the agreement, the program’s policies and expectations as well as the mandatory informed consent with the client. Be sure to give them the opportunity to ask questions prior to signing the agreement and before starting treatment.
CAMH provides a sample client–provider agreement in their online resources for professionals. The sample agreement was created by Dr. Michael Lester and Dr. Lisa Lefebvre, CAMH. You can adapt it to reflect your own specific circumstances. The document is part of the Clinic Toolkit for Methadone and Buprenorphine Providers available at http://methadonesaveslives.ca.
In Methadone Maintenance Treatment: A Community Planning Guide
About methadone maintenance treatment
Establishing a community working group
Engaging the community
Developing a methadone maintenance treatment program
Implementing the program
Evaluating the program
Appendix: Do You Know... Methadone