Date of Publication


Project Team

Jacob Burns, DNPc, RN Project Advisor: Melanie Keiffer, DNP, APRN, ANP-BC, CNE; Site Advisor: Betsy Ellis-Kempner, MS, APRN


Using Audit and Feedback to Improve Compliance to Medication-Assisted Treatment Recommendations

Jacob Burns, DNPc, RN

Project Advisor: Melanie Keiffer, DNP, APRN, ANP-BC, CNE


Background: Of the 111 opioid deaths reported in the State of Vermont in 2019, 30 were found to be prescription opioid-related and accidental. Medication Assisted Therapy (MAT) programs support patients with substance use disorders, promoting recovery and preventing overdose. Vermont uses the “Hub and Spoke” model to increase the availability of MAT for patients with OUD (Opioid Use Disorder) by increasing the number of primary care providers who prescribe buprenorphine. Hubs are the specialty opioid treatment programs while spokes are the office-based community settings where a patient receives ongoing follow up integrated into general medical care. Evidence-based documentation guidelines and clinical quality measures exist to improve the quality of care for these patients. Adherence to evidence-based treatment guidelines at one spoke practice setting was unknown.

Purpose: This project sought to evaluate compliance to evidence-based treatment recommendations for patients being treated with MAT through evaluation of provider documentation.

Methods: A documentation evaluation tool was created using the recommended American Academy of Addiction Psychiatry clinical quality measures and evidence-based practice recommendations. A retrospective review of electronic health record documentation was conducted to assess the presence or absence of 16 recommended quality measures within the provider clinical visit notes (n=12).

Results: Overall, documentation was compliant with evidence-based recommendations in most quality measures. A clinical documentation template with recommendations for improvement in 4 elements was created.

Conclusion: Audit and feedback of clinical records by providers improves consistency of documentation and may result in improved outcomes for patients with substance use disorder.

Keywords: Medication Assisted Treatment, MAT, Opioid Used disorder, OUD, Hub and Spoke, provider documentation, adherence to guidelines

Site Advisor: Betsy Ellis-Kempner, MS, APRN

Document Type