The Implementation & Effectiveness of Collaborative Documentation in Outpatient Substance Use Settings

Background: Rates of drug-related overdoses are increasing in the US, leading the government to declare it a public health emergency. As few as 13% of individuals using substance received services in the past 12 months, and 30% prematurely discontinue care, underscoring the need for strategies that effectively engage at risk individuals in treatment. Collaborative documentation (CD), where clients and providers document visit notes jointly during sessions, is an emerging person-centered practice that has been shown to increase the quality of client-provider relationships and improve overall service engagement in community mental health. However, CD has not yet been widely implemented in substance use settings, and its effectiveness within the unique context of substance use settings has not been explored. This qualitative study sought to understand barriers and facilitators to implementing CD, and its perceived effectiveness within an outpatient substance use clinic recently trained in this practice.

Methods: This study occurred within a large, urban substance use clinic that was recently trained in CD. Twenty-two substance use counselors and supervisors engaged in semi-structured focus groups. Focus group guides drew from Normalization Process Theory, a leading implementation framework that describes how new practices are integrated into routine care. Zoom-based focus groups were recorded, coded and analyzed using evidence-based rapid qualitative inquiry methods, including memo writing and coding templates, which have been shown to expedite the analytic process while producing rigorous findings equivalent to traditional qualitative techniques.

Results: Barriers to adoption included the lack of unified understanding of CD practice components and goals, which led to different approaches to implementing CD in routine care. In addition, providers indicated that clinical documentation is a cognitively demanding process and was difficult to complete in real-time. Facilitators to adoption included an organizational commitment to CD implementation, and overall positive attitudes towards the practice among respondents. Providers using CD experienced positive impacts on client engagement and empowerment, however, the practice presented unique challenges and opportunities with court mandated clients, a population that is overrepresented in substance use contexts; while documentation transparency provided an opportunity to empower these individuals, who often had limited autonomy in their care, it also elicited new concerns about confidentiality among this group, potentially limiting disclosure. Providers emphasized the need for tailored strategies to helped negotiate discussions about CD with this population, and for sustainability tools that would help them further adapt CD to different clinical scenarios and monitor how CD was being integrated into care.

Conclusion: Findings indicated that CD could increase clients’ experience in substance use treatment, holding potential as a strategy to address service disengagement. Some practice adaptations are needed to optimize CD for the substance use context, such as strategies for working with court mandated clients. In addition, results suggested that fidelity to CD would be improved by supporting the development of clinical documentation skills, by clarifying the core competencies of the practice, and by developing more sustainability tools to support long-term adoption. Research capturing the client perspective and the impact of CD on client outcomes is needed.