Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO): process of adapting collaborative care for co-occurring opioid use and mental disorders

Table 2 Documented CLARO adaptations with associated FRAME codes

#	Adaptation description	Process codes
#	Adaptation description	When	Planned?	Who decided	Ultimate decision
1	Use of consultant team to support Care Coordinator	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
1	Use of consultant team to support Care Coordinator			Clinic administrators
2	Community Health Workers performing Care Coordinator role and referring to other providers for treatment as needed	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
2				Clinic administrators
3	Addition of Written Exposure Therapy and medication for PTSD, and medication treatment for OUD	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
				Clinic administrators
				Funder (NIMH)
4	Development and use of standardized measure to track OUD symptoms	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
4				Clinic administrators
5	Addition of measure to track PTSD symptoms, the PCL-5 (PTSD Checklist for DSM-5)	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
5				Clinic administrators
6	Screening patients for social needs, and referring them to local resources as needed	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
6				Clinic administrators

Process codes
#	What modified	Level of delivery	Context modifications	Content modifications	Fidelity consistent?	Collaborative care components
1	Context	Target population	Personnel	n/a	Yes	Use of population-based registry
	Training/Evaluation		Population			Psychiatric case review
						Program oversight/improvement
2	Context	System/Community	Personnel	n/a	Yes	Patient identification and diagnosis
	Training/Evaluation					Engage in integrated care program
						Provide evidence-based treatment
						Team communication/coordination
3	Content	Target population	Population	Integrating another treatment	Yes	Provide evidence-based treatment
	Context
4	Content	Target population	Population	Adding elements/modules	Yes	Patient identification and diagnosis
	Context					Use of population-based registry
5	Content	Target population	Population	Adding elements/modules	Yes	Patient identification and diagnosis
	Context					Use of population-based registry
6	Content	System/Community	n/a	Adding elements/modules	Yes	Team communication/coordination

Rationale codes
#	Goals of modification	Sociopolitical factors	Organization/Setting factors	Provider factors	Recipient factors
1	Improve outcomes	–	Available resources	Previous training/skills	Comorbidity
1	Improve feasibility
2	Improve feasibility	Funding/resource availability	Available resources	–	–
2			Social context
3	Improve outcomes	–	–	–	Comorbidity
4	Increase engagement	–	–	–	Comorbidity
	Improve outcomes
5	Improve outcomes	–	–	–	Comorbidity
6	Increase engagement	–	Available resources	Previous training/skills	Access to resources
	Increase retention				Crisis/emergency
	Increase satisfaction

#	Adaptation description	Process codes
#	Adaptation description	When	Planned?	Who decided	Ultimate decision
7	Engaging in additional outreach activities (e.g., home visits, attend social service appts)	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
7				Clinic administrators
8	Use of interactive, practice-oriented training and ECHO for Care Coordinators; reflective supervision	Pre-implementation	Planned/Proactive	CLARO team	CLARO team
8				Clinic administrators
9	Addition of co-occurring disorders to Written Exposure Therapy and Problem-Solving Treatment trainings	Pre-implementation	Planned/Proactive	Treatment developer/ trainer	Treatment developer/trainer
9				CLARO team
10	Expanding patient registry to track progress in OUD, PTSD treatment	Pre-implementation	Planned/Proactive	Treatment developer/ trainer	CLARO team
10		Pre-implementation	Planned/Proactive	CLARO team
11	Delivery of Problem-Solving Treatment training in virtual, video-conferencing format	Implementation	Planned/Reactive	Treatment developer/ trainer CLARO team Clinic administrators	Treatment developer/trainer
12	Delivery of Care Coordinator training in virtual, video-conferencing format	Implementation	Planned/Reactive	CLARO team	CLARO team

#	Process codes
#	What modified	Level of delivery	Context modifications	Content modifications	Fidelity consistent?	Collaborative care components
7	Context	System/Community	Setting	n/a	Yes	Engage in integrated care program
						Use of population-based registry
8	Context	System/Community	Personnel	n/a	Yes	Program oversight/improvement
	Training/Evaluation
9	Context	Target population	Population	n/a	Yes	Provide evidence-based treatment
	Training/Evaluation
10	Context	Target population	Population	n/a	Yes	Use of population-based registry
	Implementation
11	Training/Evaluation	Cohort	n/a	n/a	Yes	Provide evidence-based treatment
						Program oversight/improvement
12	Training/Evaluation	Cohort	n/a	n/a	Yes	Provide evidence-based treatment
						Program oversight/improvement

	Rationale codes
#	Goals of modification	Sociopolitical factors	Organization/Setting factors	Provider factors	Recipient factors
7	Increase engagement	–	Available resources	Previous training/skills	Access to resources
	Increase retention		Location/accessibility		Crisis/emergency
	Increase satisfaction				Motivation/readiness
8	Improve feasibility	–	Available resources	Previous training/skills	–
	Reduce cost		Social context	Previous training/skills
9	Improve outcomes	–	–	–	Comorbidity
10	Improve outcomes	–	–	–	Comorbidity
11	Response to COVID-19	–	–	–	–
12	Response to COVID-19	–	–	–	–

Codes are based on the Framework for Reporting Adaptations and Modifications–Enhanced (FRAME; [2]) and the associated Coding Manual [52]. “n/a” indicates that the code was not applicable, because the adaptation did not fall within that category. “–" indicates that the rationale for the adaptation did not include factors from that social-ecological level. CLARO: Collaboration Leading to Addiction Treatment and Recovery from Other Stresses; OUD: opioid use disorder; MDD: major depressive disorder; PTSD: post-traumatic stress disorder; NIMH: National Institute of Mental Health; ECHO: Extension for Community Healthcare Outcomes

ISSN: 1940-0640