Commentary: Stronger Together

PRIOR TO THE ONSET of the COVID-19 pandemic, leaders from 4 rural and Appalachian communities in Ohio engaged in a community of practice (CoP) to support the application of the National Standards for Culturally and Linguistically Appropriate Services 1 (National CLAS Standards) into their community-based system of care for opioid use disorder. As the COVID-19 pandemic escalated and disrupted service delivery, community leaders utilized the existing CoP infrastructure to identify, share, and co-create innovative strategies to reach and serve people experiencing multiple and intersecting disadvantages while infusing the National CLAS Standards into the response efforts. This commentary details: (1) how the CoP infrastructure was formed and developed; (2) how members adapted the focus of the CoP during the initial stages of the COVID-19 pandemic to maintain and deliver a high-quality, culturally relevant system of care for opioid use disorder amidst the pandemic; and (3) why it is important to invest in the CoP as a critical form of infrastructure for rural communities. COMMUNITIES OF PRACTICE Communities of practice, by definition, are “groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in the area by interacting on an ongoing basis.”2(p4) Over the last decade, the Ohio Department of Mental Health and Addiction Services has awarded grant funding to Ohio University's Voinovich School of Leadership and Public Affairs (OHIO) and the Pacific Institute for Research and Evaluation (PIRE) to create and facilitate CoPs comprising leaders from multiple Ohio communities (viz, a multicommunity CoP) to facilitate effective responses to a variety of behavioral health issues, including substance use,3 opioid use,4 suicide prevention,5 and youth health and wellness.6 This approach has been particularly successful for leaders from Ohio's rural and Appalachian counties, which are often isolated from urban areas and from one another, as a way to nurture their capacity to ideate, share resources, and impact their communities, both independently and collectively. Establishing a CoP requires 3 fundamental elements: community, domain, and shared practice.2(p27) These 3 elements are essential to build the infrastructure necessary to establish a CoP as a knowledge structure that allows information, ideas, and experiences to be shared, applied, and reflected upon.2 Community A community includes the core set of people (or members) who desire to advance their knowledge on a particular topic or issue. The community serves as the “social fabric [for] learning.”2(p28) CoPs differ from more traditional workgroups and teams in that CoPs are organized around 3 core values: mutual respect, trust, and sharing of knowledge. These values allow members to safely share ideas, express emerging ideas, challenge thinking, and even state where they are uninformed or inexperienced. Domain The domain represents the topic or issue that the CoP seeks to research and address. Identifying the domain establishes the purpose of the CoP and creates a sense of legitimacy among members. Over time, work by CoP members on the domain will build a shared understanding of it and will help ensure members realize value from participating in the CoP. Members also continuously clarify the scope and boundaries of the domain, which, in turn, guides them in decisions about what information and activities to share and pursue. Although many CoPs coalesce and focus around a single domain, the domain is not necessarily fixed and may change or evolve over time as the needs of CoP members change.2(p29) Shared practice Next, for the community to gain more knowledge on the established domain, the group will need to engage in a shared set of practices. These may include “a set of frameworks, ideas, tools, information, styles, language, stories, and documents that community members share.”2(p27) The shared practice also includes meeting times and spaces and technology needed to facilitate member engagement on the domain. The shared routines and structures developed by the CoP may evolve over time and serve to support the community in developing a shared set of knowledge within the community. While the shared practice can be developed organically or intentionally by the community, some CoPs benefit from having “system conveners.”7(p99) System conveners, which may be individuals or organizations, support the development of a shared set of practices and function as facilitators of the knowledge transfer across the CoP. FORMING A COMMUNITY OF PRACTICE The Communities of Practice for Rural Communities Opioid Response Program (COP-RCORP) formed in 2018 with grant funding from the Health Resources and Services Administration's (HRSA's) Rural Communities Opioid Response Program.8 COP-RCORP is a multicommunity CoP that includes leaders from 4 community-based coalitions or opiate task forces located in Ohio's rural and Appalachian region. Faculty and professional staff from OHIO and research scientists from PIRE, a 501(c)3 research organization, act as system conveners. The members of COP-RCORP, along with members of the local coalitions/taskforces they represent, function as a CoP dedicated to addressing and preventing opioid use disorder. The HRSA RCORP-Implementation grant requires COP-RCORP to address 15 core activities across 3 focus areas—prevention, treatment, and recovery. Just prior to the COVID-19 pandemic, COP-RCORP members, with facilitation from professional staff from PIRE and OHIO, identified this core activity prescribed by HRSA as the domain for the CoP: Provide and assess the impact of culturally and linguistically appropriate education to improve family members', caregivers', and the public's understanding of evidence-based treatments and prevention strategies for substance use disorder/opioid use disorder and to eliminate stigma associated with the disease. The CoP provided the infrastructure needed to specifically focus on this core activity by creating a space for community leaders to coalesce and delve more deeply into how to provide culturally relevant services in a rural setting. The CoP began its work by collaboratively expanding members' understanding of the National CLAS Standards, which were designed by the US Department of Health and Human Services Office of Minority Health to advance the quality of services provided and eliminate health disparities.1 Through their study, members of the CoP learned that the 14 CLAS standards are categorized into 3 themes, which can all be organized into one Principal Standard: “Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.”1(p5) To develop the shared practice, PIRE and OHIO convened and facilitated the CoP using videoconferencing technology. CoP meetings were held on a regular schedule and typically began with members sharing reflections and updates from their local communities. Meetings also focused on the CLAS standards and included time for action planning and identification of shared next steps. This shared practice allowed community leaders participating in the CoP to emphasize the importance of identifying barriers to health care and to address health inequities as vital first steps to providing culturally relevant and responsive behavioral health services. Because a key element of the shared practice was ensuring that all members had a thorough understanding of the CLAS standards, community leaders led the local community-based coalition or opiate task force they represented through completing the Implementation Checklist for the National CLAS Standards.9 ADAPTING THE COMMUNITY OF PRACTICE TO RESPOND TO THE OPIOID EPIDEMIC DURING THE COVID-19 PANDEMIC As participants focused their work around the National CLAS Standards, the COVID-19 pandemic became a public health emergency. As new challenges and constraints emerged and local partners shifted from work related to the HRSA grant to supporting community-level COVID-19 responses, community leaders internalized the necessity of incorporating culturally relevant strategies to strengthen their local COVID-19 responses. Meanwhile, the opioid epidemic remained a significant public health threat in Ohio10 and COVID-19 was disproportionately affecting populations already experiencing health disparities.11 Almost overnight, members of the CoP faced a crucial charge: utilizing the National CLAS Standards to support community responses to 2 simultaneous crises—the opioid epidemic and the COVID-19 pandemic. Because this rural, multicommunity CoP was already set up to meet virtually, had experience with exchanging ideas and problem solving, and had system conveners (PIRE and OHIO) who were dedicated to holding the space, it was a crucial piece of infrastructure that served the community leaders as they worked in their local settings to transcend the pandemic. Specifically, the CoP infrastructure served to facilitate peer sharing, problem solving, and action learning. Peer sharing During the pandemic, community leaders prioritized continuing, and even expanding, the work of the CoP. By meeting regularly during a period when stay-at-home orders were in effect and no other venue supported real-time, cross-community sharing, the CoP structure served to connect participants and offered a space to explore new challenges, such as the intersection of cultural competency, opioid use disorder, and COVID-19. During their continued work, community leaders emphasized that populations impacted by opioid use disorder were often also the populations affected by COVID-19 (ie, populations that experience homelessness, un- or underemployment, low income, and/or chronic illnesses at disproportionate rates). As a result, CoP members broadened the domain of the CoP to focus on identifying and implementing ways to be culturally relevant and responsive to the emergent needs and constraints of both the COVID-19 pandemic and the ongoing opioid epidemic. Problem solving The CoP structure supported this additional undertaking by providing a readily accessible forum for sharing common issues, identifying and co-creating solutions, and integrating different perspectives when implementing strategies to reach and serve individuals experiencing opioid or other substance use disorders, a population that is especially at risk during the COVID-19 pandemic. For example, while discussing the impacts of stay-at-home orders and physical distancing guidelines on the behavioral health system, community leaders shared their local innovations related to how and where to offer prevention, treatment, and recovery resources (eg, food banks, Meals on Wheels, school distribution bags, grocery stores, testing centers, and public transportation) and how to continue naloxone distribution efforts (eg, moving naloxone training to an online format, setting up drive-through naloxone distribution stations, and delivering naloxone via mail). One community leader shared how a local organization responded to the rapid transition to telehealth by creating a needs assessment for behavioral health case managers to use when determining current service utilization, unmet needs, and the preferred methods of communication of clients. Action learning By the time the COVID-19 pandemic began, the CoP had established a community and shared practices supported by facilitation and had begun work on a domain. The strong foundation meant that the impact of the pandemic was not a shift in the domain away from the CLAS standards and toward pandemic responses. Instead, these challenges provided the CoP with an opportunity to put learning about the CLAS standards into action on pandemic responses by creating strategies that were culturally relevant to ensure all populations were reached. In practice, this meant that as the pandemic continued, the CoP became a space for sharing innovative local efforts and exchanging resources, which supported member communities in implementing similar strategies in real time while minimizing knowledge and resource barriers. By providing a forum for community leaders to discuss shared challenges and local solutions, the CoP provided a setting to incubate and co-create new strategies for delivering services during pandemic that were also culturally relevant (eg, developing best practices on the accessibility of messaging by considering health literacy, readability, language of origin, and culture when developing materials) and to strengthen local solutions through the addition of perspectives from other rural communities (eg, increasing distribution of drug deactivation and disposal pouches due to the inaccessibility of in-person drop-off locations). CONCLUSION What began as a CoP intentionally convened to infuse the National CLAS Standards into community-based systems of care for opioid use disorder resulted in an infrastructure capable of incubating culturally relevant responses to persistent and emerging service needs during the COVID-19 pandemic. This case study highlights the value of cultivating and nurturing multicommunity CoPs among leaders from rural and Appalachian communities and the critical infrastructure these CoPs provide to facilitate effective responses to a variety of public health issues. It also underscores the importance of system conveners, in this case, professional staff from OHIO and PIRE. The CoP structure and facilitation operationalized the desire of rural leaders to connect in a dedicated space in order to share, co-create, and implement innovative solutions, as demonstrated by the participants' prioritization and continued involvement in the CoP. This experience demonstrates how imperative it is for public and private funders, professional associations, institutions of higher education, 501(c)3 research organizations, and rural community leaders to invest in collaboratively creating, nurturing, and expanding meaningful multicommunity CoPs, especially for rural communities—because as the classic aphorism states: “We are stronger together.”