Caring for ME Lunch & Learn Webinar

Transcription

1 Caring for ME Lunch & Learn Webinar Hub and Spoke Model: Creating a Substance Use Disorder Services System of Care in Vermont Successes, Challenges and Future Opportunities Beth Tanzman, Director Blueprint for Health Tony Folland, Vermont State Opioid Treatment Authority October 3, 2017, 12-1 pm Audio is available through your computer speakers For audio by phone, call (US Toll) and enter Webinar ID #

2 Thank You to Our Sponsor! Funding for this Caring for ME webinar series is provided by: The Maine Attorney General s Office

3 QC Staff is Working to Improve the Health of Everyone in Maine

4 QC Brings Together the People Who Give, Get and Pay for Health Care to Address Shared Priorities

5 Caring for ME Be Part of the Solution! In April 2016, Maine Quality Counts (QC) and Maine Medical Association (MMA) launched Caring for ME, a collaborative effort that aims to bring together a wide set of partners to promote shared messages, educational resources, and practical tools for health care providers. Support prevention efforts Maintain a compassionate and trauma-informed approach to chronic pain management Improve the safety of opioid prescribing Appropriately diagnose addiction when it exists Improve access to effective treatments for patients with substance use disorder Join QC & MMA in Caring for Maine and be part of the solution!

6 Important Webinar Notes You are in view-only mode. Please use the Q&A function to ask questions & make comments Video screen size and location is adjustable. Tomorrow you will receive an with a link to the presentation recording and slides a link to the CME / CEU survey This webinar will be archived at

7 CME Available! CME will be available for participants who have signed into the live webinar. If you did not log into this webinar with your , submit your name and address using the Q&A feature on the tool bar at the bottom of your screen. We do not have separate CEUs for nursing staff or other healthcare professionals - but you may request a CME certificate as certificate of attendance. You must complete the survey in order to receive a certificate Please complete the survey within 1 week A CME certificate will be ed once the survey has closed.

8 CME Disclosure The speakers today do not have any relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity.

9 Today s Speakers: Anthony Folland, BA Tony Folland is the Clinical services Manager and State Opioid Treatment Authority for Vermont. Prior to the last 7 years in state government, he was employed in the social services field for nearly 20 years, having worked in both rural and urban mental health centers in a variety of capacities including: emergency services, outpatient treatment and case management, program development and staff supervision, Drug treatment courts and Medication Assisted Treatment for opioid use disorders. Beth Tanzman Beth Tanzman is the Director of the Vermont Blueprint for Health. The Blueprint for Health reforms Vermont s health service delivery network by developing patient-centered medical homes, community health teams, health information systems, payment reforms, and networks of community-based collaboratives. In addition to leading the statewide expansion of the Blueprint, Ms. Tanzman leads the state-wide Hub & Spoke program for opioid addiction for the Department of Vermont Health Access. Beth led the development of the report to the Legislature on how the health services system could address Adverse Childhood Experiences. Prior to joining the Blueprint, Beth served as Vermont s Deputy Commissioner for Mental Health leading the planning to replace Vermont State Hospital, supporting the development of intensive services for children and families, and the implementation of evidence-based services for adults with mental illness. Ms. Tanzman directed Adult Mental Health Services for the state Department of Mental Health for over a decade. Beth has an MSW from the Rockefeller College of Public Affairs and Policy at SUNY Albany. She serves as Board Chair for Alyssum, Inc. a peer-run crisis residential program in Rochester Vermont, is on the board of Pathways Vermont., a statewide Housing First organization, and is president of her home owners association.

10 The Opioid Epidemic US Overdose Deaths Drug overdoses killed 64,000 people in 2016 More than 22% increase over 2015 Leading cause of death for Americans under age 50 Opioids (prescription, heroin, fentanyl) comprise 2/3 of total overdose deaths NY Times, Josh Katz September 3,

11 Vermont is in the bottom 5 states for past-year nonmedical use of pain relievers and the top 5 for heroin use Heroin Use Age 12+ (2014/2015) Note: 2014/2015 numbers are not available for non medical use of pain relievers Source: National Survey on Drug Use and Health,

12 New England - Any Drug Overdose Deaths 40 Drug Overdose Deaths per 100,000 by State 35 Deaths per 100, Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Est. Source through 2015: CDC/NCHS, National Vital Statistics System, mortality data. Includes opioids and other drugs, 2016 VDH; MA. ME, CT, NH, RI State reported data (MA data are opioids only) Vermont Department of Health

13

14 In Annual Speech, Vermont Governor Shifts Focus to Drug Abuse By Katharine Q. Seelye January 8, 2014 New York Times 14

15 Timeline: Addressing Opioid Misuse and Addiction in Vermont First Methadone Clinic Opens (Chittenden Center) 2002 Buprenorphine Induction Hub Opened (CVSAS) 2004 Methadone in SE (Habit Opco) 2006 Patient Limits for Bup prescribers: 30 Year 1, then a max of PDMP (VPMS) data collection begins 2009 Safe Disposal of Unused Medication Rule 2013 Methadone in Rutland (West Ridge) 2013 Hub and Spoke Model (Care Alliance) 2013 Opioids for Chronic Pain Rule 2015 Naloxone Pilot Begins Buprenorphine Approved for MAT by FDA Methadone in NEK (BAART) 2003 VT Prescribers use Buprenorphine MAT for Opioid Methadone in Central VT (BAART) Dependence Rules Enacted VT PDMP legislation passed VPMS Rule Updated Mandatory PDMP/VPMS Registration 2013 Good Samaritan Law Passed 2013 Opioids overtake alcohol as primary substance in treatment Acute Pain Prescribing Rules 2017 Today 2018 Opening of Emergency Hub MAT for Opioid Dependence Rules Updated 15

16 Opportunity Leadership Clinical & Administrative Blueprint & Treatment Infrastructure Payment Reforms Community Health Teams Support for Practice Improvement Affordable Care Act Section 2703 Health Homes Conceptual Framework Hub & Spoke Effective Treatment Medication Assisted Treatment

17 Health Home for Opioid Addiction Addictions Program OTP Medical Office OBOT PCMH Community Health Team 10/3/

18 System Changes / Hub & Spoke Model Hubs (opioid treatment programs) enhanced Dispense Buprenorphine, Vivitrol (buy & bill) and Methadone More care coordination, nursing, and psychiatry Spokes (office based opioid treatment) staffed 1 FTE RN and 1 FTE Licensed Addictions/Mental Health Counselor for 100 patients Consultation between Hubs /OTPs and Spokes /OBOTs Medicaid engagement Agency endorsed caseload expansion Medicaid State Plan Amendment Health Home chronic condition of opioid addiction (initially revenue neutral expansion of services) Policy, funding & practice alignment Health, Medicaid and Health Reform Teams

19 Care for Complex Addictions the Hub HUB A Hub is a specialty treatment center responsible for coordinating the care of individuals with complex addictions and co-occurring substance abuse and mental health conditions across the health and substance abuse treatment systems of care. A Hub is designed to do the following: Provide comprehensive assessments and treatment protocols. Provide methadone treatment and supports. For clinically complex clients, initiate buprenorphine or antagonist treatment and provide care for initial stabilization period. Coordinate referral to ongoing care. Provide specialty addictions consultation and support to ongoing care. Provide ongoing coordination of care for clinically complex clients. Vermont Department of Health

20 Care for Complex Addictions the Spoke SPOKE A Spoke is the ongoing care system comprised of a prescribing physician and collaborating health and addictions professionals who monitor adherence to treatment, coordinate access to recovery supports, and provide counseling, contingency management, and case management services. Spokes can be: Blueprint Advanced Practice Medical Homes Outpatient substance abuse treatment providers Primary care providers Federally Qualified Health Centers Independent psychiatrists Vermont Department of Health

21 Payment Changes Hub OTP Spoke OBOT Monthly Bundled Rate Monthly Capacity Payment for Staff F-F-S for Buprenorphine $ based on caseload 10/3/

22 Health Homes Section 2703 Affordable Care Act Comprehensive Care Management 6 Core Services Care Coordination Health Promotion Comprehensive Transitions of Care Individual and Family Support Services Referral to Community and Social Support Services 10/3/2017

23 Hub or Spoke? Needs Assessment Treatment Needs Questionnaire by Brooklyn and Sigmon 21 item checklist with scores up to 26 Lower scores predict good Spoke outcomes Based on Addiction Severity Index (ASI) topics- legal, work, social, psychological, medical, drug use Total possible points is 26 Scores 0-5: excellent candidate for Spoke office based treatment Scores 6-10: good candidate for Spoke office based treatment Scores 11-15: Spoke if addiction physician & more program structure or Hub Scores 16-26: Hub program

24 Monitoring Treatment Response: Determining Stability OBOT Stability Index by Nordstrom 8 item checklist used to determine if a patient should be seen more frequently Most recent urine drug screen positive for illicit substances? Does the patient have fewer than 4 consecutive weekly drug-free urine screens? Is the patient using sedative-hypnotic drugs or admitting to alcohol use? Does the patient report drug cravings that is difficult to control? Does the patient endorse having used illicit substances in the past month? Does the query of the Prescription Monitoring System show evidence of unexplained, unadmitted, or otherwise concerning provision of controlled substances Did the patient report their last prescription as being lost or stolen? Does the patient run out of medication early from his/her last prescription? 10/3/

25 Addictions Medicine: Just Part of the Job o You are trusted and local o The MAT Team helps you o Other mentors will help you o You can control who you see o Treating addiction reduces stigma o Patients with opioid addiction are already in your waiting room o Embrace risk reduction o Addiction is a common condition, build MAT into routine care I believe most doctors would find this practice surprisingly enjoyable. To watch a patient transition from using to working and parenting over a matter of months is uplifting.

26 Hub & Spoke Enrollment: [VALUE] [VALUE] TotalEnrollment 26

27 Spoke Providers & Staffing [VALUE] Prescribers [VALUE] Prescribers 10 or more pts 2013 Q Q Q3 [VALUE] FTE 2013 Q Q Q Q Q Q Q Q Q Q Q2 [VALUE] Prescribers [VALUE] Prescribers 10 or more pts 2016 Q3 [VALUE] FTE 2016 Q Q Q2 SpokeProviders SpokeStaff SpokeProvidersGreater10 27

28 Expenditures MAT group Non-MAT Difference P-value Total expenditures $14,468 $14,880 -$ Total expenditures without treatment $ 8,794 $11,203 -$2,409 <0.01 Buprenorphine expenditures $2,708 -$47 $2,755 <0.01 Total prescription expenditures $4,461 $2,166 $2,295 <0.01 Inpatient expenditures $2,132 $3,757 -$1,625 <0.01 Outpatient expenditures $345 $604 -$259 <0.01 Professional expenditures $674 $981 -$307 <0.01 SMS expenditures* $2,872 $4,160 -$1,288 <0.01 Utilization (rate/person) MAT group Non-MAT Difference P-value Inpatient days <0.01 Inpatient discharges <0.01 ED visits <0.01 Primary care physician visits <0.01 Advanced imaging <0.01 Standard imaging <0.01 Colonoscopy <0.01 Echography Medical specialist visits <0.01 Surgical specialist visits <0.01 *SMS refers to special Medicaid services and include transportation, home and community-based services, case management, dental, residential treatment, day treatment, mental health facilities, and school-based services. Multivariable regression analysis, adjusted for gender, age, calendar year, clinical risk groups, Medicaid in the prior year, hepatitis C virus (HCV) status, and pre- and perinatal care. Difference = MAT Non-MAT 28

29 Journal of Addiction Medicine, 2017 Conclusions Vermont Hub & Spoke uniquely links OBOT & OTP settings in continuum from collaboration to integration Increases access to Medication Assisted Treatment Increased waivered prescribers Increased the number of prescribers seeing 10 or more patients Transfers between settings based on clinical need using common criteria Cost neutral (health care costs are increasing for MAT & non-mat groups) 29

30 Demographics & Health Status Medicaid Beneficiaries with Opioid Use Disorder 2015 Vermont Medicaid Claims MAT Treatment Group Non-Mat Opioid Use Disorder General Medicaid Members 4,834 1,379 72,874 Average Age % Female % Maternity % Chronic Conditions % CRG Significant Chronic % Depression % Hepatitis C % ADD % Asthma % Tobacco Dependence % Other SU % Mental Health

31 Challenges & Opportunities Workforce, especially in addictions treatment sector Developing institutional support for MAT Impacted group will need longer term support, costs Addictions treatment paradigm Primary care & integration APRN & PA prescribing Family support, targeted prevention services Developing advocacy 31

32 Questions?

33 Links for Article s on Vermont s Hub and Spoke Model Public-Health-Partnerships/Case-Studies/Vermont-MAT-Programfor-Opioid-Addiction/

34 Upcoming Caring for ME Webinars October 24, 2017, 12-1 pm, Vermont Project to Reduce Post-Op Prescribing of Pain Medication, Kelly Filippe, RN, and James Poole, MD, Register at zoom. October 31, 2017, 12-1 pm, MICIS*: Improving Opioid Prescribing and Patient Safety: Part 1: The Genesis of the Opioid Crisis: How We Got Here and Opioid Basics: MMEs & Tapering, with Elisabeth Fowlie Mock, MD, MPH, Register via Zoom Dec 5, 2017, 12-1 pm, MICIS*: Improving Opioid Prescribing and Patient Safety: Part 2: Practice Transformation & QI for Opioids/Chronic Pain and Harm Reduction: Naloxone & MAT, with Erika Pierce, PA-C, MMSc; Elisabeth Fowlie Mock, MD, MPH Register via Zoom Dec 13, 2017, 12-1 pm, MICIS*: Improving Opioid Prescribing and Patient Safety: Part 3: Communication Skills & Difficult Conversations/Behavioral Health Integration and Non-opioid/Nonpharm Treatments for acute & chronic pain with Elisabeth Fowlie Mock, MD, MPH Register via Zoom

35 Upcoming Caring for ME Webinars January 23, 2018, 12-1 pm, Update on Chapter 488, Gordon Smith, MMA. Register via zoom March 13, 2018, 12-1 pm, Snuggle ME Guidelines: What s New?, Kelley Bowden, Zoom Registration June 12, 2018, 12-1 pm, Integrated Care for Pregnant and Parenting Women with Opioid Use Disorders: Best Practice with Limited Resources, Daisy Goodman, DNP, Zoom Registration

36 QC launched 6 Online CME Modules with the Support of the Board of Licensure in Medicine (BOLIM) and the MMA in August Compliance with Maine Prescribing Laws Safe Prescribing & Prescribing Limits Chronic Pain Management Appropriate Diagnosis and Treatment of Addiction Safe & Compassionate Tapering Maternity Care and the Snuggle ME Guidelines