The Care Alliance for Opioid Dependence

Transcription

1 The Care Alliance for Opioid Dependence The Vermont Hub and Spoke Model John Brooklyn, MD Clinical Assistant Professor of Family Practice and Psychiatry University of Vermont College of Medicine Medical Director of Howard Center Chittenden Clinic Medical Director BAART St. Albans Hub

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3 Vermont

4 Vermont 626,000 people in VT 49 th smallest of 50 states in population in US 45 th smallest of 50 states in area in US 75% Forests Largest city is Burlington at 39,000

5 History of Opioid Use Treatment in Vermont Methadone approved in US in 1972 Vermont opened 1st methadone clinic Opioid Treatment Programs (OTP) in 2002 with 100 slots By people enrolled in 6 OTPs Buprenorphine (BPN) approved for Office Based Opioid Treatment (OBOT) in people in OBOT by 2009 Vt is #1 in US in per capita BPN prescriptions and waivered MDs

6 Hub and Spoke System Vermont's Blueprint for Health established a Chronic Care Initiative that designated Opioid Addiction as a chronic condition, like diabetes, heart disease, lung disease, etc. Idea floated of creating regional centers of addiction experts (HUBS) that would provide comprehensive services like any other specialty and would use all medications for opioid treatment- methadone, buprenorphine and naltrexone Office Based Opioid Treatment (OBOT) providers were linked in each county as SPOKES to HUBS Main goal is to prevent overdose and deal with the opioid crisis in the state in a systematic way

7 Hub and Spoke System Integrates substance use disorder into primary care and provides office based supports and a referral network for more complex cases Patients can start at a Hub and go to a Spoke for less care or can go from a Spoke to a Hub for more care Goal: No loss of treatment for Opioid dependence

8 Integrated Health System for Addictions Treatment Corrections Probation & Parole Family Services Spokes Nurse-Counselor Teams w/prescribing MD Residential Services Mental Health Services Spokes HUB Assessment Care Coordination Methadone Complex Addictions Consultation Spokes In Patient Services Substance Abuse Out- Pt Treatment Spokes Nurse-Counselor teams w/prescribing MD Pain Management Clinics Vermont Department of Health Medical Homes

9 1. Northwestern Hub HowardCenter Chittenden Clinic Chittenden, Addison & Grand Isle 2. Farwestern Hub BAART Behavioral Health Services Franklin & Grand Isle 3. Northeastern Hub BAART Behavioral Health Services Essex, Orleans & Caledonia 4. Central Vermont Hub BAART/Central Vermont Addiction Medicine Washington, Lamoille & Orange 5. Southwestern Hub Rutland Regional Medical Center Rutland & Bennington 6. Southeastern Hub Southeast Regional Comprehensive Addictions Treatment Center (Habit OPCO & Brattleboro Retreat) Windsor and Windham Vermont Population 626,562

10 SPOKES Linked to a regional HUB All buprenorphine prescribers in an office can participate as SPOKES Can be 1 doctor in private practice or group practice with many prescribers Can refer complex patients to the HUB for stabilization All SPOKES take advantage of the MAT teams in the region

11 SPOKES All community BPN providers were eligible to become SPOKES Allowed for enhanced services to be provided to offices with linkages to their regional HUBS if needed Goal was to provide enhanced services for better management of these patients with better outcomes

12 MAT Team MAT (Medication Assisted Treatment) Team is 1 FTE Case Manager and RN per 100 BPN patients and a prescribing physician Paid for by Federal matched health care dollars as part of Chronic Care Initiative What many BPN physicians had been asking for to help increase the number of patients they could serve May serve a few practices and not be on site

13 Hub or Spoke?? Triage tool needed Based on level of care needed rather than medication driven Helps physician decide where to best treat patient

14 CRITERIA FOR HUB AND SPOKE Treatment Need Questionnaire (TNQ) developed by Brooklyn and Sigmon 21 item checklist with scores up to 26 Lower scores predict good SPOKE outcomes Based on Addiction Severity Index (ASI) topicslegal, work, social, psychological, medical, drug use

15 TREATMENT NEED QUESTIONNAIRE Have you ever used a drug intravenously? 2 0 If you have ever been on medication-assisted treatment (e.g. methadone, buprenorphine) before, were you successful? YES 0 2 Do you have any legal issues (e.g. charges pending, probation/parole, etc)? 1 0 Are you currently on probation? 1 0 Have you ever been charged (not necessarily convicted) with drug dealing? 1 0 Do you have a chronic pain issue that needs treatment? 2 0 Do you have any significant medical problems (e.g. hepatitis, HIV, diabetes)? 1 0 Do you have any psychiatric problems (e.g. major depression, bipolar, severe anxiety, PTSD, schizophrenia, personality subtype of antisocial, borderline, or sociopathy)? 1 0 Do you ever use cocaine, even occasionally? 2 0 Do you ever use benzodiazepines, even occasionally? 2 0 Do you have a problem with alcohol, have you ever been told that you have a problem with alcohol or have you ever gotten a DWI/DUI? 2 0 NO

16 TREATMENT NEED QUESTIONNAIRE Are you motivated for treatment? 0 1 Are you currently going to any counseling, AA or NA? 0 1 Do you have 2 or more close friends or family members who do not use alcohol or drugs? YES 0 1 Do you have a partner that uses drugs or alcohol? 1 0 Is your housing stable? 0 1 Do you have a reliable phone number? 0 1 Are you employed? 0 1 Do you have access to reliable transportation? 0 1 Did you receive a high school diploma or equivalent ( complete 12 yrs of education) 0 1 NO

17 TREATMENT NEED QUESTIONNAIRE Total possible points is 26 Scores 0-5 excellent candidate for office based treatment Scores 6-10 good candidate for office based treatment Scores candidate for office based treatment by board certified addiction physician in a tightly structured program with supervised dosing and on site counseling or HUB Scores HUB program

18 Learning Collaborative Designed to increase training of addiction medicine in community OBOT providers, MAT teams and other staff Separate for Hubs and Spokes Curricula designed by Dartmouth College with VT physician experts input 6-8 sessions,1.5 hours in length, spread over a year

19 Learning Collaborative Sessions covered Drug screening Dealing with behavioral issues Effective treatment of cocaine, benzodiazepines, and alcohol use disorders Need for dose adjustments and induction protocols Integrating regular medical and psychiatric care into the office visit Overdose, HIV and hepatitis education

20 GOVERNOR PHIL SCOTT, STATE AND LOCAL OFFICIALS ANNOUNCE VERMONT CAN PROVIDE OPIATE ADDICTION TREATMENT AND CARE UPON REQUEST 14 September 2017

21 VT Department of Health Department of VT Health Access Hub Census and Waitlist: June 2018 Region # Clients # Buprenorphine # Methadone # Vivitrol # Receiving Treatment but Not Yet Dosed # Waiting Chittenden, Addison Franklin, Grand Isle Washington, Lamoille, Orange Windsor, Windham Rutland, Bennington Essex, Orleans, Caledonia Total Note: The Franklin/Grand Isle location opened in July Some clients are transferring from the Chittenden/Addison hub to the FGI hub. Vermont Department of Health Source: Alcohol and Drug Abuse Treatment Program

22 The statewide number of people waiting for opioid use disorder treatment in hubs has trended downward over time; the number of people served in hubs has increased Number of People in Hubs and Waiting for Hub Services Over Time In Treatment Waiting Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jan- Apr- Jul- Oct- Jan- Jan- Apr- Jul- Oct- Apr- Jul- Oct- Jan- Feb- Mar Apr- May Jun- Jul- Aug-Sep- 17- Nov Dec- Jan- Feb- Mar Apr- May Jun Oct In Treatment Waiting Vermont Department of Health Source: Alcohol and Drug Abuse Treatment Programs

23 Agency of Human Services Spoke Patients, Providers & Staffing: June 2018 Region Total # MD prescribing pts # MD prescribing to 10 pts Staff FTE Hired Medicaid Beneficiaries Bennington St. Albans Rutland Chittenden Brattleboro Springfield Windsor Randolph Barre Lamoille Newport & St Johnsbury Addison Upper Valley Total 234* Table Notes: Beneficiary count based on pharmacy claims August October, 2017; an additional 287 Medicaid beneficiaries are served by 35 out-of- state providers. Staff hired based on Blueprint portal report 11/22/17. *6 providers prescribe in more than one region.

24 Number of Medicaid Beneficiaries treated in spokes over time Region 9/13 12/13 3/14 6/14 9/14 12/14 3/15 6/15 9/1 5 12/15 3/16 6/16 9/16 12/16 3/17 6/17 9/17 12/17 3/18 6/18 Bennington St. Albans Rutland Chittenden Brattleboro Springfield Windsor Randolph Barre Lamoille Newport & St. Johnsbury Addison Vermont Department of Health Upper Valley Source: 12 DVHA/Blueprint for 16 Health22 19 Total 1,750 1,919 1,888 1,972 2,051 2,179 2,225 2,284 2,2 2,389 2,584 2,621 2,535 2,572 2,694 2,

25 Number of Spoke Prescribers Over Time Region 9/14 12/14 3/1 5 6/15 9/15 12/1 5 3/16 6/16 9/1 6 12/1 6 3/17 6/17 9/17 12/1 7 Bennington St. Albans Rutland Chittenden Brattleboro Springfield Windsor Randolph Barre Lamoille Newport & St. Johnsbury /1 8 6/ Addison Upper Valley Total Some providers prescribe in more than one region Note: Prior to 9/14, spokes were tracked by number of providers rather than number of prescribers so are excluded from this report Vermont Department of Health

26 Spoke Growth Prescribers and Spoke Staff FTEs Hired Spoke MAT Prescribers in VT 10 Patients 1, Spoke MAT Prescribers in VT 2, ,000 2,500 2,000 1,500 1, Medicaid Benefiaries 26

27 MAT per capita 625,000 Vermonters 80 % over 18 yrs old 6505 on MAT from Medicaid Data 20-30% Commercial insurance in Spokes not accounted for 860 Total MAT estimates are 7365/500,000 adults is 1.47% of the TOTAL adult population of the state on MAT Estimate 2-3% may have OUD

28 Costs Impact of Medication-Assisted Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont published in the Journal of Substance Abuse Treatment (August 2016) Highlights: Higher MAT treatment costs offset by lower non-opioid medical costs MAT associated with lower utilization of non-opioid medical services MAT suggested to be cost-effective service for individuals addicted to opioids 6-7% cost savings by 2014 by treating OUD in the Hub and Spoke Vermont Department of Health

29 MAT and Non-MAT per Capita Rate of Health Care Expenditures, Excluding Opioid Use Disorder Treatment Costs $18,000 $16,000 $14,000 $12,000 $10,000 $15,579 $15,387 $13,874 $13,820 $13,937 $13,083 $12,259 $12,532 $12,008 $9,542 $9,345 $8,864 $9,225 $8,835 $8,774 $8,514 $8,082 $7,938 $8,000 $6, Non-MAT Treatment MAT Treatment

30 MAT in jails Allowed since 2004 for up to 30 days Pilot in 2014 allowed treatment up to 90 days at few prisons if on MAT at incarceration-mtd or BPN H468 allowed on July 1, 2018 initiation of MAT/BPN for inmates pre-release with community follow-up at hub or spoke

31 The other major outcome. The most important one.. Vermont Department of Health

32 Contact info John Brooklyn, MD