IMPLEMENTING MAT INTO FEDERALLY QUALIFIED HEALTH CENTERS: CHALLENGES AND SOLUTIONS

Elizabeth Salisbury-Afshar, MD, MPHMedical Director of Behavioral Health, Chicago Department of Public Health

Rachel King, MDMedical Director of Opioid Addiction Treatment ProjectECHO, Boston Medical CenterDirector of Primary Care Integration, DotHouse Health

Elizabeth Salisbury-Afshar, MD, MPH, FAAFP, FASAM, FACPMNo Conflict of Interest

Rachel King, MDNo Conflict of Interest

Implementing MAT into Federally Qualified Health Centers: Challenges and Solutions

April 13, 2018

Learning Objectives

Describe why FQHCs are ideal sites to provide MAT services Understand different Medication assisted treatment (MAT)

delivery models that are being implemented in FQHC settings Identify ways that FQHC MAT programs are addressing commonly

encountered challenges

Agenda

Background – FQHCs and MAT ECHO for MAT Chicago MAT Learning Collaborative Small Group Work

What is a Community Health Center?

“There are three words in community health center and we tend to talk a lot about health and center, and not as much about community.”-Jack Geiger

Why do MAT services fit in FQHCs?

MAT with buprenorphine and methadone has been shown to reduce opioid-related mortality and all cause mortality1

Access to MAT is limited Approximately 1/3 of all licensed addiction treatment programs offer any

form of MAT for OUD (most of those are methadone maintenance programs)2

FQHCs are increasingly integrating behavioral health services

1- Sordo et al. BMJ 2017;357:j1550.

2- SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS): 2016

Opioid Agonist Treatments and Overdose Deaths Baltimore 1995-2009

Schwartz et al. Am Journal of Public Health. 2013; 103(5):917-922

Access to opioid use disorder medication treatment in US

Jones CM, Campopiano M, et al. Am Journal of Public Health. 2015; 105(8):e55-e63

Primary Care Models for OUD Treatment Many different models of care

Practice Based models: Office-based opioid treatment (OBOT) model (+/- care coordinator) Specialty models (pregnancy, HIV-specific, “one stop shop”)

Health System models: Hub and Spoke Health Home New Mexico ECHO Collaborative Opioid Prescribing Model

Source: Korthuis et al. Annals of Internal Medicine. 2017

Practice-Based Models Typically involve a prescriber and at least one other “glue” person

+/- behavioral health “Glue person” could be an RN, care coordinator/case manager

Assists with orientation to program, intakes Manages referrals/coordinates care Facilitates prior authorizations May or may not provide some counseling Documents behavioral health if offered off-site

May or may not have behavioral health staffing on-site

Source: Korthuis et al. Annals of Internal Medicine. 2017

Health System Models

Typically the induction and stabilization is done at another location (usually an addiction treatment center)

Once patient is stabilized (stable dose, less frequent visits), is then referred to the primary care setting

Patients can be referred back to other location if increased support is needed

Source: Korthuis et al. Annals of Internal Medicine. 2017

Collaborative Nurse Care Manger Model “Massachusetts Model”

Began expansion to 22 community health centers in 2007 Sustainable through reimbursement More than 10,000 patients treated Support providers, nurses, other staff through TTA,

shadowing, email and capacity building

Extension for Community Health Outcomes (ECHO®)All-teach, All-learn

Opioid Addiction Treatment National Collaborative:

Structure of ECHO clinic

Two sessions per month 12 session curriculum 2-hour teleECHO clinic 1 didactic (20 mins) 2 case presentations per clinic

Free CME/CEU credits, count towards NP/PA waiver

National Opioid Addiction Treatment ECHO HRSA-funded CHCs

Massachusetts OBAT ECHO Focus on Massachusetts CHCs Additional on-site support available

ECHO at Boston Medical Center

Springfield

Barre

Plymouth

Brockton

Greenfield

Worcester

New Bedford

Lawrence

Hyannis

Wellfleet

Provincetown

BostonCambridge

MaldenPeabody

Common Clinical Challenges in ECHO Cases1) Patient engagement strategies

Managing patient ambivalenceSupporting patients’ basic needs such as housing, safety, and mental health treatment

2) Medication management Provider discomfort co-prescribing psychiatric and pain medications (e.g., benzodiazepines, gabapentin) with buprenorphine

3) Untreated medical/psychiatric comorbidities Anxiety, pain, ADHD

4) Polysubstance usePatients adherent to MAT protocol but using other drugs (e.g., cocaine)

Results from National ECHO

Surveys about Case-Based Learning: 93% respondents report case discussion taught them something new 86% reported that what they learned will change some aspect of the

way they care for patients in their practice For those who presented a patient case, 85% stated that the case

discussion changed their plan of care for the patient

Chicago MAT Learning Collaborative

Developed because: Need for increased access to MAT and specifically to buprenorphine HRSA awardees reported that they would appreciate support around

program development Health centers voiced interest in learning about best practices and

collaborating with others doing similar work Health centers voiced challenges in helping providers to feel comfortable

with new scope

Chicago MAT Learning Collaborative

Two tracks: Prescribers’ Track (MD, DO, NP, PA)-> Expanded to provider’s

track (prescriber and BH staff) Short didactics followed by small group case studies **Topics are selected by participants in advance

Decision Makers’ Track (Behavioral Health Directors, Medical Directors, any other key decision makers) Discuss how to build and improve upon programs **Topics are selected by participants in advance

Each track meets quarterly for ½ day

Chicago MAT Learning Collaborative

Provider Track selected the following as topics for discussion: How to interpret urine drug screen results Harm reduction in clinical care Working with patients with co-occurring mental illness (specific focus on

benzodiazepines) Working with patients with ongoing drug use Injectable extended release naltrexone Final session- TBD!

Chicago MAT Learning Collaborative

Decision Maker Track Selected the following as topics of interest: Clinical workflows (scheduling, which team members doing which

functions) Staffing (hiring and training existing staff) Supporting team-based care Balancing between harm reduction and diversion risk Measuring and monitoring quality

Lessons Learned from Provider Track: Clinicians are largely struggling with the same things Majority of the cases discussed have been around working with patients who continue to

use drugs

Lessons Learned from the Decision Maker Track: There is a lot of administrative support that goes into creating a robust OBOT program Challenges around hiring or training staff- many with BH backgrounds have not worked

in primary care settings; many in primary care had no training in addiction Clinics have enjoyed getting to hear about each others’ programs and have learned from

each other Clinic operations often look different because of different resources and populations (i.e.

some have pharmacies on-site, some have larger uninsured populations, etc)

Chicago MAT Learning Collaborative

Ground Rules

Organizations are at different stages of implementation Feel free to ask questions

Goal is to encourage best practice/evidence based practice If someone says something that contradicts your understanding of best

practice, bring it up respectfully!

Small Group Breakout

Format Each person describe your background and most pressing challenge (no

more than 5 minutes) Group brainstorms possible solutions and strategies tried At end, 1 person from group will present 1 interesting strategy that was

discussed to address barrier

Resources

PCSS-MAT: pcssmat.org Project ECHO: echo.unm.org OBOT Protocols: bmcobat.org