The Care Alliance for Opioid Dependence The Vermont

The Care Alliance for Opioid Dependence The Vermont Hub and Spoke Model John Brooklyn, MD Associate Professor of Family Medicine and Psychiatry University of Vermont College of Medicine Medical Director BBHS Northeast Vermont Hub BAART PROGRAMS

BAART PROGRAMS

BAART PROGRAMS

Hub and Spoke System Integrated system of care like any other specialty Centers of excellence in Substance Use disorders treatment were designated as HUBS (OTPs). Added measures of physical and medical health outcomes Office Based Opioid Treatment (OBOT) providers were linked in each county as SPOKES to HUBS Referrals can go back and forth. Goal: No loss of treatment for Opioid dependence BAART PROGRAMS

History of Opioid Use Treatment in Vermont opened 1 st methadone clinic (OTP) in 2002 with 100 slots Buprenorphine approved for Office Based Opioid Treatment (OBOT) in 2003 VT quickly adopted buprenorphine and became #1 state in US for waivered MDs and doses prescribed per capita As demand for treatment created OTP waiting lists, OBOT quickly surpassed methadone clinics in people served Approximately 600 people enrolled in Opioid Treatment Programs (OTP) by 2009, even with the addition of more OTPs ~2000 people in OBOT by OB, FP, PSYCH, IM, PEDS physicians BAART PROGRAMS

OBOT CONCERNS What to do if OBOT patient was not doing well in treatment due to using illicitly, diverting, missing counseling? What to do if MD retired, lost license, moved away? What to do with large programs with 100+ people in OBOT that were essentially unregulated unlike the OTP programs? What about increasing access to treatment in OBOT? What about physicians who did not want to do inductions and were willing to take people after they were stable? BAART PROGRAMS

RESPONSE 2004, opened Bup Induction Center in Berlin to start people and then transition them to waivered MDs/Dos. Over 350 people in 3 yrs inducted Bup Guidelines written and 2005, revised in 2010 to better help providers in caring for the opioid dependent person Rules written to better regulate large programs with more than 30 people on buprenorphine brought them into line with expectations similar to OTP 2011 BAART PROGRAMS

RESPONSE Vermont's Blueprint for Health established a Chronic Care Initiative that designated Opioid Addiction as a chronic condition Allowed for creative funding of treatment modalities Governor Shumlin after election of 2012 supported expansion of funding for opioid treatment capacity in OTP’s 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-and identify medical and psychiatric conditions BAART PROGRAMS

HUBS Designated all OTP methadone programs as HUBS 5 HUBS-Northwest, Central, Northeast, Southeast, and Southwest Plan to open HUBS in all regions of the State to serve all counties by end of 2013 BAART PROGRAMS

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

HUB BUPRENORPHINE Buprenorphine could be prescribed just like methadone within the HUBS More flexibility with take homes Offered every other day or every third day dosing Introduced the use of Med-o-wheels for securing take homes of bup tablets Required all patients to FULLY DISSOLVE and ABSORB sublingually both forms of buprenorphinefilms and tablets-in a 5 minute observation period Prior Authorization process put in place by Medicaid for mono buprenorphine and all doses over 16 mg BAART PROGRAMS

BAART PROGRAMS

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Alternative Dosing Regimens Offer Double or Triple dosing of buprenorphine Well studied in early trials Petry, et al 1999 Bickel, et al 1999 Amass, et al 2000 Marsch, et all 2005 Double dosing on Mon, Wed Double or triple dosing on Friday Used as an interim measure before take homes BAART PROGRAMS

HUBS Created definable measures needing to be met Home health measures, tobacco, BMI, blood pressure, STD, HIV, Hepatitis, depression, anxiety, other drug and alcohol use assessments and intervention Biopsychosocial assessment at intake Self Sufficiency Matrix-housing, work, income, legal, mental health, substance abuse, health insurance, disabling condition, and community involvement with ratings from In crises to Thriving BAART PROGRAMS

HUB Medicaid paid a monthly rate person with enhanced rates for meeting benchmarks Needed one standard clinical service, and 1 “health home” encounter for the enhanced rate Allowed the use of buprenorphine and naltrexone with costs "carved out” from the monthly rate Separate billing for theses medications was enacted BAART PROGRAMS

SPOKES All bup providers were eligible to become SPOKES Allowed for enhanced services to be provided to offices with linkages to their regional HUBS if needed 1 FTE Case Manager and RN per 100 bup patients. Services could be in-house though additional hirings or outside consultations through regional contracts with hospitals or mental health service providers Goal was to provide enhanced services for better management of these patients with better outcomes 28 separate offices were designated as SPOKES BAART PROGRAMS

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 BAART PROGRAMS

TREATMENT NEED QUESTIONNAIRE © YES NO 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? 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 1 anxiety, PTSD, schizophrenia, personality subtype of antisocial, borderline, or sociopathy)? 0 Do you ever use cocaine, even occasionally? 1 0 Do you ever use benzodiazepines, even occasionally? 2 0 0 Do you have a problem with alcohol, have you ever been told that you have a 2 BAART PROGRAMS problem with alcohol or have you ever gotten a DWI/DUI?

TREATMENT NEED QUESTIONNAIRE © YES NO 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? 0 1 Do you have a partner that uses drugs or alcohol? 1 0 Are you a parent of a child under age 18? If so, does your child live with you? 0 1 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 1 Did you receive a high school diploma or equivalent ( complete 12 yrs 0 of education) BAART PROGRAMS

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 11 -15 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 16 -26 HUB program BAART PROGRAMS

PROGRESS All HUBS had rapid growth to full capacity Enhanced services met monthly Percentage of people on buprenorphine increased to 30% in HUBS Accepted SPOKE transfers very quickly for stabilization rather than have them dismissed from SPOKES Increase in number of practices becoming SPOKES High number of SPOKES in Learning collaborative found improvement in their practice Shift to 50: 50 split of OTP vs OBOT from 15: 85 in 2009 BAART PROGRAMS

Integrated Health System for Addictions Treatment Vermont Department of Health BAART PROGRAMS

Challenges to System Development Consistent Vision between State agencies, particularly ADAP, DVHA, Blueprint for Health, and Pharmacy Benefits administrator Understanding all the regulatory structures related to care, funding, and pharmacy benefits Determining the payment mechanism for Buprenorphine and naltrexone products outside of established case rates BAART PROGRAMS

The Pivotal Questions? ? ? Would developing this model conceivably: 1. Improve Access to Care? 2. Improve Quality of Care? 3. Be cost Effective? 4. Decrease Buprenorphine Diversion Concerns? 5. Be viable within the multitude of regulatory structures in which we all live? We thought it was worth a shot!! BAART PROGRAMS

Pivotal Question 1: Improve Access to care Pre and Current Hub and Spoke numbers served April 2012: OTP numbers served: 650 Medicaid numbers served in OBOT’s: 1700 September 2015: OTP numbers served: 2834 OTP numbers bup served: 931 OBOT Medicaid Served: 2317 Note: Physicians generally report 0 -35% of OBOT case loads outside of the Medicaid population with significant variance by region of the state . BAART PROGRAMS

Department of VT Health Access VT Department of Health Hub Census and Waitlist: September 29, 2015 Program Region Chittenden Center Chittenden, Franklin, Grand Isle & Addison BAART Central Vermont Washington, Lamoille, Orange Habit OPCO / Windsor, Windham Retreat Start Date 1/13 7/13 # Clients # Buprenorphine # Methadone # Waiting 861 262 599 291 415 183 232 0 578 203 375 11 West Ridge Rutland, Bennington 11/1 3 421 144 277 89 BAART NEK Essex, Orleans, Caledonia 1/14 559 139 420 89 2834 931 1903 480 STATEWIDE BAART PROGRAMS

VT Department of Health Department of VT Health Access BAART PROGRAMS

VT Department of Health Department of VT Health Access Notes: The August 2014 decrease in West Ridge census is due a reporting correction. The Nov/Dec 2014 Habit Opco census decrease is because of staff shortages – provider transferred stable patients to spokes and stopped taking new patients. BAART PROGRAMS

VT Department of Health Department of VT Health Access BAART PROGRAMS

BAART PROGRAMS

Waivered MDs 1 -9 pts: 49 MDs 10 -29 pts: 40 MDs 30 -40 pts: 10 MDs 41 -50 pts: 7 MDs 51 -77 pts: 10 MDs BAART PROGRAMS

Pivotal Question 2: Improve Quality of Care ACA funding for 2 FTE, non-billing responsible staff per 100 patients 90/10 funding split in Spokes (ACA section 2703 VT SPA) and roughly 30% in Hubs (directly tied to Health Home services provision) 1 FTE licensed behavioral health provider 1 FTE nurse provider Any configuration of service providers/service areas to provide Health Home Services BAART PROGRAMS

Health Home Services Defined Comprehensive care management Care coordination Health promotion Transitions of care Individual and family support Referral to community services BAART PROGRAMS

Accreditation Requirements NCQA PCMH requirements (specialty care) mirror the primary care standards: over 86% of all Vermonters in PCMH practices Blueprint for Health support: project manager and embedded staff supports First Hub (Chittenden Center) has completed its baseline NCQA assessment walk thru of data Vermont Child Health Improvement Program (VCHIP) is assessing program adherence and cost impacts BAART PROGRAMS

Pivotal Question 3: Cost Effectiveness - - - Comparative Effectiveness Public Advisory Council/ICER **Cost estimates lower than other no treatment or abstinence based treatments For Medicaid Beneficiaries, including the cost of MAT, lower overall health care costs by 7 -10% than those with 2 claims for opioid dependence in a given year from all sources State Medicaid Claims Data: “DVHA has projected that for the 2, 164 patients estimated to be served statewide, the savings will be $6. 7 million” Testimony to VT legislature 3/20/14. . BAART PROGRAMS

Pivotal Question 4: Reduce Diversion Decrease Diversion of Buprenorphine VT MAT Rules and other state regulations: Requires diversion Control Plans and use of Tox screens in larger OBOT practices Requires checking PDMP data base minimum 3 x annually for OBOT providers Prior approval process thru DVHA, particularly for higher doses and mono-product “Pharmacy Home” assignment for Rx… Spoke staffing to support care coordination and enhanced adherence to care Destabilized patients referred to Hubs for enhanced structure Hubs utilize PDMP Significant increase in access to OTP’s with higher level of medication management capacity BAART PROGRAMS

Pivotal question 5: Regulatory constraints Can this be implemented within regulatory structures that exist? Payment to providers for medication reimbursement outside of case rate that met regs for OTP’s, Medicaid Health Benefits and State Pharmacy administrators CSAT removal of Time in Treatment Requirement for Buprenorphine allowed for both increased access to care as well as ensuring take home trials to assess stability prior to transfers to Data 2000 providers VT MAT Rules aligned with both Data 2000 and 42 CFR part 8 Changed VT State Plan Amendment for Medicaid Health Homes to include OTP’s as specialty “Health Homes” BAART PROGRAMS

Summary Increase in total number of MDs/DOs waivered to prescribe buprenorphine Increase in numbers of opioid users served by each waivered MD/DO Broader adoption of disease model of treatment so there is a continuity of care for substance use disorders from HUB to SPOKE and back again More medical services provided in the SPOKES enhanced by additional RN and CM Providers express greater willingness and satisfaction in caring for opioid use disorders in PCIM settings BAART PROGRAMS