Opportunities to Improve Opioid Use Disorder and Infectious Disease Services Integrating Responses to a Dual Epidemic (2020) / Chapter Skim
Currently Skimming:
Appendix A: Case Studies of Select Programs
Appendix A: Case Studies of Select Programs
Pages 135-188
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 135... ...
The goal was to assess whether and how programs were integrating the services they provide for opioid use disorder (OUD) and infectious diseases and determine the most significant barriers to integration.
|
From page 136... ...
In 2015, ARCare began to incorporate behavioral health services in its larger clinics, and it now operates such services in 5 sites; 3 of these in Arkansas provide HIV/ hepatitis C virus (HCV) /OUD services and began providing medications for opioid use disorder (MOUD)
|
From page 137... ...
(3) Yes Outpatient Family Health Centers Plumas County Public Plumas County, Rural In coordination Yes Yes County health No Outpatient Health Agency CA with local hospital agency LifeSpring Health Jeffersonville, IN Mixed Yes Yes Yes, with syringe 501(c)
|
From page 138... ...
The model of care must be changed to accommodate integration between behavioral health and primary care, especially with the complex histories that come with patient populations who have comorbid OUD and infectious diseases. For instance, the scheduling for behavioral health is different than primary care.
|
From page 139... ...
. HRSA funding was used to develop the MOUD program, and a number of grants are used to pay for behavioral health services.
|
From page 140... ...
No data were available on patient characteristics or outcomes of integrated OUD and infectious disease treatment. Facilitator and Barriers Facilitator • ARCare's status as a community health center has been useful for integrating services in general and gaining funding opportunities to begin offering MOUD.
|
From page 141... ...
Information About Informant Frank Vega, L.M.F.T. Director of Behavioral Health KING COUNTY DEPARTMENT OF PUBLIC HEALTH Program Description The King County Department of Public Health began operating a syringe service in 1989 and now has several locations.
|
From page 142... ...
The second is Bupe Pathways, a low-barrier buprenorphine program operated by the Downtown Primary Care Public Health Clinic, which is colocated with the syringe services program and pharmacy. The third and newest is an HCV program, which operates from the syringe service and provides testing and telemedicine treatment for HCV.
|
From page 143... ...
The goal is to provide a "one-stop shop" whenever possible. The HCV treatment program is based on a nurse-driven care model, where a public health nurse provides onsite, in-person care to syringe service program clients in partnership with an offsite infectious disease physician who supervises clinical visits through a secure teleconferencing platform.
|
From page 144... ...
In addition, a survey is conducted every 2 years at the syringe services program to evaluate risk behaviors and factors affecting service uptake among its clients. Patient Characteristics and Outcomes At the downtown syringe service, there is 60 percent positivity among those tested for HCV antibodies.
|
From page 145... ...
• The syringe service program -- which provides a referral source for many other billable services -- is not itself billable. This requires the department to find external sources of funding for the syringe service program.
|
From page 146... ...
Epidemiologist Julie Dombrowski, M.D., M.P.H. Deputy Director of HIV/STD Program SOUTHCENTRAL FOUNDATION Program Description As an Alaska Native–owned, nonprofit health care organization, Southcentral Foundation serves 65,000 Alaska Native and American Indian people with more than 500,000 visits in Anchorage, the MatanuskaSusitna Valley, and 55 rural villages in the surrounding area.
|
From page 147... ...
These services have become almost completely colocated in the same clinic, and as patients become more or less stable, medically or from a mental health perspective, their care plans are transferred back and forth between the core groups. While the workflows may be different depending on what a patient is treated for, the providers and core groups are in constant, daily communication.
|
From page 148... ...
. Medications for OUD have been diffused into the medical home using this same philosophy, and there are 45 providers with DATA waivers (with a mix of PCPs and specialty care providers)
|
From page 149... ...
More specialized staff receive as much as 5 days of training on their topic areas (e.g., integrated care team training)
|
From page 150... ...
Because Southcentral Foundation was a test site for HCV treatment, it has more than 100 patients who received treatment and demonstrated remission. However, it has just moved that process from the viral hepatitis program into primary care and is now only monitoring a dozen with complete primary care–initiated and –monitored treatment.
|
From page 151... ...
In general, core OUD and infectious disease services are performed by the primary care team, with referrals out to specialty care for patients with complex mental health histories. History of Program's Integrated Services Lawrence, Massachusetts, has a population of about 80,000 and the lowest per capita income of any city in the state.
|
From page 152... ...
The behavioral health team is currently undergoing integration with the OUD and infectious disease services in order to more effectively share staff and use grant funds. Because GLFHC has been a family medicine institution and operating in a patient-first model for many years, there was very little cultural friction in convincing providers that integration could help.
|
From page 153... ...
, grants (for the Mobile Health Unit and a behavioral health counselor) , and HRSA for HIV services (primarily case management and further integration of services, since 98 percent of patient visits at GLFHC are reimbursed through insurance)
|
From page 154... ...
While GLFHC has not instituted formal feedback mechanisms for patients to provide input on integrated services, this is another investment the organization is interested in pursuing. For instance, GLFHC's providers have discussed including patients in the interviewing process for community health workers to ensure that new employees are screened by the patients whom they will be serving.
|
From page 155... ...
For instance, GLFHC did not include behavioral health services in its initial community health center proposal and then needed to update its profile to include these services (a time-consuming process)
|
From page 156... ...
. Given this, leadership and staff at the agency felt that integrated services for infectious diseases and OUD was a natural way to meet patients' needs.
|
From page 157... ...
Individual champions were identified in each of these stakeholder groups, and maintaining close relationships between these champions has been crucial. Services Provided and Model of Care In many cases, patients will visit the agency for the syringe service program or for other basic services but also be offered MOUD, naloxone, overdose prevention education, rapid testing for HIV/HCV, and a referral for HIV/HCV treatment and PrEP when necessary (via an online prescription service)
|
From page 158... ...
The MOUD program, for instance, was funded initially from a state grant to promote rural health and now relies on a 2018 HRSA grant and California's hub-and-spoke model; HIV testing is available from Ryan White funding; California funds syringe service supplies through the Office of AIDS; and public funding pays for HCV testing. Patient Characteristics and Outcomes Overall metrics of success for the health agency include the number of people served, the number of clients engaging in MOUD and showing up to appointments, the number of syringes distributed, tests completed for HIV/HCV, and the rates of undetectable viral load.
|
From page 159... ...
• The agency does not have access to the EMRs in the hospital, which prevents case managers from truly understanding the full care plan and providing continuity of care. • The lack of blanket permission to provide syringe service pro grams has meant that each county must spend time and resources getting permission from the state.
|
From page 160... ...
The Plumas County Public Health Agency has found that HIV clients who inject drugs are hesitant to use the syringe services, because they may not have developed a close relationship with the providers delivering those services. Information About Informants James Wilson Health Education Coordinator Barbara Schott, M.S.W.
|
From page 161... ...
LifeSpring treats HIV, viral hepatitis, and OUD in primary care, as well as promoting harm reduction through PrEP prescribing, condom distribution, and a colocated syringe service (run by the local health department)
|
From page 162... ...
, 20 percent are on Medicare, and the remainder are on private insurance or Indiana's insurance for low- or moderate-income people living with HIV. The community health center model has helped sustain LifeSpring in providing integrated care and offers the confidence that it can continue to meet its patients' needs.
|
From page 163... ...
• Indiana previously had a rule that community mental health centers could not provide primary care. Therefore, LifeSpring ini tially formed a separate legal entity to deliver primary care.
|
From page 164... ...
• Even though providers were all committed to providing the best possible care for patients, differing personalities and strategies for achieving that goal have caused conflict over time. Moving from a behavioral health model to a primary care model was difficult for the organization, given that it had been operating with institutional inertia under the behavioral health model for several decades.
|
From page 165... ...
In December 2018, it also integrated MOUD into its primary care program in an effort to increase access for a larger number of patients and minimize the number of internal referrals for different types of treatment. The choice to integrate OUD services into primary care -- along with HIV/viral hepatitis services -- was driven by the syringe service program 1 Program informants from CrescentCare did not provide direct edits to this case study.
|
From page 166... ...
This includes referrals to other harm-reduction services and assistance with transportation, bus tokens, SNAP tokens and applications, housing, and navigating the health system. For the combined OUD and infectious disease services, CrescentCare has one addiction specialist who oversees the IOP, one psychiatrist who sees more complicated dual-diagnosis patients, three PCPs and two NPs with DATA waivers who see patients with viral hepatitis or HIV and OUD, and an additional NP and a physician's assistant working on DATA waiver training.
|
From page 167... ...
These statistics are similar to the syringe service program; more than 1,000 individuals per week use the program, and more than 50 percent are living with HCV and 2–3 percent with HIV.
|
From page 168... ...
• A state Medicaid reimbursement restriction for HCV treatment was lifted on July 1, 2019, expanding the number of patients that CrescentCare can treat. Barriers • DATA waiver training is time-consuming (particularly for NPs and PAs, who must spend 24 hours on it)
|
From page 169... ...
The goal of integrating services was to seamlessly bring patients from testing, to treatment, to cure. Services Provided and Model of Care Patients accessing OUD and infectious disease services at Evergreen are frequently admitted through the syringe service program or the
|
From page 170... ...
In Jamestown, the syringe service program is the only service not offered in the same location. Evergreen's medical staff for OUD and infectious disease services consists of mostly PAs and NPs, along with mental health counselors and social workers.
|
From page 171... ...
• Gaining patients' consent at the first visit to share medical and behavioral health information with a range of providers makes it easier to provide integrated services over time. Barriers • The cultural split between abstinence-based treatment and a harm-reduction framework has prevented seamless communica tion between providers and staff.
|
From page 172... ...
BTC is fully integrated into the community health center's normal workflow (Montefiore) and sees about 150–200 patients per year, the majority of whom have chronic health conditions.
|
From page 173... ...
Since then, medical residents have taken the helm in providing much of the care and often conduct research or quality improvement projects in BTC. BTC is based in a community health center that has been at the forefront of providing HIV, HCV, and OUD treatment in a community setting.
|
From page 174... ...
Because BTC is integrated into Montefiore, treatment for OUD/HIV/HCV has not been a limitation financially. The infectious disease providers and staff in the community health center have helped BTC with patients, and being part of the academic program allows the clinic to focus on training medical residents who also provide services (even a high level of care to a small number of patients)
|
From page 175... ...
About three out of every four had at least one chronic health condition (e.g., HIV, OUD, or viral hepatitis) , and of this group, the average number of chronic conditions was three.
|
From page 176... ...
Having full colocation of services would likely aid in communication. • Stigma against people who use drugs or individuals living with infectious diseases may prevent patients from engaging with the medical system, and overturning this stigma requires concerted effort (even among medical providers)
|
From page 177... ...
is more effective and efficient. • Clinics must not underestimate how important it is to provide compassionate, nonjudgmental care to individuals living with infectious diseases or using drugs.
|
From page 178... ...
In 2000, it merged with the Washington Free Clinic to provide primary care, behavioral health, SUD treatment, and dental care. Whitman-Walker Health now operates in two locations and is well known for providing care to lesbian, gay, bisexual, transgender, and questioning (or queer)
|
From page 179... ...
In general, the primary champions of organizational change toward integrated services have remained the same over time. Today, Whitman-Walker Health remains an attractive option to patients with OUD because they know they will not be turned away if they begin using drugs again.
|
From page 180... ...
Operationally, this includes a standing order of naloxone at the onsite pharmacy, care plans that emphasize tapering use, connections to community resources (including syringe services available in Washington, DC, though not operated by Whitman-Walker Health) , and education about the risks of concurrent substance use.
|
From page 181... ...
TABLE A-2 Clinical Outcomes for Whitman-Walker Health Patients Whitman-Walker Health MOUD Program: January 2018–April 2019 % Notes OUD Opioid use disorder diagnosis 100.0 Prescribed buprenorphine at least once 46.4 At least 1 subsequent buprenorphine 28.0 Rx ≥6 months from first Rx PreP Patients without HIV infection 58.0 Prescribed PrEP 8.3 PrEP Rx ≥6 months from first Rx 3.3 HIV Patients with HIV 42.0 Prescribed ART 88.5 Undetectable VL 78.2 HCV Patients with HCV 34.3 Prescribed HCV medication 16.9 Virologic suppression 32.4 This likely does not reflect a low sustained virologic response rate but more likely a low treatment completion rate.
|
From page 182... ...
Patients are able to provide input to Whitman-Walker Health on services via general surveys, though there have been no specific focus groups on integrating OUD and infectious disease services. Facilitator and Barriers Facilitator • In January 2019, Washington, DC, loosened the prior authoriza tion requirement for MOUD, allowing Whitman-Walker Health to more easily prescribe and dispense.
|
From page 183... ...
Information About Informant Sarah Henn, M.D. Chief Health Officer PHILADELPHIA FIGHT Program Description Philadelphia FIGHT is a comprehensive health services organization providing primary care, consumer education, research, and advocacy for people living with HIV/AIDS and those at high risk.
|
From page 184... ...
. History of Program's Integrated Services Philadelphia FIGHT was founded as an AIDS service organization 25 years ago and now operates as a community health center with FQHC status.
|
From page 185... ...
FIGHT has an IOP for SUD treatment program called TREE that follows a 12-step philosophy to SUD treatment and a mental health clinic called the Diana Baldwin Mental Health Clinic for individual therapy. FIGHT also has a behavioral health consultant imbedded in most clinics to see patients for a limited number of visits when they are in crisis or have a specific, finite support need (e.g., smoking cessation, medication adherence, bereavement)
|
From page 186... ...
In addition, because psychiatric services are billable sessions, the more FIGHT can maintain adherence to mental health and SUD treatment, the more financially stable it will be. FIGHT aims to treat patients in families or as couples when appropriate, and Clinica Bienestar is a more fluid clinic that allows patients' families to come in as well.
|
From page 187... ...
Syringe service programs are only legal in Philadelphia and Pittsburgh, and Prevention Point in Philadelphia is the only legally sanctioned one; while there are providers who can prescribe syringes to prevent HIV and viral hepatitis, it is not a robust enough workaround to the state restriction. Advice for Other Programs • Treating OUD patients effectively will help manage other chronic illnesses, including the treatment and prevention of HIV, HCV, and serious bacterial infections.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.