Transcript Vermont Hub and Spoke Model - The Care Alliance for

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
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Hub and Spoke System
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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
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History of Opioid Use Treatment in Vermont
Vermont opened 1st 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
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OBOT CONCERNS
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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?
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RESPONSE
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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 OTP2011
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RESPONSE
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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
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HUBS
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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
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Vermont
Population 626,562
1. Northwestern Hub
HowardCenter 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
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HUB BUPRENORPHINE
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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
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Alternative Dosing Regimens
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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
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Double dosing on Mon, Wed
Double or triple dosing on Friday
Used as an interim measure before take homes
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HUBS
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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
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HUB
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Medicaid paid a monthly rate per 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
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SPOKES
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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
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CRITERIA FOR HUB AND SPOKE
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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
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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
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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)
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TREATMENT NEED QUESTIONNAIRE ©
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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
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PROGRESS
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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
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Integrated Health System for Addictions Treatment
Corrections
Probation &
Parole
Family
Services
Residential
Services
Spokes
Nurse-Counselor Teams
w/prescribing MD
HUB
Mental
Health
Services
Spokes
Assessment
Care Coordination
Methadone
Complex Addictions
Consultation
Spokes
Substance
Abuse OutPt Treatment
Nurse-Counselor teams
w/prescribing MD
Spokes
In Patient
Services
Pain
Management
Clinics
Medical
Homes
Vermont Department of Health
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Challenges to System Development
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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
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The Pivotal Questions???
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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!!
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Pivotal Question 1: Improve Access to care
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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
.
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Department of VT Health Access
VT Department of Health
Hub Census and Waitlist: September 29, 2015
Program
Region
Start
Date
#
Clients
#
Buprenorphine
#
Methadone
#
Waiting
1/13
861
262
599
291
7/13
415
183
232
0
578
203
375
11
Chittenden
Center
Chittenden, Franklin,
Grand Isle & Addison
BAART Central
Vermont
Washington, Lamoille,
Orange
Habit OPCO
/ Retreat
Windsor, Windham
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
7/13
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Department of VT Health Access
VT Department of Health
Hub Census Over Time by Region
3000
2500
Census
2000
Rutland/Benn
1500
Essex/Orl/Cal
Windam/Windsor
Wash/Lam/Orange
1000
Chit/FGI/Addison
500
0
1
2
3
4
5
6
7
2013
8
9 10 11 12 1
2
3
4
5
6
7
2014
Month
8
9 10 11 12 1
2
3
4
5
6
7
8
9
2015
Date of Last update: 09/29/2015
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Department of VT Health Access
VT Department of Health
Number of People Served in Opiate Treatment Hubs Over Time By Region
1000
900
800
600
500
400
300
200
Chittenden Center
BAART Central Vermont
Habit OPCO / Retreat
West Ridge
BAART NEK
100
9/17/2015
9/3/2015
8/6/2015
8/20/2015
7/9/2015
7/23/2015
6/25/2015
6/11/2015
5/28/2015
5/14/2015
4/30/2015
4/16/2015
4/2/2015
3/19/2015
3/5/2015
2/19/2015
2/5/2015
1/8/2015
1/22/2015
12/25/20…
12/11/20…
11/27/20…
11/13/20…
10/30/20…
10/2/2014
9/18/2014
9/4/2014
8/21/2014
8/7/2014
7/24/2014
7/10/2014
6/26/2014
6/12/2014
5/29/2014
5/15/2014
5/1/2014
4/17/2014
4/3/2014
3/20/2014
3/6/2014
2/20/2014
2/6/2014
1/23/2014
10/16/20…
Date of Last update: 09/29/2015
0
1/9/2014
People Receiving Services
700
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.
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VT Department of Health
Department of VT Health Access
Total People Served in Hub and Total Number Waiting Over Time
3000
2500
# of People
2000
1500
Total Currently being served
Total Active Waiting
1000
500
0
Date of Last update: 09/29/2015
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Waivered MDs
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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
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Pivotal Question 2: Improve Quality of Care
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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
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Health Home Services Defined
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Comprehensive care management
Care coordination
Health promotion
Transitions of care
Individual and family support
Referral to community services
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Accreditation Requirements
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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
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Pivotal Question 3: Cost Effectiveness
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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..
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Pivotal Question 4: Reduce Diversion
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Decrease Diversion of Buprenorphine
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VT MAT Rules and other state regulations:
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Requires diversion Control Plans and use of Tox screens in larger OBOT practices
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Requires checking PDMP data base minimum 3x annually for OBOT providers
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Prior approval process thru DVHA, particularly for higher doses and mono-product
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“Pharmacy Home” assignment for Rx…
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Spoke staffing to support care coordination and enhanced adherence to care
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Destabilized patients referred to Hubs for enhanced structure
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Hubs utilize PDMP
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Significant increase in access to OTP’s with higher level of medication
management capacity
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Pivotal question 5: Regulatory constraints
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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”
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Summary
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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
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