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

What is the Hub and Spoke? It is designed to treat opioid use disorder as a chronic disease under the Vermont Blueprint for Health Main goal is to prevent overdose and deal with the opioid crisis in the state It divides Vermont into regions by counties Each region has a specialized addiction center of expertise known as the HUB that is an opioid treatment program (OTP) Each Hub is connected to all the waivered buprenorphine doctors’ offices known as SPOKES All SPOKES have a dedicated MAT (medication assisted treatment) team A MAT team is made of 1 registered nurse and 1 licensed clinical social worker for 100 patients on buprenorphine under Medicaid

Hub and Spoke Chronic disease model Harm Reduction and long term treatment are major foci Linkage to Primary Care for all with Opioid use disorder Based on Team model with staffing to coordinate care

Vermont Population 626,562 Northwestern Hub 2. Farwestern Hub HowardCenter Chittenden Clinic Chittenden, Addison & Grand Isle 2. Farwestern Hub BAART Behavioral Health Services Franklin & Grand Isle 3. Northeastern Hub 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

HUBS Began as methadone programs (OTPs) in 2002 Become HUBS in 2013 when system was created Added buprenorphine to treat opioid use disorders in 2013 Added naltrexone in 2015 Full array of services-medical evaluations, psychiatric services, on site counseling, drug testing, case management Staffed with Addiction Specialists- Board Eligible or Certified Each Hub has flexibility to choose how they want to structure themselves under our state guidelines

HUBS Open access to services Referrals come from Department of Corrections Criminal Justice System/ Drug Courts Regional Rapid intervention/court diversion programs Department of Children and Families Post hospitalization for overdose or injection related medical conditions Pain clinicians Residential programs for aftercare Obstetricians

HUBS Serve as referral center for SPOKES in the regions Collaboration between HUBS in different regions Higher level of service with daily dosing of medications On site urine testing On site counseling and groups Address mental health issues Address medical issues, especially pain Conversion to methadone if needed from buprenorphine

HUBS Serve as induction centers for buprenorphine for SPOKES Induct, stabilize and maintain on buprenorphine Earn take homes and reach a need for a lower level of care Connect patients with primary care providers (PCP) for general care Transfer patients to providers who prescribe buprenorphine (may be PCP)

HUBS Provide educational resources and leadership to the community Provide on site and phone consultation to medical and psychiatric providers Train physicians on substance use disorders Refer to next level of care-Intensive outpatient or residential programs-for higher need patients Serve as a safety net for all people with opioid use disorder so they don’t lose their treatment due to ongoing drug use or aberrant behaviors

HUBS Dedicated to meeting Meaningful Use standard All people are assessed and counseled/referred for: Tobacco use (99% of OUD patients smoke!!) Blood pressure measurement Weight issues and nutritional counseling Depression with PHQ-9 and anxiety with BAI Prescription Monitoring system check HUBS have met NCQA standards All are CARF accredited

HUBS Medicaid and most commercial insurers cover HUB services For uninsured, State ADAP grant covers services with an attempt to get all enrolled with insurance Standard monthly reimbursement is a bundled rate for at least one medical service and one clinical service per month Enhanced monthly rate is the standard rate with an additional clinical service which can include a “health home” encounter listed as comprehensive care management, care coordination, health promotion, transitions of care, individual and family support, or referral to community services

HUB medications Methadone is included in the bundled rate Buprenorphine is billed separately and paid outside of the HUB rate Suboxone Film is preferred Prior authorization needed for mono product, combo tablets or doses over 16 mg Offer every other day double dosing or triple dosing with buprenorphine to reduce travel. Enacted rules to make sure med was fully absorbed after 5 minutes with witnessed dissolving Naltrexone is offered and billed outside the bundled rate

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

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

MAT (Medication Assisted Treatment) Team Cornerstone of the SPOKES effectiveness Many buprenorphine providers had declined to increase the number of people they treated due to the extra work involved in caring for those with OUD Consists of 1 each fulltime equivalent registered nurse and licensed clinical social worker Funded under Vermont’s Blueprint for Health, Chronic Care Initiative known as the Care Alliance for Opioid Dependence Pays for the services of both people per 100 buprenorphine patients enrolled in Medicaid

MAT (Medication Assisted Treatment) Team Some teams are embedded in the practice Many teams visit practices, meet patients at alternative sites, or speak on the phone Play a huge role in the patient’s care Provide community education and outreach to local medical providers who may be considering buprenorphine prescribing

Registered Nurse Involved in prescription management-PA process, med renewal, checking Prescription Monitoring System Manage the call back procedure, counting films, calling pharmacies Help with management of drug testing Promote coordination of medical services with buprenorphine prescriber Help the physician manage the panel of patients and educate

Licensed Clinician Master’s level in social work, psychology, drug/alcohol, or counseling Provides brief counseling or referral to more intensive services Provides group counseling Provides some clinical case management Provides prescribers with a “reality check” in managing the patient’s clinical stability Make referrals to the HUB if unstable Coordinate intake of stable patients from the HUB into the SPOKE

MAT team Limited to Medicaid funded patients Prescriber needs to have a minimum number of patients for it to be an effective use of time, i.e. 10 or more With MAT team, many prescribers have increased closer to the limit of their waiver Many new prescribers have enrolled due to MAT team services NO COST!!! to the practice to have MAT services Mirrors number of Community Health Team members for Diabetes around the state

Improved access to care

HUB vs SPOKE How to decide where to go for treatment? Needed a triage tool that would guide the physician in determining the level of service needed With buprenorphine in HUBS, it was no longer necessary for a person to only get buprenorphine in an office based system

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) topics- legal, work, social, psychological, medical, drug use

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

TREATMENT NEED QUESTIONNAIRE © YES NO Are you motivated for treatment? 1 Are you currently going to any counseling, AA or NA? Do you have 2 or more close friends or family members who do not use alcohol or drugs? Do you have a partner that uses drugs or alcohol? Are you a parent of a child under age 18? If so, does your child live with you? Is your housing stable? Do you have a reliable phone number? Are you employed? Do you have access to reliable transportation? Did you receive a high school diploma or equivalent ( complete 12 yrs of education)

TNQ scoring Low scores of 0-5 We thought any provider could deal with this person in an OBOT Spoke Score of 6-10 Any OBOT Spoke provider with on site behavioral health program and access to an addiction specialist as a mentor Score of 11-15 Needed Hub level or addiction specialist with resources at hand such as counseling, drug screening, and admin help Score of 16 or higher Hub level However, lower scores could be at a Hub and move to a Spoke over time if on bup (or methadone for pain)

TNQ Most valuable at initial contact and not designed to measure progress over time Gives the provider a “snapshot” that requires further questioning at intake Can be given to patient to answer on own and then handed to provider May be administered by admin staff but needs to be evaluated further by provider or trained personnel

Validity Many of the items have been shown to be predictive of stability in treatment These items were given scores of a 2 Intravenous drug use Cocaine use Benzodiazepine use Alcohol use Chronic pain Previous success in medication assisted treatment program

Validity Rest of the items added to look at issues that will impact decisions on treatment location and were given scores of 1 Employment and education Psychological issues Medical issues Family and social supports Legal issues, especially drug dealing Travel and access issues Motivation

TNQ copyrighted Copyrighted under Creative Commons Attribution-Non Commercial- No Derivates 4.0 International License. If used must: Attribute it to authors (Brooklyn and Sigmon) No commercial use or distribution without permission No changes to be made We agree to give you rights to use this in your work and to share it amongst your organization but not to release it to anyone outside of your organization or group with whom you are working. The Creative Commons disclaimer on the bottom of the form must not be removed or altered.

OBOT Stability Index Developed By Ben Nordstrom, MD while at Dartmouth Designed to assess for ONGOING stability in the SPOKES Can be used by MAT team and used to decide if more services are needed in the SPOKE or a referral to the HUB is needed

Learning Collaborative Headed by Mark McGovern, Ph.D. Dartmouth College Geisel University of Vermont College of Medicine VT and NH Addiction specialists VT ADAP Met to agree on topics needed for improving the quality of care in the HUBS and SPOKES Attended by staff and providers “Addiction 2.0 and 3.0”

LEARNING COLLABORATIVE Each entity had specifics measures to report on at each session to measure progress toward goals such as: waiting list reductions retention in treatment responses to drug using behaviors psychological assessments reducing diversion assessing dose adequacy care coordination Mentoring by addiction experts is KEY

Med-o wheels Purchased from vendor Epill.com Used for pregnant women originally for buprenorphine tablets Alarm alerts when to take the medication Tamper resistant and has clear view from behind of pills in the wheel Up to 28 days of medication can be loaded in the wheel

Telehealth and wheels New SAMHSA grant allowed purchase of 30 wheels for both buprenorphine and methadone tablets Reduces travel to clinic Allows for remote areas to get treatment for OUD Can combine this with video conferencing for counseling and medical visits

Telehealth and wheels New State of Vermont telehealth grant will allow for observed dosing outside of the clinic with store and forward video feed of person taking dose from the wheel. Will reduce risk of diversion Makes callbacks easier Can add videoconferencing to the service provided

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