One Step at a Time MaineHealth’s Efforts to Respond to the Opioid Crisis Caring for Me December 12, 2018

MaineHealth Addresses the Opioid Epidemic Prescribing Workgroup Identified a common set of tools and processes to support safe prescribing practices for acute and chronic pain patients to be implemented across the MH System. Education Workgroup Developed recommended tools and content to educate prescribers and practice staff about: * Opioid use disorder and best practice for treating it; *best practices for acute and chronic pain prescribing; *Opioid use and alternatives for patients, families and the public Treatment Perinatal: Identified education and process standards (SnuggleME) to implement across MH system; Identified Hub and Spoke approach to treat pregnant women and babies. Treatment: Developed three-part treatment model relying upon behavioral health and primary care to provide MAT & behavioral health supports to patients with opioid use disorder. Each subgroup developed a set of recommendations that was approved by the broader workgroup and brought to the System’s CMO Council and Board for final approval. Process was really important. Bottom up decision making allowed for crucial physician buy-in Learning collaborative supports implementation across the system.

Progress: Focus on Unnecessary Opioid Prescribing # Patients with ≥100 MME* per day at MaineHealth Member-Owned Practices** MaineHealth Epic Electronic Medical Record (2015 – 2017) 3-year rolling averages *MME=Morphine milligram equivalents **Data from practices at Franklin Community Health Network, Memorial Hospital and Southern Maine Health Care are not included, because these practices were not using the EPIC electronic medical record during the whole time period presented (July 2015 – December 2017).

Progress: Education & Communications 150 providers trained to provide Medication Assisted Treatment Training about Opioid Use Disorder, prevention and treatment for clinical teams Co-Hosting community discussions throughout service area Conference attended by 130 clinicians focused on IMAT Patient education materials

MaineHealth Board’s Focus on Treatment “By Sept. 30, 2017, and with support from Maine Behavioral Health, every MaineHealth local health system will actively provide Medication Assisted Treatment in one or more adult primary care practices for patients with opioid use disorder.” “By Sept. 30, 2018, MaineHealth members will have served 900 patients with OUD through hubs operated by Maine Behavioral Healthcare and primary care Patient Centered Medical Homes located in each local health service area.” Transition slide Katie will present the slide and Jerry will go from here By Sept. 30, 2019, MaineHealth members will have served 700 new patients with OUD through hubs operated by Maine Behavioral Healthcare and primary care Patient Centered Medical Homes located in each local health service area.

Primary care offices & integrated behavioral health clinicians: MaineHealth’s Treatment Model: Primary Care + Specialty Substance Use Services Hubs: Biddeford Springvale Portland Damariscotta Augusta Lewiston Brunswick Farmington Rockland PCMH Intensive Hubs Community-based behavioral health centers: Medical Evaluation & Screening Induction of IMAT Intensive Outpatient Treatment Stabilization Treatment Specialty Treatment Consultative Support for Intermediate& Primary Care Practices. PCMH Spokes: Patient Centered Medical Homes provide MAT and supportive behavioral health services for patients in maintenance phase and with support from behavioral health. Intermediate: Primary care offices & integrated behavioral health clinicians: Screening IMAT inductions & treatment Ongoing treatment for stabilization & maintenance phases PCMH Intermediate: North Conway Norway Belfast Patient Centered Medical Homes throughout the service area will provide treatment for stable patients This collaborative care model is based on treatment model recommended by successful Boston addiction specialists . This focuses on primary care. NAS is another population – same approach, with hubs being. PCMH Goal: Ensure that any patient within the MaineHealth service area has access to evidence-based treatment for Opioid Use Disorder.

MaineHealth Member and Affiliate Hub, Spoke, and Intermediate Locations Farmington Livermore Falls Augusta Belfast Norway North Conway, NH Rockland Lewiston Damariscotta Brunswick Portland* Sanford Biddeford *Portland Hub in development

Goal Met! Patients Served 10/1/17 – 9/30/2018 Local Service Region Hub IOP Services Hub Patients Total Served by Spokes Total Maine Medical Center / Maine Medical Partners McGeachey Hall provides IOP for dual diagnosis 131 218 349 Franklin Evergreen BH provides IOP and therapy 41 23 64 LincolnHealth Partnered with ARC Damariscotta & Brunswick for hub services n/a 98 Western Maine Health Care Partnering with Common Ground, Crooked River & Tri County for hub services 114 Pen Bay MBH EMBARK Rockland provides hub services 149 16 165 Waldo County General Working with MBH EMBARK Rockland 10 Southern Maine Health Care MBH hubs in Springvale and Biddeford 130 7 137 Memorial No IOP available 109 MBH Other ACT Team Services Total Patients Served Since October ‘17 Hidden costs of not doing this – tremendous. Endocarditis, NAS and other medical sequallae of addiction. And medical management of these patients. Also discuss the fellowship here. 1,056

The Investment MaineHealth has invested significant financial resources in developing these services Training, education and treatment support for uninsured patients Currently adopting new Opioid Health Home model across intermediates and spokes Source of revenue to support uninsured patients Hubs will follow suit Maine Behavioral Healthcare’s hub to open in January Expanded access to acute treatment in greater Portland Increased capacity for comprehensive primary care in primary care spokes

The Challenges Cultural Differences between community mental health programs and primary care Medical model not easily aligned with community recovery model (“client” versus “patient” Substance use services under-resourced Transportation, transportation, transportation Funding doesn’t support robust treatment model 42 CFR Part 2 creates significant barriers to aligned treatment Data collection and outcomes measures Need for better alignment between housing, employment/educational opportunities and treatment providers