Implementation of Long Acting Naltrexone: Pitfalls & Progress 12 th Annual Statewide Conference: Integrating Substance Use, Mental Health, and Primary Care Services Mary Taylor Fullerton, MFT Matt Boyle, CADC II

 Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose.  Mary Taylor Fullerton; San Mateo County Behavioral Health & Recovery Services  I have no financial relationships to disclose  I will not discuss off label use and/or investigational use in my presentation 2 Disclosures Implementation of Long Acting Naltrexone: Pitfalls & Progress Mary Taylor Fullerton & Matt Boyle

 Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose.  Matt Boyle; San Mateo County Behavioral Health & Recovery Services  I have no financial relationships to disclose  I will not discuss off label use and/or investigational use in my presentation 3

Outline Pilot background Program Implementation Successes & Challenges Lessons Learned Data / Outcomes Policies & Procedures Next Steps

 18 months; 17 clients  Criteria  18+  Chronic alcohol misuse  2 Emergency Dept (ED) visits last 2 months  Not currently using opiates The Pilot

Outcomes   Alcohol cravings & Urge to Drink   Emergency Dept. visits –  6 mo pre Pilot - average 5.8 ED visits  6 mo post Pilot - average 0.2 ED visits   Drinking Days per month  6 days - At start of Pilot  0.4 days – After 2 months of Pilot The Pilot

Outcomes  Increased stable housing  Increased behavioral health service utilization  Some participants employed Client story: Pete The Pilot

Collaboration between:  Health Plan of San Mateo  Behavioral Health & Recovery Services  Horizon Services – Palm Avenue Detox  HealthRight 360; MAT / PC Clinic  Voices of Recovery of San Mateo Pilot to Program

System wide Goal: any door… Medication Assisted Treatment IMAT Team Primary Care Interface MAT BHRS Clinics MAT / PC Clinic NRT Clinic

System wide Goal: any door… Medication Assisted Treatment IMAT Team Primary Care Interface MAT BHRS Clinics MAT / PC Clinic NRT Clinic

 Behavioral Health - Alcohol & Other Drug Services  BHRS Supervisor  BHRS Analyst  BHRS Case Manager / Assessor Specialist (5)  BHRS Benefits Analyst  Behavioral Health – Primary Care Interface Team  MAT MD  BHRS Case Manager / Assessor Specialist (4) BHRS Implementation

New MAT Services IMAT

 Identifying population  Hiring passionate staff  Comprehensive Training  Motivational Interviewing  Trauma Informed Care  Strength Based Case Management  SBIRT; ASAM Dimensions Implementation Successes

 Promoting MAT amongst providers  IMAT Vehicles  Emergency Dept. integration  Shift huddles  Referral process  Data sharing  Ct success stories Implementation Successes

 Clinic timing  Learning Hospital system  Promoting MAT amongst providers  Establishing procedures & policies  Building from ground up (+ / -)  Probation partnering  Beds, beds, beds …. And housing Implementation Challenges

 Primary Care Clinic Integration  Client Care ownership  Continuity in referrals  Staffing busy ED  Tracking trends  Removing Barriers  Integration  Hands OFF vs. Warm Hand Off  General [outdated] attitudes towards SUD - stigma Implementation Challenges

 Importance of being a great partner  The critical non-crisis hours  Collaborative care & Communication  The warm handoff  Everyone is motivated for something  Clients & partners Early Lessons Learned

Data & Outcomes

 Basic demographic info  Insurance (for HPSM)  Referral Source  Housing status  Frequency to ED, “High Utilizer List”  Cost Utilization (to come w/ LEAN)  # Connected to services or referred to treatment  # Receiving injection  MD: Vitals, Urge to Drink, Drinking Days Data collected

 Outreach and engagement  Referral to care providers  SUD Assessment for inclusion in MAT  Improvement in physical and psychiatric health  Reduction in urge to drink (Urge to Drink Scale)  Reduction in alcohol consumption (Drinking Days)  Reduction in utilization of emergency services  Increased utilization of primary care services  Housing status Outcomes Measured

 New program codes in Electronic Medical Record  AD BHRS MAT Episode, designated Service & Discharge Codes  Excel Spreadsheet “Client Tracker”  End of Shift Reports at ED/PES  HPSM “High Utilizer” / cost utilization list  Multiple EMR research  Monthly Quality Improvement Committee (QIC)  Review High Utilizer lists of the ED, PES, and other systems, create engagement plans.  Case presentations highlight barriers, gaps and service needs. Collection Methods

Weekly Data Reporting: San Mateo Medical Center LEAN Reports IMAT Referrals SMMC EDSMMC PESCJ/LE/Prob.Call CenterAOD TxInnovative Care Clinic Other Community Refl. TOTAL Week of: * 10/02/ /10/ /01/15 -10/10/ IMAT Outcomes Total Referred Active Cases Outreach / Engagement Not Interested in Services Engaged & Referred to Provider Waiting on Dr. appt. Have Received Vivitrol IM Number of Injections 6/01/ /10/

 344 Referrals  140 Active Clients  In Outreach / Engagement or Case Management phase  16 unique clients  total of 40 Vivitrol injections  32 clients waiting on a doctor's appointment  While we wait for MAT clinic to open Outcomes: 6/01/15 – 10/23/15 (pre-HR360 clinic)

 In nearly 5 months, only 1 of 16 Vivitrol clients has had subsequent alcohol-related ED/PES visit  Five of our initial IMAT clients have completed 90 days of residential AOD treatment!  3 of the 5 were high utilizers of emergency services  ED & PES Shift Huddle Report Outs Data / Outcomes as of

Client stories: Erik  Ranked #3 on HPSM priority population “High Utilizer" list; over $103,000 in health care costs in 2014 alone  Not including several visits to other ED’s and jail  Since July 2015, has not visited the ED, PES or jail  using PC and MH clinics to meet health care needs  Will receive 5 th Vivitrol injection next week  Scheduled to graduate from 90 day treatment program 11/09 Outcomes

Policies & Procedures

IMAT Electronic Health Record Procedures

Electronic Community referral form

San Mateo Medical Center Referral Procedures

IMAT Job Duties at San Mateo Medical Center

IMAT Transportation Challenges: Proposal

 On-boarding new clinic  Streamlining referral & communication process with contracted partners  Opioid Use Disorders  ASAM Criteria, dimension ratings  Prepping for Drug Medical Waiver  Adding billable components (Case Management, Withdrawal Management) Next Steps

Thank you! Q & A