1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Improved access to care

22. 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

23. 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

24. 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?

25. 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)

26. 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 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)

27. 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

28. 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

29. 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

30. 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.

31. 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

33. 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”

34. 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

36. 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

37. 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

38. 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

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