1. 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

2.  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

3.  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

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

5.  18 months; 17 clients  Criteria  18+  Chronic alcohol misuse  2 Emergency Dept (ED) visits last 2 months  Not currently using opiates The Pilot

6. 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

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

8. 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

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

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

11.  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

12. New MAT Services IMAT

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

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

15.  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

16.  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

17.  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

18. Data & Outcomes

19.  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

20.  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

21.  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

22. 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: * 10/02/15 - 10/10/151320001218 6/01/15 -10/10/1512431853311185 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 6/01/15 - 10/10/15185947553221433

23.  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)

24.  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 10.23.15

26. 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

27. Policies & Procedures

28. IMAT Electronic Health Record Procedures

29. Electronic Community referral form

30. San Mateo Medical Center Referral Procedures

31. IMAT Job Duties at San Mateo Medical Center

32. IMAT Transportation Challenges: Proposal

33.  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

34. Thank you! Q & A