mat in primary care: expanding access1viuw040k2mx3a7mwz1lwva5-wpengine.netdna-ssl.com/wp...mat in...

MEDICATION ASSISTED TREATMENT

COMMUNITY OF PRACTICE

MAT in Primary Care: Expanding Access

April 11, 2019

Disclosures

No individuals in a position to control content for this

activity has any relevant financial relationships to

declare.

WELCOME &

INTRODUCTIONS

Purpose of MAT CoP

To promote and support the successful implementation of

an integrated MAT approach in healthcare settings.

MAT CoP Resources

• MAT Google Group

To join discussions about MAT program development, email Adelaide

Murray at Adelaide_murray@jsi.com.

• Resources & Tools

Resources to support implementation of MAT programs can be accessed

on the Center for Excellence website:

http://nhcenterforexcellence.org/resources/community-of-practice-

resources/

• MAT Technical AssistanceSubmit requests to the Center for Excellence:

http://nhcenterforexcellence.org/center-services/request-ta/

Objectives

1. Describe strategies for overcoming potential challenges

to implementing MAT.

2. Identify available resources to support MAT

implementation.

3. Use workflow templates and protocols to support MAT

implementation.

4. Discuss systems level challenges related to MAT

implementation.

MAT in Primary Care:

Expanding AccessLinda Barton, RN, Care Manager, MAT

Shelley Friedman, RN, MSN, MBA, Clinic Manager

Dr. Brian Lombardo, Family Practice/Medical Director for Primary Care

Dr. Erin McNeely, Internal Medicine/Assistant Medical Director for Primary Care

Lauren Senn, Practice Director

Alice Peck Day Memorial Hospital, Lebanon, NH

Disclosures: We have nothing to disclose except that we love primary care.

Overview and Objectives:

Understand the potential of doing MAT in primary care.

Explore resources and pitfalls for implementation.

Introduce workflow templates and protocols.

A National Epidemic: How did we get here?

2016: 63,632 US drug overdose deaths

66% of those involved opioids

Rate of overdose deaths increased by 21.5% from 2015-2016

States with the highest rates of death due to drug overdose in 2016

- West Virginia (52.0 per 100,000)

- Ohio (39.1 per 100,000)

- New Hampshire (39.0 per 100,000)

- District of Columbia (38.8 per 100,000)

- Pennsylvania (37.9 per 100,000)

https://www.cdc.gov/drugoverdose/data/statedeaths.html

How Can we Help?

2015: Only 30% of SUD-specific programs (nationally) offer medications for opioid use disorder

The Primary Care Potential:

medication + brief intervention counseling = similar outcome as formal treatment program

Goals of Medication Assisted Treatment:

• Decreasing mortality

• Increasing retention in treatment

• Reducing medical and SUD treatment costs

• Reducing opioid overdose among patients in treatment

• Increasing abstinence from opioids

• Lowering a person’s risk of contracting HIV or hepatitis C

+ Meeting patients’ primary care needs

Barriers to starting our own MAT practice

1. Stigma

https://www.npr.org/2018/10/31/662009650/social-stigma-is-one-reason-the-opioid-crisis-is-hard-to-confront

2. Previous Behavioral Issues Surrounding Patients on Chronic Opioid Medications

3. Workload and Resources

1. Lack of Behavioral Health Support

2. Lack of Social Work Support

4. Training

1. Waivers- Cost and Time

2. Support Staff Education and Training

3. Behavioral Health Awareness

APD

• Intensive MAT & SUD Tx

Implementation process

• All staff education

• Ongoing mentorship

State stigma largely resolved

CHESHIRE

• Moms in Recovery

• PC: BH consult expansion

& MAT grant from FHC

• Established as Keene HUB

• Defined principles for BH

care improvement

• MFS reverse integration

project

• Stigma identified as key

barrier > active trainings

2019

MT ASCUTNEY

• Education & awareness

training

CONCORD

• Talks from expert groups

to help staff

• MAT implementation

Community Group

Practices

• Two embedded BH

specialists

• Two supervisors with

week long OUD training.

• Targeting staff

trainings

NASHUA

• BH integration pilot • Routine screening MH & SUD

• Embedded MH services

• Engaging PCPs in MAT

State stigma improving

DHMC

• Academic grand rounds

• IM, Hospitalist, FP, ED

Pedi section/in service

trainings

• Opioid Addiction

Treatment Collaborative

Efforts to Combat Behavioral Health Stigma at your D-HH

D-HH

SYSTEM(Responding Sites)

MANCHESTER

• Classes on Stigma at the nurse

and MA level.

• Needs to get to providers

Resource Allocation:

Education:

• Waiver Training

• Additional CME Days

• Staff Workshops

• Clinic Shadowing

• Certified Recovery Coach

• Mentoring Calls

Staffing:

• Per Diem Nursing Support

• Staff hours for MAT work

• Medical Records

• Scheduling Support

• Dedicated MA and RN

• Planning and Development

Resources!

DHHS:

Substance Abuse and

Mental Health Services

Administration

American Academy

of Addiction

Psychiatrists:

BU and UVM

Alice Peck Day

Primary Care

NH Foundation for

Healthy Families

5-state

mentoring

pilot

project

GRANT $

Mentoring

Resources

PCSS (Providers’ Clinical Support System)

Headrest

Templates and Protocols

Treatment

Needs

Questionnaire

Copyrighted under Creative Commons

Attribution-Non Commercial-No

Derivates 4.0 International License

Current State

For Patients:

Convenience

Reduced stigma

Cost

Comprehensive care

For Providers:

Satisfaction

Collaboration

Continuity

DK 50 years old -

• Started using at age 9 - sister shared drugs with her.

• Had been in treatment with Dr. Mason but disappeared.

• Returned when PCP started doing MAT.

• Complications of sepsis and spinal abscess, hospitalized.

• Has engaged in plan of care but continues to use, albeit less.

• Declines residential treatment because of 13 year old son.

• Son has behavior problems.

• No financial assistance - no clothes, no car, no money.

JK 25 years old -

• Long history of drug use since early teen years.

• Methamphetamine is drug of choice but also opiates.

• Inconsistently engaging.

• Last drug screen poly-pharmacy.

• Anticipating a visit RN spent hours trying to prepare an inpatient stay.

• Broad array of barriers

JM 46 years old -

• Long history chronic back pain after spinal abscess and surgery.

• Comes from dysfunctional family with history of addiction.

• On chronic methadone for pain and compliant for some time.

• Also on “benzos-attempted” wean.

• Decompensated—admitted several times to BB retreat.

• Started using IV again after someone stole his methadone

prescription.

• Admitted to program.

• Added Klonopin, increased dose of buprenorphine and changed it

to three times a day.

• Relatively stable and compliant with all aspects of care plan.

Initial MAT Visit

MAT Follow Up Visit

References

• The American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of

Medications in the Treatment of Addiction Involving Opioid Use, May 27, 2015.

• The American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of

Medications in the Treatment of Addiction Involving Opioid Use, May 27, 2015.

• Lee JD, Grossman E, DiRocco D, Gourevitch MN. Home buprenorphine/naloxone induction in primary

care. Journal of General Internal Medicine, 24(2):226-32. doi:10.1007/s11606-008-0866-8. Epub 2008 Dec

17. PubMed Central PMCID: PMC2628995.

• https://www.dhhs.nh.gov/dcbcs/bdas/documents/matguidancedoc.pdf

ADDITIONAL CASE STUDY DISCUSSION

QUESTIONS?

DISCUSSION OF FUTURE TOPICS

Harm Reduction & Diversion

CoP Meeting Schedule

Location: NH Hospital Association

From: 2:30pm – 4:30pm

June 13

August 8

October 10

December 12

Final Thoughts

• Utilize Google Group for questions, event/resource sharing,

and discussion!

• 2 CEUs and CNEs available

• Please hand in your evaluation!

Thank you for coming!

REKHA SREEDHARA, MPH ADELAIDE MURRAY

REKHA_SREEDHARA@JSI.COM ADELAIDE_MURRAY@JSI.COM

REBECCA SKY, MPH MELISSA SCHOEMMELL, MPH

RSKY@HEALTHYNH.COM MELISSA_SCHOEMMELL@JSI.COM

MOLLY ROSSIGNOL, DO FAAFP FASAM REGINA FLYNN, BS

MROSSIGN@CRHC.ORG REGINA.FLYNN@DHHS.NH.GOV

PETER MASON, MD

PETER.MASON68@GMAIL.COM

LINDY KELLER, MLADC

LINDY.KELLER@DHHS.NH.GOV