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Medication Assisted Treatment- A Group Model

Improvement in Access, Wait Times, Provider and Patient Satisfaction

Eric Haram, LADC Haram Consulting

March 6 2017

Objectives

• Define current volumes seeking MAT in Maine, regional disparities and impact.

• Describe community health improvements from increased access to MAT.

• Exposure to strategies for improving MAT access and Pt through-put by using MAT groups for medication management.

Scope of Problem Heroin related death overdoses Maine and Nation

Source, National Data: USCDC; Multiple Cause of Death Files from the National Vital Statistics System, 2002-2013.

Heroin related death overdoses, Maine vs. Nation: 2002-2013

14 Source, Maine Data: Maine Department of Health and Human Services, Office od Research, Data and Vital Statistics

2.2

2.8

1.8

3.3

2.4

1.9

1.5

1.0

0.5 0.7

2.1

4.3

0.7 0.7 0.6 0.7 0.7 0.8

1.0

1.1 1.0

1.4 1.9

2.7

0.0

1.0

2.0

3.0

4.0

5.0

Maine

Nation

Drug Abuse Affecting Maine’s Babies

*Data%from%the%Office%of%Child%and%Family%Services%4

178$234$

295$

394$

526$

627$

710$

835$

976$ 995$

0%

200%

400%

600%

800%

1000%

1200%

2006% 2007% 2008% 2009% 2010% 2011% 2012% 2013% 2014% 2015%

Drug$Affected$Babies,$$born$2006>2015$

Drug%Affected%Births%

In$SFY$2015,$8%$of$all$babies$born$were$drug$affected.$$

In response to increasing opioid overdose deaths, the Maine Opioid Collaborative formed 3 Task Forces (Prevention, Law Enforcement and Treatment). •  . Convened in 2014 and 2015, the MOC Treatment Task Force was

guided by the following Statement of Purpose:

The goal of the treatment task force was to create recommendations for standards of care based on existing evidence, working collaboratively with other organizations and listening to the needs and innovations throughout Maine communities

What We Learned

• There is strong stigma against people who use drugs, and also against medication-assisted treatment (MAT)

• Medical providers are reluctant to get involved, often because of stigma and perceived lack of training and expertise

• Too many affected individuals have inadequate insurance and cannot afford treatment

• There has not been a comprehensive plan to expand treatment services, including MAT in the state-funded system, leading to extreme geographical disparities

• These disparities contribute directly to the increasing frequency of fatal overdoses

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2%

SAMHS Licensed Sites for MAT, 2015

SAMHS MAT by location, 2015

*“Buprenorphine%in%Maine”,%M.%Thompson,%A.%Crowley,%%D.%Cohen,%reports%published%online%–%Penquis%Regional%Linking%Project%

hYp://www.maine.gov/dhhs/samhs/osa/data/cesn/Heroin_Opioids_and_Other_Drugs_in_Maine_SEOW_Report.pdf%

•  112 Identified by State of Maine

•  43 confirmed prescribing

•  30 were primary care providers

•  Only 13 licensed SA Treatment agencies provide MAT!

•  Represents unplanned, geographic clustering of MAT services with a statewide capacity to serve 4300 pts.

•  1/7’th of the needed capacity for the estimated volume of untreated opioid dependence in Maine.

•  Those seeking treatment but unable to access it in Maine 25,000 to 30,000.

Poor Capacity to Meet Maine’s Demand MAT in Publicly-Funded SUD Treatment System: What We Learned

• MAT with FDA-approved medications offers best chance at recovery and stopping overdose potential

• The Federal Block Grant and Maine collect data on patient and program level wait times for all purchased addiction treatment services.

• Wait time data for treatment, with MAT, is an excellent predictor of community mortality rates from overdose.

Reduced Wait Times: Access to Medication Improves Engagement and Reduces Overdose Deaths

• Admission Conversion rates for opioid addicted clients are up 60% over baseline

0

5

10

15

20

25

30

35

Baseline25%

Post Implementation85%

5

29

20

34

Number attending first treatent session following Opioid MAT Implementation

There are Effective Models to Replicate

• Access to addiction treatment, integrated w/ MAT, results in decreased mortality rates from overdose

•  In Bath/Brunswick, where full array of treatment services-integrated with MAT, is available without wait list, there were no reported overdose deaths in 2015.

• However, other areas of the state where these services are not readily accessible have experienced rampant increases in the frequency of fatalities from overdose

EXAMPLE: Expansion of MAT in N. Cumberland & Sagadahoc Counties 2006-2016

OP Level 1 –D

OP and Psych

12-18 wks.

IOP Level II.1 –

D (300 pts)

(3-12 wks)

Ambulatory Detox PHP? Level II.5-D

ASAM PPC-2R Central Intake

Pt. Enters Continuum

HUB ALL

PROGRAMS HAVE MAT

Primary Care

SPOKE (45-90

pts)

Recovery Coaching

%%%%%E.%Haram,%%Addic_on%Resource%Center%at%Mid%Coast%Hospital.%%2015%

Outcomes: MAT Partnering with Law Enforcement and Recovery Coaching Sagadahoc and Lincoln County Sheriffs’ partner with treatment to divert drug and alcohol related offences from jail into treatment services.

% Re-Arrest Free As compared to national average of 55% (www.pewtrust.org/sentencing and corrections)

79%

%%%%%%E.%Haram,%%Addic_on%Resource%Center%at%Mid%Coast%Hospital.%%2010%

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Promising Practice: Specialty Programming for Mothers •  MAT, Healthy Generations/Snuggle ME

•  Cross-Departmental Coordinated Care for opioid dependent pregnant patients (Addiction Treatment, Women’s Health, Maternity, Pediatrics)

•  Systematic screening for Opioid Use/Dependence •  Improved Care- MAT, Reduced Stigma, more predictable deliveries

0%5%

10%15%20%25%30%35%40%

MCH% US

%

Na_onal%Childrens%2008%

Na_onal%Childrens%2010%

Na_onal%Childrens%2011%

Chicago%2009%

Chicago%2012%

EMMC%2012%

18.75%

31%36%

24%

16%

32%

23% 22%

$NICU%Average%Length%of%Stay%

$

$

0%

10000%

20000%

30000%

40000%

50000%

60000%

70000%

MCH% US

%

Na_onal%Childrens%2008%

Na_onal%Childrens%2010%

Na_onal%Childrens%2011%

Chicago%2009%

Chicago%2012%

EMMC%2012%

32493.75%

53723%62388%

41592%

27728%

55456%

39859% 38126%

Average%Cost%per%case%

E.%Haram%%Addic_on%Resource%Center%at%Mid%Coast%Hospital.%2015%

Managing Volume, Quality and Diversion: Retention, Increased Continuation = more patients!

0

10

20

30

40

50

60

70

80

Baseline Dec 8-Jan Feb Mar April May June July Aug Sept Oct Nov

Num

ber

of C

lient

s

Number of Clients Prescribed Buprenorphine - by Month

Managing Volume, Quality, and Diversion

• As volume increases access for new pts. is decreasing •  Bottlenecks in maintenance apt. schedule begin drive access for new patients.

• Deviation from practice standards to accommodate rapid pace •  Work-arounds that compromise pt. and public safety.

Pilot MAT Groups - Group Structure

• MD and clinician co-facilitator • Typical group size 8-12 •  90 min • Level system

•  Weekly x 4-6 ! Biweekly x 4-6 ! Monthly ongoing

• Membership of groups is fluid • Drop down a level to intensify treatment as closer monitoring needed • Patients may arrange a different group that week if they have a

scheduling conflict

Typical MAT group session

•  Announcements •  Individual check-ins •  Problem Focused, counseling and coordination of care •  Check in sheet serves as treatment plan •  Co-facilitator reinforces recovery skills and acts as scribe •  Other patients share suggestions, common experiences •  Psycho-education woven in throughout •  Meet with patients outside of group as needed to discuss sensitive issues/ co-

occurring psych symptoms •  Billed as a series of individual appts (CPT 99212)

Business Case MAT Groups

• Used PDCA cycles to pilot one group for 8 wks. •  Better use of multidisciplinary team approach •  Consistent application of standard of care

• Replicate intervention with two 1.5 hour groups per week. •  2 groups per week takes 12 hours per month vs. 26.5 hours per month for MD to

see same case load individually. •  2 groups per week absorbs 112 encounters per month. •  Increase monthly average from 8 to 16 inductions. •  Increase monthly average from 2 to 7 psychiatric evaluations. •  Will result in increase revenues in the amount of $41,000.00 per year-NET.

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MAT Groups: Improved safety, efficiency and satisfaction

Improvement$ ConLngencies$Documenta_on%a%breeze% Making%sure%to%share%with%full%

team%Codfacilitator%helps%keep%things%organized;%Urines,%Pill%Counts%

Must%be%shared%among%team%members.%

Codfacilita_on%avoids%physician/team%split%%

Bolus%of%pa_ents%to%pharmacies%

No%lost%_me%to%nodshows,%late%pa_ents%

Size%of%groups%can%be%inconsistent%%

MOC Treatment Task Force Members

Name$ PosiLon$ AssociaLon$Eric%Haram%%Co+Chair% LADC,%Owner% Haram%Consul_ng%Patricia%Kimball%%CodChair% LADC,%CCS,%Program%Director% Wellspring%Peter%McCorison%% LCSW,LADC,Program%Director% AMHC%Bob%Fowler% LCSW,CCS,%Execu_ve%Director% Milestone%Founda_on%Merideth%Norris% DO% Grace%Street;%Private%Prac_ce%Vinjay%Amarendran% MD,%Addic_onologist%% Acadia%Hospital%Mark%Sholl% MMC/ERMD% Maine%Medical%Steve%Diaz% MD,%FAAFP,%FACEP,CMO% MGMC,%Augusta%Patricia%Hamilton,% FNP,%Director%of%Public%Health% City%of%Bangor%Lisa%Letourneau% MD,%MPH,%Execu_ve%Director% Maine%Quality%Counts%%David%Moltz% MD,%FASAM% Mid%Coast%Hospital/%(ARC)%

Noah%Nesin% MD,%FAAFP,CMO% Penobscot%Comm%Health%Care%