MEDICATION ASSISTED TREATMENT

COMMUNITY OF PRACTICE

SUBSTANCE USE DISORDER

TREATMENT & RECOVERY SUPPORT SERVICES

Presentation & Discussion

February 15, 2018

WELCOME

Purpose of MAT CoP

To promote and support the successful implementation

of an integrated MAT approach in healthcare settings.

Objectives

1. Describe the levels of care available to treat

substance use disorders;

2. Identify substance use disorder treatment and

recovery support services and resources available in

NH; and

3. Compare MAT practice approaches to provide

and refer patients to treatment and recovery support

services.

MAT CoP Resources

• MAT Google Group To join discussions about MAT program development, email Rekha Sreedhara at

rsreedhara@jsi.com or Rebecca Sky at rsky@healthynh.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 Assistance Submit requests to the Center for Excellence:

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

Overview of

Substance Use Disorder

Treatment & Recovery Support Services

Evaluation

• Diagnosis

• Severity

• COD or Confounding Issues

• Readiness

• Level of Care

ASAM Assessment

Levels of Care for SUD Treatment

• Withdrawal Management

• Early Intervention

• Outpatient Services

• Intensive Outpatient

• Partial Hospitalization

• Residential Services

Medication–Assisted Treatment

• Office-Based Opiate Treatment (OBOT)

– Integrated in Medical Practices

– Stand-alone opiate treatment clinics • Buprenorphine

– Some Vivitrol

• Opiate Treatment Program (OTP) – DEA licensed

• Methadone – Some Buprenorphine and/or Vivitrol

Recovery Support Services

• Recovery Support Services – Services provided to an individual and/or

their families to help stabilize and support

recovery.

• Peer Recovery Support Services (PRSS) -

Non-clinical services designed to help

people achieve and maintain their recovery

provided by people with lived experience of

addiction and recovery.

Peer Recovery Support Services

• Telephone Peer Recovery Support Services: Regular telephone

check-ins that provide support, encouragement, and

information.

• Peer Recovery Coaching: Meetings with a trained peer coach

who assist individuals to develop and implement a recovery

plan.

• Wellness Activities: Group activities that enhance recovery and

wellness (e.g. yoga, meditation, arts, music, financial literacy).

• Mutual Support Group Meetings: 12 step groups, SMART

Recovery, All Recovery, Refuge Recovery, Veteran’s support,

family support groups.

Considerations

• Insurance coverage

• Language/cultural competence

• Location/transportation:

–Can the patient and their family easily access the

treatment facility?

• Family support

• Treatment history:

–How many past treatment episodes?

–Which levels of care were received?

Interim or Adjunct Services

• Encourage participation in PRSS (e.g. recovery

coaching, telephone recovery supports)

• Encourage participation in mutual support groups

• Encourage participation in other community-

based or faith-based programs supportive of

recovery

• Establish frequent phone/in-person check-ins

• Provide or refer for group and/or individual

counseling

Treatment & Recovery Support Resources

NH Statewide Addiction Crisis Line

1-844-711-HELP (4357)

Regional Access Point Services

Provide information, referral and clinical

support to people seeking SUD treatment

www.nhtreatment.org

Treatment & Recovery

Support Resources

Treatment & Recovery Support Resources

https://www.dhhs.nh.gov/dcbcs/bdas/d

ocuments/resource-guide-treatment.pdf https://www.dhhs.nh.gov/dcbcs/bdas

/documents/recovery-resource-

guide.pdf

Alice Peck Day Memorial Hospital

Multispecialty Clinic

• Presenter: Peter Mason, MD – MAT Prescriber

peter.mason68@gmail.com

• Location: Lebanon, NH

• Setting: Hospital-based

• Number of MAT Patients: Monthly census of 15-20

patients since 2005

DR. PAUL RACICOT

DR. PAUL FRIEND

DR. MELISSA HANRAHAN

COREY GATELY, MLADC,

CLINICAL PROGRAM COORDINATOR

LRGHealthcare Recovery Clinic Hillside Medical Park, Gilford

Franklin Regional Hospital, Franklin

LRGHealthcare Recovery Clinic

Hospital-based MAT

Clinic is operated out of our Occupational Health Offices on both campuses

Opened in October 2015 in Franklin location

Opened in December 2016 in Gilford location

3 providers

4 other staff members (MLADC, BSW, MA, Secretary)

Current Caseload

Current caseload is 225 patients.

We have seen 500+ patients since we opened.

We coordinate with approximately 40 different counselors/agencies.

We are often dealing with multiple counselors and multiple programs within those agencies.

Referral from Counselors

Counselors and agencies in community can make referrals after they have completed an evaluation.

Clients are required to remain in counseling, at some level, throughout their participation in our program.

Counselor/Agency provides referral information and the client calls for an appt. after that information is received.

Counselor/Agency decides the appropriate level of care to begin with.

Collaboration

MLADC and BSW staff maintain contact with counselors and agencies in the community through phone, email, and in-person collaboration.

We also utilize a “Confirmation of Counseling” form for some clients (complete and return to us).

Confirmation of Counseling form was developed after struggling to reach some of our “outlying” counselors.

Because of our volume, it is often difficult to coordinate with counselors. Increasing our staffing has helped.

Coordination is helpful in the ongoing process of determining what level of care is most appropriate for the client. And we encourage the clients to see our collaboration as supportive vs. punitive.

Looking ahead…

Beginning to develop avenues for induction of Suboxone in the Emergency Department and directly referring those patients to our clinic.

Evaluation of clinical need would be done by our staff and we would refer out to community agencies.

Until counseling can be established in the community, we would provide individual counseling in order to meet insurance requirements.

Goodwin Community Health Center

• Presenter: Kevin Zent, MD - MAT Prescriber

KZent@goodwinch.org

• Location: Somersworth, NH

• Setting: Federally Qualified Health Center

• Number of MAT Patients: 171 served since 2016

Discussion

Presentation & Discussion

MAT MANAGEMENT IN AN FQHC SETTING

Goodwin Community Health

MAT Program Goals

Risk reduction

Increase functionality

Offer options – Vivitrol and suboxone

Access multiple treatment modalities – recovery coaches, LADC therapy, IOP

Goodwin MAT History

2015 - Strafford Co. public health encourages providers to get buprenorphine waiver and start program

2015 – first Vivitrol

Drafted general policies/procedures based in part on Boston Medical Center

1/16 Applied for grants (1 federal, 1 state BDAS for uninsured), sought board approval

4/16 Started bup MAT program w 4 waivered providers and 1 MAT nurse coordinator, 2 LADC with 2 student LADC for IOP

Current Goodwin MAT Team

MAT nurse coordinator

MAT team MA

LADC (4)

CRSW (1)

Recovery coaches (2)

Bup waivered providers (6 – 4 physicians, 1 PA, 1 ARNP in waiting)

Prequalifiers

Primary care patient

Diagnosis of opioid SUD

Desire and ability for counseling/LADC

Able and willing to avoid polypharmacy with benzos, other substances

Current Workflow

WITS intake through CRSW

LADC intake for suitability, motivation

Round table presentation/discussion w MAT team reviewing use patterns, UDS, labs, ASAM criteria

Formulate initial MAT plan, can we treat in GCH program or does pt deserve higher level of care

Provider visit/nurse visit

MAT Provider Visit

Review and educate about options

- Vivitrol

- Suboxone

- Methadone clinic

- 28 day in pt rehab

- “Cold turkey”

MAT Provider Visit (cont.)

Education on program, consents

- Weekly visits until success x 1 mo (at least)

- Diversion concerns = auto dismissal

- Relapses will trigger tighter observation, not discharge

- Polysubstance use

- LADC and IOP attendance

Suboxone Treatment Phases

In house vs home induction

Post-induction – call or visit next day

Stabilization – weekly

Maintenance – if successful may gradually lengthen frequency to monthly

Monitoring Objective Data

UDS

Quick dip UDS vs send off

1:4 bup/norbup ratio

Consistency of levels

Randoms if 2 wks or greater

Oral swab vs observed UDS

Wrapper counts at visits

Random strip counts

LADC/IOP visit attendance

Monitoring NH PDMP

Vivitrol Treatment

Timing is of essence

Samples helpful

Naltrexone oral 50mg

Prior auths

Informed consent

Require LADC counseling

Pitfalls

Appropriate selection criteria

Attendance to counseling

Individualizing relapse plan w opioids

Relapse planning w stimulants, other substances

Diversion concerns

Minimal treatment for meth

** Response – weekly care management meeting!

Measuring Outcomes

GCH data pending

Retention rates in program – 3 mo, 6mo

Rates of opioid free UDS

Statewide Progress in

Developing MAT Programs

MAT Quality Planning Tool

Purposes:

To assess progress &

continual quality

improvement

To measure the

development of MAT

services across the state of

NH

To identify training &

technical assistance needs

Assessment Participation

• Assessments submitted between January 2, 2018 - February 2, 2018

• 13 MAT Programs

– 7 hospitals

– 5 health centers

– 1 opioid treatment program (OTP)

• Self-report

Testing the Tool

Tool Categories

• Program Development – Staffing – Training

– Policies and Procedures

– Other Infrastructure Needs

• Program Implementation – Staffing

– Training

– Patient Evaluation

– Treatment Delivery

MAT Best Practice Implementation

On average across the 13 programs, the

progress of implementing each best practice

falls between in development and developed.

In Development

Developed Regularly

Implementing

0 1 2 3

A1

A2

B1

B2

B3

C1

C2

C3

C4

C5

C6

C7

C8

C9

C10

C11

D1

D2

D3

D4

D5

D6

A1

B1

C1

C2

C3

C4

C5

C6

C7

C8

C9

C10

C11

C12

D1

D2

D3

D4

D5

D6

D7

D8

D9

D10

D11

D12

MAT Quality Planning - Average Status N=13

Not Developed In Development Developed Reg ImplemNo/None Some Most All

Pro

gram

Im

ple

me

nta

tio

nP

rogr

am D

eve

lop

me

nt

Program Development

0.00 1.00 2.00 3.00

A1

A2

B1

B2

B3

C1

C2

C3

C4

C5

C6

C7

C8

C9

C10

C11

D1

D2

D3

D4

D5

D6

MAT Quality Planning - Program Development Average Status N=13

Sta

ffin

g -

Tra

inin

g

Not Developed In Development Developed Reg ImplemNo/None Some Most All

Po

licy

an

d P

roce

du

res

Oth

er

infr

ast

ruct

ure

Program Implementation

0.00 1.00 2.00 3.00

A1

B1

C1

C2

C3

C4

C5

C6

C7

C8

C9

C10

C11

C12

D1

D2

D3

D4

D5

D6

D7

D8

D9

D10

D11

D12

MAT Quality Planning - Program ImplementationAverage Status N=13

Not Developed In Development Developed Reg ImplemNo/None Some Most All

Staf

fin

g -

Trai

nin

gTr

eat

me

nt

Init

iati

on

Tre

atm

en

t D

eliv

ery

Treatment and Recovery Support

Best Practice Implementation

• 20 treatment and

recovery support

specific best practices

• Areas of growth

potential with

application of today’s

content

Quality Planning Summary

CoP Meetings

Every other month on third Thursday from

2:15PM - 4:30PM

Next Meeting:

Thursday, April 19, 2018

2:15PM – 4:30PM

Coming Soon…

Second Edition of the

Guidance Document on Best Practices:

Key Components for Delivering Community-Based

Medication Assisted Treatment Services for Opioid Use Disorders in NH

What’s New?

Current Info on Prescribing, Legislative and Medications Changes

Updated Content on Treatment Planning, Drug Testing and Confidentiality

Reference List of Current & Relevant Literature

New Planning Tool to Assess MAT Development and Implementation

New Section on Inducting Patients onto Buprenorphine

Updated List of Resources

Continuing Education Credits

• 2 CEUs and CNEs available.

• Evaluation survey is required to receive

credits.

LINDY KELLER, MLADC REGINA FLYNN, BS

LINDY.KELLER@DHHS.NH.GOV REGINA.FLYNN@DHHS.NH.GOV REKHA SREEDHARA, MPH ANNA GHOSH, MPH REKHA_SREEDHARA@JSI.COM ANNA_GHOSH@JSI.COM REBECCA SKY, MPH ALLISON PIERSALL, BS RSKY@HEALTHYNH.COM APIERSALL@BISTATEPCA.ORG

SANDRA KIPLAGAT, MS MOLLY ROSSIGNOL, DO SANDRA_KIPLAGAT@JSI.COM MROSSIGN@CRHC.ORG PETER MASON, MD KEVIN ZENT, MD PETER.MASON68@GMAIL.COM KZENT@GOODWINCH.ORG