The New York State Office of Alcoholism and Substance Abuse Services (OASAS), as a recipient of a State Opioid Response Grant (SOR) from the Substance Abuse and Mental Health Services Administration (SAMHSA) put out a grant with the objective of providing funding to provider networks to assess current clinical and program workflows and practices that impact access, engagement, retention, and access to Medication Assisted Treatment (MAT). The grant funding is intended to support programmatic restructuring, implement best practices for the treatment of opioid use disorder (OUD) and achieve fiscal sustainability.
In October 2019, Coordinated Behavioral Health Services (CBHS) and Coordinated Behavioral Care (CBC) Independent Practice Associations (IPA) were awarded funds to develop initiatives that, in collaboration, were synergistic and complementary of the stated mission of the grant described above called the OASAS Behavioral Health Care Collaborative (BHCC) MAT Expansion Award.
CBHS IPA, is comprised of 30 non-profit, community behavioral health (BH) and disability service providers, and 59 affiliates. CBC IPA is a provider-led organization of 50+ community BH agencies across the five boroughs. Both IPAs are dedicated to improving the quality of care for Medicaid beneficiaries with serious mental illness, chronic health conditions and/or substance use disorders.
The region CBHS providers serve continues to struggle with overdose death rates higher than the statewide average. Five out of the seven counties we serve have a death rate higher than the 2018 statewide average, and all counties’ death rates either increased or were flat between 2017 and 2018. From 2016-2017, the Hudson Valley region saw an increased overdose death rate in Dutchess, Orange, Sullivan, and Ulster counties. Putnam, Rockland, and Westchester rates stayed flat or decreased. The region has also seen the Opioid Use Disorder (OUD) epidemic shift toward synthetic opioids with such deaths increasing 135% from 2016-2017. Since 2017, the region has improved in reducing OUD-related hospitalizations, however, this progress has been inconsistent particularly in Dutchess County where the rate of ED visits for OUD is higher than the statewide average. Sullivan, Ulster, Dutchess, and Orange counties had the four highest rates of OUD deaths, when the rate across the state for counties outside of NYC dropped. Many socioeconomic factors in the region compound this, such as higher than average rates of unemployment, housing insecurity, and individuals skipping medical care due to costs. The region also has significantly higher rates of poor mental health (MH), depressive disorder, and poor physical health.
In NYC, while rates of opioid overdose, related emergency department (ED) visits and hospitalizations in the rest of New York State have outpaced those in New York City (NYC), overdoses in NYC have skyrocketed, with opioid-involved overdose deaths nearly tripling since 2010. In 2018, 892 people in NYC experienced overdoses related to opioid pain relievers, 360 overdosed from heroin, and roughly 25,000 unique clients were admitted to OASAS-certified chemical dependence treatment programs for any opioid. The rate of ED visits for opioid overdose in NYC was 26.7 per 100,000 residents in 2018 and 25.9 per 100,000 in 2017. The Bronx is a particularly high-need community, with the highest poverty rate (28%) and the highest rate of fatal opioid overdoses (31.9 per 100,000 residents) in NYC. In 2017, 60% of opioid overdose fatalities in the Bronx were among the Latino population, reflecting the borough’s highly diverse population and demonstrating the critical need for opioid treatment services that meet the area’s language needs. In the Bronx, almost 60% of individuals over the age of five speak a language other than English at home, most frequently Spanish. Central Harlem (21.8 per 100,000) and Washington Heights-Inwood (20.2 per 100,000) also have rates of opioid-related deaths higher than the city average (16.4 per 100,000). East Harlem had the highest rate of opioid overdose death of any NYC neighborhood, increasing from 32.1 per 100,000 in 2017 to 50.4 per 100,000 in 2018. CBC understands its role as a centralized and coordinated provider-led entity in the identification, referral, and outreach/engagement of individuals with OUD. CBC’s network includes hundreds of clinics and treatment programs, care coordination, recovery, and social service providers, including 144 SUD treatment programs and 14 OASAS programs, including OTPs and CD-OP, available in a wide range of languages.
It is, therefore, a natural partnership for CBC and CBHS to work together on this initiative in a joint manner. Over the next year, CBC and CBHS will develop different but complimentary approaches for improving our network’s practices to increase same day access, initiation of Medication Assisted Treatment (MAT), and continuity of care from acute to community settings.
CBHS has developed a program model, CBHS MAT-Paths, that includes multiple treatment paths in order to address the complex needs of the population served and will be packaged for replicability, fidelity, and contracting with managed care plans. CBHS will work with providers to implement this new program across the network and ensure progress is being made to turn the tide on OUD. Each program strategy includes the following key components:
Implement and Extend Peer Support: CBHS will utilize peer specialists to engage with and support recipients from inpatient hospitalization and detox to community connection and successful reintegration and participation in treatment. Peers are a primary intervention which improves patient adherence with MAT.
Expand Referral Resources and Infrastructure: CBHS has already established infrastructure to support referrals among our network partners and increase referral efficiency and timeliness for our members, clients, and partners. CBHS will facilitate same day access to services and use CBHS as a hub to connect individuals to immediately available treatment services and ensure prompt initiation of MAT.
Build an innovative MAT-specific bundled payment model for CBHS OUD Providers: CBHS has entered preliminary discussions with managed care partners to develop a bundled payment arrangement for an episode of treatment for OUD. A bundled payment methodology would impact program sustainability and reward those in our network who can succeed in generating outcomes, including reductions in hospitalizations and mortality rates related to opioid use and improved overall health, wellbeing and quality of life. CBC’s goal will be to streamline services by creating capacity for same-day access and provide support for individuals as they transition from acute settings to community-based providers. In order to ensure that providers new to, and those expanding, delivery of MAT services deliver high quality services, CBC will offer a series of Learning Collaboratives (LC), built on the principles of Project ECHO (Extension for Community Healthcare Outcomes) training. These learning sessions will aim to increase the number of providers/prescribers who are proficient in and capable of assisting individuals with OUD/SUD access appropriate interventions, such as MAT.
As a technology innovator, CBC intends to identify and evaluate technology solutions to improve adherence to treatment and access to care for individuals already in treatment. According to a 2018 meta-analysis of the use of telehealth in Opioid Agonist Therapy (OAT) (of which buprenorphine is one type), “Patients with telehealth-delivered OAT had a retention rate of 50% at one year of treatment compared to 39% for patients with in-person OAT.” CBC will review existing technologies and explore the feasibility and cost of using a solution across the network. Providers, including those trained through CBC’s LC, will be able to participate in a pilot project that utilizes new Technology Assisted Care (TAC) or telehealth capability.
By joining forces, CBC and CBHS together, will reach over 80 community-based providers across NYC and the Downstate NY region, working to increase access to MAT and greatly enhance a provider’s ability to better meet the needs of their clients with OUD/SUD.
