Presbyterian Health Plan
For about 20 years, New Mexico has been at or near the top of the list of states with the highest annual rate of opioid deaths.1 In 2007, Presbyterian Health Plan staff recognized that OxyContin was among the plan’s top-prescribed medications, with significant variation in the amount and dosages of the drug that were being prescribed. Health plan leaders changed the drug formulary to significantly reduce OxyContin prescribing. Between 2007 and 2012, the health plan succeeded in reducing OxyContin prescriptions by 80 percent.2
But the opioid crisis continued to worsen. By 2016, the health system had suffered several sentinel events involving opioids, which set in motion an intensified effort to address opioid addiction. Administrative and medical directors, along with physicians trained in addiction treatment, formed the Presbyterian Substance Abuse Task Force to develop a multi-faceted plan to address the problem.
While the work of the Substance Abuse Task Force was underway, Presbyterian Health Plan received $3.5 million to design and implement an innovative care model targeting individuals with opioid dependence.
Developing and Sharing the Clinical Model
With the state allowance, health plan leaders developed a multi-faceted, multi-stakeholder approach to increase screening and treatment for substance use disorders. A multidisciplinary task force made up of medical directors, behavioral health specialists and addiction experts from Presbyterian Healthcare Services and medical directors and behavioral health and government program leaders from the health plan analyzed cost and utilization data and studied a range of existing clinical models for opioid use disorder treatment.
By the end of 2016, the team had developed a clinical model with multiple components and a strategic plan for operationalizing it. The team shared its findings and clinical model across the organization in department meetings and through written communications. Working with administrative and clinical leaders, the team also began to oversee the building of the operational infrastructure to support the initiative.
In 2017, the team launched the Integrated Substance Use Disorder and Community Collaborative Initiative, designed to engage patients any time they touch the delivery system.
The initiative takes an integrated approach to the opioid epidemic, involving primary care, behavioral health, emergency services and hospital care. Key aspects include the development of a universal screening tool for substance use disorders (SUD); widespread training in prescribing drugs that are appropriate for treatment, including buprenorphine; opioid stewardship to support standardized, evidence-based treatments; engagement and care coordination from peer support workers with lived behavioral health experience who have stabilized and are in recovery; and partnerships with community and faith-based organizations focused on recovery, housing and other non-traditional services.
Extensive Training Programs
The team identified clinical education as its top priority, launching a comprehensive campaign to train and educate clinicians and other staff on chronic pain, SUDs and medication-assisted treatment (MAT).
Presbyterian’s training programs or courses in SUD interventions include face-to-face education and computer-based learning modules addressing appropriate use of opioids, federal and state guidelines regarding chronic opioid therapy, the identification of aberrant drug-related behaviors and opioid use disorder, use of naloxone, use of universal screening tools, MAT for opioid use disorder, and motivational interviewing skills. Many offer CME credits.
In addition, the organization offers, at no cost, a federally approved buprenorphine waiver training program that certifies qualified providers to prescribe specific Schedule III, IV and V narcotic medications in settings other than an opioid treatment program.3 Presbyterian also makes this training available to prescribers from other community health care organizations in the state or in neighboring states.
In addition, special training is provided to all emergency department staff in the Presbyterian Health Services network on how to recognize and treat opioid use disorders in the emergency department, particularly how to initiate MAT before the patient leaves. As research shows the effectiveness of initiating MAT in the emergency department, this approach is spreading across the nation.
Community and Peer Partnerships
“In the past, our delivery system hasn’t always relied on connectivity with other providers in the community. The health plan has worked hard to forge partnerships with community organizations to form a stronger, more coherent network of services for our patients with SUDs.”
Gray Clarke, MD, Medical Director, Presbyterian Health Plan
The health plan has spearheaded a new focus on forging community partnerships for step-down and after-care for patients being treated for SUDs. This includes partnerships with faith-based organizations, recovery services, methadone clinics, respite care settings, family mental health services, housing groups and other non-traditional services impacting health.
In addition, the initiative included creation of a Peer Engagement Support and Coordination program, and the hiring and training of peer support workers, following firsthand experience by the health plan indicating that peer support is more effective in helping patients with SUDs than traditional care coordination.
Peer support workers are individuals in recovery and stabilized from their own substance use disorders and/or behavioral health experiences. With lived expertise in recovery, resilience and accessing care and support, these workers have a unique ability to engage with patients with SUDs. The health plan has hired and trained five peer support workers to date, and has educated the delivery system about their role and importance.
Peer support workers are found in inpatient settings, in the Ambulatory Intensive Care Clinic, and at two hospitals, with plans to expand their reach considerably. While patients may have a case manager at a local site such as a hospital or clinic, peer support workers coordinate care across the entire system and with community resources and organizations with whom Presbyterian Health Services partners, such as residential treatment programs, intensive outpatient services, resources for MAT, and other human service organizations such as faith-based groups or housing authorities.
By the first quarter of 2018, 154 providers or staff had received training in chronic pain management; 96 had completed the eight-hour buprenorphine certification course; and more than 120 had participated in Grand Rounds focused on pain and addiction. In addition, 28 physicians had been trained in identification of intoxication and substance use disorders by the U.S. Probation Field Support staff. Twenty open trainings on opioid best practices had been offered, and 24 onsite trainings to Presbyterian Medical Group practices. In all, more than 550 providers and advance practice clinicians had attended substance use disorder-specific training at Presbyterian Healthcare Services. Additional accomplishments include:
- Removal of Prior Authorization requirements for generic Suboxone
- Development of predictive analytics (AGC) to target at-risk populations
- Integrated Addiction Medicine Team touched approximately 1500 individual lives
- Telementoring model Extension for Community Healthcare Outcomes (ECHO) launched
- Peer Support co-located in Espanola
- > 300 providers and APCs attended substance use disorder specific trainings at Presbyterian
Additionally, by the second quarter of 2018, system-wide opioid prescriptions decreased by 16 percent, buprenorphine prescriptions increased by 50 percent and naloxone prescriptions nearly tripled.
1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
2. Alliance of Community Health Plans. Ensuring Safe and Appropriate Prescription Painkiller Use: The Important Role of Community Health Plans. Nov. 2012.
3. Substance Abuse and Mental Health Services Administration. Buprenorphine Waiver Management. Jan. 18, 2018. https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/training-materials-resources/buprenorphine-waiver
CASE STUDY: Collaborate to Improve Substance Use Disorder Treatment
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