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Bringing Care Coordination to the Fight for Recovery From Opioids

Mary Caffrey
A symposium at Seton Hall Law School examined the role of care coordination and transitions in helping those with substance use disorder find success in treatment. Some experts say that managed care has not supported care coodination despite evidence that it works and ultimately saves money for health systems.
When naloxone is used to reverse an opioid overdose, that should not be the end of the story, but rather the beginning of a “continuum of care” that puts the patient in touch with medical and social services, a case manager, a place to stay, and a recovery coach who has walked in that person’s shoes.

Too often, that doesn’t happen, because of a fragmented healthcare system, and because payers ignore evidence that care coordination works and saves them money, according to experts from across law enforcement and healthcare. They gathered Thursday at Seton Hall Law School in Newark, New Jersey, for a daylong symposium, “Opioids: Care Coordination, Transition, and Engagement.”

While New Jersey does not have one of the absolute highest rates for opioid addiction, it listed last year among the states where heroin and opiate deaths were on the rise.1 The fight against opioid addiction, and the response to the arrival of fentanyl, has been bipartisan; the legislature overwhelmingly supported former Republican Governor Chris Christie’s creation of a 5-day cap on initial opioid prescriptions and requirements for insurers to cover initial inpatient stays without prior review. Thursday’s keynote speaker, New Jersey’s new Attorney General, Gurbir Grewal, made a point of crediting his predecessor, Christopher Porrino, for implementing these steps and for suing opioid manufacturer Purdue Pharma.

Yet, here and elsewhere the numbers remain staggering. Speakers, who included former Democratic New Jersey Governor Jim McGreevey, cited fentanyl as the “game changer” that demands a wholly different response to halt the death toll from drugs, which accounted for 64,000 deaths nationwide in 2016, including a 40% spike in New Jersey.2 Grewal unveiled a program called NJ CARES to better coordinate the anti-opioid efforts of his department, which include prescription drug monitoring, providing recovery coaches, and insurance fraud enforcement. But for an epidemic he called “unprecedented” in its scope, reach, and pace, dollars and programs are not enough, Grewal said. Saving lives requires everyone in the system to step outside their “comfort zones” and think creatively.

“Without prioritizing prevention, treatment, and recovery, we won’t see any gains,” he said. Both Grewal, a former county prosecutor, and Ocean County Prosecutor Joseph Coronato, a panelist, have shifted from the “name and shame” approach to tie-in social services and healthcare, connecting addicts with treatment. Coronato, whose county was ground zero for New Jersey’s epidemic, presented data for 2017 that showed his multi-pronged approach appears to have reduced overdose deaths by 21%, the first drop since at least 2013.

“We are making choices to put lives over stigma. We are making the choice to put lives over death,” Grewal said. “We have chosen to move outside our typical areas of responsibility.”

An ACO for the Re-Entry Population?
Care coordination—the need for a point person, either in the primary care practice or the health plan—to assist a patient in managing highly fragmented services, has been a recognized need in US healthcare for more than a decade. Groundbreaking work such as the Institute of Medicine’s Lost in Transition, documented the critical need for posttreatment planning for cancer patients, creating the rise of the nurse navigator.3 Work by the University of Washington on collaborative care showed how integrating behavioral health services into primary care would encourage patients with diabetes to seek care for depression, improving both their scores on mental health questionnaires and clinical measures for blood pressure and glycated hemoglobin.4

The question has always been: who pays for care coordination? CMS has created codes in the Physician Fee Schedule to encourage chronic care management in Medicare, and new payment models, notably the accountable care organization (ACO). But the experts who spoke at Seton Hall said care coordination has been slower to arrive for those addicted to opioids, despite obvious need.

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