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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.
Evidence Builds, but Will Payers Listen?
The American Journal of Managed Care® (AJMC®) visited Coronato in early 2017, when Ocean County was poised to report its highest number of drug overdoses ever for a single year: 211 for 2016. Coronato was launching Blue HART (Heroin Addiction Recovery & Treatment), which allows addicts to report to a police station at appointed times to seek treatment and even turn in narcotics without fear of arrest. The program quickly expanded from 2 to 4 towns in Ocean County, whose death rates from drug overdoses rivaled the counties in southeast Ohio and parts of West Virginia. As Coronato shared with the attendees at Seton Hall, in the first year, 350 people came in and asked for help; as of January 31, 2018, Ocean County’s overdose death toll was 166 for 2017, even as naloxone deployments dropped 35% for the year.

The county formed an early partnership with RWJ Barnabas to use recovery coaches to counsel people with addiction when they reach the ED, to get them into treatment without interruption. Nurse navigators also ensure continuity. Last year, 560 people were helped this way. Connie Greene, MA, CAS, CSW, CPS, vice president for the RWJ Barnabas Institute for Prevention, said the presence of the recovery coaches didn’t just help the patients in crisis—they changed the mindset of the staff.

“The staff was not skilled about substance use disorder,” Greene said. “They used terrible language to describe them.”

Once a staff member told a recovery coach, “I got a loser for you in Bed B.” Green said the coach responded, “'I was once that loser in Bed B.' The stigma started to change.”

Ocean County’s success isn’t just about connecting people with recovery coaches and treatment. It also stems from tracking what worked and what didn’t. Recovery specialist John Brogan, a former drug user who once tried to hang himself, said the continuum of care is what makes the difference.

“Even if they do leave the treatment center—and they probably will leave the treatment center—the recovery specialist can snatch them up and get them to a meeting that night,” Brogan said.

Coronato’s results were not the only success reported at Seton Hall. Beth Tanzman, MSW, executive director of the Vermont Blueprint for Health, reported on initiatives the state has taken to keep that state’s drug overdose death rate below the rest of New England. Vermont was an early adopter of MAT, and created a structure similar to the patient-centered medical home to deliver coordinated care. Consisting of the “hub,” a specialized treatment center for complex addictions, and the “spokes,” the system of FQHCs, primary care physicians, and mental health providers who offer ongoing care, the system has nearly doubled the number of physicians prescribing MAT, and led to dramatic drops in reported opioid use among patients served by the system. [Note: Listen to Barbara Cimaglio, deputy health commissioner of the Vermont Department of Health, explain the strategy in an AJMC® podcast from March 2017.)

Terry L. Horton, MD, FACP, FASAM, chief of the Division of Addiction Medicine for Christiana Care Health Services in Delaware, reported not only better outcomes, but also savings. Christiana Care saw an associated rise of infections along with substance use disorder and designed an intervention to using peer-to-peer interviewing and partnering with a social worker for discharge planning. The intervention, Project Engage, identified 415 patients who were transitioned into addiction treatment, and saved approximately $3000 per patient.5 Christiana has also designed an opioid withdrawal screening tool and clinical pathway to keep the right patients on MAT.

Horton’s is one of relatively few studies involving care coordination and opioid or heroin treatment. A small feasibility study published in 2017 reported on a 4-part intervention given to 30 patients who showed up in the ED having misused prescription drugs. After 6 months, patients reported favorably on the quality of the intervention but didn’t report changing their behavior.6 A study by Jewell et al of 205 users of injected drugs, mostly heroin, found that residential treatment saved a health system $2.43 million over 6 years, despite a 32% relapse rate.7 Like the Christiana Care study, Jewell et al, saw an association between rising infections and substance abuse. A study just published involving the rapid increase in mental health care sought by members of the military and veterans—including for opioid misuse—in the ED setting suggests care coordination is poor.8 The first randomized controlled trial involving care coordination to reduce opioid-related ED visits found the savings for intervention participants was $3200 per person at the end of 12 months, and encouraged a longer-term study.9

However, Horton said in his experience, managed care companies don’t care about such evidence when deciding whether to pay for care coordination for substance use disorder. In fact, despite the emphasis on coordination in areas like oncology or diabetes, Medicare offers the worst-case scenario for seeking reimbursement in care coordination for substance abuse, Horton said. This occurs despite the documentation by the HHS Office of the Inspector General that a significant rise in opioid use among seniors came after the implementation of Medicare Part D.

Brogan credited McGreevey, Coronato, and local chiefs of police for coming up with common sense ways to promote recovery.

“Going into court and getting a warrant lifted because someone’s 6 months clean and sober … you see this magic happen,” Brogan said. “Define success—not dead, how about that?”

References
1. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017/ CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov
2. National Institutes of Health. Overdoes death rates. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Updated September 2017. Accessed February 23, 2018.
3. Hewitt M, Greenfield S, Stovall E. From cancer patient to cancer survivor: lost in transition. Washington, DC, National Academies Press, 2006.
4. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.
5. Pecoraro A, Horton T, Ewen E, et al. Early data from project engage: a program to identify and transition medically hospitalized patients into addictions treatment Addict Sci Clin Pract. 2012;7:20 doi: 10.1186/1940-0640-7-20.
6. Whiteside LK, Darnell D, Jackson K, et al. Collaborative car from the emergency department for injured patients with prescription drug misuse: an open feasibility study. J Subst Abuse Treat. 2017;82:12-21. doi: 10.1016/j.jsat.2017.08.005.
7. Jewell C, Weaver M. Soroi C, Anderson K, Sayeed Z. Residential addiction treatment for injection drug users requiring intravenous antibiotics: a cost-reduction strategy. J Addict Med. 2013;7(4):271-276. doi: 10.1097/ADM.0b013e318294b1eb.
8. Wooden NR, Brittingham JA, Pitner RO, Tavakoli AS, Jeffery DD, Haddock KS. Purchased behavioral health care received by military health system beneficiaries in civilian medical facilities [published online February 6, 2018], 2000-2014. Mil Med, 2018; doi: 10.1093/milmed/usx101.
9. Murphy SM, Howell D, McPherson S, Grohs R, Roll J, Neven D. A randomized controlled trial of a citywide emergency department care-coordination program to reduce prescription opioid related visits: an economic evaluation. J Emerg Med. 2017;53(2):186-194. doi: 10.1016/j.jemermed.2017.02.014.

 



 
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