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.
Frank Mazza, program director for the Hudson County Department of Corrections and its Community Integration Program, has used the tools of the Affordable Care Act to drive change for those leaving the corrections system, who are often chronically homeless and not in touch with a primary care provider. Hudson County has a Federally Qualified Health Center (FQHC) within the corrections facility, one of the few in the country. Hudson uses medication assisted treatment (MAT) to treat addiction, and engages clients in workforce training.
And yet, Mazza said, much depends on what happens after people leave. “Successful treatment for this population is reliant upon a uniform approach for health insurance, housing assistance, public assistance, healthcare navigation, and case management,” which historically has been lacking. “The role of re-entry should always be to heal that fragmented system.”
That’s what Mazza and McGreevey, in his role as chairman of the New Jersey Reentry Corporation
, have been trying to do. The nonprofit McGreevey chairs works closely with government agencies like Mazza’s to smooth the path to employment, health, and stability for those leaving the corrections system, many of whom landed there because of substance use issues. McGreevey advocates the use of MAT and drug courts to increase the chances of success, and pointed out that treatment costs far less than incarceration. It’s up to the system to create “seamless linkages” to connect people between stages of recovery, he said.
If care coordination challenges a patient who has insurance, a family, and a place to stay, imagine what it is like for someone recovering from heroin addiction who has none of these things—but who has a trail of warrants, unpaid bills, and chronic health problems. “A lot of our clients have hepatitis C, diabetes, HIV,” McGreevey said. “It’s a challenge to get the antipsychotic medications,” and other expensive therapies.
Mazza’s description of what happens in Hudson County is nothing less than what an ACO does, but without the advantages that designation would bring. It’s not enough, for example, to enroll people in Medicaid; those who have never used health coverage must be taught how. Mazza identified 27 “frequent users” of the system and used vouchers to put them in permanent housing; only 2 landed back in jail.
He warned the attendees that this is not easy.
“Whenever you try to develop a re-entry system at the local level, you find there are reimbursement variations across the systems, which discourage the coordination of care, they also encourage the duplication of services and unnecessary care. Components of care are not speaking to one another, which will impact the level of care. The most important piece of what corrections brings is understanding who that person is, and educating the various systems when they walk out of our jail as to need, and to how best to apply those systems to the person.
“But more than that, jails have a responsibility and understanding of the needs of their inhabitants, and [they] hold these systems accountable," Mazza said.
He has developed a proposal for a full ACO, which would be a public–private partnership based on the Hennepin Health model
in Minnesota. The proposal, which was provided separately to attendees, would aim to generate revenue to invest in a sober living center, to reduce unnecessary visits to the emergency department (ED).
Evidence Builds, but Will Payers Listen?
The American Journal of Managed Care®
) 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?”
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
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.