The second white paper issued this year by the American Association for the Treatment of Opioid Dependence (AATOD) focused on coordination of care. Essential steps include integrating service delivery between opioid treatment programs (OTPs) and DATA (Drug Addiction Treatment Act) 2000 practices, and between OTPs and primary and behavioral health services.
In “The Opioid Treatment Program as a Hub for Coordinated Care,” Kenneth B. Stoller, MD, and Mary Ann C. Stephens, PhD, write about the ways OTPs can provide more services. Sometimes this amounts to counseling and consultation only. It’s a new paradigm.
OTPs can be key in accomplishing the goals of coordinating care for a high-need population. OTPs are open 6 to 7 days a week; they provide medication, counseling, and other services; have frequent staff contacts; and offer medical services.
One way OTPs can help DATA 2000 providers: make counseling and wrap-around services available to patients who are receiving their prescribed buprenorphine, but no other services. Offering ancillary services can be helpful, particularly “for providers with little experience,” the paper notes. Vermont’s hub-and-spoke model is the best example of coordination between OTPs and DATA 2000 providers.
Another model of coordination is that of Collaborative Opioid Prescribing (CoOP), a bottom-up care coordination model Dr. Stoller developed at Johns Hopkins. It’s more localized than Vermont’s model, uses a single OTP as a hub, and links the OTP with primary care, psychiatric, or office-based buprenorphine care.
Psychiatric providers and pain-treatment providers are ideal collaborators for OTPs. Many OTP patients have mental health conditions, and many have pain. Frequent contact between OTP staff and patients can give support to psychiatric providers. The OTP staff can perform several functions: help monitor psychiatric symptoms; improve outcomes, by observing the patient taking psychiatric medications; and deliver therapeutic messages, such as developing a positive self-regard and using effective coping skills—all during routine encounters.
The OTP can also be an expert consultant to pain physicians, not only for OTP patients, but for pain patients who might be having problems with substance use disorders, with opioids or other substances. OTPs are also experts in the pharmacology of opioid analgesia.
Methadone or buprenorphine are the recommended treatments for pregnant women with opioid use disorders. Obstetric providers are key to improving access to treatment for patients who need specialized care to improve outcomes for mother and child. Also recommended are wraparound services, including housing, parenting classes, and more.
Coordinating with primary care physicians is yet another model, probably one of the most difficult. When a physician has a patient with a substance use disorder, getting that patient to an OTP could help not only with the drug use but with other problems that are difficult for primary care personnel to manage, such as HIV.
In addition to medical providers, payers are key collaborative players in OTPs. If the OTP will be furnishing only counseling (as when a prescriber provides buprenorphine only), the OTP must be able to bill for the counseling—and be paid for it. In general, provider payment for time spent in care coordination is not allowed; reimbursement models for care coordination need to be encouraged.
Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA) of New York State, Inc., and vice president of the West Midtown Medical Group, wrote about how to transform co-located physical health care in an OTP model to a fully integrated model. The infrastructure and expertise for this is now in place.
The New York story required close coordination with the state, as part of both Medicaid redesign and a local waiver. The goal is the “triple aim”—enhancing the patient’s experience, improving the health of populations, and reducing per-capita health care costs. OTPs can accomplish this by coordinating with the complete health care system.
For more on New York’s program, go to http://staging3.atforum.com/2015/06/success-new-york-medicaid-to-reimburse-otps-for-buprenorphine/.