California Hub and Spoke evaluation: a patient-centered approach to - PowerPoint PPT Presentation

California Hub and Spoke evaluation: a patient-centered approach to assessing access to treatment UCLA Integrated Substance Abuse Programs October 2019 Kendall Darfler, Aida Santos, José Sandoval, M. Eva Vazquez, Liliana Gregorio, Valerie P . Antonini, Darren Urada

Overdose Death Rates by County (2018) Data source : California Department of Public Health (CDPH) Opioid Overdose Surveillance Dashboard

Overdose Rates by Substance (per 100,000) 6.0 5.3 5.0 4.0 3.0 2.0 1.7 1.6 1.0 0.0 2012 2013 2014 2015 2016 2017 2018 Any Opioid Any Opioid & Amphetamine Fentanyl Data source : California Department of Public Health (CDPH) Opioid Overdose Surveillance Dashboard

Overdose Rates by Race/Ethnicity Data source : California Department of Public Health (CDPH) Opioid Overdose Surveillance Dashboard

Treatment Availability: Counties with OTPs 26 Counties without OTPs Services 32 Counties with OTPs Data source : Department of Health Care Services (2019)

Hub and Spoke Model Hubs Spokes Consultation MAT Team Patients Information Mostly community health centers Mostly OTPs DATA 2000 waivered provider Highly structured Maintenance treatment Methadone, buprenorphine, naltrexone Buprenorphine, naltrexone

California Hub and Spoke System

Evaluating California Hub and Spoke • Real-world considerations • Rapid response = short timelines • Unique context of each network • No randomization, pragmatic • Mixed methods

Evaluating California Hub and Spoke • Evaluation Goals • Has CA Hub and Spoke expanded access to MAT? • What are the major barriers to implementation? • Which promising practices have hubs and spokes employed to address barriers? • Provide feedback to implementation efforts

Methods • Monthly data reports • Provider surveys • Spoke site visits • Patient interviews • Administrative data • Limited Image source : The Gender Spectrum Collection. https://broadlygenderphotos.vice.com/

Provider Surveys

Site Visits

Patient Interviews

Preliminary Outcomes

New MAT Patients in Hubs per Month 600 Baseline H&SS Implementation New patients starting MAT 500 431 423 410 420 417 401 382 383 410 386 381 400 376 372 361 355 362 358 352 329 340 331 330 325 309 314 307 300 278 275 256 248 200 99 106 95 93 87 85 81 100 78 78 75 73 63 55 48 45 43 43 36 37 32 31 22 18 15 15 16 13 13 10 7 19 14 11 13 9 9 9 0 8 7 8 8 7 8 7 8 5 5 5 5 6 6 6 6 6 4 4 3 4 4 2 Methadone Buprenorphine XR-NTX

New MAT Patients in Spokes per Month 600 Baseline 566 H&SS Implementation 532 518 511 509 483 497 New patients starting MAT 500 476 466 429 410 402 400 400 377 376 358 320 302 294 292 300 280 276 274 274 269 264 248 246 230 233 200 100 66 56 56 57 54 55 50 50 48 49 46 47 43 36 37 35 34 32 32 29 29 26 26 23 14 13 11 8 8 7 0 Buprenorphine XR-NTX

Preliminary Patient Outcomes • 96.2% of patients completing follow up interviews still in treatment after 90 days • No reported overdoses

Preliminary Patient Outcomes 30 25 20 Days per Month 15 13.4 11 8.9 10 5 2.4 1.4 0.1 0 Prescription opioid use Illicit opioid use Injection Treatment Initiation 3 Months

Preliminary Patient Outcomes 10 9 8 6.9 7 Scale of 0 - 10 6 5 4.5 4 3 2.1 2 1.3 1 0 Life Satisfaction Cravings Treatment Initiation 3 Months

Waivered Providers in Spokes 400 395 361 356 343 350 341 327 317 315 310 300 69.1% 282 275 71.7% 259 254 67.1% 248 250 241 67.3% 238 66.3% 66.7% 63.6% 63.4% 64.5% 201 200 188 61.5%57.4% 65.4% 164 161 164 60.2% 154 63.1% 60.1% 149 150 55.6% 61.2% 61.0% 56.2% 67.1% 59.1% 59.1% Total waivered providers 100 57.0% % waivered providers with patients 50 0

Non-prescribing waivered providers were less likely than those who had prescribed to agree that: I feel confident prescribing buprenorphine ( p < .005). I have the mentorship I need to effectively treat patients with opioid use disorders ( p < .01).

To what extent do you find the following to be barriers to prescribing buprenorphine? 5 Extremely 4.5 Considerably 4 3.5 Moderately 2.91 3 2.52 2.5 2.35 Slightly 2.15 2.09 2.06 2 1.88 1.72 1.66 1.62 Not at all 1.5 1 Patient Staffing Lack of Time Pharmacy Reimbursement Lack of Space Lack of Fear of Legal Lack of Support Community compliance Resources Availability Issues Mentorship Consequences from Leadership Opposition

Hub and Spoke Expert Facilitators • Barriers Addressed • Attitudes & Stigma • Knowledge about MAT • Workflow and resources • Leadership support • Lack of expertise for complex cases • Support for newer prescribers

http://uclaisap.org/MATPrescriberSupport

Spoke Administrators Hub and Spoke Model is useful HSS has had a positive impact on community resources Care coordination with the Hub is effective The Hub has a strong working relationship with my Spoke 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Strongly Disagree Disagree Neither Agree/Disagree Agree Strongly Agree

Has Hub and Spoke expanded access to MAT in CA?

Spoke Buprenorphine Patients: Predicted vs. Actual 600 566 Baseline H&SS Implementation 532 518 509 497 511 483 500 476 466 487 429 410 400 400 402 358 377 376 292 300 274 274 320 269 302 294 246 280 276 233 230 264 248 200 100 0

Patient-Centered Access to Health Care Model/image source : Levesque, et al. (2013). Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International journal for equity in health , 12(1), 18.

Domains of Patient-Centered Access • Availability • Whether services are available and reachable • Approachability • Outreach and education efforts that allow patients to identify treatment services • Acceptability • How acceptable care is to patients, especially those from marginalized backgrounds • Affordability • How affordable services are to patients • Appropriateness • The quality and adequacy of care provided, patient choice Levesque, et al. (2013). Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International journal for equity in health , 12(1), 18.

Availability of Spokes

“ There's many times that I almost went out and used because, you know, I just couldn't take it anymore. Just to go dose was the hardest thing ever. ”

Promising Practices: Availability • Start prescribing buprenorphine • Offer low-barrier care

Approachability

“She would go out to the parks. And if somebody was not in good shape or didn’t show up and didn’t have a phone, she would go out to the park because she knew that’s where they hung out. And if they weren’t there she would ask their other friends… Yeah, she was amazing. And she would come into our meetings and say, ‘Hi, I’m your new best friend. And this is my phone number. You call me any time you need me. Day or night, I am available.’ And it was really amazing the support she gave.”

Provider Outreach “There are several online resources... But I think it’s nice having a local network to tap into.”

Promising Practices: Approachability • A multifaceted approach to advertising • Normalizing MAT in health care settings • Employing peer support workers to build community relationships and recruit potential patients • Developing a listserv with other local practitioners • Increase screening for substance use disorders

Acceptability

How often do you feel discriminated against by health care professionals? Always 4% Frequently 11% Sometimes 8% Very Rarely Never 15% 62%

Patients from Marginalized Backgrounds • Less than half (44%) of spoke administrators felt that their spokes had adequate resources for housing supports to provide to patients experiencing homelessness • People of color were significantly less likely to feel that their treatment was affordable ( p <.001) • Overall need to increase recruitment with patients from marginalized backgrounds

Spanish Speaking Patients • 5.7% of patients are not fully able to access services in their preferred language • 13% don’t have the staff and other resources needed to treat patients who speak a language other than English • 21% don’t offer outreach and education materials in languages other than English Image attribution: Mark Morgan on Flickr