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)

5.3 1.7 1.6 0.0 1.0 2.0 3.0 4.0 5.0 6.0 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

26 Counties without OTPs Services 32 Counties with OTPs

Treatment Availability: Counties with OTPs

Data source: Department of Health Care Services (2019)

Hub and Spoke Model

Hubs Spokes

Mostly OTPs Highly structured Methadone, buprenorphine, naltrexone Mostly community health centers DATA 2000 waivered provider Maintenance treatment Buprenorphine, naltrexone

Patients Information Consultation MAT Team

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

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

New patients starting MAT

Baseline H&SS Implementation

230 233 274 246 274 269 292 264 248 276 302 294 320 280 358 400 466 410 377 376 402 483 497 429 518 476 509 532 566 511 11 8 14 8 7 13 26 35 29 32 36 37 29 34 32 26 23 54 48 56 46 50 50 43 55 49 66 56 57 47

100 200 300 400 500 600 Buprenorphine XR-NTX H&SS Implementation Baseline

New MAT Patients in Spokes per Month

New patients starting MAT

Preliminary Patient Outcomes

• 96.2% of patients completing follow up interviews still in

treatment after 90 days

• No reported overdoses

Preliminary Patient Outcomes

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

Preliminary Patient Outcomes

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

161 149 154 164 164 188 201 248 241 238 254 259 275 282 310 327 317 315 341 343 361 356 395 50 100 150 200 250 300 350 400

Total waivered providers % waivered providers with patients

59.1% 59.1% 61.0% 61.2% 56.2% 55.6% 63.1% 60.1% 65.4% 60.2% 61.5%57.4% 63.6% 66.7% 66.3% 67.3% 71.7% 67.1% 69.1% 67.1% 57.0% 64.5% 63.4%

Waivered Providers in Spokes

were less likely than those who had prescribed to agree that:

Non-prescribing waivered providers

I feel confident prescribing buprenorphine (p < .005). I have the mentorship I need to effectively treat patients with opioid use disorders (p < .01).

2.91 2.52 2.35 2.15 2.09 2.06 1.88 1.72 1.66 1.62 1 1.5 2 2.5 3 3.5 4 4.5 5

Patient compliance Staffing Resources Lack of Time Pharmacy Availability Reimbursement Issues Lack of Space Lack of Mentorship Fear of Legal Consequences Lack of Support from Leadership Community Opposition

Not at all Slightly Moderately Considerably Extremely

To what extent do you find the following to be barriers to prescribing buprenorphine?

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

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

The Hub has a strong working relationship with my Spoke Care coordination with the Hub is effective HSS has had a positive impact on community resources Hub and Spoke Model is useful

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

230 233 274 246 274 269 292 264 248 276 302 294 320 280 358 400 466 410 377 376 402 483 497 429 518 476 509 532 566 511

487

100 200 300 400 500 600 Baseline H&SS Implementation

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

• ut 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

Never 62% Very Rarely 15% Sometimes 8% Frequently 11% Always 4%

How often do you feel discriminated against by health care professionals?

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

• ther than English

Image attribution: Mark Morgan on Flickr

Promising Practices: Acceptability

• Consider building on-site transitional housing or develop strong connections with referral

resources for patients experiencing homelessness

• Use mobile clinics or offer transportation services, such as vans, to patients living in rural

areas

• Develop strong connections with referral resources for patients with co-occurring mental

health conditions

• Ensure equitable access to treatment for people of color. In particular, offer financial

resources to make sure treatment is affordable

• Offer all materials in languages other than English, especially outreach and education

materials.

• Hire staff who are bilingual
• Provide stigma training to all staff (prescribers, MAT teams, front office staff), and training
• n cultural competence and trauma-informed care to all practitioners
• Connect with naloxone distribution programs and pharmacies to ensure that all patients

have access to naloxone in case of an overdose, especially those living in rural areas

“A lot of our patients are extremely underserved and low-income. And I think that the grant is just a huge blessing in a lot of ways, because without the opportunity [the patients] probably wouldn’t pursue [treatment].”

Affordability

Promising Practices: Affordability

• Tailor support to the needs and existing treatment capacity of

each spoke

• Develop sustainable funding mechanisms for current grant

services

Appropriateness

Participant treatment experiences (mean scores 0-5)

4.54 4.52 4.27 4.25 3.85 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 People at the treatment center care about whether I am doing better. The staff at this treatment center treat me with respect. The people at this treatment center spend enough time with me. I have a say in deciding about my substance abuse treatment that I am receiving here. The amount of time I had to wait to get services was acceptable to me.

“The patient who presents for treatment deserves to be met and assisted at their current stage of readiness for change… the patient’s ability to take the significant risk of choosing sobriety requires patience and acceptance on the part of the treatment

• provider. Miracles do happen more frequently than one might

normally expect.”

Promising Practices: Appropriateness

• Patients should be presented with all medication options and be

fully informed in planning their treatment alongside the prescriber

• Offer individual and family therapy, but do not make therapy a

requirement for accessing medications

• Take a harm reduction approach to providing treatment and

meet the patient “where they are at.”

Conclusions

• Barriers to getting care happen along a continuum
• Centering patient perspectives is important to assessing access

to treatment

• CA Hub Spoke is getting more patients into treatment
• More providers are prescribing, but gaps remain

Thank you!