Integrated Opioid Treatment and Recovery Centers (IOTRCs) – No Wrong Door

Individuals with an opioid use disorder (OUD) have high rates of co-occurring medical and psychiatric complications.  Left untreated, these complications are associated with significant morbidity and mortality, resulting in increased healthcare costs and threatening public health.  Effective care coordination that addresses the complexity and variability of OUDs should be multifaceted and not a “one size fits all” model. Persons with an OUD often have complex treatment needs that require concurrent and coordinated attention to addiction, medical, psychiatric, and social problems.  OUD patients do best when they have access to a full range of medication assisted treatment (MAT) options in a variety of settings.  They can also benefit from assistance in locating and navigating an array of social and recovery support services (Stoller et al., 2016).

In April 2017, Nevada was awarded a Fiscal Year (FY) 2017 State Targeted Response to the Opioid Crisis Grant (Short Title: Opioid STR) to address the opioid crisis by increasing access to treatment, reducing unmet treatment needs, and reducing opioid overdose related deaths through the provision of prevention, treatment and recovery activities for opioid use disorder (OUD) (including prescription opioids as well as illicit drugs such as heroin).

Using this funding, the Nevada Division of Public and Behavioral Health (DPBH) established a hybrid system of coordinated care for OUD in Nevada, based on the Vermont Hub and Spoke Model of Care for Opioid Use Disorders and the Collaborative Opioid Prescribing (CoOP) program model design that was initially developed and implemented at Johns Hopkins Hospital (Stoller, 2016). The goal of this innovative program delivery model is to increase the availability, utilization, and efficacy of medication assisted treatment (MAT), and provide pathways to evidence-based recovery and support services by establishing an Integrated Opioid Treatment and Recovery Center (IOTRC) System for Nevada residents with OUD.

Figure 5. IOTRC Care Coordination Model

Care is coordinated during the entire treatment episode at a minimum through ongoing telephonic and electronic communication between IOTRC staff and partner providers.  Services at IOTRC and/or referral to a formal collaborative partner(s) for needed services are provided with a “warm hand off” and follow-up communication by care coordinator, peer specialist, or other IOTRC staff. IOTRCs refer out to a variety of other service providers through formalized care coordination agreements, for example, pain management clinics, recovery programs, behavioral health services, psychiatry, and obstetrician (OB)/neonatal services.

Mobile Recovery Outreach Teams with IOTRCs

All IOTRCs provide mobile recovery units to conduct outreach and engagement services.  The scope of required services in each IOTRC network include comprehensive substance use disorder (SUD) and co-occurring disorder (COD) assessments, MAT induction and maintenance, and group and individual counseling based on a service-recipients needs per American Society of Addiction Medicine (ASAM) Criteria. Required wrap-around services include care coordination, peer recovery and support services, links to recovery/transitional housing, psychiatric evaluation.

Goals of the mobile recovery outreach teams include:

1. Increased rates of identification, initiation, and engagement in treatment;

2. Increased adherence to and retention in treatment;

3. Reductions in overdose deaths, particularly those due to opioids;

4. Reduced utilization of emergency departments and inpatient hospital settings for treatment where the utilization is preventable or medically inappropriate through improved access to other continuum of care services;

5. Fewer readmissions to the same or higher level of care where the readmission is preventable or medically inappropriate; and

6. Improved access to care for physical health conditions among beneficiaries.

Milestones of the mobile recovery outreach teams include:

1. Access to critical levels of care for OUD and other SUDs;

2. Widespread use of evidence-based, SUD-specific patient placement criteria;

3. Use of nationally recognized, evidence-based SUD program standards to set residential treatment provider qualifications;

4. Sufficient provider capacity at each level of care;

5. Implementation of comprehensive treatment and prevention strategies to address opioid abuse and OUD; and

6. Improved care coordination and transitions between levels of care.

Opioid Overdose Prevention – IOTRCs Provide Naloxone

IOTRCs also provide opioid overdose prevention activities, including but not limited to, the prescription of naloxone, distribution of naloxone (provided through a Naloxone Virtual Dispensary) to individuals identified as at-risk, including friends, family members and others able to assist with an opioid overdose, and community promotion of the use of naloxone to reduce mortality in individuals identified with an OUD.

Spotlight on IOTRC Activities: Mobile Teams in Nevada’s Hospitals

Part of the IOTRCs’ efforts include the establishment of mobile recovery outreach teams to provide support and engagement in services following an overdose, as well as distribute naloxone, the antidote for opioid overdose, to individuals in the community who are at-risk for experiencing an opioid related overdose. The mobile recovery outreach teams are uniquely formed to include peer support specialists who have lived experience dealing with addiction. For underserved and/or stigmatized populations, peer-based support within the larger clinical and treatment frameworks can help facilitate advocacy, and peers can individually serve as an envoy into additional recovery activities (Gagne et al., 2018). These teams are being used in the community, and alongside other organizations, to help provide pretreatment engagement for those who may be at risk.

One targeted area to provide outreach is in emergency departments as they are an ideal environment to intervene with an individual who has just experienced an overdose. Based on the elevated risk for death among people who survived a non-fatal overdose, the moments following medical stabilization subsequent to an opioid overdose provides a critical moment for the opportunity to delivery risk reduction services including assessment, opioid overdose education and take-home naloxone, peer recovery coaching and support, and linkage to medication assisted treatment (Ellison et al., 2016). However, quite often hospital staff do not have the expertise or workforce to provide outreach at the time the patient is there. Because of this, many patients leave the emergency department without intervention or dismiss themselves against medical advice, and it is possible for these patients to visit the emergency department again for subsequent overdoses. Many Nevada emergency departments have recognized this gap in services and are utilizing mobile outreach teams to bolster their ability to address the needs of patients who present with an opioid overdose or who are diagnosed with a primary/secondary opioid use disorder. These teams can provide specialized services for patients that supplement and extend the services currently provided through emergency medical care.

When a qualifying patient presents in the emergency department, mobile outreach teams are dispatched to the hospital to provide support from a peer recovery specialist and a certified drug and alcohol counselor.  If the patient is willing to speak with them, the team will provide a brief risk assessment and motivational interview, connections to care (as established by their hub and spoke model) including medication assisted treatment, pain management services, health care, housing, and overdose education and take-home naloxone. Mobile teams are currently operating in Southern Nevada under Center for Behavioral Health in North Vista Hospital and Mountain View Hospital, with additional facilities in the planning or negotiating stages.  Mobile teams are currently operating in Northern Nevada under Center for Behavioral Health in Carson Tahoe Regional Hospital, with additional facilities in the planning or negotiating stages.

In addition, faculty in the School of Community Health Sciences at the University of Nevada, Reno have received a grant from the Laura and John Arnold Foundation (LJAF) to study the implementation of this program, under an innovative partnership between LJAF and the National Institute on Drug Abuse (NIDA). The first year of the study is currently being used to determine the feasibility and acceptability of the mobile recovery teams. The subsequent three years will examine whether the program is effective in reducing ER re-admissions, increasing linkages to treatment, and reducing overdose deaths.

If you or your organization are interested in more information about mobile teams providing services in Nevada hospitals, please contact: Krysti Smith at the Center for the Application of Substance Abuse Technologies (CASAT) at ksmith@casat.org.

References

Ellison, J., Walley, A. Y., Feldman, J. A., Bernstein, E., Mitchell, P. M., Koppelman, E. A., & Drainoni, M.-L. (2016).

Identifying Patients for Overdose Prevention With ICD-9 Classification in the Emergency Department,

Massachusetts, 2013-2014. Public Health Reports, 131(5), 671-675.

Gagne, C. A., Finch, W. L., Myrick, K. J., & Davis, L. M. (2018). Peer workers in the behavioral and integrated health

workforce: Opportunities and future directions. American Journal of Preventive Medi- cine, 54, S258–S266.

http://dx.doi.org/10.1016/j .amepre.2018.03.010.

Stoller KB, Stephens MAC, Schorr A. Integrated service delivery models for opioid treatment programs in an era of

increasing opioid addiction, health reform, and parity. Rockville, MD: Substance Abuse and Mental Health

Administration, July 13, 2016 (http://www.aatod.org/policies/mat-hub-setting-whitepapers/).