Suboxone Prescribing in Primary Care: A Practical, Interactive Discussion of Programs & Strategies

• Meghan Fondow, PhD, Primary Care Behavioral Health Manager• Ryan Jackman, MD, Medical Director, St. Mary’s Family Medicine Addiction Medicine Clinic• Beth Zeidler Schreiter, PsyD, Chief Behavioral Health Officer

Session # G5

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018

Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

• Identify different interdisciplinary roles that contribute to a successful outpatient buprenorphine program.

• Summarize practical components of a buprenorphine program that need to be considered when implementing buprenorphine based care into a clinical setting.

• Describe steps that need to be taken within his/her clinical setting to implement buprenorphine based therapy.

Agenda1. Example of MAT program in Colorado

2. Comments from administration

3. Example of MAT program in FQHC in Madison, WI

4. Small group discussion

5. Reconvene and report out

The Bridge to Nowhere

Barriers to Implementation

Barriers to Primary Care Physicians Prescribing Buprenorphine Annals of Family Medicine March/April 2014

Models of CarePractice-based modelsOBOTBHIVES”One-stop shop” modelIntegrated prenatal care/MAT

Systems-based modelsHub-and-spoke (VT)Medicaid health homeNurse care manager (MA)Collaborative opioid prescribing model (MD)

https://www.denverhealth.org/services/behavioral-health/patient-stories/becoming-mother-getting-cleanKorthuis PT et al. Ann Intern Med 2016

Western Colorado

St. Mary’s Family Medicine (SMFM)Level 3 PCMH CenterTotal patients: 6,079Visits in 2017: 22,526

Payer MixMedicaid 47%Medicare 23%Private 23%Uninsured 6%

ProvidersFaculty 12Residents 26NPs 3

PhD MFT 2Fellows 2Care Coordinators 4

PatientPrimary

Care Physicians

Integrated Behavioral

Health

Care Coordination

Clinical Staff

ResidencyStaff

Subspecialty clinics

Procedures

Sports Medicine

AMC

SMFM PCMH Model

HIV

AMC Structure

SMFM Pod

CC

RN

MA

AMC MFT

MD

REFE

RRAL

SO

URC

E

Addiction Medicine ClinicAddiction Medicine Clinic opened 12/2017Lead physician: AM Board certified

# of unique patients - 52# of suboxone pts – 30◦ Active – 18◦ Successful transfers – 9 ◦ Lost to care – 5◦ Pregnant – 7

Waivered Physicians – 6 Faculty, 3rd year residents

SMFM MAT Clinic ProcessReferral from

SMFM PCP

Review for Appropriateness by MAT provider

Front Desk asked to schedule

patient for intake

Patient evaluated by MAT provider

and BHP

Induction Scheduled

Rx given

Patient presents for induction

w/ Rx

Patient contacted/seen

within 3 days

Patient seen weekly by team

Patient seen monthly (after 1-2

months)

Requisites:-OUD mod/sev-ASAM Level 1-Motivated, Accepts referral-Informed Consent reviewed -Rx for MAT and labs ordered

Access Community Health CentersFQHC with 5 locations◦ Medical, Dental, Behavioral Health

Over 26,000 patients served in 2017 across all sites

PCBH model of integrated care◦ Program is well-established, in place for over 10 years

Health Promotions Clinic (HPC)◦ Co-located within primary care◦ Run by addiction medicine physician◦ Coordinated by BHC team

HPC Referral WorkflowPatient identified

with substance use issue

• Provider identifies issue in visit, or identified with screening

• Provider offers BHC visit

Referral to BHC

• BHC conucts further assessment of substance abuse• including hx of use,

treatment and current use

• Screen for co-morbid mental heatlh issues

• reviews insruance status and options for outpatient care

BHC completes referral to HPC

• using set HPC referral smartphrase

• explains HPC policies and procedures

• Obtains verbal informed consent

HPC team reviews referrals, discusses as needed with BHC

• If approved, message sent to HPC support to schedule patient

• If referral declined, BHC staff to enter note into chart with treatment options and sends to PCP. BHC staff that referred patient for follow up contact

Referral Decision Tree

Indications for HPC referral: 1. No failed trials

of MAT 2. High Risk Factors

(Pregnant, small children, IV drug use with HIV)

3. Enrolled in treatment, on waitlist for MAT

4. Desire to transfer care and stable on MAT

Referral to HPC

Assessed by HPC team to be appropriate for treatment in Primary

Care and possible MAT options

Patient seen weekly, then monthly in HPC until

stabilized

Severe opiate use disorder, recent discharge

from methadone clinic, other risk factors

Referral to methadone clinic, IOP, dual diagnosis program, or other appropriate level of

care in the community

Transition back to primary care

Stable patient in

HPC

HPC provider to

write summary

note

HPC provider to confirm provider

willingness to take on transfer

Documentation of transfer plan in problem list

BHC assists with

scheduling transfer of care at last

HPC visit

New Suboxoneagreement

completed and documented

by PCP

BHC can see patient at time of transfer to

assist in process

Lessons learnedMessaging to the community◦ Verbiage on how to explain access to care to outside agencies

Messaging to patients◦ Setting up appropriate expectations◦ Discussing levels of care and the need to find the best match

Messaging to staff◦ Helping staff to understand what the program includes, and the verbiage to explain it to

others◦ Scripting

Documentation and compliance to regulatory guidelines

Small Group DiscussionPlease break into small groups to discuss the following:◦ What do you need to develop a MAT program in your own health system?

◦ Specific barriers

◦ What do you already have that you can build on within your system or in partnership with another system?◦ Patient need?◦ Administrative buy-in?◦ Staff and provider buy-in?

1. Ober A J, Watkins KE, Hunter SB, Ewing B, Lamp K, Lind M, Becker K, Heinzerling K, OsillaKC, Diamant AL, Setodji CM. (2017) Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: findings from the SUMMIT study. BMC Family Practice, 18(1): 107-130.

2. Hutchinson, E., Catlin, M., Andrilla, C. H. A., Baldwin, L.-M., & Rosenblatt, R. A. (2014). Barriers to Primary Care Physicians Prescribing Buprenorphine. Annals of Family Medicine, 12(2), 128–133.

3. Barry, D. T., Fazzino, T., Necrason, E., Ginn, J., Fiellin, L. E., Fiellin, D. A., & Moore, B. A. (2016). The availability of ancillary counseling in the practices of physicians prescribing buprenorphine. Journal of Addiction Medicine, 10(5), 352–356.

4. Knudsen HK, Lofwall MR, Walsh SL, Havens JR, Studts JL. (2018). Physicians’ decision-making when implementing buprenorphine with new patients” conjoint analyses of data from a cohort of current prescribers. Journal of Addiction Medicine 12(1): 31-39.

5. Saloner B, Daubresse M, Caleb Alexander G. (2017). Patterns of Buprenorphine-Naloxone treatment for opioid use disorder in a multi-state population. Med Care 55(7): 669-676.

Bibliography / Reference

Learning AssessmentA learning assessment is required for CE credit.

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