Bridging the Gap: Telemedicine as a Path to Primary Care Pharmacotherapy for Opioid Use Disorder
Update: Elimination of X-Waiver
Since this webinar was delivered, the federal government has removed the DATA-Waiver (X-waiver) requirement for prescribing buprenorphine. As of January 12, 2023, practitioners with a current Drug Enforcement Administration (DEA) registration that includes Schedule III authority can prescribe buprenorphine for opioid use disorder (OUD) in their practice if permitted by applicable state law. For more information on the X-waiver removal and guidance on requirements, visit the Substance Abuse and Mental Health Services Administration website, including the page on training recommendations, and the DEA website.
We hope you find the webinar informative. Please reach out to Program Assistance with any further questions.
Good morning and thank you for joining this UR Medicine Recovery Center of Excellence webinar. Today we will be discussing Bridging the Gap: Telemedicine as a Path to Primary Care Pharmacotherapy for Opioid Use Disorder. This webinar is a product of the HRSA Rural Communities' Opioid Response Program and we are delighted to be on of the rural centers of excellence in substance use disorder and to have this opportunity to discuss the topic with you today. This webinar is the first of many products that we look forward to sharing during year two of this three-year grant.
Before we get started, we would like to review with you some basics about our Zoom webinar platform. If you have technical issues, please let us know in the Q&A box and we will assist you. If you're dialing in, you can view the slides via yesterday's reminder email, or send us an email at firstname.lastname@example.org We will have a few audience polls today so please follow the on-screen directions when prompted.
We will end with a discussion period, so please feel free to ask questions in the Q&A box throughout the course of the presentation. And closed captioning is available and can be activated by clicking clicking the CC button at the bottom of your screen. we wanted to start with a short poll so we can best address your needs during our session today. Please let us know what brings you to today's webinar.
Can you please bring up the poll? Please note that MOUD means medications for opioid use disorder. and it is intended as an alternative term for the more commonly used MAT, medication assted treatment, in this poll. If you would like to indicate another goal feel free to add it in the Q&A box.
When you're ready you can go ahead and enter your answers to the poll. So as you can see there is a a diversity of expectations for today's webinar. We appreciate you answering that and we'll take that into account as we work through today's presentation. So we often get the question, "what does your center of excellence do?"
Primarily we aim to reduce morbidity and mortality related to substance use disorder, particularly as related to synthetic opiods. First and foremoset, we are disseminating evidence-based practices throughout identified communities in New York, Kentucky, Ohio and West Virginia. These practices are first identified few research and carefully adapted to rural communities such as the practice we will review today around creating a bridge from SUD treatment programs to primary care based MOUD. Many of our programs form an ecosystem of recovery and approach to addressing a wide range of needs across the community and the continuum of care by implementing several programs simultaneously.
These programs will be discussed in a future article series and will be accompanied by tools that support communities with implementation. Please reach out to us at any time for support in planning for and implementing implementing these programs. Our contact information will be shared shared at the end of this session. I would like to introduce our speakers today, starting with Dr.
Holly Russell Dr. Russell is assistant professor of Family Medicine at the University of Rochester Medical Center. Dr. Russell is board certified in addiction medicine and is founder and director of the addiction program at Highland Family Medicine.
For the last 3 years, she has been working on a project looking at how to expand access to treatment for opioid use disorder within primary care settings including the use of telemedicine technology. We also have the pleasure of hearing from Michele Lawrence. Michele is co-principle investigator for the University of Rochester's Recovery Center of Excellence and an assistant professor of psychiatry and community and preventive medicine. She has worked closely with rural communities for 18 years creating financially viable hospitals, primary care and behavioral health programs that partner with each other to improve the health of these communities and all of their residents Dr.
Russell, let's start today by understanding more about pharmacotherapy for opioid use disorder itself. Perhaps Perhaps you can lay the foundation for us by explaining how medications help in the treatment of OUD as well as what medications are used and how they work. Yes, thank you, Christine. First a note about the terminology.
As Christine mentioned before, medication-assisted therapy or MAT has been a term that we have traditionally used to describe these medications. However, as we move towards an understanding of substance use disorders as a chronic disease, we are moving towards using the term for medications for opioid opioid use disorder. MAT can perpetuate the disorder as different than other chronic diseases. We would never describe the use of metformin for diabetes as medication-assisted treatment.
or, say, medication assisted treatment for when advocating for diuretics for blood pressure management. So we're trying to get away from using the acronym MAT and instead using medications for opioid use disorder or simply pharmacotherapy. There are three types of medications that are approved by the FDA to to treat opioid use disorder. All three work primarily on the mu opioid receptors in the brain.
Methadone, which works as a full opioid aggonist, has been approved since the 1970s for use. However, it can only be prescribed for opioid use disorder in specially regulated opioid treatment programs, often referred to as OPTs. Buprenorphine which historically had been used IV as a pain medication, is a partial agonist on the opioid receptors. Because it is only a partial agonist, there is a feeling to the opioid effects and it is nearly impossible to overdose on.
In the year 2000, a special law that we will discuss more on the next slide, allowed buprenorphine, commonly prescribed in combination with naloxone, to be prescribed as a treatment for opioid use disorder in settings outside of traditional opioid treatment programs. Thirdly there is treatment with naltrexonem which is a full antagonist, so It blocks any activity activity on the opioid receptors. This is available in both an oral medication, which was approved in in the 1980s as a treatment for opioid use disorder, but was popularized in the in the 90s as a treatment for alcohol use disorder.
It is also available in a long-acting injection called vivitrol. Determination medication's types is based on individual's needs and community access to the different treatment options. Psychosocial therapy is also very important. However the evidence is less robust, and all newer guidelines for the treatment of opioid use disorder enforce that medication should not be withheld if behavioral behavioral treatment is not easily available.
In today's discussion of telemedicine, buprenorphine which is also prescribed as Suboxone or Zubsolv will be the focus. Medications for opioid use disorder is an evidence-based practice that significantly decreases mortality. The medications work by preventing withdrawal symptoms, reducing opioid cravings or decreasing the brain's response to future drug use. And they help to normalize brain structure and function.
Large systematic reviews and randomized controlled trials show that patients with opioid use disorder who receive these medications are less likely to die from overdose or other causes related to their addiction. Patients who receive medication have higher treatment retention rates, better long-term treatment outcomes, and improved social functioning. They are also less likely to inject drugs or transmit infectious diseases. The longer a patient receives treatment, the better.
These medications also help people restore their functionality, improve their quality of life, and reintegrate into their families and communities. These medications save lives, but the majority of people with opioid use disorder in the United States receive no treatment at all. So access to these medications is all the more critical, because we're in a current wave of overdose involving involving synthetic opioids. So Fentanyl, Carfentanil, you've likely heard about this and They are significantly more potent than the naturally derived heroin.
And especially in our current climate of trying to understand how race and structural racism affects healthcare outcomes. It's important to understand understand that while access to evidence-based treatment is core across the board, there are stark inequality inequalities against generational, racial, ethnic, and economic groups to treatment. The medicines can be used in various settings. In the emergency departments, patients can be given the medicines to help with withdrawal in an urgent way.
They're of course described at substance use treatment organizations. But they can also be prescribed in primary care. As I referenced earlier, in the year 2000, we had the data 2000 law. This law allowed clinicians to prescribe buprenorphine outside of traditional opioid treatment programs The goal of the legislation was to expand access to these life-saving medications.
In 2000 the law began with physicians with current DEA registration and outlined ways for those without fellowship training to complete an 8-hour course in order to prescribe buprenorphine. In the year 2016, the comprehensive addiction and recovery act expanded expand expanded prescribing privileges to advanced practice providers. Including NPs and PAs who must complete 24 hours of education. In addition to the to the initial training clinicians must register with SAMHSA and the DEA and they must also affirm capacity to refer patients for appropriate counseling counseling and ancillary services.
I you want to know that this is frequently a key misunderstanding in the law that creates a barrier. This part of the law is often read that providers must refer patients for these services. But the law simple reply says they must have the capacity to refer. So it is quite rare that a clinician would not have the capacity to refer for appropriate counseling and ancillary services.
So this should not be a barrier. Additionally outlined in the law are patient panel sizes. So clinicians may prescribe buprenorphine to 30 patients during the first year. And then they are eligible to increase to 100 after the first year.
And after being at 100 for a year and meeting specific criteria, some clinicians may apply to increase to 275 patients. Another frequent misunderstanding is how long does the patient count towards your panel size and the answer is how long was the prescription for. If you write a one-week prescription, the patient only counts towards your 30-patient limit for one week. So thank you Dr.
Russell for that foundational understanding. Michele you now that we understand the basics around this type of treatment perhaps you can spend some time to also help us understand the challenges to medication-based treatment in rural communities specifically. >> Sure. Many of the challenges faced by rural communities are listed on the slide and they give you a sense that implementing MOUD MOUD can sometimes feel like an impossible task.
The first step on any journey though is to take a step forward. And the Bridge program that we're talking about today provides provides a way to take a step towards MOUD within the primary care practice, which is the ultimate goal. I want to focus on 3 challenges that I think are most significant in both urban and rural communities. Bias, expectation and ???
At this moment in history I think we're all becoming increasingly aware that despite our best intention we carry with us some bias. That bias is often formed based on our experience or the experience of our close friends and family and can act as an barrier to implementing change. We have bias about our patients and sometimes that clouds our ability to help them achieve help. For example we might believe that patients have chosen addiction at some level, but it's important to understand that no one chooses addiction.
This is a horrible disease. So how did we get here? Many rural communities have an economic base in manufacturing or mining or other industries where physical labor can result in pain-related injury. OxyContin seemed to be a solution to this pain and the pharmaceutical industry mislead well-intentioned physicians to believe that opioids were not addictive.
As a result many people were prescribed too much pain medication for too long and did become addicted. Once the legal prescribing stopped or became too expensive, there were drug dealers available to fill the gap. In fact many rural communities were targeted by unscrupulous physicians looking to make a quick buck and drug dealers, like ??? Our communities and our patients have had the odds stacked against them from the beginning.
And now when we recognize these problems and we want to increase access to MOUD in the community, it's important to recognize that bias won't go away on its own. It's deeply embedded and so are the concerns that this cycle could could repeat itself with a new drug or a new treatment. We need to recognize and respect the concern and reluctance that healthcare providers that some communities may feel in a visceral way about coming involved in prescribing MOUD One of the ways to overcome this is through sharing the evidence behind MOUD practices like we're doing today. It's also very important to be clear about expectations and the role that we want primary care to embrace.
In the Appalachian Regions in the New York State, we focus on engaging primary care providers in providing treatment to sustain recovery, not initiate recovery. We recognize that it's hard to initiate recovery in small practices with limited space. We leave the front and the treatment cycle to our partner organizations who have the expertise, the staffing, the space, and the resources to be effective in that very important work. Finally to the extent these organizations or the full continuum of care is not present present in a community, it's important to identify that challenge and engage organizations to come into the community in order to create access to and warm hand-offs with those programs.
So the bridge is a temporary solution to increase access to care while allowing communities to address bias and expectations and create warm hand-offs that make MOUD and primary care successful in the long run. And that helps all of us. Why does this matter to you or your community? Why should we invest in overcoming these challenges?
The bottom line is this investment in healthcare is critical to the success of our community. Families have lived in Appalachia for generations. They have strong ties to the land and to their community, and that's true for any rural community. When people move away.
they tend to want to return to their rural community at some point in their life. And we want them to return to a community that is thriving. One of the foundational pieces of a strong economy is access to healthcare. It's hard to work, run a business, or take care of your family when you're not feeling your best.
We can see that right now with the coronavirus pandemic. Hopefully we will not be sending our residents an hour or two away to get a flu shot or a new COVID vaccine. But why do we ask people who want to recover from this terrible disease of addiction, to drive that far to access the medication that keeps them in recovery and allows them to contribute in a positive way to our community. By bringing the treatment into our community, we make it easier for people with an addiction, and for the family, friends, and neighbors who look out for them to hold down a job, run a business and take care of their family.
So in summary, the bridge program is designed to prove short-term support for two to three years years to the community in the form of access to ongoing MOUD treatment after having been treated in a treatment organization. And that treatment is often provided by telemedicine. And that bridge gives the community the space to increase MOUD access at treatment organizations and within primary care practices. Thank you Doctor Russel and Michele.
There certainly are some challenges but also opportunities here. So it seems that in order to operationalize this concept, we should break it into three semple it into three simple steps. The first step is how do we build the bridge in the first place? And then then step 2.
How do we operate that bridge? Including elements such such as referrals, enrollment, scheduling, technology and the like. And finally, step 3. Where does the bridge lead?
With these steps in mind, Michele, what are the most important things to consider when you build the bridge? I think you want to begin by assessing community readiness for MOUD and the amount of interim capacity that you need to build. Community readiness early on, this might be two to three people who support the idea of increasing access to MOUD. It might be a hospital ED provider, a peer at a treatment organization, a provider or administrative champion.
Over time, these early adapters will begin to build a shared vision across a community through their conversations. It's also important in this initial phase to evaluate the MOUD capacity that exists in the community. You may have one or two providers who are engaged in providing MOUD. And it's important to look at that versus the patient needs.
What is the demand for the service and how do you expect that to change over time? And then estimate the time that it may take to create the local MOUD capacity that you think you need. So it might be a year, it could be two or three years. Secondly, you want to focus on engaging community partners.
So where a patient is presenting today if they don't have access to MOUD. It may be that they're presenting to treatment organizations and it's important to meet with those organizations and understand whether they're bottle bottlenecked within their organization or along the recovery pipeline. Those might be access to capacity on the front end. It may be capacity capacity on the back end.
And so it's important to understand where that's occurring. It's also important to understand the impacts that any change that may occur across the community, the introduction of a bridge program, the introduction of MOUD in primary care, it's important to understand the impact that that may have on treatment organizations and to work with them to bring that about in a way that is successful for all parites Finally, there is a piece about finding a provider champion. The bridge is a short-term response to a situation in which there is not enough local access to care. So you may need to partner with a provider outside the area to provide MOUD during the bridge period.
The role of the provider champion though goes beyond providing just a clinical clinical service. This person is a leader in the change management process. They're also going to be involved in collaborating with local hospitals, medical staff, treatment organizations, lab organizations, as they set up the bridge. And it's really important that are working with a primary care base as we move towards the goal of bringing MOUD into those practices.
So the MOUD bridge program is designed to provide short-term support to the community between the current practice environment and the future state. I do want to note here as well that the provider providers who are offering MOUD through the bridge program are not offering primary care. They should be working in collaboration with local primary care providers, because ultimately we want this to transition back into primary care practices. Thanks Michele.
Dr. Russell, you serve as the clinical program champion for this program. Would you mind explaining your role as well as how you built this bridge in collaboration with SUD treatment organizations and others? And also how is telemedicine an important component of this bridge program?
Yes, thanks Christine. So in regards to the clinical program champion. So this person I strongly recommend, come from a background in primary care. We need to approach this with sensitivity to the immense pressures that primary care clinicians are under.
Oftentimes when I meet and speak with them their first response is I'm expected to manage a patient's diabetes, blood pressure, pressure, insomnia all within one 15 minute visit and now you want me to add another problem? I'm also supposed to manage their their opioid use disorder? And I think the ability to listen thoughtfully and approach this from a sense of shared understanding of these burdens is really key. This is even more critical in under-resourced settings, such as these rural environments where the burdens for primary care clinicians are even higher.
Once PCPs feel they are understood and heard, then the clinical program champion can begin to share their successful experiences with prescribing these medications. But that really can't start until the PCPs feel that their concerns are being heard and validated. The person serving as the clinical program champion also needs to be skilled at relationship building. Because this has to go in multiple directions, including the substance treatment organizations and the PCPs.
One mistake that we made early on was with a substance treatment facility that was about two hours away. We had multiple phone and video meetings with them over the course of six months and they seemed very enthusiastic about partnering with us, but we never got any referrals. And finally we drove down and we met them in person. We had a great meeting, and immediately we got multiple referrals of stable patients who were felt to be ready for a telemedicine bridge program with us.
When we asked them for feedback as to why we were now getting referrals that we weren't earlier, they said they needed to meet us in person in order to feel comfortable trusting us. And to be able to message their patient that's we were trustworthy. I think they actually said we needed to be able to tell patients you were nice. So that was a really important lesson for us, in terms of how important trust building and relationship building really is.
In that sometimes unfortunately even though it requires a long drive, it needs to be done in person to create these relationships. The person in the champion role also needs the clinical and administrative skills to run the program. Including scheduling coverage, and being available to consult with the substance use treatment facilities if there are questions about the appropriateness of referrals or that type of question. Again, to reiterate, the scope of this practice is very specifically around pharmacotherapy for medications for opioid use disorder and it is supplementing, not providing primary care.
And it really is a temporary solution with the goal being to promote and grow the capacity in the local community to prescribe these medications. The clinical practice champion is also available to help facilitate the transition of patients to telemedicine when they are stable and then potentially back to a higher level of care when needed. So prior to COVID-19, I think there was much more skepticism about the appropriateness of using telemedicine for this type of treatment. However, we've all been thrown thrown into an environment where we often did not have a choice if if we wanted to safely continue to prescribe these medications for patients without putting them at risk for contracting COVID.
Our experience, and the experience of many in this field, is that the relaxation of rules surrounding the use of telemedicine for patients, has resulted in an expansion of access for patients to these life-saving medications, with very few downsides. In fact, the research shows us that outcomes, patient satisfaction and adherence to medication is is as good as if not better than office-based prescribing of these medications. � Using telemedicine is an approach that works to expand access in rural communities. One thing to note is that we're primarily talking about buprenorphine.
Again, this is commonly prescribed as a brand name Suboxone or Zubsolv. Methadone is still highly regulated and can only be prescribed in opioid treatment programs when it's prescribed as a treatment for for opioid use disorder and naltrexone orally can be considered for telemedicine but it does not require a special license to prescribe and therefore can be done routinely in primary care. Naltrexone injection can also be done routinely in primary care and is not a great fit for telemedicine as it requires nursing staff to administer One thing to consider is there are patients who may not be appropriate for telemedicine-based approach, and these might be patients who are still requiring a higher level of care.
Maybe those who have a pattern of missing visits, � medications between scheduled scheduled visits. Those who are requiring frequent dose changes, or those who have active or unstable mental health disorders. One thing though is patients with active depression or anxiety typically do very well well with telemedicine. So in general we are talking about patients with much more complicated mental health issues.
In thinking about the operations of the bridge program specifically, can you explain how referrals and the intake process work? And do you have any lessons learned to share about the most effective way to communicate the process to the patients? Yes. The process begins with strong communication.
Again, this is is always key. You can't go wrong with more communication. We begin with strong communication between the clinical program champion and the substance use treatment organization. These two entities must coordinate and develop the referral criteria.
We have an intake packet that we've developed that's part of the toolkit that will accompany this webinar. The packet can and should be adapted for each treatment agency with their input on to how to improve it and how to make it most applicable applicable for their specific community and patient panel. It's important to collect as much information as possible from from the onset to ensure that telemedicine is appropriate for the particular patient. We usually ask about about attendance at visits, any unexpected results results on urine screens, and the current dosage of medication.
The intake packet also also includes a patient agreement that assures that everyone understands expectations, and this includes both the patient and the clinician participating in the telemedicine program. Shared expectation helps prevent problems later on. The intake process is a key step to assuring the success of these patients in the program. We recommend having a staff member who is identified to be the bridge program coordinator, and who will be the point person to receive the packet The intake packet is usually completed by the patient in coordination with or with help from the counselor at their treatment program.
The packet is then faxed or emailed. You can set up whatever process works for your particular office. And again, it's helpful to have a person identified who receives these packets so they don't end up -- if your office is like mine -- in the general fax files of papers that often is not perfectly distributed. This staff member can ensure that the packet is reviewed in a timely manner.
This is usually done by the clinical program champion or perhaps by a team of clinicians. And if it's felt that the patient is appropriate for the telemedicine bridge program, then the patient will be contacted by the coordinator to schedule a telemedicine appointment. We have been asking patients to practice the technological aspects ahead of time especially if they're not familiar with the platform being used. One thing to reiterate is that the referral process must be a two-way street.
If the patient becomes less stable at any time, there needs to be a way for the treatment program to reengage the patient in a higher level of care. >> Thank you, Holly. So this is a basic flow chart detailing some of the process that Dr. Russell has described.
Please refer to our toolkit after this webinar for assorted materials including the PowerPoint from today, as well as more detail around this process flow and other items that will be useful to you as you look to implement these programs. With good planning, my understanding is that logistics are very manageable. What about about logistics around telemedicine itself and making sure patients are comfortable with the process, and perhaps you can share a few of the differences between telemedicine through an office setting versus from a patient's home. Sure.
So the technology we use for telemedicine is often the same as the use of video-based platforms for work or social reasons, that we've all gotten all too familiar with over the last six months. The key is for patients that may not be familiar to practice logging in, or practice using the link before hand. And this helps them know if they need to ask for technological assistance from a family member, or we can also provide help from an office staff if needed. I have a running joke with one of my patients who always needs to call her 13-year-old son over for help to start the visit, that I need to actually start paying him for IT support as part of our office staff.
And we find generally that sometimes we're surprised who is really good at this technology and who isn't. But absolutely 13-year-olds are perfect to to have around to help with this. As Christine mentioned, there are two different settings where telemedicine can be used. One is office-based.
physically sitting in an existing office office space in a location that does not currently have a clinician who can prescribe buprenorphine. In this type of a setting there is a nurse or medical assistant who will more traditionally room the patient, get vital signs, and they can be responsible for activating activating the video connection. This helps eliminate some of the technology challenges that can occur. The key to this type of telemedicine is really identifying the space and the timing.
So we have rented space that we use in one of the locations, and it's only available on the third Thursday of the month. So that does limit things in terms of which clinician can staff this as well as when patients are able to come. In this setting, the nurse or MA can collect the urine for the urinalysis. In the second setting, a patient is actually in their home, and this has become much more widely used during the pandemic by all of us.
This setting setting has the advantage of complete scheduling flexibility, in terms of when the space might be available, and it also takes away any barriers that might exist for a patient with transportation. You do need to make arrangements for patients to drop off a urine sample at a lab, and patients need to make sure they have access to a private place to have the appointment, as well as reliable Internet. One of the most important parts of preparing to start telemedicine is working out the details of scheduling. With regular in-person patient care, we generally have our patients schedule our follow-ups when they approach the checkout desks.
One of the biggest workflow challenges we had was sorting out the process for assuring follow-up appointments were scheduled. This has been really important, because we have to make sure that patients don't fall through the cracks with missing their follow-up appointments. The way that we have decided to schedule follow-up appointments is that our clinicians were actually trained to do scheduling, and then as a backup we route the chart to our staff coordinator to make sure that we've done it correctly or there are certain clinicians who are not able to get the training. As with all technology there will always be glitches so it's important to know that the phone is always a backup option.
And while currently the reimbursement reimbursement rate can differ and are often lower in person or video visits, the most important thing is making sure patients get the care they need at the time they need it. As Christine mentioned, we have a toolkit that will be available that has a more detailed comparison of office-based and home-based telemedicine and many more tips on preparing for telemedicine as well as a pro forma that can be used to work through some of the financial issues. Thank you, Dr. Russell.
Now for the final step, it would be helpful Michele if you would share your experience where this bridge should lead, including the future state we're working towards and the role that primary care can ultimately play in that environment Sure. So ultimately we all want to access the healthcare that we need on a regular basis from the providers that we know and trust to live and work in our community. That local access improves the ability of patients to remain in recovery for a longer period of time. So as we've noted on the slide, the goal here is to be able to access that pharmacotherapy in local primary care practices.
The bridge program is just intended to be a short-term program of two to three years that gives our primary care providers the time they need to build into their their practice some of the support they need to do this successfully And to obtain the certification they need. That may also involve involve incorporating care management support into their practice. We'll be talking at a future webinar about some of that care management support a little more. And how care managers can help with screening patients and begin to get them them enrolled in treatment at an earlier point in the process.
Great, thank you. So Dr. Russell, how are you engaging with the primary care practitioners in the southern tier of New York State and when PCPs are ready to prescribe MOUD, how do you help patients transition to their care? So I think one of the biggest first steps is just to get your foot in the door.
Find ways to get an audience with local PCPs. We've started on a very small scale and met with a few local PCPs that we had personal connections to, and we were able to listen to and understand their concerns. There's also quite a lot of published data about barriers to prescribing buprenorphine, so I would also suggest reviewing that. We then used connections through our regional accountable care network network as the next step.
They have a big twice a year large conference and we were able to give presentations at these where we discussed our understanding of the pressures that PCPs are under, and we really appreciate and understand where the fear was coming from. And then we moved on to trying to share our very positive experience with prescribing these medications. They did a lot of myth busting about the realities of our practice, versus the perceptions that we had heard and the anticipated problems that we had gotten questions about. Again, this is why I think it's critical that the clinical program champion needs to have a background in primary care.
This person absolutely needs to have credibility among an audience of primary care clinicians. The next step for us was really encouraging and facilitating clinicians getting their X-waiver certification. We created a train the trainer program so we have a large bench of clinician clinicians who are waiver trainers, but we realized getting the training was not enough. We had a lot did not PCPs who got the training but never went on to get their DEAX waiver and never went on to actually prescribe.
We realized we were asking our PCPs PCPs to take a big leap of faith and we had to create a safety net so they knew if they t ook this leap with us they would feel safe. Some of the wraparound services that we've included as a safety net include additional training for primary care providers beyond the waiver waiver training. We have some staff-based trainings as well that help do myth busting and understanding the staff concerns concerns. We also offer to review charts for challenging cases and we offer to provide support by phone and email, and we also created a paging paging system for urgent situations.
Again, our toolkit has a lot of these resources in them and some guidelines on training and mentoring PCPs. So a big question about ending the bridge is how do you transition care toPCPs. Well, if you're facilitating the waiver training, it gives you an advantage, as you may be aware of when and who among the local PCPs has received the waiver training. If not, we find that the patient can also act as the first line of communication, especially if they have a good and trusted relationship with their PCP.
The patient can ask the PCP if they've received the training. or if they're thinking they might be able to prescription buprenorphine. We've actually had several situations where a PCP became convinced to prescription buprenorphine simply because a patient asked them to provide this service. and this even includes some of our more cantankerous older physicians who were not open to the idea.
The transition to PCP-based care is another situation to make sure a patient does not fall through the cracks. So even if a visit is schedule with a PCP, we always also schedule a follow-up with a bridge provider which can then be canceled once we are certain the patient is actually receiving a prescription from the PCP. This can be done either through the patient notifying us us, or by having a staff look on the prescription monitoring monitoring program to see if the patient has received the prescription. It's also really important for PCPs to understand that opioid use disorder is a chronic disease, and like all chronic diseases, there will be times where it is well controlled, and times where there is poor control.
Relapse or use of substances is an expected part of the recovery journey. As part of our toolkit we do have a guideline for managing managing relapse. We do ask that you note that while there are patterns, all patients in all use of substances are different at different times. The guidelines are truly meant to be helpful, but should not be viewed as a strict algorithm.
Given what we know about these medications for opioid use disorder, our number one guidance is to continue the medications if at all possible, unless you feel there is a true safety concern. And again, it is critical that PCPs have an open line of communication with substance use treatment organizations. Just as if you would refer to cardiology if a patient with congestive heart failure had an exacerbation, you would also refer back to a higher level of care for substance use if the patient was using illicit substances and you were uncomfortable or unsure of how to manage it. Thanks, Dr.
Russell. So Michele, how and when can a bridge program be closed, and how do program leaders know that goals have have been met to manage this process? So this goes back to where we started with the community needs assessment. It's important throughout the bridge program to continually track the demand for treatment versus the supply of treating providers.
You should be bringing more primary care providers up throughout the program so it's good to continue to monitor that. It's also important to monitor the overall trends in opioid use disorder. Are those rising and falling and how does that impact your demand. While you'll probably never have every provider in a community offering MOUD, if there are enough providers to offer patients of choice of where to go to get primary care and MOUD and there is some access capacity built into the system that allows new patients to enter into recovery and sustain their recovery, then I think you're there.
And there will be more information in our tools that show a little bit about that closure process. Thank you, Michele. In interest of time and the wonderful questions that you're submitting, I'm just going to skip past this slide which is a recap of the steps and move on to the next slide, which is another poll that we'll do just very briefly, that asks you additional questions about your desired topics for learning. We see one of those that is most interesting to the audience today is telemedicine as a strategy for expanding access to treatment.
So I'll start with the first question that came in, and this is for both Dr. Russell and Michele. Have you talked to medical professionals, treatment organizations, or other healthcare leaders who are against use of medications for OUD? How do you approach those approach those conversations?
And have you been able to change people's minds? So Michele, if we could start with you. Sure. I think we have to remember that this is that this is -- these kinds of programs are a big shift and we are shifting our culture to view addiction as a disease and not a choice.
It's also a big shift from seeing seeing abstinence as a complete solution to recognizing harm reduction is a bridge to success. And the bridge program and many other recovery center of excellence programs that will be disseminating require significant change in both attitudes and programs and change is hard and people are going to avoid change in all kinds of ways. It's much easier to keep doing what we've always done. With that in mind, I think it's important, back to a point that Holly mentioned, to try to really understand, where each individual is coming from, and how they see the barriers.
Sometimes that barrier may be a lock of education or understanding about MOUD treatment. But other barriers may include a personal or professional experience with MOUD, which is coloring their view. It may be insufficient personnel or financial resources that allow a person It might be or an organization to accomplish what we're asking asking of them. It might be a decision-maker who is opposed to MOUD, or other team members who are opposed to MOUD, or local beliefs that treating MOUD will bring more patients with opioid use disorder disorder into the community.
And possibly inadequate treatment capacity somewhere along the continuum of care. These things that I've mentioned are all challenges that we have faced in New York State, and we have been successful in overcoming those challenges. But it is not easy work. Change is hard, and it takes time.
If you invest in building that mutual understanding on the front end, and continue to invest in building the understanding along the way, because there's going to be new learning and new challenges along the way, that will help change to move forward. And we'll be talking more about some of the other programs that I mentioned in our future article. But let me turn it over to Holly to get her perspective from the physician side. Yeah, thanks Michele.
So I would say absolutely we have been able to change minds. I have this running joke credit Christine and Michele that I missed my calling as a used car salesperson because I just love the challenge of trying to get clinicians who have their minds set up that this is something they're never going to do to get them to agree this is something they can do and it will be clinically satisfying. Part of the reason we're able to change minds is that, as I said, we've been doing this in my primary care practice we've been doing this for seven-plus years years. And we have been able to grow the program.
Because Because the clinicians love it and the patients love it and it's one of the rare things that's a win-win for clinicians and patients. So I think the other place where we have run into problems of judgment is actually at mutual support groups that patients attend. So sometimes they'll get messaging from these groups or from their family and friends that by being on these medications they're not truly in recovery. And so my response to this is to encourage the patients to review with their family and their their support people that these medications are backed by decades of evidence across continents and shown to be life-saving.
them around talking to the people they're getting this judgment from that their treatment for medical conditions should really be between them and their physician. I think I'm also always happy to include people in the patient's visits, so that we can facilitate these conversations, explaining the safety and evidence around these medicines, and I think that also can sometimes help change minds and hearts around this. Thank you very much. I appreciate those answers.
Before we move on to the next question, I just want to let the participants know that we'll be putting a link to a survey in the chat, or make that available to you at the close of our session, actually, as well as you exit your browser so we look forward to your feedback there. Now moving on to the next question, Dr. Russell, which is also for you. Can patients become addicted to these medications?
Many long-term medications that patients take for our chronic diseases They cannot stop the medications without having withdrawal symptoms. Many long-term medications that patients take for our chronic diseases will also cause physical symptoms if they are stopped suddenly including including medications for anxiety, blood pressure, et cetera. So this is not different than any other long-term medications that we use for other chronic diseases. Great,, thank you.
So another question that we've gotten live in chat is for you, Michele Which is how do you best assess the needs of the community? You've made reference to community needs assessment, but where would you begin for that? So I think there's a couple of places that you can start. Certainly most communities conduct a formal community needs assessment, but I think what we have found to be really successful is to go out and meet with primary care providers across the community.
We actually, at the start of this, made an effort to go out and meet with every single primary care provider in the counties that we were targeting this program for. And we also met with the treatment organizations to really sit down and understand where their challenges were coming from. I strongly encourage those in-person discussions, because they're so much more effective than trying to interpret the response to a survey. Great.
thank you for that. And the next one, Dr. Russell, is for you. How do you address a client who has no or very limited access to Internet or video in order to accommodate these telemedicine visits?
Yeah, so that's a great question and it is definitely something that has come up for our more under resourced patients. I think so one answer is that might be a patient for whom the at-home telemedicine is not a viable viable option for. So certainly if there is a clinical office that can be used, either borrowed or rented or some sort of agreement that can be can be made. Additionally other things that we have had patients do as workaround are, if if there's community Internet available.
So parking outside of a library. Of course you don't want to do a sensitive medical visit inside the library, but sometimes the wifi is strong enough outside of a public space, outside of a medical space. So if there is a medical campus, oftentimes will have very strong wifi. I often check my email from my car outside of my office.
And then additionally there are sometimes sometimes -- we may just need to do a visit over the phone if the patient doesn't have access to good Internet. That's strong enough to do a video visit. You know one thing -- I just want to add to that. In some of the communities we work with, we're looking at adding wifi wifi hotspots in the parking lots of healthcare organizations that we work closely with.
Which can boost the access that's available. So that could be an option as well. Thank you and we have time for just one more question before we close and give our contact information. This is really for one or both of you you.
And the question is, can you talk about reimbursements for mentoring, consulting, or training, and are we here doing any collaborative care billing today? So I think the reimbursement challenges -- let me talk about this from two aspects. So first of all, when you incorporate MOUD into a primary care practice, that can be a very financially viable program. And under value-based contracting it's likely to generate gain sharing because it allows people to engage in prevention and treatment in a very cost-effective way.
There's also a lot of reimbursement reimbursement mechanisms around care management in the primary care practice that can cover the cost of those programs. And we'll be talking about those more when we talk through our behavioral healthcare management and collaborative care practice models. When you're talking about the bridge program, just like any other program that's a temporary program or a start-up program, when you're starting something up, there's some costs that may not be reimbursed. So it is important to think through right at the beginning what are all the costs that you expect to incur and how are you going to cover those.
And certainly there's some planning and implementation grants to HRSA that can cover some of that, but there are also a lot of other organizations that are are very interested in this work right now. So some of the things things you should think through are the start-up costs. So you might need to allocate time for both your operational team convening and the provider champion in particular. Holly has talked a lot about some of the work she does outside of just regular treatment.
And how you would compensate a provider for being that provider champion. The other thing to think through is just what is the reimbursement rate in the community that's being served. So a lot of times you are able to bill for a lot of the work that you're doing, but you need to consider in the community that you are going to be providing the work in, is that reimbursement at the same level as what you expect in the community you have historically worked worked in. And so just making sure that you have thought through all of those things is really important.
I think one of the challenges broadly is that the healthcare system doesn't reimburse for change management. And so that is disappointing, but I think there are lots of places that you can find grant funding and particularly through HRSA. Some of the implementation and planning funding that can be used exactly for that purpose. Great, thank you.
And if you could go to the next slide please. We are at the top of of the hour. Just a minute over. And I wanted to thank you for your participation in our discussion today.
Please take a moment to answer this survey, which is in the chat for you. And will also be available upon exit from your browser. As a reminder, a recording of this webinar, the slides themselves as well as tools and other materials will be made available on our website at Recovery Center of Excellence Excellence.org. Thanks again for joining joining and we look forward to hearing from you in the future.
Pharmacotherapy supports people with opioid use disorder (OUD) on their path to recovery. Also known as medications for opioid use disorder (MOUD) or medication assisted treatment (MAT), it involves prescribing an FDA-approved medication such as buprenorphine to decrease the cravings and the fear of withdrawal that drive opioid use. It is one of the most effective evidence-based treatments for OUD.
Patients may begin MOUD in a variety of settings. Initial treatment generally occurs in an inpatient or outpatient setting, with 3-5 times/week contact including therapy and social supports in addition to medication. After several weeks or months in this initial phase, visits are spaced out and patients transition to a medication maintenance phase and continuing care. This transition can be accompanied by the risk of encountering people or places that make opioids available to the patient. Therefore, continuing pharmacotherapy is critical to keeping the cravings for opioids at bay. Patients who have not been using have also lowered their tolerance and are at increased risk of overdose and death if they do use.
Access to maintenance MOUD is often limited in rural primary care practices for various reasons. The history of the opioid crisis, including past prescribing practices, has led to concerns among providers and community members. PCPs in rural communities also struggle with meeting the demands of a very large practice, often without adequate support.
In this webinar, Dr. Holly Russell and Michele Lawrence of UR Medicine Recovery Center of Excellence discuss telemedicine MOUD as a bridging strategy. They go through key questions involved in implementing a program, including:
- How do we build the bridge?
- How do we operate the bridge?
Where does the bridge lead to?
The bridge approach provides:
- the community time to heal and develop trust
- physicians time to become trained in MOUD and build the care management infrastructure into their practice that is necessary to support chronic behavioral health conditions like OUD
- patients with local access to the medication that is critical to their recovery and survival
A crucial element of a bridge program’s success is that the providers giving temporary support be engaged with the community before and during the program. Engagement includes periodic visits to the community to meet with PCPs, treatment programs, patients, and community members. This builds mutual understanding and respect that ultimately creates a new foundation of trust on which to rebuild local access to care.
Holly Russell is Assistant Professor of Family Medicine at the University of Rochester Medical Center. Dr. Russell is board certified in Addiction Medicine and is the founder and director of the Addiction Medicine program at Highland Family Medicine. For the last three years she has been working on a project looking at how to expand access to treatment for opioid use disorder within primary care settings including the use of telemedicine technology.
As the assistant vice president of business development and assistant professor of community and preventive medicine at University of Rochester Medical Center, Michele Lawrence works closely with rural community hospitals and their medical staff to create financially viable health care delivery systems that improve access to care for these communities.