Appendix A

Case Studies of Select Programs

SEMI-STRUCTURED INTERVIEW

The semi-structured interview was created by National Academies of Sciences, Engineering, and Medicine staff and the committee, drawing information from the Substance Abuse and Mental Health Services Administration (SAMHSA)-Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions Framework and the Greenhalgh et al. (2004) framework for Diffusion of Innovations in Service Organizations. The goal was to assess whether and how programs were integrating the services they provide for opioid use disorder (OUD) and infectious diseases and determine the most significant barriers to integration. The questions focused on the program characteristics, services delivered, and model of care (when data were available, programs submitted information about clinical outcomes related to integration, though outcomes were not the focus of the committee’s review). Broad questions were asked initially, followed by questions about more specific topics the committee deemed important to understand about each program (e.g., any barriers the program faced, including external factors impacting integration; the programs’ views toward harm reduction and patient-centeredness; organizational structure and culture; staffing and training available; major organizational change agents; business model viability; and resources available for integration). The set of topics discussed for each interview are outlined in Box A-1. The committee organized information about each of the programs in Table A-1.

ARCARE

Program Description

Founded in 1986, ARCare is a network of 47 community health center-funded primary care clinics across 3 states, beginning as primary care clinics and incorporating HIV care in 1999. ARCare has 500 employees in the clinics, 5 pharmacies, and 3 wellness centers. In 2015, ARCare began to incorporate behavioral health services in its larger clinics, and it now operates such services in 5 sites; 3 of these in Arkansas provide HIV/hepatitis C virus (HCV)/OUD services and began providing medications for opioid use disorder (MOUD) in 2017.

History of Program’s Integrated Services

ARCare has 17 federal and state grants to fund chronic disease management, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), behavioral health, substance use services,

TABLE A-1 Program Information

^a Federally Qualified Health Centers (FQHCs) are designated community health centers that operate as part of the Health Center Program administered by the Bureau of Primary Health Care within the Health Resources and Services Administration. The Health Center Program provides grants to FQHCs under section 330 of the Public Health Service Act (42 U.S.C. § 254b). See https://www.gao.gov/assets/700/690490.pdf (accessed December 5, 2019).

and several other specialized programs. However, this integration has occurred only recently. The behavioral health program in the Little Rock location has been in place only for 3 years, and the MOUD program for even less time than that.

The primary motivation for integrating services was to provide better care for patients and produce better outcomes. ARCare leaders seeking integration were aware of the literature that care integration can increase medication compliance, patient satisfaction, and patient wellness, which justified moving forward with it. Another motivation was to provide services in an immediate fashion, rather than through referral-based care (which can produce high no-show rates). The last reason was that integrating care could provide more information for providers, who would then be able to treat a patient more holistically.

ARCare hired a consultant to assist with integrating behavioral health into primary care services, but this has been difficult (and it is not as integrated as it would like). With the exception of a few providers who have taken initiative to become Drug Addiction Treatment Act (DATA) waivered and treat infectious diseases, there is minimal face-to-face communication between providers treating different diseases. A primary reason for this is that providers “speak different languages,” and finding common ground can be difficult. Moreover, directives from leadership must be given with a soft touch; because providers are difficult to find and retain, any mandate (e.g., to integrate services) that brings about increased administrative burden is likely to receive pushback from providers and increase the risk of workforce turnover.

The model of care must be changed to accommodate integration between behavioral health and primary care, especially with the complex histories that come with patient populations who have comorbid OUD and infectious diseases. For instance, the scheduling for behavioral health is different than primary care. A health professional may be able to see 30 patients in a day; a behavioral health provider may only be able to see 7 or 8. Therefore, providers from both perspectives have to adjust. ARCare leaders have tried to communicate the value of integration and to prove that it is in the best interest of patients.

Services Provided and Model of Care

The several sites that have integrated OUD and infectious disease services are built around providers who can treat both diseases. For instance, an HIV provider in Little Rock sees HIV patients 2 days per week, and prescribes MOUD another 2 days per week. She is able to see patients from both perspectives and provide services for the range of needs.

The other clinics that offer MOUD do not have infectious disease specialists onsite but have rotating infectious disease specialists that may visit once per week or several times per month. At these sites, the coordination becomes more difficult given the infrequency that providers are able to address patients with complex needs. Having additional dedicated providers for integrated care is a goal, but finding providers can be difficult.

At the larger clinics, a care visit typically entails a patient who comes in for primary care and is screened for OUD or infectious diseases, which can be treated in this setting. If a patient needs behavioral health services or MOUD, a hand-off is made with a behavioral health provider during the initial visit. Then, the behavioral health provider offers a brief intervention, schedules a follow-up appointment, and provides educational materials about MOUD. At the next visit, the provider will conduct a consent process to share behavioral health data with the medical team, conduct a urine drug screen, and begin MOUD if necessary. In general, ARCare providers want to be sure that a patient is ready for medication, as providers are limited in how many prescriptions they can dispense (additional info on this barrier is outlined below).

Across the several integrated care sites, three physicians and three nurse practitioners (NPs) have X waivers and routinely prescribe MOUD. Only one of these providers is an infectious disease specialist; the others are family practice providers. Buprenorphine is the primary medication, although a few patients have been prescribed naltrexone if they are no longer taking opioids. With respect to harm reduction, the integrated clinics prescribe pre-exposure prophylaxis (PrEP) and distribute condoms. ARCare does not have syringe services. Providers at ARCare are trained using the Hazelden Betty Ford COR-12 Model, and perform some training onsite and some training with a COR-12 instructor offsite.

Because Arkansas is not a Medicaid expansion state, most individuals have private insurance purchased on the marketplace. A small portion of patients are insured through Medicaid. In terms of financial sustainability, ARCare’s Federally Qualified Health Centers (FQHC) status has been crucial for providing services in general (including integrated services). HRSA funding was used to develop the MOUD program, and a number of grants are used to pay for behavioral health services. Still, the program’s sustainability is an open question, and convincing providers to engage in and bill for comprehensive visits has been a difficult task (e.g., billing a “99215” visit code for a comprehensive evaluation versus a standard primary care visit billing code). With reimbursement through Medicaid, it may be possible to bill visits for comprehensive care and generate enough revenue to sustain integrated care. Case management is another service that ARCare would like to perform with greater frequency, but it is not billable.

With respect to patient feedback, ARCare provides patient surveys on a regular basis and administers a questionnaire at each visit assessing patient satisfaction.

ARCare has seen a small number of patients with infectious diseases who access the MOUD program, though these numbers continue to increase. More individuals in ARCare’s care have viral hepatitis than HIV, and this is also true for those on MOUD.

Patient Characteristics and Outcomes

ARCare’s overall measures of success include uptake and eventual downward titration of buprenorphine and effective re-engagement with individuals following relapse. For infectious disease services, reduced viral load is the primary outcome. In general, ARCare wants to provide services that make patients feel accepted and welcome.

No data were available on patient characteristics or outcomes of integrated OUD and infectious disease treatment.

Facilitator and Barriers

Facilitator

• ARCare’s status as a community health center has been useful for integrating services in general and gaining funding opportunities to begin offering MOUD.

Barriers

• Integrating medical records for infectious disease and OUD patients has been difficult (from both the technological and patient privacy standpoints). This makes it difficult for providers to communicate effectively about patients, reduces continuity of care, and increases the chances that services are duplicated.
• Because certain HIV patients have a clinical need for opioid medications for pain, individuals living with HIV who also have an opioid dependence must be more carefully managed (including the care plans and medications).
• Some medical staff have been resistant to integration because they feel it will slow their patient workflow (both spending more time with patients and taking more time to enter information into the record).
• Behavioral health services can only be billed if a licensed clinical social worker (LCSW) provides the care in Arkansas, whereas in other states anyone with a professional license can bill. This interferes with ARCare’s ability to provide care with a limited workforce.

• The DATA waiver training is lengthy (especially for non-physician prescribers). Some providers have found the training to be redundant and clinically irrelevant.
• In their first year of prescribing MOUD, providers can only have 30 active prescriptions. This limited number is one reason why ARCare screens patients thoroughly before prescribing MOUD: it wants to ensure that the prescription will be used for someone who is ready for treatment.

Advice for Other Programs

• Make a clear action plan for institutional change, gain buy-in from various stakeholders, and follow through with the decisions. There is a general culture among leadership at ARCare for changing programs to fit the needs of patients, and that it is acceptable to make mistakes if the intention is positive (as long as no harm is done to patients). In one scenario, ARCare was incorrectly reporting its MOUD prescribing, and the Drug Enforcement Administration (DEA) audited the organization. With assistance from the DEA, ARCare wrote an action plan to change its practices and was better off for it.

Information About Informant

Frank Vega, L.M.F.T.

Director of Behavioral Health

KING COUNTY DEPARTMENT OF PUBLIC HEALTH

Program Description

The King County Department of Public Health began operating a syringe service in 1989 and now has several locations. Other services at these locations include testing for HIV, viral hepatitis, tuberculosis, and other infections to which people who use drugs are prone; treatment readiness counseling and case management services; education about harms associated with drug use and how to minimize them; and safe disposal of contaminated equipment.

History of Program’s Integrated Services

Modeled after several other programs (including in New York City and San Francisco), this program began integrating services to provide patients with low-barrier treatment in one visit, and in one location.

This was especially important given that the target population does not always make appointments on time, is chronically homeless, and faces significant stigma in the community. The King County Department of Public Health has also sought to integrate services into programs that patients already trust—this includes, primarily, the syringe service program, which is a primary referral source for other services. It gets patients in the door to more intensive treatment for OUD and infectious diseases.

Three primary programs operate out of the King County Department of Public Health. The most established is the Max Clinic, which is designed to provide high-intensity, walk-in, low-threshold care to patients living with HIV. The clinic also offers wraparound services, such as food assistance, transportation assistance, cell phones, and cash incentives. The second is Bupe Pathways, a low-barrier buprenorphine program operated by the Downtown Primary Care Public Health Clinic, which is colocated with the syringe services program and pharmacy. The third and newest is an HCV program, which operates from the syringe service and provides testing and telemedicine treatment for HCV.

In 2017, following the creation of a multi-stakeholder task force to address opioid use in King County, the city elected to expand access to buprenorphine. In tandem, a survey given to syringe service users found that 80 percent were interested in stopping or reducing opioid use. As a consequence, low-barrier buprenorphine treatment was piloted at the downtown Seattle syringe services program. Bupe Pathways has been successful, enrolling 456 predominantly unstably housed people to date. The department has made a commitment to expand capacity to meet the demand. This will entail expanding to six exam rooms in the next year and hiring an addiction medicine physician.

The department has long held the credo that it is best to “serve patients where they are at” in a low-barrier manner. Operationally, this means providing as many services as possible under one roof and viewing behavioral health and medical health as connected.

Leadership in the city and state has encouraged further integration (department and division heads, county leadership, and state legislators). In practice, the staff running various public health programs have sought collaboration and communication across divisions and departments and feel supported by the county leadership in doing so. One example of this is a burgeoning partnership between the buprenorphine program and the correctional facilities, wherein MOUD will be offered to inmates and will continue after they are released. Staff are vocal about the needs of their patients, and leadership is responsive to bottom-up communication.

Patients have expressed that colocation, assistance with transportation, and continuity of care between providers has made them feel included and assisted in their care needs.

Services Provided and Model of Care

In general, the syringe service provides a useful entry point for other services (including testing for infectious diseases and MOUD). Staff will point patients toward the range of available services. The goal is to provide a “one-stop shop” whenever possible.

The HCV treatment program is based on a nurse-driven care model, where a public health nurse provides onsite, in-person care to syringe service program clients in partnership with an offsite infectious disease physician who supervises clinical visits through a secure teleconferencing platform. In this model, patients with low disease complexity (e.g., early-stage HCV infections) meet with the nurse to complete initial assessment labs, ensure appropriate insurance coverage, and schedule a telemedicine visit with an infectious disease physician who specializes in HCV. During that visit, the physician assists the nurse in performing physical exams, eliciting the patient’s complete medical history and medication list, and describing the treatment plan. Patients who initiate treatment can securely store medication at the syringe services program for the entire course of treatment. Referrals are made to additional onsite support services (e.g., substance use disorder [SUD] treatment, primary care, social work) to facilitate successful completion of treatment and ongoing engagement with harm-reduction services. Complex cases requiring additional monitoring are referred out to a local HCV specialist. So far, this program has served several patients, but it is too soon to determine whether it will be successful long term. The goal is to provide low-barrier HCV treatment in an environment where patients are comfortable and able to access additional support services.

With respect to training, the public health nurse conducting the HCV work was already familiar with this population, having worked in the Bupe Pathways program. The department has developed a mission and vision document for new practitioners and team members at the time of onboarding. Because many of the department’s clients have complex and stigmatized health needs, there has been a strong push among the staff to ensure that the culture is focused around compassionate, nonjudgmental care. Still, much of the learning among staff and providers with each program is more informal and has a “learn-as-you-go” style.

Financial sustainability has been a perennial issue for these programs. While the MOUD program receives funds from local sales taxes, and the city and county provide public funding, there are few stable pools of funding to sustain the range of services the department staff would like to offer. The public health nurse for HCV care is funded on the last year of a grant, and the department staff hopes to find more permanent funding. Treatment for HCV at the syringe service program is now in its fifth and final year of a Centers for Disease Control and Prevention (CDC) grant,

which the department is using to build up its information technology (IT) infrastructure and improve reimbursement billing efficiency. Billing for the telemedicine visits has posed another problem, because the provider is part of a separate system. Additionally, insurance does not always cover the full amount for HCV labs, and the department will have to absorb that cost by some other mechanism.

For HCV, grant funding is available but is often focused on screening and linkage to care (rather than treatment). Because of this, it is unclear where the revenue will come from to pay for treatment for HCV long term. In general, the goal is to make each of these programs sustainable through patient-generated revenue, but there is no delineated path forward to make this a reality.

Staff at the department are confronted with the difficulty of having to react to the quickly changing needs of King County residents: there has been a large rise in methamphetamine use (both injection and non-injection), which the department is not equipped to treat.

The Max Clinic and Bupe Pathways programs have systems in place to routinely monitor patient outcomes. In addition, a survey is conducted every 2 years at the syringe services program to evaluate risk behaviors and factors affecting service uptake among its clients.

Patient Characteristics and Outcomes

At the downtown syringe service, there is 60 percent positivity among those tested for HCV antibodies. Although there has been a small uptick recently, HIV prevalence is relatively low among people who inject drugs in King County.

Because the HCV telemedicine program is in its early stages, there are no outcome data available. Several patients have begun HCV treatment through this program.

According to researchers in the King County Health Department, HIV care is more well established, and for the Max Clinic,

Facilitators and Barriers

Facilitators

• The restriction on HCV treatment that required patients to abstain from all drug use was recently lifted, allowing the department to refer patients to treatment with more confidence (and now to treat patients that are still using drugs via telemedicine).
• There was previously a state restriction on the amount of time someone could receive MOUD, but the state lifted this restriction.

Barriers

• The department has had to invest substantial resources into IT to keep communication firewalls between electronic medical record (EMR) systems when necessary.
• Because the department does not have an onsite physician to bill for the telemedicine visit for HCV care, they are billing the current physician to grant funding under a no-cost extension from CDC. This is ultimately not a sustainable way to fund the program, but billing is difficult for the out-of-network physician.
• The syringe service program—which provides a referral source for many other billable services—is not itself billable. This requires the department to find external sources of funding for the syringe service program.
• Obtaining the DATA waiver through training is arduous and is a barrier for providers.
• There have been philosophical barriers between those that favor harm reduction and those that favor an abstinence-based treatment program. To make sure that the department is the right fit for staff, employees created an introductory pamphlet on harm reduction and low-threshold care.

Advice for Other Programs

• Barriers to care take many forms. Even a battery of questions at the first visit can be a deterrent for future visits. Ensuring that providers are meeting patients where they are is crucial.
• A traditional medical workflow is unlikely to be successful for patients who are chronically homeless, frequently use drugs, or are stigmatized by society. Much more attention is needed for this population to remain engaged in care.

• Invite as many stakeholders to provide input as is possible. Connect with other treatment centers, homeless services, and community-based services.
• Use high-quality data-collection methods, and be aware that the best predictors for success in certain programs may be different than expected. For instance, the only significant predictor of retention in the Bupe Pathways program was whether a client was already taking buprenorphine beforehand.
• Individuals who have stable housing are much more likely to remain engaged in medical services, which indicates that partnering with community-based organizations that can provide housing may be an effective way to increase treatment compliance and retention.

Information About Informants

Brad Finegood, M.A., L.M.H.C.

Strategic Advisor

Joe Tinsley

Drug User Health Manager

Hilary Armstrong, M.P.H.

Project/Program Manager

Julia Hood, Ph.D.

Epidemiologist

Julie Dombrowski, M.D., M.P.H.

Deputy Director of HIV/STD Program

SOUTHCENTRAL FOUNDATION

Program Description

As an Alaska Native–owned, nonprofit health care organization, Southcentral Foundation serves 65,000 Alaska Native and American Indian people with more than 500,000 visits in Anchorage, the Matanuska-Susitna Valley, and 55 rural villages in the surrounding area. Southcentral Foundation is also a large employer in the area, with more than 2,700 employees across its more than 80 programs. Southcentral has nearly 2 million virtual encounters per year, and operates under a colocated and integrated medical home model.

History of Program’s Integrated Services

According to the senior medical director of quality improvement, moving toward a medical home model was—in general—a process of shifting specialty, high-end care into a primary care setting. This approach holds true for SUD services and HCV treatment, heart failure, rheumatologic diseases, and others. The goal is to prevent segregating one particular disease or condition to a location but rather to think about an entire patient’s life course and how to treat the multitude of medical issues that arise over time. There was an explicit focus to avoid over-designing the medical system to treat certain illnesses over others; rather, the goal was to build a system that could adapt to a changing consumer base segmented by people rather than disease state. The core competency that Southcentral Foundation aimed for was to connect patients with all the information they need and to create a medical home that is personalized and relationship based as much as possible. Segmentation by condition of specialist still occurs in settings where special architectural design or work prevents integration or colocation (e.g., audiology or physical therapy). Yet, even for those exceptions, accepting people back to the medical home as quickly as possible is still the design goal.

Each core medical service has its own business group and an executive sponsor for that group. The Primary Care Core Business Group developed a strong relationship with the Mental Health Core Business Group, which is how any problems are resolved regarding continuity of care between the services. These services have become almost completely colocated in the same clinic, and as patients become more or less stable, medically or from a mental health perspective, their care plans are transferred back and forth between the core groups. While the workflows may be different depending on what a patient is treated for, the providers and core groups are in constant, daily communication. While there still exists some specialization at separate locations for high-end medical needs, such as complicated obstetrics and perinatology or medically managed detox, integrated or colocated care has been achieved as much as is possible. The driving principles have been to bring services as close together as possible and to remove barriers that result in waste, delay, or loss of transfer efficiency (e.g., no-shows).

A major intervention has been to take the capacity burden (such as refilling medications, monitoring known repeat labs, vaccinations, or scheduled injections) off of specialty care and allow specialists to spend more time with patients. In the medical home, on the other hand, patients can be managed in a much higher capacity system with greater continuity. Medications can be refilled, labs can be monitored, injections can occur once the plan and diagnosis are clear, and stability can be established.

Southcentral Foundation has also learned that even this integrated care model clinic does not meet the needs of all patients. For instance, it was not meeting the needs of homeless populations in Anchorage, so it located an integrated care team in the largest homeless center in the city. Because people could walk to receive care, they were much likelier to use the medical home instead of the 911 or emergency rooms (ERs) in the area. This reduced the number of ER visits and 911 calls involving homeless individuals. Southcentral Foundation built a similar program at a homeless teen shelter.

Services Provided and Model of Care

Each patient that Southcentral Foundation interacts with is assigned a case manager and a medical home primary care physician (PCP), supported by clerical support staff and a medical assistant, respectively. Each of these teams of four staff members may have as many as 1,400 patients under their purview (~150 of whom are actively managed, with the rest monitored or supported with ongoing refills, vaccinations, or lab monitoring). While these teams are generalists—and work to establish relationships and continuity by person, not disease—there are times when a unique skill or knowledge is required. In such cases (as with HIV or HCV care) there is a coordinating specialized case manager who can support newly diagnosed people on any of the 64 medical home generalist teams while leaving the patient in place. Unique labs, medications, studies, or additional services are facilitated from the primary care medical home team with “coaching” by these specialized roles. This prevents care fragmentation, waste, and loss of continuity and preserves the capacity to attend to all of the other health needs a patient may have that are not typically well met by more specialized services (e.g., vaccinations and cancer screens).

Medications for OUD have been diffused into the medical home using this same philosophy, and there are 45 providers with DATA waivers (with a mix of PCPs and specialty care providers). PCPs do not initiate MOUD at Southcentral Foundation but collaborate with addiction medicine providers to continue to prescribe to stabilized patients. The rationale for this protocol is the limit on the number of prescriptions that a provider can write: if addiction specialists begin patients on medications and PCPs take over once a patient is stable, all providers are able to stay under the limit. Buprenorphine products are the most commonly used at Southcentral Foundation, but some naltrexone products are also used.

Mental health providers are also colocated and within the workflow of the medical home, and there are dedicated rooms in the primary care clinic for more intensive therapy interventions. This is true for many

services in the medical home model: if Southcentral Foundation is able to provide care that does not require highly specialized equipment or a building footprint, the organization has brought that care into the medical home. According to Southcentral Foundation, this also has the advantage of reducing stigma because patients with mental health disorders, SUDs, or infectious diseases are all seen at the same front desk and treated by the same providers (no other patients know why they are visiting the clinic).

Southcentral Foundation has implemented robust data-collection techniques and analyses for quality improvement: labs are frequently ordered by the primary care teams’ case manager, then scheduled in a blood draw and vaccination clinic staffed by a medical assistant who works independently. This allows specialty providers more time with patients.

Surveys are rarely mailed out; instead, patients provide feedback on iPads after visits, with more than 300 live surveys per day. Twitter and Facebook are monitored for mentions to assess how patients feel about the services. Southcentral Foundation writes in its newsletter when it has changed a particular practice in response to patient feedback.

In addition, providers and their care teams are provided daily and weekly feedback on patient satisfaction, the number of prescriptions written, patient visit numbers, and a host of other metrics. Southcentral Foundation has found that—even with no explicit directive to improve on certain metrics—these feedback tools generally improve each provider team’s outcomes through increased awareness. And, importantly, each team is judged as a unit rather than as individual providers. Hence, there is mutual incentive to help team members improve their practice.

In terms of staff training, 100 percent of the Southcentral Foundation workforce undergoes a communications and work-style training to instill best practices for working in teams. Clinical staff also receive a training on having difficult conversations, mentoring, and conflict. More specialized staff receive as much as 5 days of training on their topic areas (e.g., integrated care team training). The goal of this training is to ensure that providers are aware of the culture Southcentral Foundation wants to create but also to make sure that providers are providing care at the top of their license. So, while physicians may have to sign off on vaccines, they are not the ones delivering vaccines.

The primary payers for Southcentral Foundation’s services are Medicaid and Medicare (~40 percent) and private insurance (~30 percent); the remainder have no insurance (which is effectively reimbursed by the Indian Health Service block grant). Most of the organization’s revenue comes from patient visits, but it also applies to relevant grants (though, typically, it will only apply to grants to create services that it would have already added otherwise).

Patient Characteristics and Outcomes

Patients seen in Anchorage are all Native, whereas smaller clinics in neighboring villages will have all populations. Southcentral Foundation has 133 HIV-positive patients in the clinic (115 are on antiretroviral therapy [ART] with an undetectable viral load), and a specific case manager supports the medical home primary care teams to ensure all necessary medications and monitoring are in place. Based on risk screening criteria, 52 patients are on PrEP and have been for more than 6 months.

About 1,000 people are on MOUD (although some take them for alcohol use disorder rather than OUD; some have both). Of those on MOUD, about 40 percent are considered stable (and are being prescribed by a PCP rather than an addiction specialist). These patients undergo a toxicology screen periodically and then receive a refill of their current dose.

Because Southcentral Foundation was a test site for HCV treatment, it has more than 100 patients who received treatment and demonstrated remission. However, it has just moved that process from the viral hepatitis program into primary care and is now only monitoring a dozen with complete primary care–initiated and –monitored treatment. The vast majority will be solely managed from the medical home. Based on the initial recommendations, Southcentral Foundation has screened 8,371 of the 14,419 total relevant patient population for HIV.

Facilitators and Barrier

Facilitators

• Up-front investment in data collection and a focus on quality improvement. As Southcentral Foundation was attempting to integrate services, it needed to know whether that integration was working.
• A culture of long-term thinking has allowed Southcentral Foundation to remain focused on a primary goal and absorb mistakes.

Barrier

• Overdesigned national systems that do not encourage innovation and quality improvement for providers and health care administrators at the local level.

Advice for Other Programs

• Look for partnerships within and outside the health care system to build coalitions.

• Do not focus on quarterly profits; instead focus on providing the best possible care to patients to build a reputation.
• Build an infrastructure and medical model that promotes patient continuity and minimizes attrition. This model should have clear accountability and tasks for staff members.
• Develop a systematic way of tracking and collating data. Problems cannot be managed if an organization is unaware that they exist, and they cannot be fixed if no one is accountable.
• There needs to be a professional workforce layer focused on quality improvement (above and beyond the providers themselves). This workforce needs to offer continuous, immediate feedback to providers on their performance.
• While it is good to be ambitious, overreaching can stretch organizations too thin. Building slowly, piloting programs, and scaling up successful programs is a recipe for success. Organizational change is slow, so this should not be a deterrent to following through on good ideas.

Information About Informant

Steve Tierney, M.D.

Senior Medical Director of Quality Improvement

GREATER LAWRENCE FAMILY HEALTH CENTERS

Program Description

Greater Lawrence Family Health Centers (GLFHC) is a collection of community-based health care clinics. Established in 1980, GLFHC sees approximately 60,000 patients annually across 6 primary care sites and also operates a mobile health van and 14 sites delivering health care for the homeless. The care delivery is built around family physicians and a family medicine residency model, although each site integrates care slightly differently and the level of integration varies between sites. In general, core OUD and infectious disease services are performed by the primary care team, with referrals out to specialty care for patients with complex mental health histories.

History of Program’s Integrated Services

Lawrence, Massachusetts, has a population of about 80,000 and the lowest per capita income of any city in the state. Lawrence is nearly 75 percent Latinx, with a significant portion of the population speaking

only Spanish. In 2016, there was sharp rise in newly diagnosed HIV cases, many of which were attributable to injection drug use. In 2018, Lawrence saw a 20 percent increase in overdose deaths, placing it among counties with the highest overdose rates in the state. In response to these concurrent OUD and infectious disease outbreaks and the great need in the community, GLFHC began integrating services to both prevent new cases and provide effective treatment. In 2017, GLFHC began to restructure programs such that HIV, viral hepatitis, and SUD would fall under the same leadership. In addition, GLFHC’s Health Care for the Homeless program was more tightly integrated with the primary sites by sharing resources and knowledge between staff. The behavioral health team is currently undergoing integration with the OUD and infectious disease services in order to more effectively share staff and use grant funds.

Because GLFHC has been a family medicine institution and operating in a patient-first model for many years, there was very little cultural friction in convincing providers that integration could help. Providers have become more aware, however, that they must treat infectious diseases and OUD simultaneously for maximum efficacy. While GLFHC has had a buprenorphine clinic predating the recent increase in overdose deaths, there was no major impetus historically to move this care into the primary care setting. Now, all physicians specializing in HIV have DATA waivers and are comfortable prescribing buprenorphine.

GLFHC has expanded its services through grant funding and coalitions in the community. Recently, for instance, it was awarded an Evidence-to-Intervention grant to begin a mobile buprenorphine program intended for people who inject drugs and also are living with HIV. GLFHC has also started a program called Bridge, wherein patients admitted to the emergency department (ED) can be inducted on OUD treatment and linked back to outpatient services to continue receiving MOUD.

Services Provided and Model of Care

The family physicians at GLFHC have different areas of expertise (e.g., HIV, viral hepatitis, SUD, behavioral health), and they attempt to provide as much care as possible without referring patients elsewhere. In addition to the programs already running, GLFHC is seeking to expand its internal mental health care capacity.

On the harm-reduction front, GLFHC has a syringe service program funded by the Massachusetts Department of Public Health. It distributes 20,000 syringes per month, naloxone, and education materials. GLFHC has received funds to create three syringe kiosks throughout the community and better advertise syringe services and disposal services. Patients who enter the clinic are also provided naloxone via a standing order at the pharmacy and prescribed PrEP as necessary.

The MOUD program consists primarily of buprenorphine, with several dozen patients on naltrexone. All HIV specialist clinicians (three physicians; one physician assistant [PA]) are DATA waivered and have been trained to treat viral hepatitis. In addition, there are several NPs (including one who works on the Mobile Health Unit) who can prescribe MOUD. Across the system, NPs have been trained to treat HIV, viral hepatitis, and OUD.

Following a Bureau of Substance Addiction Services State Opioid Response grant, GLFHC is beginning a Bridge Clinic, which intends to initiate ED patients on buprenorphine before they are released. Then, these patients are connected with primary care through GLFHC, and additional medical needs can be addressed (including screening for HIV, viral hepatitis, or initiation on PrEP). There is a similar program funded by the state to screen patients in the hospital for OUD and connect them with OUD treatment and testing/care for infectious diseases.

GLFHC’s Mobile Health Unit provides MOUD (primarily buprenorphine) for approximately 20 people each week and treatment and care for HIV. The Mobile Health Unit also offers PrEP and vaccinations and is attempting to develop a sustainable treatment program for viral hepatitis.

An additional program funded by the Massachusetts Department of Public Health is a linkage for testing of HIV, viral hepatitis, and sexually transmitted infections in the county’s correctional system. This program links patients back to infectious disease care after release and is expanding to include MOUD linkage after release.

HIV care is funded by Ryan White and has grown from 320 patients to 370 in the past 3 years. Many of these patients were recently infected with HIV, so GLFHC was very interested in engaging and retaining them early in the process.

GLFHC’s hope is that all providers feel comfortable prescribing PrEP and conducting baseline screenings, and it has held several clinic-wide trainings on PrEP and hepatitis screening/treatment. The addiction medicine team has also hosted trainings on harm reduction and the principles of addiction medicine. Several of GLFHC’s clinics have at least one nurse manager who covers HIV, buprenorphine, and viral hepatitis; they were trained on how to manage those services.

The majority of patients accessing services through GLFHC are insured by Medicaid or Medicare, and about 20 percent are insured privately. GLFHC’s funding sources are diverse and include the Massachusetts Department of Health (for overdose education, naloxone training, and addiction medicine programs), grants (for the Mobile Health Unit and a behavioral health counselor), and HRSA for HIV services (primarily case management and further integration of services, since 98 percent of patient visits at GLFHC are reimbursed through insurance). Ensuring stability of funding is a perennial issue, but that much of GLFHC’s patient

population is insured allows grant funding to go toward improving coordination of services. The hope is that by integrating services early, GLFHC will be able to save the health system money in the long run despite some up-front investment.

While GLFHC has not instituted formal feedback mechanisms for patients to provide input on integrated services, this is another investment the organization is interested in pursuing. For instance, GLFHC’s providers have discussed including patients in the interviewing process for community health workers to ensure that new employees are screened by the patients whom they will be serving.

Patient Characteristics and Outcomes

GLFHC’s patients seeking integrated treatment for OUD and infectious diseases (particularly through the Mobile Health Unit) tend to be homeless with some documented psychiatric diagnosis. Approximately 500 individuals are on MOUD through GLFHC, and about 40 percent of that group are living with HIV or viral hepatitis (or both).

Among all HIV patients (362, as of May 2019), 92 percent have been prescribed ART, and 82 percent have viral load <200 copies/mL. Eight percent of those on ART have viral load >200 copies/mL. Since 2014, 309 patients have been treated for HCV, 28 of whom still remain on treatment; 276 patients completed at least 12 weeks of treatment, and 91 percent had a sustained virologic response (although this number includes those who were lost to follow-up, did not complete treatment, or died for unrelated reasons).

While a majority of the Mobile Health Unit’s clients are experiencing homelessness, GLFHC is still concerned that it is not reaching a large enough portion of the homeless population. It is difficult to know where to find patients, who may move back and forth between neighboring towns or outside of city limits. In addition, the Mobile Health Unit has heard anecdotally that there may be an extra level of stigma for people who inject drugs and also have HIV or viral hepatitis. It could be, for instance, that an infectious disease diagnosis pushes an individual further into isolation from other people who use drugs because of the stigma associated with a diagnosis.

Facilitator and Barriers

Facilitator

• The overall push toward decriminalizing SUD has facilitated increased access to treatment. Historically, is has been difficult to provide OUD treatment in state-funded jails, but this is becoming

Barriers

• It is difficult for mid-level providers to obtain a DATA waiver to prescribe MOUD. The 24-hour training is a disincentive.
• Recruiting and retaining Spanish-speaking providers (particularly mental health providers) prevents GLFHC from delivering culturally competent care.
• Even with perfectly integrated services, GLFHC may still be underused because of ongoing stigma toward infectious diseases and OUD.
• Structural barriers within the community health center protocol can be onerous to overcome. For instance, GLFHC did not include behavioral health services in its initial community health center proposal and then needed to update its profile to include these services (a time-consuming process).
• Syringe service programs need to be approved by local municipalities. Simplifying this process would provide an easier avenue for patients to access care, as the syringe service program has been a main referral source to GLFHC’s buprenorphine program.

Advice for Other Programs

• Develop strong lines of communication with providers outside of organization. When GLFHC has to refer patients to outside behavioral health providers or the local opioid treatment program for methadone, the communication between GLFHC and that outside provider could stand to be improved. GLFHC does not always know which prescriptions patients have been given or whether they have been seen by that provider. Developing stronger communication will ensure greater continuity of care.
• Set up several entry points for further care. GLFHC has the regular clinic, the Mobile Health Unit, and the Bridge Clinic, all of which are designed to further engage patients in treatment at different touch points.

Information About Informant

Christopher Bositis, M.D.

Clinical Director, HIV and Viral Hepatitis Programs

PLUMAS COUNTY PUBLIC HEALTH AGENCY

Program Description

The Plumas County Public Health Agency includes a rural clinic that has built a coalition of partners throughout Plumas County and neighboring counties. The clinic provides basic services, testing for infectious diseases, MOUD, harm-reduction techniques, and educational materials. Since the early 1990s, the clinic has been building on its core services. In 1994, the clinic started offering reproductive health services through a MediCal waiver, Family Pact. With the Ryan White Part B program in 1996, the clinic expanded its services to include comprehensive treatment and case management for people in Plumas County living with HIV. In the late 1990s, the clinic expanded to offer outreach clinics with limited hours and services in three neighboring communities. The clinic has close collaboration with staff at the local hospital (frequent, in-person conversations) to follow up with treatment regimens but does not explicitly share EMR systems, staff, or providers.

History of Program’s Integrated Services

In 2018, CDC named Plumas County as “at risk” for an HIV outbreak due to injection drug use (CDC, 2018b). Given this, leadership and staff at the agency felt that integrated services for infectious diseases and OUD was a natural way to meet patients’ needs. The original plan for reducing the prevalence of infectious diseases and OUD was focused on harm reduction and increased access to treatment. Specifically, the agency’s plan was threefold: reduce the number of prescriptions of opioid medications, increase prescriptions for and access to MOUD, and increase naloxone access.

Prior to 2016, no providers at the agency, or in the county, had received a DATA waiver to prescribe MOUD, so this was a first step toward greater integration of services. The director has been interested and involved with integration, and there has been significant buy-in throughout the organization. This was the case because most people know or have heard of someone who is struggling with OUD. Under the current director’s leadership, the agency has adopted an approach that focuses on the “spectrum of harm.” This entails focusing on an individual patient’s needs, ranging from harm reduction and testing to treatment. Plumas County recently received a $200,000 grant from the HRSA Rural Communities Opioid Response Program, allowing the agency to support staff working toward holistic treatment for SUD.

From a staffing perspective, integration within the agency has been relatively seamless. Because the department is small, it is easy to

learn about other staff members’ work, programs, and ideas. Still, the greatest step toward integration was forming a county-level coalition of stakeholders from hospitals, law enforcement, the district attorney’s office, the behavioral health system, and public health departments from neighboring counties. Individual champions were identified in each of these stakeholder groups, and maintaining close relationships between these champions has been crucial.

Services Provided and Model of Care

In many cases, patients will visit the agency for the syringe service program or for other basic services but also be offered MOUD, naloxone, overdose prevention education, rapid testing for HIV/HCV, and a referral for HIV/HCV treatment and PrEP when necessary (via an online prescription service). However, the clinic does not currently treat HIV/HCV. Instead, it refers patients to the local hospital (HIV treatment is paid for by Ryan White funds and includes case management; HCV treatment does not). The agency does not provide treatment for HIV/HCV because it does not want to duplicate services already on offer in the local hospitals; instead, it has helped the hospitals to build capacity for treating these infections. Program integration with the local hospitals has helped to sustain access to treatment.

For patients with HIV, the case management includes transportation to the hospital with the case manager and follow-up reviews with the agency and hospital staff.

The clinic also has a mobile van, which targets outreach to people who inject drugs throughout the community. Mobile services include syringe access and disposal, HIV and viral hepatitis rapid testing, naloxone distribution, and harm-reduction counseling.

The agency has 9 staff members in the health education division and 12 staff in the clinic, including 1 physician and 1 PA; the remainder are nursing staff. The DATA-waivered physician who provides buprenorphine treatment is also the county’s public health officer. In one specific circumstance, this physician prescribed naltrexone rather than buprenorphine.

The staff are encouraged to take advantage of trainings offered by the state, and locally, they have hosted harm-reduction and MOUD training to educate providers in other counties. Within the organization, there have been no explicit trainings for staff on integrated services; instead, much of the training has been peer to peer. The agency has had to be creative to find ways to train staff on integration. When the department started a syringe service program, it used federal HIV funds to train the syringe service staff on HIV testing. Without this mechanism, there would not have been a way to pay for this kind of training.

Patients have had some opportunities to provide input on services, with limited success. The clinic has received useful patient feedback through surveys, and the syringe service program held focus groups with the broader community; this also provided valuable input. On the other hand, while the coalition meetings that take place between different community stakeholders are public, they are not typically well attended by people who use drugs. There are no explicit programs for families, except that they may be incorporated into treatment or provided naloxone at the patient’s discretion.

The vast majority of patients that come into the clinic (about 75 percent) are on Medicaid. Twenty percent have private insurance, and 5 percent are uninsured.

To remain sustainable over time, the agency has tried to leverage federal grants toward instituting permanent services. One of its goals is to prevent and treat infectious diseases and OUD, because these diseases are so closely linked. But funding has been difficult to obtain, and there is always a concern that the funding will not be sustainable long term because programs are funded through several different mechanisms. The MOUD program, for instance, was funded initially from a state grant to promote rural health and now relies on a 2018 HRSA grant and California’s hub-and-spoke model; HIV testing is available from Ryan White funding; California funds syringe service supplies through the Office of AIDS; and public funding pays for HCV testing.

Patient Characteristics and Outcomes

Overall metrics of success for the health agency include the number of people served, the number of clients engaging in MOUD and showing up to appointments, the number of syringes distributed, tests completed for HIV/HCV, and the rates of undetectable viral load.

The agency sees 3,000 patients per year. In the 5-county region in which the agency operates, there are approximately 80 HIV clients, and about 10–15 that are co-infected with HCV. HIV prevalence is still relatively low compared to many other regions with substantial intravenous drug use, which is why CDC designated Plumas County as at risk for an outbreak. However, HCV positivity results have remained steadily high for the population over the past several years, with nearly 30 new cases of HCV reported annually in a county of less than 20,000 people.

In the past year, 45 individuals have been initiated on MOUD, about half of whom remained on it for longer than 6 months. The agency has heard from patients that there is a stigma for seeking treatment for OUD. While opening a syringe service has broken down barriers for accessing treatment, there may be many in the community who could use treatment services but have yet to do so.

Facilitators and Barriers

Facilitators

• Close partnerships with the community hospital, behavioral health clinics, and the criminal justice system have allowed for much greater integration of care than would be possible if these stakeholders were operating alone.
• In 2018, the state lifted the previous HCV treatment restrictions (e.g., requiring a fibrosis score of 2 or higher). Treatment is now more widely available to a greater number of patients.

Barriers

• Neighboring counties have different Medicaid managed care systems, and the regulations are different for providing treatment and payment. Patients must then try to navigate different systems for the same treatments.
• The agency does not have access to the EMRs in the hospital, which prevents case managers from truly understanding the full care plan and providing continuity of care.
• The lack of blanket permission to provide syringe service programs has meant that each county must spend time and resources getting permission from the state.
• Finding transportation to the clinic and syringe service can be difficult for many of the people who need the services the most. For patients who need methadone, the closest clinic is 1.5 hours away.
• The agency has been awarded Ryan White funds (Parts B and C) for HIV care, treatment, and prevention. Because Plumas County does not currently have a high prevalence of HIV (but has been labeled at risk for an outbreak), most of the funds are used to maintain the treatment and case management programs, and less is available for the prevention necessary to avoid an outbreak.
• The 8- or 24-hour DATA waiver training is an issue for many providers.
• The lack of broadband Internet access in rural areas prevents the agency from attempting telemedicine visits with patients. Because transportation can be a barrier, telemedicine would be a useful alternative.
• Although there is the possibility of grant funding, there are no simple financial mechanisms for covering case management for patients living with HCV (whereas Ryan White funds case management for patients living with HIV).

• There is currently no availability of methadone for SUD treatment in Plumas County. Though a physician could register with the DEA, the issue lies in the county clinics’ capacity to provide daily care and maintenance for patients.

Advice to Other Programs

• Start small, and grow slowly. The agency would not have been as successful had it tried to implement many new services all at once. Instead, it has incrementally added services and plans to continue this trend.
• Apply for as much external funding as possible. Grant funding can be difficult to receive, but without external funding, it will be hard to expand services or demonstrate that additional services are worth funding through more sustainable mechanisms.
• Ask the people using the services what their opinions are, and base services around the needs of the community.
• Engage and develop a trusted relationship with law enforcement. If patients are concerned they will be apprehended by law enforcement when visiting a mobile van for clean syringes, they will stop using that service.
• Open communication with the criminal justice system is also crucial, as it can allow patients to be lined up for treatment upon release from the corrections system.
• Do not underestimate the role of stigma. The Plumas County Public Health Agency has found that HIV clients who inject drugs are hesitant to use the syringe services, because they may not have developed a close relationship with the providers delivering those services.

Information About Informants

James Wilson

Health Education Coordinator

Barbara Schott, M.S.W.

Health Education and HIV/AIDS Program Manager

LIFESPRING HEALTH SYSTEMS

Program Description

LifeSpring Health Systems has its roots in community mental health, beginning as a mental health care center in 1963. It has since transitioned

to a comprehensive behavioral health care center, and it adopted primary care services in 2008. In 2015, LifeSpring was awarded community health center status amid a rural HIV outbreak in Indiana. In tandem with this arc toward further integration, LifeSpring served as a resource for people living with HIV (or at-risk populations) who had concurrent behavioral health needs. LifeSpring has strong integration between OUD and infectious disease services.

History of Program’s Integrated Services

After primary care services were added, integrated care evolved quickly due to the complex needs of patients. Because LifeSpring has been operating since the 1960s with a focus on the social determinants of health, it was relatively easy to gain buy-in from staff and leadership as to the necessity of integrating care services. Overall, the leadership championed integration between OUD and infectious disease services—it was important to the board, chief executive officer, and management team. However, the process of integrating did pose some challenges. When integrating behavioral health with primary care, there was occasional staff conflict over processes, logistics, and language, but the common understanding that patients would be the first priority allowed staff and providers to work through this. Leadership at the organization thought integration was important and had a clear, patient-centered strategy. They also granted lower-level staff and providers flexibility in how to actually implement the integration protocols. This created strong morale among the staff and promoted positive flow of information upward to leadership.

Services Provided and Model of Care

LifeSpring operates on a medical home model, where a patient’s needs are addressed in one visit and one location whenever possible. Case managers will schedule appointments for patients, follow up with them to make sure they know when to come to the clinic, and ensure that they have transportation back and forth. If a patient needs to visit an external provider, a case manager will make sure to call that provider for any necessary information after the visit. LifeSpring treats HIV, viral hepatitis, and OUD in primary care, as well as promoting harm reduction through PrEP prescribing, condom distribution, and a colocated syringe service (run by the local health department).

Since incorporating auxiliary treatments (including OUD treatment) into primary care, LifeSpring has increased its flexibility to respond to a diverse set of patient needs. Now, providers in behavioral health feel more comfortable treating physical health needs, and vice versa. This has become especially important for patients with behavioral health needs,

as they may not want to express these needs over the phone. Coming to the clinic for primary care, on the other hand, feels like a more natural process and allows patients to talk about their behavioral health needs in a nonjudgmental context. According to LifeSpring, this allows for continuity of care: the patient can be scheduled immediately with a therapist and can learn about or be prescribed MOUD as necessary.

LifeSpring does not have a certified infectious disease doctor on staff, but does have a visiting infectious disease doctor once per month, and patients with complex care needs can be seen at that time. Spread across several sites in Indiana, LifeSpring has several full-time and several part-time psychiatrists; 2 family medicine physicians; 9 NPs who specialize in either psychiatry, HIV care, or family medicine; 20 therapists; and a range of case managers and medical assistants.

LifeSpring’s MOUD program includes naltrexone and buprenorphine, both of which can be prescribed on a patient’s first visit. LifeSpring can provide referrals and transportation to an opioid treatment program for methadone. There are nine providers (physicians and NPs) with DATA waivers.

New staff at LifeSpring go through an orientation to adjust them to the integrated model of care. This training includes specific instruction on harm reduction and nonjudgmental, compassionate care. This orientation is intended for staff at every level; it is LifeSpring’s goal to have staff facilitate care rather than act as a barrier. LifeSpring providers have also taken part in Project ECHO to prescribe HCV treatment.

Most patients are on Medicaid (~60 percent), 20 percent are on Medicare, and the remainder are on private insurance or Indiana’s insurance for low- or moderate-income people living with HIV. The community health center model has helped sustain LifeSpring in providing integrated care and offers the confidence that it can continue to meet its patients’ needs. Even though integrating care has been time-consuming from an EMR and billing perspective, LifeSpring has been accustomed to integration in this way because it has always treated complex medical needs as a community mental health care provider.

LifeSpring believes in the philosophy “nothing about us, without us,” which has been the driver for administering patient feedback surveys in person and on its website. While there have been no formal focus groups to assess patient feedback, it is common for providers to talk to patients in waiting rooms and ask how they feel about LifeSpring’s services. Additionally, annual surveys provide feedback about services and the ability to access care. LifeSpring is also governed by a board of directors made up of individuals, a majority of whom are patients of the health center. With respect to families, LifeSpring has hosted a “lunch and learn” about naloxone, where it distributes naloxone and provides training on how to use it. Lifespring also has an educational program for families and friends of people with SUDs.

Patient Characteristics and Outcomes

LifeSpring’s main measures of success are retention in care for OUD and infectious diseases and the speed of care delivery. In line with its patient-centered philosophy, LifeSpring also believes that success for one patient may not be success for another. Sometimes, stability or patient empowerment is the best measure of success, even if that patient is still using drugs.

LifeSpring’s Jeffersonville site (the largest clinic) serves about 2,500 patients per year, 1,500 of which have SUD. The two smaller locations see approximately 1,500 and 450 patients per year, respectively. System-wide, it has about 50 patients living with HIV and undergoing treatment. All three locations have MOUD and infectious disease treatment. There are several patient populations that LifeSpring believes it has not fully reached: individuals experiencing homelessness, individuals in the criminal justice system, people who use intravenous drugs, and undocumented immigrants.

• 91 percent on MOUD after 6 months
• 67 percent on PrEP after 6 months
• 79 percent with undetectable viral load (HIV) after ART initiation
• 48 percent with a sustained virologic response (HCV) after treatment initiation (though HCV treatment is relatively new at LifeSpring)

Facilitators and Barriers

Facilitators

• There was previously a Medicaid rule that prohibited billing for medical and mental health care services on the same day. Indiana has relinquished this rule, which has facilitated integrated treatment.
• Indiana previously had a rule that community mental health centers could not provide primary care. Therefore, LifeSpring initially formed a separate legal entity to deliver primary care. However, the state has since removed that restriction, and LifeSpring now provides both types of care under one system.
• Gaining prior authorizations for MOUD was previously time-consuming for case managers, or patients needed to fail with first-line treatments in order for LifeSpring to be reimbursed for buprenorphine. Now, under the leadership of a new Secretary of Family and Social Services, many prior authorization barriers have been eliminated. This allows for delivering care to patients sooner and more consistently.

Barriers

• LifeSpring was intent on maintaining the same EMR for its patients across behavioral health and primary care. This proved difficult, as it needed to adjust the EMR to suit the needs of both sets of providers. What was acceptable for behavioral health care providers was onerous for PCPs, and vice versa.
• Case management for primary care patients is not easily reimbursed, unless they also have a concurrent behavioral health issue. This makes it more difficult to reimburse for integrated services in the primary care setting.
• Some providers cannot be reimbursed for services for integrated care at all. For instance, only LCSWs can bill for frequently needed services under the community health center model. Employees with a master’s degree in counseling, on the other hand, cannot.
• In rural areas, there is a significant workforce shortage. It is difficult to incentivize providers with niche expertise to work significant hours at certain locations.
• For the past several years, Medicaid has restricted treatment for HCV patients with F1 and F2 liver fibrosis levels. As of July 2019, this rule was relinquished and these patients can be admitted for treatment at LifeSpring.
• Even though providers were all committed to providing the best possible care for patients, differing personalities and strategies for achieving that goal have caused conflict over time. Moving from a behavioral health model to a primary care model was difficult for the organization, given that it had been operating with institutional inertia under the behavioral health model for several decades.

Advice for Other Programs

• Adopting an integrated EMR between behavioral health and primary care is crucial for maintaining continuity of care.
• Maintaining open lines of communication between different stakeholders and providers is crucial. LifeSpring has created a multidisciplinary work group that meets frequently and includes administrators, providers, executives, and finance staff.
• Upon an initial visit, provide a consent form to patients that allows behavioral and physical health information to be shared across providers. If patients provide consent for this, it allows for better communication between providers about patients’ needs.

Information About Informant

Beth Keeney, M.B.A.

Senior Vice President for Community Health Initiatives

CRESCENTCARE

Program Description

CrescentCare¹ began as an AIDS service organization, transitioning to a full-service health care organization and receiving FQHC status in 2014. CrescentCare has played a large role in New Orleans as a provider of HIV testing and harm-reduction services; this includes the city’s first syringe service program, which opened in 2009 (the New Orleans Syringe Access Program). In December 2018, CrescentCare opened a new 40,000-square foot health center easily accessed by public transportation. The organization has 250 staff members and 24 providers and serves 18,000 patients annually, the majority of which are seen in primary care. The arc of OUD and infectious disease services integration at CrescentCare has been folding OUD treatment into primary care, where HIV testing and treatment have already been a primary focus. Integration with viral hepatitis care is ongoing, as explained in further detail below.

History of Program’s Integrated Services

Historically, CrescentCare conducted HIV testing and referred patients to other clinics for OUD treatment (including psychiatric services and MOUD). Yet, the recent integration of infectious disease services with OUD prevention/treatment felt like a natural fit: because CrescentCare started as an HIV services organization, the providers and leadership felt it was necessary to successfully treat OUD to prevent further HIV infection. Ultimately, CrescentCare’s history of integrating these services stems from the needs of patients. While OUD treatment initially was primarily focused on sobriety, CrescentCare has transitioned to a harm-reduction approach since implementing its syringe service program.

In early 2018, CrescentCare was awarded a SAMHSA grant to support an intensive outpatient program (IOP), which included behavioral therapy for 9 hours per week run by addiction specialists and MOUD. Yet, this method of integration proved too difficult for some patients, who were not able to complete the IOP or were not ready for that level of treatment. CrescentCare created a dedicated buprenorphine clinic for 2 days per week, run by a nurse manager. In December 2018, it also integrated MOUD into its primary care program in an effort to increase access for a larger number of patients and minimize the number of internal referrals for different types of treatment.

The choice to integrate OUD services into primary care—along with HIV/viral hepatitis services—was driven by the syringe service program

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¹ Program informants from CrescentCare did not provide direct edits to this case study.

already located in the clinic and the harm-reduction outlook of the staff. CrescentCare specifically hired a coordinator of the IOP who understood harm reduction and patient centeredness and wanted to expand access to prevention and treatment services. CrescentCare has also hired peer navigators who are in recovery themselves through a program called Recovery Works.

Throughout various leadership changes, several key players have remained champions of integrated services. Allison Dejan (Prevention Programs Manager) and Sharon Isolde (IOP Coordinator) have continued to push for more integrated services, and other providers have remained engaged through peer-to-peer education.

Services Provided and Model of Care

The clinic is well equipped and comfortable, providing same-day PrEP, HIV/viral hepatitis testing and treatment, and MOUD. The colocated syringe service program is the primary entry point for additional care, as it also conducts HIV/viral hepatitis/syphilis testing and same-day start for HIV ART. Key to the success of the program have been peer coordinators (who act like patient navigators) and two nurse managers for the MOUD program who have been doing SUD recovery for many years and helped newly hired clinicians.

A number of wraparound services are available for HIV patients through Ryan White funding. This includes referrals to other harm-reduction services and assistance with transportation, bus tokens, SNAP tokens and applications, housing, and navigating the health system.

For the combined OUD and infectious disease services, CrescentCare has one addiction specialist who oversees the IOP, one psychiatrist who sees more complicated dual-diagnosis patients, three PCPs and two NPs with DATA waivers who see patients with viral hepatitis or HIV and OUD, and an additional NP and a physician’s assistant working on DATA waiver training. CrescentCare prescribes buprenorphine and naloxone in its MOUD program.

CrescentCare can treat HCV in its primary care clinic concurrently with MOUD but was historically unable to treat most patients with HCV medication because Medicaid only reimbursed treatment for liver fibrosis stage 3 or higher. Following several lawsuits challenging this restriction, the state of Louisiana relinquished this barrier to care on July 1, 2019. Since that time, CrescentCare can treat patients with liver fibrosis stages 1 and 2.

With respect to staff training, there have been several grand rounds lectures on the integration of infectious diseases and OUD services. It has also helped to have an addiction psychiatrist located in the same area as

PCPs, who are able to ask for assistance. Finally, CrescentCare has had several peer-to-peer education sessions follow DATA waiver training to make providers more comfortable prescribing MOUD. Stigma has played an important role in preventing further integration: even with HIV (which CrescentCare has focused on for many years), it took a long time to evolve toward an embracing rather than a punitive culture (e.g., for patients that miss appointments). The peer-to-peer education has helped reduce this stigma.

Financially, CrescentCare was able to begin the IOP program through a grant from SAMHSA and funding from HRSA through the Substance Abuse Service Expansion Technical Assistance program. Most patients using primary care services at CrescentCare are insured by Medicaid, as are about 80 percent of patients on MOUD. As the volume of patients accessing MOUD through the primary care program continues to increase, CrescentCare may consider applying for additional grant funding. However, it is cautious about this prospect because it does not want to inadvertently filter out certain patients from the overall pool of patients who need services (i.e., if CrescentCare is awarded a grant that applies specifically to patients living with HIV, this may limit its ability to treat patients with other illnesses). Indeed, this has already been the case with one of their programs: Recovery Works has a peer coordinator component, but based on the terms of the grant, it can only be used for patients living with HIV who also require SUD treatment and cannot be used for uninfected patients. Instead, CrescentCare hopes that the services it provides, and payments from insurers, can provide enough value to make the programs sustainable. For now, since the integration of OUD treatment with HIV/HCV in primary care is in its early stages, it is difficult to predict whether this will remain financially viable long term. One concern is that patients with OUD and infectious diseases tend to have many barriers to care (e.g., difficulty accessing or remaining in treatment programs, unstable housing, lack of transportation, stigma, or a distrust of the medical system).

Patient Characteristics and Outcomes

While more than 200 clients are served at any given time in the SUD program (not integrated with primary care), CrescentCare’s integrated program is substantially smaller (i.e., 20 patients in May 2019). Overall, 62 percent of patients on MOUD at CrescentCare are HCV positive, and a handful are HIV positive. These statistics are similar to the syringe service program; more than 1,000 individuals per week use the program, and more than 50 percent are living with HCV and 2–3 percent with HIV.

Facilitators and Barriers

Facilitators

• Patient and peer navigators are important for integrated services to operate effectively because they assist patients in getting the full range of services that they need, or the range of services that they feel they can take on at any given time.
• A New Orleans city ordinance that strongly supports syringe access has helped create a harm-reduction culture, and is one reason that the CrescentCare syringe service program is popular among people who inject drugs.
• A state Medicaid reimbursement restriction for HCV treatment was lifted on July 1, 2019, expanding the number of patients that CrescentCare can treat.

Barriers

• DATA waiver training is time-consuming (particularly for NPs and PAs, who must spend 24 hours on it). The lack of financial support for this training creates an incentive not to follow through.
• Negative media coverage around people who inject drugs may prevent patients from seeking treatment and can stigmatize patients and providers/organizations.
• Lack of true coalitional support among various human services in the city is an issue (e.g., patients have the perception that police are frequently arresting patients for possession of drug paraphernalia, which makes patients hesitant to seek medical services related to substance use).
• Even when services are available, it can be difficult for patients to access (e.g., lack of stable housing, transportation, or ability to navigate available Medicaid services).

Advice for Other Programs

• More dedicated trainings and time to learn would facilitate a fully patient-centered culture that is nonjudgmental.
• Starting integrated services slowly, ensuring that providers have enough time and flexibility to see patients for longer and to treat patients who cannot make appointments on time, every time.
• Do not assume that the most intensive treatments will always be the best—a light touch treatment plan can sometimes be better for patients who struggle to access the clinic on a regular basis.

Information About Informants

Nick Van Sickels, M.D.

Chief Medical Officer

Jason Halperin, M.D.

Infectious Disease Physician

EVERGREEN HEALTH

Program Description

Operating for more than 30 years, Evergreen Health is a comprehensive health care system with 450 employees located in Buffalo, New York (with a satellite operation in Jamestown, New York). Evergreen started as an AIDS service organization, providing navigation and treatment for people living with HIV/AIDS. Today, it provides SUD treatment, primary/specialty care, and pharmacy services. In both Buffalo and Jamestown, Evergreen has several buildings in close proximity (walking distance). Evergreen has active communication, collaboration, and integration of OUD and infectious disease services.

History of Program’s Integrated Services

Evergreen has a long history of providing care to underserved populations in the community, and that history drives the mission today (now including people with other chronic illnesses). This ethos remains in the organization’s culture and was the main driver for integrating as many services as possible: to serve the needs of patients with complex needs in a way that makes life easier for them. In line with this, both patients and leadership have stated that access to SUD treatment is important, including MOUD. Evergreen has had strong support from leadership for integrating services, and developed a strategy for moving toward integration up front. However, Evergreen remained flexible about the needs of patients and various staff members, adjusting its integration strategy over time. Because of its long history in western New York, Evergreen has built a reputation for being a welcoming and nonjudgmental organization with a strong harm-reduction philosophy. The goal of integrating services was to seamlessly bring patients from testing, to treatment, to cure.

Services Provided and Model of Care

Patients accessing OUD and infectious disease services at Evergreen are frequently admitted through the syringe service program or the

walk-in sexually transmitted infections clinic, where staff will inform them about the range of services available. In general, Evergreen provides patients with access and knowledge but recognizes that they are the ones to make the ultimate choice about which care they want to receive. This includes HIV/viral hepatitis testing and treatment, MOUD, case management and care coordination, or other medical or behavioral health needs.

At the Buffalo location, the infectious disease prevention and treatment, harm reduction, and SUD treatment occur in one building. In Jamestown, the syringe service program is the only service not offered in the same location.

Evergreen’s medical staff for OUD and infectious disease services consists of mostly PAs and NPs, along with mental health counselors and social workers. Physicians primarily conduct HIV/HCV treatment. Buprenorphine services were previously housed only in the medical clinic but are now offered at the harm-reduction center and outpatient counseling clinic. Two PAs have full-time caseloads for MOUD (200–300 patients), and there is 1 NP with 80 patients. Most prescriptions are for buprenorphine, and a handful are naltrexone.

Internal staff training for these services includes attendance at other departments’ staff meetings to learn more about prescribing or patient care for specific populations, as well as frequent in-services. Evergreen produces well-curated, user-friendly informational memos on various topics related to OUD and infectious disease services, including PrEP prescribing and infectious disease testing. At new-hire orientation, staff are trained explicitly on the culture of harm reduction, MOUD, and sexual health and PrEP.

From a financial perspective, most patients are insured through Medicaid, and patient visits and the onsite pharmacy can be sources of revenue. Although harm-reduction services and the walk-in infectious disease testing are more difficult to fund, Evergreen has substantial grant assistance from the New York State Department of Health and smaller grants from numerous other organizations. Still, because these services act as an entry point for other billable services, they are useful from a revenue perspective. Evergreen has determined that the average patient uses three services, which provides a diversified source of income.

In terms of input on services, Evergreen has hosted support groups for patients’ families to solicit feedback. This was met with limited success because of low turnout. Evergreen also has a variety of survey mechanisms (from basic comment cards to longer, comprehensive surveys), and weekly consumer feedback among people who use drugs and are seeking treatment. Finally, the organization has long-standing, monthly meetings for people living with HIV, an effort that has been successful in soliciting

feedback. There is a similar consumer feedback group among people who are currently using or formerly used drugs.

Patient Characteristics and Outcomes

Evergreen has attempted to focus more on care for pregnant women, women with small children, and patients in the criminal justice system (especially after incarceration). The organization is also seeking to incorporate patients’ own measures of success as organizational metrics. Outcome data were otherwise not available.

Facilitators and Barriers

Facilitators

• New York does not have fibrosis restrictions on treatment for HCV, allowing Evergreen to treat a larger number of patients.
• Gaining patients’ consent at the first visit to share medical and behavioral health information with a range of providers makes it easier to provide integrated services over time.

Barriers

• The cultural split between abstinence-based treatment and a harm-reduction framework has prevented seamless communication between providers and staff. Rather than focus on one or the other, Evergreen has made an effort to provide options for patients depending on their specific needs.
• MOUD is not widespread in correctional facilities. Evergreen sees patients who have made progress on overcoming OUD but then are incarcerated and progress is derailed.
• The training to receive an X waiver is time-consuming and acts as a disincentive to prescribe.
• Gaining prior authorization to dispense medications can be time-consuming for staff.
• Because of restrictions on same-day billing, Evergreen has had to schedule patients on different days for health care services and mental health services. This interrupts their goal of providing continuous, seamless care.
• While many services at Evergreen use the same EMR, this has required coaching for providers on how to enter information so that it is usable by other providers.
• Mental health and SUD services are not reimbursed at the same rates as other medical care, making sustainability for these services more difficult.

Advice for Other Programs

• Providing in-depth coaching for providers on how to use an integrated EMR is crucial to truly integrated services.
• Staff must have a strong understanding of patient-centered, compassionate, and nonjudgmental care techniques, as well as a harm-reduction philosophy.
• It is important to have open lines of communication with law enforcement, local health departments, community organizations, and other health care providers. Integrated care requires organizations to be partnership oriented.
• Just as patients need to be provided compassionate care, the organization must facilitate compassionate outreach to its staff.
• Collection and curation of quality data are the main drivers of process improvement.

Information About Informant

Emma Fabian, M.S.W.

Senior Director of Harm Reduction

BRONX TRANSITIONS CLINIC

Program Description

Bronx Transitions Clinic (BTC) is one site among 29 in the Transitions Clinic Network (TCN). TCN clinics offer primary care, drug treatment, treatment for infectious diseases, and connections to social service support for previously incarcerated individuals. The TCN offers an implementation strategy, needs assessment, guidance, relationship building, and training for new clinics seeking to become a transition clinic.

Montefiore’s Comprehensive Health Care Center and the Osborne Association (OA) collaborated to develop BTC. Both organizations serve predominately working-class minority communities in the Bronx, New York. The OA provides grant-funded discharge planning at New York State prisons. Medical services are paid for by health insurance. BTC provides comprehensive treatment, including primary care, HIV, SUD, and mental health treatment. Because of its focus specifically on formerly incarcerated individuals, other health care organizations have consulted BTC for advice on how to care for this population.

BTC is fully integrated into the community health center’s normal workflow (Montefiore) and sees about 150–200 patients per year, the majority of whom have chronic health conditions. BTC provides care 2 half-days per week with a voluntary physician, including one open-access session. Following initial visits, patients are integrated into the

physicians’ primary care panel and may schedule follow-up visits. Because of their full inclusion within the community health center, BTC’s services are highly integrated—with the one exception of a full mental health care team.

History of Program’s Integrated Services

In 2009, a group of physicians in Montefiore learned about the Transitions Clinic in San Francisco and sought to replicate these services in the Bronx. The primary goal was to provide medical care to patients coming from the corrections system. With guidance from Dr. Shira Shavit and colleagues, these physicians championed the idea of a transitions clinic in the Bronx, where OUD treatment was needed. In the beginning, much of the medical care was delivered by volunteer physicians and other medical staff, and it was clear that this was not a sustainable long-term strategy. Several grants to BTC—and a grant from the Center for Medicare & Medicaid Innovation to TCN—allowed BTC to continue operating with paid staff. Since then, medical residents have taken the helm in providing much of the care and often conduct research or quality improvement projects in BTC.

BTC is based in a community health center that has been at the forefront of providing HIV, HCV, and OUD treatment in a community setting. That center developed a buprenorphine program in the mid-2000s as part of the BHIVES project, driven by Dr. Chinazo Cunningham of Montefiore. Because of Montefiore’s history with otherwise underserved populations, most of the providers and trainees are committed to this mission—integrated HIV/HCV/OUD care is a part of Montefiore as a whole. The community health center’s administration, providers, and other staff members embraced a program dedicated to serving formerly incarcerated individuals.

Services Provided and Model of Care

BTC provides team-based care, the most important component of which is community health workers (CHWs). These individuals have lived experience with criminal justice and have training in motivational interviewing and patient navigation. The CHW performs outreach to community agencies and serves as a patient liaison between the criminal justice and health care systems. TCN has a curriculum for CHWs and a certification process for post-corrections training.

BTC provides HIV and viral hepatitis testing and treatment, MOUD, PrEP, overdose education, naloxone distribution, and other primary care services. Today, the care model is built around medical residents, who provide the clinical care under the supervision of Dr. Fox and other

experienced physicians. Because BTC is part of the Montefiore system, it is able to use social worker staff and medical staff at the community health center as well.

There is one area that BTC would like to see bolstered among its services: mental health care that is specific to individuals in the criminal justice system. While there are numerous psychiatrists and psychologists in the Montefiore network, BTC has not been able to connect and collaborate on clinical care for the mental health issues that accompany corrections system experience. Instead, BTC refers out patients with complex mental health histories (~25 per year).

Buprenorphine-naloxone is the primary medication used for OUD, although a handful of patients have been prescribed extended-release naltrexone (XR-NTX). In addition to BTC, there are two opioid treatment programs (that prescribe methadone) within walking distance, one of which is integrated into the Montefiore system. To complement MOUD, BTC also hosts a patient support group for those taking buprenorphine.

Training for staff is centered around providing culturally competent care. Providers are trained through a six-session program of case-based modules with background readings. Modules focus on patient-centered OUD/HIV/HCV care, trauma-informed care, barriers to medical care for formerly incarcerated individuals, and other critical topics. Training for the front-desk staff and nursing staff has been more informal, with presentations at staff meetings approximately yearly. This includes anticipating stigma and destigmatization, trauma education, physical exam training, and protecting confidentiality of care.

With respect to feedback, BTC has distributed patient satisfaction surveys and performed focus groups with patients in the past, but with mixed success. Patients have provided feedback over time in more informal ways, and BTC draws information about how to improve the clinic through the larger TCN network.

From a financial perspective, almost all patients are insured by Medicaid, and the small percentage of uninsured patients are seen on a sliding-scale basis. Because BTC is integrated into Montefiore, treatment for OUD/HIV/HCV has not been a limitation financially. The infectious disease providers and staff in the community health center have helped BTC with patients, and being part of the academic program allows the clinic to focus on training medical residents who also provide services (even a high level of care to a small number of patients). As services have become more comprehensive, it has been harder to secure funds to cover everything. This is the primary reason BTC has not expanded its mental health treatment capacity—another grant to cover those services might be limited in time or scope and would not guarantee sustainability.

Patient Characteristics and Outcomes

BTC’s primary measures of success are demonstrated reductions in ED visits, report arrests, and recidivism. From a medical perspective, BTC aims to achieve similar clinical outcomes to patients who do not have criminal justice involvement.

In a 2014 publication, BTC conducted a retrospective cross-sectional study reviewing all 266 patients’ EMRs from July 2009 to January 2013 (Fox et al., 2014). Patients were 41 years old on average, mostly male, mostly racial/ethnic minorities, and insured through Medicaid. About three out of every four had at least one chronic health condition (e.g., HIV, OUD, or viral hepatitis), and of this group, the average number of chronic conditions was three.

The median number of days between release from prison and the first medical visit was 10 days, and 54 percent were seen within 2 weeks. Of the 102 participants with chronic diseases, 72 percent had returned to the clinic at least once for follow-up care within 6 months of their initial visit. Overall, 38 percent of participants were retained in care at 6 months, including 45 percent of those with at least one chronic disease. Factors associated with retention in care at 6 months included HIV infection and depression (Fox et al., 2014).

For infectious disease treatment, a 2018 study from BTC showed that HIV viral load (VL) suppression was similar between BTC patients and a matched comparison group of community-based patients, suggesting that the BTC intervention was able to achieve typical outcomes (Masyukova et al., 2018) despite the numerous challenges facing formerly incarcerated individuals during community reentry. PrEP uptake has been low among BTC patients, but it is offered routinely. In 2014, of the 28 patients with HIV infection, 86 percent were retained in care at 6 months, 82 percent received ART, and 54 percent had a suppressed VL.

From 2009 to 2013, of the 27 patients receiving buprenorphine treatment for OUD, 33 percent were retained in care at 6 months, and 19 percent had reduced opioid use confirmed by urine drug testing (Fox et al., 2014). Improving retention has been a target for quality improvement and has led to the development of a support group for buprenorphine-treated patients.

As of 2016 (Hawks et al., 2016), of the 451 patients accessing care through BTC, 317 (70 percent) were screened for HCV, and 106 (33 percent) tested positive. Of those 106 patients, 93 (88 percent) were evaluated for HCV viremia and 84 (79 percent) were confirmed to have chronic HCV infection; 19 percent of the total sample had chronic HCV infection. Of these 84 with chronic HCV, 48 (57 percent) received specialist referral, 30 (36 percent) were evaluated, 8 (10 percent) initiated treatment, and 5 (6 percent) completed treatment and achieved SVR. Some treatment

lapses occurred because patients were deemed unstable for treatment (12 percent) or reincarcerated (5 percent). Chronic HCV infection was common among clinic patients. Few were treated and cured. Patients lost contact with providers before consideration for antiviral therapy. Referral to specialty providers was a gap in care. Since 2016, BTC has implemented a new HCV care program, including direct-acting antiviral treatment. Though no outcome data are available yet, providers have noticed an increase in treatment uptake and retention.

Facilitators and Barriers

Facilitators

• Collaborating with a community-based organization that provides services to people with criminal justice involvement and their families aided in building trust with potential patients and correctional partners. Staff make contact with future patients before they are released from incarceration. Patients are rapidly and consistently linked to medical care post-release.
• New York State prisons assist patients in applying for Medicaid prior to release. The majority of patients have Medicaid activated within 3 days of release.
• A new law in New York requires that each Medicaid managed care organization must cover one of the formulations of buprenorphine without prior authorization. This has reduced the amount of time BTC employees spend acquiring prior authorization.
• HIV specialty care plans within Medicaid cover comprehensive services and MOUD, which allows BTC to provide wraparound services more easily.
• New York Medicaid allows for HCV treatment at any level of fibrosis and even if patients continue to use drugs. This facilitates HCV care.

Barriers

• Data privacy restrictions have made it difficult for CHWs to access complete information and referral notes for patients when they have been referred out for mental health services. Having full colocation of services would likely aid in communication.
• Stigma against people who use drugs or individuals living with infectious diseases may prevent patients from engaging with the medical system, and overturning this stigma requires concerted effort (even among medical providers).

• There is no sustainable reimbursement mechanism for the high level of care that BTC provides to patients. BTC providers (the medical residents) spend up to 1 hour at a time with patients, provide strong continuity of care, and help patients access basic services like cell phones and pharmacies (which, for some patients, are entirely new experiences given long bouts of time in correctional facilities).
• Resources and providers are not readily available to provide comprehensive mental health care, which is vitally important for the populations that BTC treats. The sustainability of grants for mental health care services is questionable.
• Individuals who have HCV but who do not qualify for Medicaid—of which there are several at BTC—are eligible for a state insurance program that reimburses for HCV care but not HCV medications. In these cases, BTC has had to ask pharmaceutical companies for charitable donations.

Advice for Other Programs

• Clinics must cultivate a patient base, rather than expecting that patients will show up. This requires establishing a referral source for patients to access the clinic. Some TCN sites, for instance, work directly with parole or with discharge planners at correctional facilities. Community-based organizations can serve as good referral sources as well, since they have a wide-ranging connection with individuals who may need medical care.
• Caring for justice-involved patients is similar to caring for other marginalized groups, but there are some unique issues that deserve attention. Chronic conditions, such as HIV, HCV, and OUD, are highly prevalent. Histories of trauma are common, and trauma-informed practices are essential. Exposure to incarceration itself, and especially solitary confinement, can have a lasting impact on mental and physical health. The collateral consequences of incarceration, such as employment discrimination or housing restrictions, can affect access to medical care. There is a growing body of literature on care for criminal-justice-involved patients.
• When integrating buprenorphine treatment, adopting a nurse-care manager model (also known as the “Massachusetts model”) is more effective and efficient.
• Clinics must not underestimate how important it is to provide compassionate, nonjudgmental care to individuals living with infectious diseases or using drugs.

Information About Informants

Aaron D. Fox, M.D.

Director, Bronx Transitions Clinic

Shira Shavit, M.D.

Executive Director, Transitions Clinic Network

WHITMAN-WALKER HEALTH

Program Description

Whitman-Walker Health was created in 1973 as an evolution from a volunteer-led telephone helpline for gay people struggling with alcoholism. Continuing as an AIDS service organization with Ryan White funding in the 1990s, Whitman-Walker Health has historically provided housing assistance and a food bank to people living with HIV and AIDS. In 2000, it merged with the Washington Free Clinic to provide primary care, behavioral health, SUD treatment, and dental care. Whitman-Walker Health now operates in two locations and is well known for providing care to lesbian, gay, bisexual, transgender, and questioning (or queer) (LGBTQ) communities: about 50 percent of patients are LGBTQ overall (the main site ranges 60–70 percent LGBTQ, and the Max Robinson site from 30–40 percent). Today, there is full integration between OUD and infectious disease services at the smaller site (Max Robinson) and nearly full integration at the main site.

History of Program’s Integrated Services

Beginning as an AIDS service organization, Whitman-Walker Health developed an integrated approach from the start, providing wraparound services. To remain viable, Whitman-Walker Health expanded its services in 2000. Integration between infectious diseases and OUD did not occur until more recently. In the late 2000s, a Whitman-Walker Health psychiatrist received an X waiver for MOUD, so these medications remain only in the behavioral health program. Medications were folded into the primary care setting because of high demand from patients—who needed combined services in an accessible and convenient way—and providers’ initiative to meet this demand. This multidisciplinary approach was key to Whitman-Walker Health’s success at integrating, and it was significantly easier to integrate at the smaller of the two sites because the providers there were in close contact; they knew each other and their patients well.

Whitman-Walker Health’s expansion was a function of programs growing out from other programs and staff remaining open to the new needs of patients. Still, historically, not all staff, providers, and executives have

bought in to increased integration. In the 2000s there was a provider-led push to bring SUD treatment into primary care, but this effort was halted because there was a concern among some administrative leaders that having SUD patients in waiting rooms would deter other patients from visiting the clinic. In short, there was a significant stigma (or perceived stigma) against SUD patients. As this example illustrates, change happened slowly. Changing the culture required perseverance and repeated conversations with the organization’s leadership, staff, and providers to get buy-in. Providers needed to be convinced by the evidence that incorporating SUD into primary care could produce better outcomes for patients, and executives needed their financial concerns allayed. Whitman-Walker Health’s success over time is a function of repeated discussions about patients’ needs, with genuine listening, validation, and understanding of different stakeholders’ concerns. In general, the primary champions of organizational change toward integrated services have remained the same over time.

Today, Whitman-Walker Health remains an attractive option to patients with OUD because they know they will not be turned away if they begin using drugs again. Its approach is to “meet the patients where they are,” providing but not mandating treatment, and to keep lines of communication open. According to Dr. Henn, this approach was different even 5 years ago.

Services Provided and Model of Care

Primary care is the entry point for other services at Whitman-Walker Health. Patients who have HIV, viral hepatitis, OUD, or any other medical need are seen and managed through primary care. The ongoing goal is to create a seamless visit for patients without unnecessary referrals. Providers typically rotate back and forth between the two sites to ensure that full coverage for all medical needs is available at both sites. Another reason for integrating services into primary care is that stigma against drug use is easier to address in that setting, as it can be treated alongside any other medical need that requires the PCP’s guidance and expertise.

The specific SUD services staff are all licensed psychotherapists and psychologists, and Whitman-Walker Health is therefore able to more easily integrate treatment of mental health disorders with SUD. It provides more specialized programming for methamphetamine, heroin, or prescription opioid users and individual SUD-focused psychotherapy or in a group setting.

Whitman-Walker Health’s MOUD program uses buprenorphine and naltrexone, along with weekly therapy groups, individual counseling, or additional psychiatry if the patient needs and wants this level of care. Whitman-Walker Health recently developed a rapid entry to MOUD, called “Welcome MAT” (MAT refers to “medication-assisted treatment,” a term the

committee has elected not to use, as it provides a false impression that medications are only useful in the context of other kinds of treatment for OUD). Through this program, patients can schedule an appointment, or simply walk in to the clinic, see a PCP with an X waiver, and begin MOUD that day. Whitman-Walker Health also offers peer SUD counselors. These individuals, who have overcome SUDs themselves, are invaluable to providers and patients; they create a “link” between patients and the medical system.

While staff will rotate between sites to ensure full coverage, the Max Robinson site includes two infectious disease physicians, one double-boarded medicine pediatric physician, and three PAs. At the main site, staff includes eight infectious disease physicians (two are volunteers), three family practitioners, one double-boarded medicine pediatric physician, one internist, three NPs, and nine PAs. Most PCPs and psychiatrists have X waivers to prescribe buprenorphine, long-acting injectable naltrexone, and oral naltrexone. As of this writing, Whitman-Walker Health providers are not currently performing home inductions, but they do aim to provide same-day or next-day inductions at the clinic.

With respect to harm reduction, Whitman-Walker Health has explicitly adopted a risk reduction model that is well known and accepted by staff. Operationally, this includes a standing order of naloxone at the onsite pharmacy, care plans that emphasize tapering use, connections to community resources (including syringe services available in Washington, DC, though not operated by Whitman-Walker Health), and education about the risks of concurrent substance use.

Whitman-Walker Health has a mix of payers. Washington, DC, implemented Medicaid expansion following the Patient Protection and Affordable Care Act, and 50–60 percent of patients are on Medicaid. Another 30 percent are privately insured, and the remainder are on Medicare. Washington, DC, also has an additional insurance benefit called the DC Healthcare Alliance for residents who do not qualify for Medicaid but are not fully financially stable; a small percentage of patients receive care paid for by this program. Whitman-Walker Health depends on its FQHC reimbursement status and pharmacy as its primary sources of revenue. Patient visits—regardless of the type of visit—generally do not produce sustainable revenue. The pharmacy produces revenue from privately insured and Medicare patients but not from Medicaid patients because Medicaid only reimburses Whitman-Walker Health at cost for dispensed medications. Although most patients are on Medicaid, the mix of patient payers using the pharmacy generally allows Whitman-Walker Health to recoup costs. As an FQHC, Whitman-Walker Health is able to offer significantly reduced pricing on drugs from its pharmacy through the 340B Drug Pricing Program.

Integration of SUD and infectious disease services into primary care has altered the day-to-day routine of providers and required some

additional, informal training. Because some of the care is more time intensive, the number of patients that providers can see has been reduced. Additionally, it has become clear to staff that greater flexibility is required: working with patients that have complex behavioral and physical health needs—in addition to difficult lives outside the clinic—has meant that providers have had to be more accommodating of missed or late appointments. Whitman-Walker Health has therefore implemented a number of provider-led education strategies, including trainings on SUD by psychiatrists and brown bags and case conferences on OUD and infectious disease treatment. While each provider must go through the federally mandated MOUD training, staff felt that this training was inadequate for making providers comfortable enough to prescribe. As a result, the program instituted a residency model internally to train recently X-waivered providers.

Patient Characteristics and Outcomes

Whitman-Walker Health’s general measures of success are the length of time that patients stay engaged in treatment programs and remain on lower dosages of drugs or abstinent from drugs, reduced VL for HIV, and virologic suppression for HCV. For patients in the MOUD program, outcome data are available in Table A-2.

Whitman-Walker Health serves 20,000 patients annually, 2,000 of which are transgender or gender nonconforming. About 3,000–4,000 of the total patient population is living with HIV (1,500 are on PrEP), and about 500 are living with HCV (roughly the same prevalence of HCV in Washington, DC, as a whole). About 40 percent of patients are African American, 60 percent are 21–40 years old, and 70 percent are residents of Washington, DC. Several hundred are on buprenorphine, and a small percentage are on XR-NTX. Whitman-Walker Health does have some concern that it is failing to reach certain populations, including pregnant women, additional opioid users who could take advantage of buprenorphine management, and populations outside of the 21- to 40-year range.

Patients are able to provide input to Whitman-Walker Health on services via general surveys, though there have been no specific focus groups on integrating OUD and infectious disease services.

Facilitator and Barriers

Facilitator

• In January 2019, Washington, DC, loosened the prior authorization requirement for MOUD, allowing Whitman-Walker Health to more easily prescribe and dispense. Before this change, staff spent significant time seeking prior authorizations.

Barriers

• The federally required MOUD training is time-consuming and could be more clinically relevant. The training should instead focus on withdrawal management, induction and titration practices, and navigating the prior authorization process (in states where that is necessary). Because training is a barrier, there are too few providers to treat the number of patients in need.
• The inability to bill for group therapy through Medicare is a lost opportunity for revenue.
• For patients on Medicare, Whitman-Walker Health is unable to bill for both medical and psychiatric appointments on the same day.
• Title 42 of CFR Part 2 requires that Whitman-Walker Health take extra care in describing its services, and therefore patients may be unsure what services are offered (e.g., it cannot advertise that it has an MOUD team in primary care, even though PCPs are legally certified to prescribe MOUD).

• The work of peer SUD-recovery specialists is not billable, even though these support staff are crucial to providing quality integrated care. Whitman-Walker Health is currently able to pay for a portion of this cost through grant funding, but this will be difficult to sustain long term.

Advice for Other Programs

• The main driver for integrated services was that all staff members agree that their job is to serve the needs of the community. Constant reminders of that fact may create the cultural change required to integrate services.
• Seeking opportunities to introduce flexibility into service delivery is important (e.g., finding windows of opportunity to create walk-in clinics for OUD treatment, and then managing other care needs at that time).
• Do not assume that providers with an X waiver will be comfortable prescribing. Instead, seek other opportunities for MOUD training internally.
• Seek opportunities to break down silos through provider networking, and take advantage of new collaborations to treat new problems. At Whitman-Walker Health, initial collaboration between psychiatry and primary care has now allowed PCPs to treat more complex psychiatric conditions than in previous years, removing the need to refer patients out.
• Embrace a harm-reduction philosophy, rather than an abstinence-only approach.

Information About Informant

Sarah Henn, M.D.

Chief Health Officer

PHILADELPHIA FIGHT

Program Description

Philadelphia FIGHT is a comprehensive health services organization providing primary care, consumer education, research, and advocacy for people living with HIV/AIDS and those at high risk. Across several locations, FIGHT provides primary care and SUD services regardless of a patient’s insurance or ability to pay. Two sites—the Jonathan Lax Treatment Center and the Clinica Bienestar center—provide buprenorphine

and long-acting naltrexone integrated into the clinics. A third, the John Bell Center, is a more general internal medicine clinic and offers long-acting naltrexone. FIGHT’s goal is to provide culturally competent, integrated, patient-centered care and to treat patients in a “one-stop shop” model (e.g., same-day appointments, medical case management, nutrition services, general services assistance, SUD treatment, onsite pharmacy).

History of Program’s Integrated Services

Philadelphia FIGHT was founded as an AIDS service organization 25 years ago and now operates as a community health center with FQHC status. Because of its history, FIGHT has always met patients where they are at. Recently, FIGHT saw a need in the community and responded to increased deaths in Philadelphia due to overdose with fentanyl.

Overall, there was broad support for integrating OUD and infectious disease services, including from the medical/clinical staff and from leadership. The executive director is an innovative leader with a vision and a belief that innovative ideas should be supported—including an application for a Special Projects of National Significance grant to engage individuals of Puerto Rican descent with a history of injection drug use in HIV care, which FIGHT was awarded. FIGHT has spent years establishing trust in the community and collaborating with other centers in the area (e.g., harm-reduction centers, housing-first organizations, and syringe service programs).

The overall implementation of integrated services was incremental, and the shared philosophy of harm reduction and OUD as a chronic disease also changed incrementally. As with many organizations, the shift was gradual for medical providers to understand that relapse is a common occurrence and that treatment programs should reflect the chronic nature of OUD. Since FIGHT is a mission-driven nonprofit, many of the staff are likeminded in their approach to patient-centered care. Even those who are not X waivered understand the importance of integrating OUD and infectious disease treatment. Every day, the staff works through a list of patients to make sure treatment plans and follow-up plans are in order. This process is not always seamless, and adding additional services into a PCP’s workflow is challenging, but the staff has agreed that active SUD treatment is needed in Philadelphia.

Services Provided and Model of Care

FIGHT’s overall aim is to offer colocated services under one roof. On the harm-reduction front, FIGHT was one of the first clinics to offer PrEP. FIGHT is not currently offering PrEP to people who use drugs on a large scale, but that is a primary goal. In addition, FIGHT is working to provide

PrEP in the city’s syringe service programs and to use those programs as a gateway for other care (HIV or viral hepatitis care, MOUD, or general primary care).

The Jonathan Lax and Clinica Bienestar centers offer both HIV primary care and co-infection treatment with viral hepatitis, as well as MOUD. In addition, FIGHT offers HIV/viral hepatitis prevention education at patient visits and conducts a prevention education summit in June every year. For OUD, prevention is a key component of FIGHT’s workflow. It adheres to chronic pain guidelines for prescribing and engages patients about OUD often.

FIGHT hires near-peer educators (many with a shared experience of SUD) in order to provide patient-centered care. There are services that FIGHT does not provide in-house but aims to in the future: (1) individual, specialized mental health therapy and SUD therapy, and (2) a stronger harm-reduction program, with support groups. FIGHT has an IOP for SUD treatment program called TREE that follows a 12-step philosophy to SUD treatment and a mental health clinic called the Diana Baldwin Mental Health Clinic for individual therapy. FIGHT also has a behavioral health consultant imbedded in most clinics to see patients for a limited number of visits when they are in crisis or have a specific, finite support need (e.g., smoking cessation, medication adherence, bereavement).

FIGHT can provide buprenorphine and long-acting naltrexone, and 75 percent of patients start buprenorphine at home (except those coming from the criminal justice system, who are more often started on long-acting injectable naltrexone at the clinic). FIGHT has eight providers at the Jonathan Lax Center, five with X waivers. When someone presents at the front desk, there is someone there who can check rapid urine drug screens and a pharmacy tech to run prescription drug monitoring programs. FIGHT also has medical case managers, which is crucially important given patients’ high incidence of psychosocial needs. FIGHT has built lines of communication between sites and between referring providers and medical case managers to help ensure that patients make it to their appointments (FIGHT frequently refers patients to methadone maintenance and daily buprenorphine programs when they require more structure and support than FIGHT provides).

FIGHT has recognized that education about SUD in medical schools has not historically been adequate and aims to correct that inadequacy through its own internal education. This includes implicit bias training, training during AIDS education month, and allowing all who work there to be trained. Early on, FIGHT provided naloxone training (for clinicians and patients) to raise awareness about the opioid crisis and empower staff to recognize opioid overdoses and use naloxone. FIGHT recently provided long-acting injectable naltrexone training for clinicians and safer injecting practices for clinicians and medical staff (medical case managers).

From a financial perspective, the center operates on Ryan White and community health center funding, and the 340B pricing allows for MOUD and helps the overall program operate smoothly. Moving forward, it may make sense to expand services rather than referring out patients with complex medical histories. In addition, because psychiatric services are billable sessions, the more FIGHT can maintain adherence to mental health and SUD treatment, the more financially stable it will be.

FIGHT aims to treat patients in families or as couples when appropriate, and Clinica Bienestar is a more fluid clinic that allows patients’ families to come in as well. In the beginning of a patient visit, patients will sign a (non-binding) agreement with the provider to ask for help if needed, stay committed to treatment, and attempt to stay off drugs. Near-peer employees are key to ensuring that patients feel in control of their treatment plan.

Patient Characteristics and Outcomes

FIGHT’s measures of success include viral suppression loads (of those on ART treatment this past year, 83 percent had viral suppression). FIGHT also records other important metrics of SUD stability, including weight gain, housing stability, healthy relationships, return to work/school, and better engagement in the rest of patients’ health care (initiating HCV treatment, taking other necessary medication). The most important metric of success is whether patients remain on OUD treatment. When FIGHT offers OUD treatment and stabilizes patients on MOUD, the work load diminishes because the patients’ needs are reduced.

FIGHT has a total of 220 patients on buprenorphine or naltrexone, with about half the naltrexone patients being treated for OUD and the rest for alcohol use disorder. Of those on MOUD, about half are HCV positive and 75 percent are HIV positive. Of those newly diagnosed with HIV, a vast majority are also positive for HCV.

Many of FIGHT’s patients are homeless, and many have not previously engaged in HIV care. Philadelphia has seen a 115 percent increase in HIV incidence since 2016, and those with OUD are increasingly Caucasian and younger than in previous eras.

Facilitators and Barriers

Facilitators

• Philadelphia has a task force to combat the opioid crisis, including a subcommittee on public education and prevention between the department of health and the mayor’s office. Through this,

• FIGHT has discussed changes to prior authorization process, changes to medical licensure, and public health campaigns to expand access to naloxone.

• In Pennsylvania, PAs and nurses are able to prescribe buprenorphine, which increases the overall pool of prescribers.

Barriers

• FIGHT has not had much difficulty with prior authorization. If it orders the formulation of buprenorphine that is accepted by Medicaid, it does not need prior authorization and has not wasted much staff time through this process. However, it would be useful from a medical perspective to be able to offer all formulations and dosages that a patient might need, rather than what the insurance dictates.
• State restrictions on syringe services. Syringe service programs are only legal in Philadelphia and Pittsburgh, and Prevention Point in Philadelphia is the only legally sanctioned one; while there are providers who can prescribe syringes to prevent HIV and viral hepatitis, it is not a robust enough workaround to the state restriction.

Advice for Other Programs

• Treating OUD patients effectively will help manage other chronic illnesses, including the treatment and prevention of HIV, HCV, and serious bacterial infections.
• Provide peer-to-peer training opportunities for clinicians.
• Do not expand too quickly. Start with a small number of patients, and scale upward.
• Hire and train near peers. Listen to individual patients.
• Be comfortable accommodating randomness and patients who do not make it to appointments on time.
• Allow patients to begin buprenorphine treatment at home.
• Use several metrics to evaluate OUD treatment success other than just decreased substance use, including weight gain, housing stabilization, return to work/school, repaired relationships, and improved engagement in other medical care.

Information About Informant

Laura Bamford, M.D.

Medical Director, Clinica Bienestar

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