How To Develop a Telemedicine Initiative For Opioid Dependence

How To Develop a
Telemedicine Initiative For
Opioid Dependence
Thomas Stuber, President/CEO
Lorain County Alcohol and Drug Abuse Services, Inc.
James Evans, Sr. Vice President
Meridian Community Care, Inc.
Deborah Broaddus, LPCC-S
Lorain County Alcohol and Drug Abuse Services, Inc.
Need
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Ohio is experiencing a Narcotic and Heroin
Epidemic
Lorain County statistics:
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1999 we were averaging 7 heroin and narcotic
admissions per year. We now see that every 2-3
days.
In 2011 enough narcotics were prescribed to
provide every man, woman, child, and infant with
60 doses. (graph)
Need Continued
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70% of LCADA’s client base is Opiate
Addicted
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Women’s Residential (16 bed) 80%
Men’s Day Treatment (24) 100%
Women’s Day Treatment (24) 90%
Women’s IOP (48) 70%
Men’s IOP (60) 65%
LCADA’s Waiting List is now at 115 and 70% are
addicted to narcotics or heroin
Adolescents 40% report regular use of narcotics
History of Suboxone Efforts in Lorain County
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2009 Suboxone Contract was given to local
mental health center
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Over the next 18 months the center went through
4 Physicians, each with a different philosophy and
approach.
Program was not supported by administration.
Each physician left the organization, thus
stranding clients and putting the program in limbo.
Only 50 clients served.
History – Continued
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Contract was provided to LCADA September
2011
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Suboxone Project Manager was hired.
Significant difficulty hiring a physician. This would
bring the program to a grinding stop.
Solution
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Evidence indicated that E-Therapy was effective
 SAMHSA’ 2005 National Survey on Drug Use and Health
respondents reported they did not receive treatment due to the
following barriers:
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Survey conducted by Metanoia, a nonprofit clearinghouse for
mental health websites reveiled:
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44% due to cost
19% due to stigma
21% due to access
90% of online clients felt that E-Therapy helped them.
Many participants also felt that they would not have initially sought face-toface therapy.
Most that sought online therapy later used face-to-face counseling (Alleman,
2002).
Research supported that E-Therapy was effective to deliver
education, assessment and diagnosis, direct treatment, and
aftercare. (Maheu, et al., 2005; Stofle, 2004)
Solution Continued
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Needed to sell the use of Telehealth/ETherapy of the state—OARP
Found a partner in Meridian
Engaged a team from both facilities—first
meetings were via Teleconferencing
Defined Business and Clinical Model
Completed MOU
Implementation
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Secured approval for Demonstration Project from the
state
Completed MOU and developed Interagency Team
ODADAS Low Dose Protocols Model
Contracted Lab and Pharmacy
Agreed to 6 month medication support and then taper
D/C meds while client is still in treatment
Identified selection criteria for clients
Identified contracting requirements for clients
Dan’s video
NE OHIO ACCESS TO MAT
ACCESS ISSUE IN N.E. OHIO
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Disproportionate access to MAT services
Significant diversion issues
Unnecessary high dose prescribing practices.
Absence of care coordination between
physicians and evidence based practices for
treatment requirements.
Treatment retention with Office Based
provider patients is extremely poor.
% of Buprenorphine Slots available for 20-45 yrs Population by NE Ohio Counties
Wayne County
Trumbull County
Summit County
Stark County
Portage County
Medina County
Mahoning County
Lorain County
Lake County
Jefferson County
% of Population in Tx
Holmes County
Harrison County
Geauga County
Cuyahoga County
Columbiana County
Carroll County
Ashtabula County
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
MERIDIAN ADMISSION CRITERIA
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Comply with Federal Standards
We differ in requiring a failed treatment
experience or documented struggle of
attempting to quit.
Pregnant opiate addicts: Methadone vs.
Subutex depends on recovery environment,
co-occurring disorders and motivation.
BIG START UP SNAG #1!
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Malpractice Insurance for Tele-medicine is a
required rider on policy
A specific rider for Suboxone Tele-medicine
is not only a requirement but it can be a
nightmare.
Best solution if there is any sense of
confusion for the underwriter is bring him/her
in and meet the teams.
BIG START UP SNAG #2
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Having enough physician slots available for
the partnership
Yet to be adequately solved
OTP Suboxone Waiver may be the answer
START UP SNAGS
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Know who is in the room!
Framing informed consent for the client from
the Tele-medicine perspective
Too many cooks can spoil the broth
Blending the chronic care model of the
physician with the acute care model of the
provider
START UP SNAGS
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Are partnering agencies holding the same
values and integrity?
Need for residential detoxification prior to
induction?
Reasonable geographic access to initial
physical and induction
Who runs the treatment plan?
Clinical assessment using
ASAM Criteria
Possible Suboxone candidate?
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Enters recommended level of care
Weekly tele-medicine
visit
LCADA Staff/Patient
Induction/Hx/Phys
SUBUTEX AND PREGNANT
CANDIDATES
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At start up the program pregnant women
were not being induced on subutex
After running the program for several month
we started accepting pregnant women
Coordination of care with an OBGYN in the
providers area with clear communication links
is essential for Meridian and for LCADA
LCADA hired a nurse to fill the medical gap
LESSONS LEARNED
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Establish a reliable point person
Document all contact phone numbers, fax numbers
and e-mail addresses
Determine if there will be a set number of clients to
be included in the program and keep a roster for
active and closed charts, keeping in mind the
physician’s Suboxone clients limit
Charts (EMR or paper) should be kept in both
locations for clinical staff at origin base and medical
staff and physician at satellite office.
LESSONS LEARNED
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Prior to induction client information should be faxed to satellite
office so chart can be prepared.
Name - Gender
DOB
SSN
Primary Care physician
Diagnosis
OB/GYN if applicable
Pharmacy preference (we use one pharmacy)
LESSONS LEARNED
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Determine if pharmacies will accept a faxed copy of
the script until the original can be mailed. If not
determine how prescription will be sent.
Set up laboratory services to be completed prior to
induction if possible or first Telemedicine visit.
CBC-d, CMP, RPR, Hep B Sag, Hep C ab, U/A
micro, HIV (optional)
Results should be sent to both locations and
added to charts
Lessons Learned
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Drug screens should be negative for benzodiazepines
Documents to be faxed/transferred after each Telemedicine appointment
Instant 9 panel UDS to include Buprenorphine
Pill/film count prior to appointment
Medical Department OARRS report (as necessary)
Cameras should be located to enable the physician to assess client
close up
Clients should be brought into the Telemedicine room with a counselor
and all necessary paperwork
Physician to document meeting with progress note
Allow 5-8 minutes for each follow up after induction and document
minutes for billing purposes
Following the appointment fax prescription to designated pharmacy
No hard copy needed for pharmacy
LESSONS LEARNED
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Permanent variance request asks for the
inclusion of the requirement for the physician
possessing the required prescriptive authority
of medication assisted treatment utilizing
interactive video-conferencing do so under
the scope of services of a certified ODADAS
program.
LESSONS LEARNED
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As a result of this variance opiate dependent
individuals enrolled in treatment in areas of
Ohio with limited access to medication
assisted services will have the opportunity for
seamless coordination of care through two
ODADAS certified organizations with policies
and procedures as well as memorandums of
understanding ensuring medical and
treatment service continuity.
WHERE DO WE GO FROM HERE?
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More treatment staff training on MAT/chronic
care model
Increasing the capacity of Suboxone slots
The role of the electronic medical record in
the coordination of care
Education of the community including AA/NA
community regarding MAT
Education of the medical community
Recruitment of doctors to get certified
Telemedicine Equipment Utilized