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   Ohio is experiencing a Narcotic and Heroin Epidemic Lorain County statistics:   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  70% of LCADA’s client base is Opiate Addicted        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  2009 Suboxone Contract was given to local mental health center     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  Contract was provided to LCADA September 2011   Suboxone Project Manager was hired. Significant difficulty hiring a physician. This would bring the program to a grinding stop. Solution  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:     Survey conducted by Metanoia, a nonprofit clearinghouse for mental health websites reveiled:     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      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          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      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    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!    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    Having enough physician slots available for the partnership Yet to be adequately solved OTP Suboxone Waiver may be the answer START UP SNAGS     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     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? . Enters recommended level of care Weekly tele-medicine visit LCADA Staff/Patient Induction/Hx/Phys SUBUTEX AND PREGNANT CANDIDATES     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     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         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     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            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  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  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?       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