Models for Medication-Assisted Treatment for Opioid Use Disorder, Retention, and Continuity of Care. APPENDIX 4: Site Visit Reports



IBM Watson Health

July 2020

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on September 7, 2019.





  • Site Description
  • Unique Aspects of the Site
  • Information on Study Research Questions
  • Additional Key Information From Visit
  • Table 1. Number of Patients Served by ETS and Their Retention


  • Site Description
  • Unique Aspects of the Site
  • Information on Study Research Questions
  • Additional Key Information From Visit
  • Table 1. RAM Preliminary Follow-up Data


  • Site Description
  • Unique Aspects of the Site
  • Information on Study Research Questions
  • Additional Key Information From Visit
  • Table 1. MSBI Gouverneur Clinic Retention Rates at 30, 90, 180, and 365 Days, by Year


  • Site Description
  • Unique Aspects of the Site
  • Information on Study Research Questions
  • Additional Key Information From Visit


  • Site Description
  • Unique Aspects of the Site
  • Information on Study Research Questions
  • Additional Key Information From Visit



The following acronyms are mentioned in this appendix.

ACS New York Administration for Children's Services
ADHD Attention Deficit Hyperactivity Disorder
APG Ambulatory Patient Group
ASAM American Society of Addiction Medicine
AUD Alcohol Use Disorder
BHO Behavioral Health Organization
CCC Oregon Central City Concern
CCO Coordinated Care Organization
CDP Chemical Dependency Professional
CEP Community Engagement Program
CFS Child and Family Services
CJS Criminal Justice System
COWS Clinical Opiate Withdrawal Scale
CVAM Central Vermont Addiction Medicine
CVMC Central Vermont Medical Center
DBT Dialectical Behavior Therapy
DSM-V Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
ETS Washington Evergreen Treatment Services
FDA HHS Food and Drug Administration
FFS Fee For Service
FQHC Federally Qualified Health Center
FTE Full-Time Equivalent
HIV Human Immunodeficiency Virus
IOP Intensive Outpatient
K2 Synthetic Marijuana
KEEP Key Extended Entry Program
LADC Licensed Alcohol and Drug Counselor
LGBT Lesbian, Gay, Bisexual, and Transgender
MAT Medication-Assisted Treatment
MDT Multidisciplinary Team
Mg Milligram
MPR Medication Possession Ratio
MSBI New York Mount Sinai Beth Israel Gouverneur Clinic
MTC Maryland Treatment Centers
OBOT Office-Based Opioid Treatment
OTC Oregon Old Town Clinic
OTP Opioid Treatment Program
OUD Opioid Use Disorder
PCP Primary Care Provider
PDMP Prescription Drug Monitoring Program
QI Quality Improvement
RAM Rapid Access to Medication-Assisted Treatment
SAMHSA HHS Substance Abuse and Mental Health Services Administration
SBIRT Screening, Brief Intervention, and Referral to Treatment
SUD Substance Use Disorder
VA U.S. Department of Veterans Affairs
WCSARP Washington County Substance Abuse Regional Partnership
XR-Bupe Extended-Release Buprenorphine
XR-NTX Extended-Release Naltrexone



Site Name: Evergreen Treatment Services (ETS)

Location: 1700 Airport Way South, Seattle, Washington 98134

Date Visited: May 13, 2019

Site Description

Evergreen Treatment Services (ETS) is a private non-profit organization with locations in the Seattle, Renton, Olympia, and Grays Harbor, Washington, areas. We visited the Seattle location. Most of its services are funded by Medicaid billing. ETS also has contracts with the City of Seattle and relies on grant funding (e.g., a grant from law enforcement covers diversion and allows ETS to work with difficult-to-engage HIV patients).

All patients have a diagnosis of opioid use disorder (OUD); ETS will treat other substance use disorder (SUD) conditions if the diagnosis is co-occurring with OUD. Common other SUDs are methamphetamine, cocaine, alcohol, and benzodiazepine use disorders. It does not treat adolescents but does treat pregnant women. The population now includes a larger proportion of homeless patients, those with chronic or severe mental illness, and young adults, compared to the past.

ETS offers opioid treatment program (OTP) services and has a small practice of prescribing buprenorphine. Buprenorphine prescribing is most common at the rural Grays Harbor location. ETS has a grant to enhance office-based opioid treatment (OBOT) prescribing within the FlexCare nurse manager care model, which is a hub-and-spoke model, and can refer patients to the OTP as the hub. ETS also operates the REACH program, which is a large program that serves "vulnerable, chronic homeless adults with SUDs and other comorbidities." REACH is funded through contracts and grants.

ETS currently has 1,334 patients in treatment. Of those, 436 have been in treatment for more than 4 years (see Table 1).

TABLE 1. Number of Patients Served by ETS and Their Retention
Retention No. of Patients
Less than 30 days 64
31 - 60 days 37
61 - 90 days 19
91 - 120 days 12
121 - 150 days 19
151 - 180 days 26
181 days - 1 year 173
1 - 2 years 263
2 - 3 years 186
3 - 4 years 99
More than 4 years 436
Total Census 1,334

ETS works directly and indirectly with Harborview Medical Center, which is affiliated with the University of Washington. ETS also works with community partners, including the Hepatitis Education Program and the needle exchange program.

Unique Aspects of the Site

Washington State, American Association for the Treatment of Opioid Dependence, and the FDA have issued statements indicating that patients should not be denied treatment for OUD simply because they are using benzodiazepines. ETS is one of the few treatment programs locally that keep people who take benzodiazepines in treatment, although it will not allow those taking Xanax to participate in treatment. Xanax has a higher mortality rate when used with methadone. Xanax is also more popular for illicit use among the patient population. ETS hopes to influence prescribing behavior in the community through this policy and reduce the number Xanax prescriptions to stop diversion and illicit use.

Information on Study Research Questions

Question 1: What variables affect retention in SUD treatment across disorders? How have these changed with the evolution of drug use patterns?

Site Information

ETS discussed several issues that can impede patient retention. The largest source of discharge is people who walk away and do not return. Patients are discharged if they miss 11 consecutive doses. ETS is focused on getting patients on a stabilized dose early and safely. A number of patients linger at 30 mg/day because they do not come in for dose evaluation and their dose cannot be increased beyond the initial limit. ETS has started a discussion on how to get people stabilized more quickly, especially those who do not regularly attend.

Some barriers to accessing and staying in treatment are transportation to the site and finding childcare for the appointment time.

For those who chose to taper off medication-assisted treatment (MAT), their choice usually is prompted by scheduling issues around dosing. Specifically, construction workers have conflicting schedules with ETS's dosing times (which are 5:30 a.m. to 1:00 p.m.). If someone voluntarily tapers, ETS offers aftercare services during which patients can see their counselor.

Question 2: What are evidence-based methods to address treatment retention in SUD treatment, and how do these apply to treatment of OUD?

Site Information

ETS has implemented several practices to help retain patients in treatment.

  • Unlike some providers that schedule dosing windows, ETS does not put patients into time slots. ETS uses broad dosing hours to maximize the ability of people to obtain medication.

  • During the intake process, ETS looks at how to get patients to come back for treatment and get them engaged early in treatment. The intake process has changed, including creating treatment on demand if there is an open medical slot. Patients can be admitted to treatment the same day they walk in the door. If patients have to come back (because ETS is unable to serve them), they are given head-of-the-line privileges the day they return. ETS is trying to shorten the amount of time between when patients say they want treatment to when they are admitted into treatment.

  • It does not discharge patients for having a positive urine screen, because substance use can be considered a symptom of the patient's illness. ETS may discharge patients presenting for being intoxicated or if the patient is dealing or acting unsafely at the clinic.

  • ETS has switched to unobserved urine collection. For many people, the pressure to produce a sample is a barrier, and there is added pressure when being observed. Further, observed collection is demeaning.

  • ETS uses an engagement tracker to closely monitor for the first 90 days of treatment. The engagement tracker is color-coded and addresses risk factors for avoidable discharges, such as being homeless; being under 30; being new to treatment; having a co-occurring diagnosis; being LGBT; and other risk factors. This lets ETS keep better track of the risk factors and allows the peer recovery specialist to step in before the patient leaves treatment. It can contact patients by flagging their dose.

  • When a patient misses two consecutive doses, ETS reaches out to the patient.

  • ETS has a mobile methadone clinic that travels to two neighborhoods that do not have a fixed clinic. This expands capacity and is more convenient for some patients, so it probably helps retention.

  • The Grays Harbor clinic uses telehealth as part of buprenorphine treatment, using a prescriber in Seattle. That clinic, however, is closing shortly.

Question 3: Are there promising models of psychosocial support that assist in maintaining an individual in MAT for OUD? Do longer, more continuous durations of treatment result in better outcomes?

Site Information

ETS offers individual counseling, group therapy, peer support, case management, and acupuncture. Every patient in treatment receives an ASAM assessment, and a treatment plan is developed. This process allows ETS to look at all the patient's needs at intake and to understand what must be addressed to help the person maintain stability, including mental health treatment and housing.

The primary treatment modality is individual counseling. Every patient has an individual counselor. ETS uses motivational interviewing, which is a style of counseling that works well with developing a relationship and helping patients who are not in the action phase of change. Motivational interviewing is used on an ongoing basis, and those skills are used to reinforce change. Many of the counselors use a cognitive therapy approach, looking at how thoughts and feelings affect cravings. A small number of counselors have specialty training in dialectical behavior therapy (DBT) and trauma-informed care. ETS also offers psychiatric education around the risk of ongoing use early in treatment. ETS also provides limited psychiatric services to those patients who cannot get it elsewhere.

ETS is expanding the number of counseling groups offered because the size of its client population has increased greatly. Current groups include ones related to seeking safety and co-occurring diagnoses, as well as groups for men, women, older clients, and LGBT clients.

Six months ago, ETS hired a peer engagement specialist who approaches patients as an equal. This work is ongoing, but the particular focus is on engaging with patients in the first 90 days of treatment, beginning at intake. This helps remove some of the shame that new patients may feel.

Case management is part of receiving treatment at ETS. Currently, there are two case managers onsite 3-4 days a week, but it is looking to hire more case managers and to provide more out-of-office case management. The case managers work to connect people to services and will help make the call if necessary. The ETS clinic also has case management through the REACH program for those who need additional support.

ETS also offers acupuncture at the Seattle location.

Question 4: How have changes in reimbursement policy affected the provision of services? Have reimbursement policy changes expanded retention in treatment?

Site Information

ETS currently is contracted with the behavioral health organization (BHO) in the state, which manages and integrates care. The BHO system will end and the payment structure will change next year when medical care is integrated with behavioral health in the state. ETS is reimbursed at a bundled rate as an OTP. This rate does not include case management, and having it incorporated into the bundle would be very helpful, especially because ETS recently has been able to hire more case managers. As part of the state's HealthierHere initiative, ETS reports measures that are part of a value-based payment model. Retention is one measure, as are measures relating to the use of the PHQ9 and patient perception of care.

Additional Key Information From Visit

  • In response to the opioid epidemic, ETS is working to get more people into treatment. One barrier to accessing treatment has been a statutory limit on number of patients per license and a county limit on the number of licenses. The restrictions on number of patients gradually have been lifted. The patient population has grown substantially, and there are now more young adult patients.

  • Every patient has an assigned medical provider. These providers take an active role in coordinating medical care. There is a small primary care provider (PCP) program, whereby a Harborview Medical Center PCP is onsite 2 half days per week. ETS also provides some Hepatitis C treatment onsite and through the link with the HEP C project downtown for screenings for Hepatitis C and HIV.

  • Although Evergreen case managers reach out to patients who miss two doses, they do not have a standard mechanism to try to re-engage those discharged after 11 consecutive missed doses. Evergreen noted that its patients often do not have either stable housing or a consistent cell phone number where they can be contacted.

  • The state's chemical dependency treatment requirements affect provision of services. The Washington Administrative Code requires that all patients receive counseling with a Chemical Dependency Professional (CDP). CDP counseling is separate from other professional counseling, and even a psychiatrist cannot bill for drug counseling unless the psychiatrist is also a CDP. Until very recently, a CDP visit was required at least once a month. Now the requirement is based on the patient service plan and is revisited every 6 months. There have been times in the past when ETS could not admit new patients because it did not meet capacity with its CDPs. CDPs are not paid well but have a high cost of licensure, which disincentivizes people from entering that profession. ETS is working on a commitment to support CDPs and offer continuing education courses. The case managers also must be CDPs.

  • County trainings for motivational interviewing are always full, so ETS is considering adding an internal training on motivational interviewing to further spread its use.

  • ETS expands its staff capabilities by using physician assistants and nurse practitioners as medication providers. Frequently, physician assistant students do rotations in the clinic. Additionally, ETS has a fellow from the Swedish Medical Center, and some residency programs send residents for half days.

  • ETS also is exploring getting licensed as a community mental health center to provide mental health services in house.



Site Name: State of Vermont hub-and-spoke model, as implemented in Central Vermont, including emergency department buprenorphine induction

Location: Central Vermont Medical Center (CVMC), Central Vermont Addiction Services, Washington County Substance Abuse Regional Partnership Meeting (WCSARP) Community Meeting, Treatment Associates

Date Visited: June 18, 2019

Follow-up Call: July 8, 2019

Site Description

The State of Vermont is the most mature example of the hub-and-spoke system of treatment. The original design of the system called for patients to be inducted in MAT at a hub clinic (an OTP) and stepped down to a spoke clinic (often an outpatient general practitioner) after stabilization and for continued treatment. The hub remains available if restabilization is needed. There are six service regions in the state. This report details information gathered from the central Vermont region, in Washington and surrounding counties. For this region, the hub is Central Vermont Addiction Medicine (CVAM), located in Berlin, Vermont, and part of BAART (Baymark), with several spokes in the surrounding communities (Gifford Medical Center in Randolph (a specialty spoke or "super spoke," which cannot provide methadone but includes addiction specialists), Treatment Associates in Morrisville and Montpelier (both specialty spokes), and CVAM's spoke in Berlin. In addition to the original hub-and-spoke model, Vermont is implementing rapid access to MAT (RAM). The pilot for this has been the emergency department at the CVMC in Berlin, although the RAM model is spreading across the state.

The site visit included meetings with the CVMC emergency department team, the CVAM hub team, and attendance at a regional meeting of the WCSARP. We were supposed to meet with Treatment Associates, but that in-person meeting was cancelled. We held a follow-up call by phone with Treatment Associates after the site visit. See below for more information on the site(s).

Unique Aspects of the Site

Use of Buprenorphine:

Historically, and until recently, there were no methadone clinics in Vermont because they were prohibited. As the opioid crisis grew, patients initially were transported to Massachusetts for methadone treatment, and in 2002, the first methadone clinic was allowed to open. As a result of this history, however, Vermont uses buprenorphine far more than methadone and more than most states. This approach allows patients to be stepped down from specialty to less intense settings. Patients who are treated with methadone must remain in treatment at the hub because the spokes are not OTPs. Using the community buprenorphine infrastructure allows the emergency department to be involved with inducting patients through the RAM program.

RAM Program:

Traditionally, the emergency department did not induct people into MAT; rather, patients would see a specialist for induction. However, because buprenorphine has been available in general medical offices for a number of years in Vermont, the state and CVMC decided to begin using the emergency department as an induction site. The emergency department at CVMC had considerable prior experience with inducting MAT for AUD. The emergency department began by conducting Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol use and other drugs (integrated into the electronic medical record), which laid the groundwork for the emergency department to begin prescribing for AUD in 2014. SBIRT reframed the approach to substance use treatment to make it a part of triage. SBIRT helped get people to think in terms of the disease model of addiction. Community stakeholders and the WCSARP supported the MAT program for AUD, and that paved the way for the RAM emergency department buprenorphine prescribing program and RAM and facilitated pathways from the emergency department to further treatment.

The RAM pilot began in July 2018. People presenting in the emergency department who are inducted on buprenorphine include individuals who have overdosed, who are in withdrawal, and who want entry into the MAT system. Anecdotally, many people who come into the RAM program are not in withdrawal but know their buprenorphine dose from using buprenorphine on the street. Many people do not want to be sick and are "doing their own MAT."

The MAT for AUD program was adapted for OUD with three primary changes:

  1. Emergency department providers are trained in buprenorphine prescribing. All CVMC emergency department physicians are now waivered under the Drug Addiction Treatment Act to prescribe buprenorphine, allowing for more flexibility than use of the "72-hour rule" would allow. Subsequent work with other emergency departments has led to the realization that having waivered providers in the emergency department cannot be optional and that it is essential to making the process work. CVMC tries to make RAM easy for providers. The CVMC emergency department paid the providers for 8 hours of training at their normal rate. This was an administrative expense but was important to getting many providers to take the training. CVMC noted that one way to expand this at other hospitals would be to make the number of waivered providers a quality measure, which would help get support from the hospital to fund the training.

  2. The emergency department now has substance use specialists and licensed alcohol and drug counselors (LADCs) available to assist emergency department physicians. The emergency department also received a grant for recovery coaches. A recovery coach (peer recovery specialist) from the local recovery center works with the patient in the emergency department, using a Recovery Coach Emergency Department Checklist.

  3. Guaranteed follow-up was introduced. The emergency department worked with the regional hub and super spokes. Between the hub and two super spokes, every day is covered and each day the emergency department can refer a patient to a location. The patient should be seen within 72 hours at the most. The recovery coach that the patient met in the emergency department follows up by phone or text with the patient to encourage the patient to get to the appointment.

While in the emergency department, patients receive a medical assessment to confirm that they meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria for OUD and receive a Clinical Opiate Withdrawal Scale (COWS) assessment. CVMC provides a paper checklist (for DSM-V and COWS) to the patient to complete. The COWS is nurse administered. The screening tools also are integrated into the electronic medical record, which makes screening a low-barrier program for providers. The emergency department provider prescribes buprenorphine, which may be provided in any of the following ways: dose only, dose and pack to go, pack only, referral only, and dose plus prescription. The emergency department prefers to give patients go-packs of medication to bridge the time until their hub or spoke appointment. The first time that a local pharmacist received a buprenorphine prescription from the emergency department, there were multiple calls to confirm its legitimacy. The team concluded that pharmacists need to be oriented in advance to seeing prescriptions for buprenorphine and filling such prescriptions.

In Vermont, patients are presenting with co-occurring crack or cocaine use. RAM has seen an increase in men over women, and the mean age is consistently in the mid-30s. The program has not treated any adolescents but would do so in consultation with other providers. The CVMC RAM program keeps statistics. The program is working to improve the consistency of follow-up data, but Table 1 provides preliminary data.

TABLE 1. RAM Preliminary Follow-up Data
Outcome 3 months 6 months 9 months
Follow-up rate
   Total referred 18 34 74
   Followed up 14 28 60
   Consistent 6 11 26
   Inconsistent 6 5 0
   Discharged 2 1 23
   Expired 0 1 1
   No attendance/no-show 4 6 12
Follow-up within 72 hours 13 24 49
Follow-up exceeded 72 hours 1 4 3

Information on Study Research Questions

Question 1: What variables affect retention in SUD treatment across disorders? How have these changed with the evolution of drug use patterns?

Site Information

CVMC: Geography and transportation are barriers to retention. It is particularly hard for patients in rural mountainous areas to get to treatment. Some patients may have a provider in their county but are required to start at a hub that is farther away and difficult to reach. Patients may have positive and negative connotations regarding each place. The hubs encounter the most stigma because they tend to treat the sickest people (those early in treatment and not yet stable). The dosing line is uncomfortable. There is exposure to people who may entice patients toward illicit drug use. The emergency department also may be intimidating. Some patients' worst experiences with health care may have been in the hospital. Not all providers in the emergency department are enthusiastic about prescribing (providers are not required to prescribe, and a second provider can be there if needed).

CVAM: The following are items that CVAM identified as areas for improvement in retention:

  • There is an opportunity for growth in making the system appear integrated for patients moving from the hub to the spokes, particularly in terms of having the patient feel that moving to a spoke is part of his or her recovery process. The hub is starting to do more spoke informational groups to help educate patients. CVAM also is working to create a level system where a lower or higher (yet to be determined) level will earn high privileges. It is not meant to be considered a level of treatment but rather a way to guide people in moving to the spokes. This will allow patients to understand what to expect in the first 3 months, the next 3 months, and so forth through 1 year.

  • Helping patients understand the treatment process by setting the stage and helping them understand what to expect are a big piece of treatment. If patients can come into CVAM from the emergency department knowing what to expect, fewer patients will be surprised.

  • Some RAM patients are very complex and may have mental health struggles or be a pain patient. If insufficient information is received from the emergency department, the hub needs to investigate to understand the patient's needs. It may only receive the last dose letter and the COWS assessment from the emergency department. For most Suboxone® patients, the doctor at CVAM meets the patient for 15 minutes during the intake process. When the patient is referred from the emergency department, this intake meeting is not done. CVAM felt that more information could be shared between the emergency department and the hub, particularly for the more complex cases. This also was noted by CVMC emergency department, which had tried to streamline its paperwork for follow-up. This issue was raised separately by both sites.

  • CVAM also receives referrals from the spokes. Communication between the hub and the spoke is very important for these referrals. The ability for one clinic to call another clinic makes it possible to focus referrals on the patient, instead of just a checklist. The spoke patients' information needs to be organized and reviewed by the doctor. The spoke clinics may feel hesitant to disengage the patient without receiving permission from the hub doctor. CVAM is working to develop a standard referral process from the spokes back to the hubs.

  • Some patients are retained in the hub, and some are stepped down to a spoke. There are a number of considerations. If patients are on methadone, they cannot be stepped down. Many patients have been to multiple providers or have opinions about different providers. For example, some spokes may require more urine analyses or counseling than the hub, and this may feel like a punishment rather than a reward and may deter patients from moving to a spoke.

  • CVAM is working to establish a common definition of stable across axes to overcome transition challenges. People can be unstable in many different ways.

Treatment Associates: Treatment Associates has some clients who have been in treatment for more than 10 years and some who have been in treatment for just 1 day. Treatment Associates has a general understanding that clients are more successful over a long period of time if they are engaged in treatment for a longer period of time. Treatment Associates is working on the understanding that if it can keep clients in treatment, it can improve clients' treatment.

Treatment Associates is starting a program to assess clients in treatment using a questionnaire given at the start of treatment, at 6 months, and again at 12 months. The program is still very new, but it is trying to answer the questions around keeping people engaged by finding out what is working in treatment and in life.

Treatment Associates has a lot of movement of clinicians, which is a blow to the clients. Clients find it challenging to continually retell their story to new clinicians, and when a clinician leaves, the clients lose their connection and can disengage from treatment. The workforce piece is essential to retention. Treatment Associates does not punish clients for relapse. However, clients have the mindset of punishment, so they try to hide relapse or leave treatment. Treatment Associates does observed urine analysis, except for a few clients who have unobserved urine analysis for trauma-related reasons.

Treatment Associates is continuously trying to improve its intake process and the process for how clients are moved through transitions. Treatment Associates does not lose a lot of clients in the beginning, but it is working to smooth the process overall. Treatment Associates brought on additional staff to conduct intake as part of the RAM program. The transition process is where clients are lost. More clients are lost for non-MAT services (alcohol, cocaine, and marijuana treatment) than are lost for MAT services. The MAT is the incentive to keep clients coming back in.

Treatment Associates loses most clients to incarceration. Vermont has made improvements in the past year to ensure that MAT is maintained in jail and to make sure there is a plan in place when the person is released. The Department of Corrections and the criminal justice system (CJS) are working to improve care coordination with providers. Other barriers to retention are transportation, childcare, and lack of housing.

Question 2: What are evidence-based methods to address treatment retention in SUD treatment, and how do these apply to treatment of OUD?

Site Information

The sites have implemented several practices to help retain patients in treatment.

CVMC: The emergency department at CVMC is trying to understand whether there is something it can do as an emergency department and in partnership with the treatment pathway to keep people in treatment. The clinics have reported that the patients are not aware of what to expect when they reach the hub, so the emergency department is working to educate patients that treatment is not just getting a pill.

The recovery coaches help retain patients in treatment. Having the recovery coaches is the key to the success of the RAM program. The recovery coach is paged any time that the emergency department has a patient in need of buprenorphine treatment, and the recovery coach is there in person with the patient. The recovery coach also follows up with the patient by phone or text. The coach may have a later physical meeting with the patient and will continue working with the patient, if the patient wants the coach to help. If patients do not attend treatment within 72 hours, they are not lost. People have entered treatment at the hub a range of 12 hours to 21 days after receiving a referral from the emergency department. Most patients appear at the hub within 48 hours. They may not need to be reinducted if they miss the window, because induction can be done in the office if it is appropriate.

The emergency department is working to understand whether retention rates differ by those who receive one dose, one pack, or a referral. Anecdotally, the patients who receive more medication from the emergency department tend to move into further treatment better. In many ways, this is counterintuitive, but it gives patients some stability to get to treatment.

CVAM: The 90-day retention rate at CVAM for December was 74 percent.

  • CVAM is both a hub and a spoke and is both an OTP and a prescriber of buprenorphine. This allows flexibility.

  • CVAM starts methadone dosing at 5:30 a.m. and continues until 11:30 a.m. (6-10 a.m. on weekends). Early dosing is convenient for patients who have jobs and who need a dose early. The patient community does a good job of accommodating each other's schedules and allowing for line skipping.

  • Urine analysis is typically unobserved, but patients are cautioned to expect observed urine analysis at some point because it is used to confirm medication.

  • CVAM does not dismiss patients who relapse. If a patient continues to use at high levels, CVAM will increase or decrease the dose on the basis of the patient's use or the patient may be referred to residential treatment. Few patients are dismissed from treatment. One was discharged because he could not change his vocabulary and it was affecting other patients.

  • CVAM works to meet the patients where they are. On occasion, patients can become disenchanted during treatment, and anger may be the result of a patient needing to be heard. CVAM works to hear patients and work toward a solution. The management team meets to discuss hard cases.

Treatment Associates: Treatment Associates offers full addiction treatment and mental health treatment. Clients are treated for mental health needs and provided addiction treatment for alcohol, cocaine, marijuana, stimulants, and opioids, with and without medication. Most clients are in opioid treatment with MAT. Treatment Associates is building up its AUD treatment program with the knowledge that AUD has been overshadowed. Treatment Associates is owned by a psychiatrist and can provide short-term mental health medication. However, Treatment Associates tries to connect those patients to a regular practitioner. Treatment Associates has prescribed the pill form of naltrexone, but no injections. Treatment Associates also is using sublingual Suboxone™ and Sublocade™ injections.

Treatment Associates is associated with Turning Point, the peer recovery network in the area. Treatment Associates suggests that clients connect with Turning Point and occasionally has the Turning Point coaches come into Treatment Associates to talk about the services offered. Treatment Associates does a lot of case management around connecting clients to resources. Treatment Associates does not have structured arrangements or meetings with Turning Point at this time. Treatment Associates also has regular meetings with the Department of Corrections and the local hub. Treatment Associates works with the Central Vermont Association of Treatment Professionals and the Central Vermont Community Response Team, a team consisting of housing services, child services, corrections, and prenatal services, which are focused on pregnant and postpartum women.

Treatment Associates is working to think outside the box with its services and determine how it can improve from just a counseling and therapeutic program to a program that addresses other parts of people's lives. Treatment Associates has started offering some childcare, telemedicine for counseling, Saturday groups, a book club, and an exercise program for people in recovery. Treatment Associates offers different connections to community mental health programs, psychiatric providers, hospitals, and local PCPs.

Clients are moved to the hub when they are not meeting the requirements around urine analysis and medication counseling. Clients will be moved to a higher level of care if they are a danger. Treatment Associates will move in steps, starting with a move to intensive outpatient (IOP) treatment, then to the hub, and finally to inpatient treatment. Clients are reluctant to move to the hub or inpatient treatment, but a move to IOP is less invasive.

Question 3: Are there promising models of psychosocial support that assist in maintaining an individual in MAT for OUD? Do longer, more continuous durations of treatment result in better outcomes?

Site Information

CVAM: Patients are required to receive 60 minutes of psychosocial counseling per month. CVAM does not require that the entire 60 minutes occur at once. Because reimbursement is through a bundled payment, CVAM can be flexible with the counseling time. Patients may receive shorter, more frequent visits to meet the 60-minute requirement. As a patient becomes more stable, the frequency can be decreased. CVAM focuses on making a counselor connection. Engagement is both the impediment to successful treatment and the answer to successful treatment. Patients are not discharged because of missed counseling.

When reviewing patient cases, CVAM tries to match patients to a good counselor for that patient during the intake interview. It is possible to refer patients to counselors outside CVAM if it is clinically preferred.

CVAM also uses groups for treatment. CVAM offers psychosocial skills support, such as training for jobs, budgeting, life skills, and tobacco cessation. It would like to offer more trauma-informed care. CVAM currently relies most on individual counseling but plans to include changes with the level system that encourages greater use of groups.

CVAM provides counselor training. It encourages counselors to use the structure of motivational interviewing (stage of change, continuum of change). Counselors use motivational interviewing throughout the process to keep patients engaged. Some patients come in ready to do the work. Some patients come in just looking for medication, and once a counselor pulls them in, the counselor uses motivational interviewing strategies.

Maintaining workforce has been a challenge for CVAM. Some clinics have one nurse. If that nurse is away from work, the clinic will ask nurses from other clinics to cover. CVAM has no per diem nurses at present. Maintaining counselor staff is also a challenge. Counselors must be LADC licensed. Currently, two counselors at CVAM are licensed LADCs, and other counselors are working on licensure. Counselors are an underpaid position. Many come to the hub for 1 year and then move on to private practice or to work in the hospital, where they can make a much higher salary.

Treatment Associates: Treatment Associates has a strongly therapeutic-focused program. Clients are expected to do counseling as part of treatment but will account for individual needs for counseling. Clients are expected to attend anywhere from two sessions per month to five sessions per week, and this can be a combination of individual and group sessions. Treatment Associates offers a wide variety of groups, including cognitive behavior, DBT, and life skills. Clients can choose which groups to be a part of. Treatment Associates also does IOP, which consists of 9 hours per week of counseling and incorporates family and life skills. Clients can choose the approach that is the right fit for them, rather than Treatment Associates offering a specific approach. Motivational interviewing is the backbone of treatment and has been incorporated into all levels of treatment, including case management, individual counseling, and group counseling.

The program is based on a phased system, with phases indicated by urine analysis and attendance. Treatment Associates generally tries to lean on the phase system when someone is not engaging in counseling, providing increased support when needed. If someone is not stable enough to meet the counseling requirements, Treatment Associates will try to increase the structure around the chaos in his or her life. Counseling is important but no longer technically required for a client to receive medication.

Question 4: How have changes in reimbursement policy affected the provision of services? Have reimbursement policy changes expanded retention in treatment?

Site Information

Vermont Medicaid uses the health home managed care model for payment. This allows flexibility in terms of services provided and avoids quantity-based fee for service (FFS) payments. Both hubs and spokes benefit from enhanced staffing. Hubs are reimbursed through bundled payments and spokes have the benefit of one full-time equivalent (FTE) nurse and one FTE licensed clinician case manager for every 100 patients across multiple providers and their offices.

As a hub, CVAM is reimbursed by Medicaid through bundled payments. If a patient prefers or needs to see an outside provider, CVAM can refer them out. That provider is paid via FFS reimbursement, and CVAM still is paid the bundled rate for the services it provides, as long as it meets the requirements for its bundle. The spoke, Treatment Associates, does not participate in value-based purchasing. Most of its patients are covered by Medicaid, and Treatment Associates offers a sliding scale for self-pay patients.

Uninsured patients in Vermont tend to be the working poor, who have too much income to qualify for Medicaid. For these patients, treatment at the hub may be better financially because hub patients do not pay for medication. This is beneficial for patients without insurance. Spoke clinics may help patients with the cost of the visit but cannot help with medication costs.

Medicaid can pay for transportation, if there is no vehicle registered to the patient's home. Patients can appeal if they have a vehicle registered but it is unavailable to them. There are no prohibitions on going outside the catchment area, but Medicaid will transport patients only to the closest clinic. The hospital can help patients with understanding transportation or with their appeal if transportation is denied.

Additional Key Information From Visit

  • Vermont has successfully eliminated its wait list for treatment.

  • In 2017, the statewide initiation in OUD treatment rate was 60-65 percent (75-80 percent for Washington County) and the statewide engagement rate was 40-45 percent (55-60 percent for Washington County).

  • One lesson learned at CVMC is that patients will come to its emergency department from surrounding areas that do not have emergency department (RAM) prescribing. CVMC is working with other locations to start emergency department prescribing programs and is sharing materials with other programs. It already has protocols in place. The RAM program also has been improving its practices around data collection. There is a challenge in finding time for a person to collect the data and analyze it. CVMC has received a grant from the accountable care organization. This package contains funding to:

    • Create materials that can help other emergency departments start such a program.

    • Help with data collection and analysis, specifically to make it less laborious and to help them understand which data points are worth tracking to understand how long someone stays in treatment.

  • The state is beginning work on RAM Phase II to pilot messaging to people in need of, but not seeking, treatment in central Vermont. This audience includes people who may have misconceptions about treatment or are experiencing barriers to treatment. Materials were developed that include messaging to address the most frequently mentioned barriers to treatment, such as transportation or childcare issues. This messaging was scheduled to be launched summer 2019.

  • Pregnant women are inducted into treatment in the same way as other patients. The emergency department has a robust obstetrics case management system that is used to get women into treatment quickly. There also is a women's health clinic in the hospital building. Women can continue their obstetrics care in that clinic, but they may not deliver at CVMC. If the child is at risk of withdrawal, the hospital has a withdrawal protocol. The women's health clinic does not have any providers who are waivered, but University of Vermont Medical Center's Comprehensive Obstetrics and Gynecological Clinic can prescribe buprenorphine and provide obstetrics care for high-risk women.



Site Name: Mount Sinai Beth Israel (MSBI) Gouverneur Clinic

Location: 109 Delancey Street, New York, New York

Date Visited: June 20, 2019

Site Description

Mount Sinai Beth Israel (MSBI) Gouverneur Clinic is part of the large Mount Sinai health system. Mount Sinai acquired Beth Israel in 2015. The Gouverneur Clinic is one of many OTPs and other facilities in the MSBI health system. The clinic serves 480 patients currently, and the MSBI system is licensed to treat 6,000 patients across ten clinics.

The local population of this clinic has changed over time. There are more younger patients now than in the past. The patient population is more male than female. Gentrification has changed the neighborhood and the population. The older population more often uses heroin; the younger population more often uses pills. The clinic is seeing some fentanyl use. The clinic offers training on overdose prevention, and patients and staff carry Narcan®. The clinic sees cocaine, crack, marijuana, K2, fentanyl, and benzodiazepines as the most frequent co-occurring substances. About 70 percent of the clinic population has some form of mental disorder, such as depression or anxiety. Some patients are diagnosed with schizophrenia, borderline personality, or ADHD, and some have intellectual disabilities.

The clinic has the rest of the MSBI system as a major partner. The clinic also has linkage agreements with providers at clinics all over the city. One important linkage is with certain long-term residential programs, where the clinic provides methadone to the residents (because residential programs are not licensed as OTPs). The residential program pharmacy takes custody of the medication through a special exemption arrangement with the SAMHSA Center for Substance Abuse Treatment. The clinic also has partnerships with programs that help with housing. The clinic social workers and counselors also can help patients with housing.

The clinic follows outcomes, including overall functioning, vocational status, criminal justice activity, and overdoses. The clinic has a coordinator of children and family services, who is aware of all active Administration for Children's Services (ACS) cases. The clinic tracks the number of patients who receive overdose prevention training and who have a naloxone kit (although naloxone is not always used for the person who has it because the patient could use it for a friend).

Unique Aspects of the Site

KEEP Program at Rikers Island:

MSBI Gouverneur Clinic works with the Key Extended Entry Program (KEEP) at Rikers Island to keep incarcerated individuals on MAT. The clinic has a good relationship with KEEP. When a patient is discharged from Rikers, the patient has 30 days to come back to the clinic for MAT. Individuals at Rikers are retained on the clinic rolls.

Staff Composition:

The staff at the MSBI Gouverneur Clinic encompasses a wide range of specialties, including a physician, physician assistant, counselors, a social worker, nurses, and other staff. Primarily, the doctor does the prescribing. The physician assistant has been trained and can prescribe when the doctor is not in. The physician assistant does the admit physical, annual physical, and vaccines and deals with medical issues. Some of the other staff at the clinic are vocational rehabilitation counselors, financial counselors, a coordinator for Child and Family Services (CFS), and a patient advocate. The CFS coordinator and the patient advocate travel to multiple clinics in the system.

The staff at the clinic have stayed with the clinic or the larger health system long term. The staff are unionized and have good compensation and benefits, which helps with staff retention. All counselors must be credentialed as certified alcohol and substance abuse counselors.

Information on Study Research Questions

Question 1: What variables affect retention in SUD treatment across disorders? How have these changed with the evolution of drug use patterns?

Site Information

The clinic's objective in retaining people is to keep them "for as long as possible or forever." Research shows that patients who leave treatment have a greater chance of relapse. MSBI Gouverneur Clinic has had patients in the clinic for decades. But the treatment for these longer-term patients is different from treatment for more recent patients. They often are part of a cohort of patients who are on a low dose of methadone, with reduced pick-up schedules. Some people can taper, and some may switch to buprenorphine. The clinic has seen retention periods get longer, because patients realize that they need to stay in treatment. Keeping the homeless in treatment is hard because they change locations all around the city.

TABLE 1. MSBI Gouverneur Clinic Retention Rates (%) at 30, 90, 180, and 365 Days, by Year
Retention, Days 2012 2013 2014 2015 2016 2017 2018 2019
30 76 79 90 90 90 87 87 91
90 71 69 75 76 81 79 79 75
180 61 54 64 65 63 70 68  
365 46 42 49 52 49 60 64  

The first day of treatment is the longest day, because the patient meets with everyone on staff. Once a patient is accepted into treatment, the patient is assessed on the day of admission using the ASAM assessment to determine whether the patient meets the criteria for admission. The patient is given a wellness screening and a screening for suicide risk. The patient meets with a counselor to discuss the treatment plan. These treatment plans are how the patient is monitored throughout treatment. During the wellness screening, the patient is screened for mental health to determine whether he or she needs a mental health referral. The social worker can make these referrals to the hospital or to another more intensive program. Counseling is required once per week for the first 90 days of treatment. The clinic feels strongly about weekly or sometimes more than once per week counseling. The New York State Office of Alcoholism and Substance Abuse Services has relaxed the regulations on pick-up schedules. Patients can get reduced pick-up on the basis of a clinical assessment, which can help patients stay in treatment longer. Patients also are seen by the doctor to assess dose more frequently during the first 30 or 90 days.

The clinic does not have transportation burdens in the city. If a patient cannot attend during dosing hours, the clinic will transfer the dose to the late-day clinic (located elsewhere in the city). The clinic also may give a courtesy dose for patients from other clinics. Patients with children who cannot afford childcare bring their children to treatment. The clinic does not offer childcare services. Parents may come for counseling and dosing when their children are in school. Parents who are doing well and maintain abstinence and sobriety can have reduced visits and counseling schedules.

MSBI Gouverneur Clinic is working to improve care coordination for primary care and mental health treatment. Sometimes patients do not want to sign consents for that treatment. The clinic has some patients assigned to the MSBI health home organization because of difficulties with patients willing to give consent. For patients who give consent, the clinic can coordinate care with an outside doctor or mental health care provider. When a patient is hospitalized, the hospital will call the clinic to find out the patient's dose. Hospitals also will call the clinic when a patient is discharged.

Question 2: What are evidence-based methods to address treatment retention in SUD treatment, and how do these apply to treatment of OUD?

Site Information

The clinic uses a multidisciplinary approach, and when patients are having difficulty, they will be asked to participate in a multidisciplinary team (MDT) meeting. Some patients have difficulty tolerating the structure of the program--they may feel like the staff is telling them what to do. In these instances, the counselors can take patients into an MDT, which brings multiple disciplines to bear on the patient and helps the patient feel connected and better understood.

The clinic does not discharge patients who relapse, but patients must be working toward their treatment goals. Patients who are continuously using may be transferred to a higher level of care. Patients who are not trying or not engaged in the treatment process may be discharged. Most patients will be asked to meet with the MDT or accept referral to a higher level of care before discharge becomes a possibility. If a patient is not appearing for treatment, before the patient is discharged, there is a process to reach out and try to pull the patient back into treatment. At 7 days, the patient gets a call. At 14 days, the patient is sent a letter. Some patients are transient and do not provide correct phone numbers or use burner phones. But patients know where the clinic is, and although it may take multiple attempts, the patients often come back.

Patients may be abstinent from opioids but using another substance. The clinic offers counseling about co-occurring substance use. If a patient is using benzodiazepines, the clinic will ask the patient to show a prescription for the medication. If the patient is using illicit benzodiazepines, the clinic will not restrict methadone unless the patient is sedated. The clinic's concern around benzodiazepines is that the patient may appear fine but is sedated after dosing. The clinic will call emergency medical services if needed. The clinic checks the Prescription Drug Monitoring Program (PDMP); however, methadone is not listed on the PDMP, so other prescribers will not know from the PDMP that the patient is receiving it.

MSBI Gouverneur Clinic always does unobserved urine analysis. If there is a concern about adulteration, it will do an oral swab test. For reduction in schedule or for ACS cases, the clinic does an oral swab test. Observed urine analysis would allow counselors to ensure that the person is using his or her own urine; some patients get embarrassed if they relapse and try to hide it by using another person's urine. Most counselors have a good relationship with the patients and work hard to not demonstrate disappointment if a patient relapses in treatment.

MSBI Gouverneur Clinic does not yet offer peer recovery coaching. The clinic provided peer recovery training for 70 patients to become peer coaches. Some of these patients went on to become peer coaches, but then the state instituted a test as part of the certification requirements. Some trainees are doing their testing, and some are working on their hours. The clinic also received a grant from the state for a peer advocate. It has peers who volunteer in the program helping the patients get set up for a group or engaging with newer patients.

Question 3: Are there promising models of psychosocial support that assist in maintaining an individual in MAT for OUD? Do longer, more continuous durations of treatment result in better outcomes?

Site Information

MSBI Gouverneur Clinic offers a variety of groups. The clinic prides itself on the groups, including a pharmaceutical group that teaches patients about medication, a dual diagnosis group, a women's group, a harm reduction group, a life skills group, and an overdose prevention group. The clinic's quality improvement (QI) projects have not been specifically focused on retention, but staff members believe that groups have helped promote retention. The clinic has enhanced the group programming it offers and the clinical skills of the staff to conduct effective sessions (there is annual counselor training). Patients may attend more than one group, but the clinic does not encourage attending more than one group per day (to make sure that there is group access for all patients). Patients can join groups 5 days per week. A patient's first group is usually the orientation group, which orients them to everything about the program, including the loitering policy and the toxicology policy, and helps them understand the program. The clinic also has a choir that is very popular among patients and is considered an effective method of providing patients with recreational opportunities in a non-drug setting. Similarly, the staff tries to engage patients in other such activities, for instance, picnics in Central Park.

The counselors are trained in motivational interviewing and use a cognitive approach to treatment. Motivational interviewing continues throughout treatment. The clinic takes a trauma-informed approach to trauma treatment but does not actively treat trauma.

Question 4: How have changes in reimbursement policy affected the provision of services? Have reimbursement policy changes expanded retention in treatment?

Site Information

Within the MSBI Gouverneur Clinic, 85 percent of patients are covered by Medicaid. Methadone treatment is reimbursed at a per-service rate, set by the state on the basis of type of service, frequency, and so forth, for Ambulatory Patient Groups (APGs). The rest of the patients are self-paying, on a self-pay scale based on salary. Commercial insurance is starting to cover treatment, so patients are starting to use that. The MSBI Gouverneur Clinic gets deficit funding from the State of New York. The clinic is primarily an OTP but provides buprenorphine for a small number of patients. Staff members report that patients typically do not want buprenorphine, on the basis of their experience using buprenorphine on the street. Those on buprenorphine usually will see a physician in an office, and "do not want to be engaged in treatment."

OTPs are not part of value-based purchasing in New York. They are reimbursed through APG categories. In 2015, reimbursements went from a bundled rate to a per-service rate. The state determined what services could be provided and how much should be reimbursed on the basis of types of service, frequency, and so forth.

Additional Key Information From Visit

  • The MSBI Gouverneur Clinic is participating in a Hepatitis C initiative research project.

    • Because it is such a large organization, the clinic often is asked to participate in research projects.

    • The clinic was selected to participate in a University of Buffalo Patient-Centered Outcomes Research Institute grant using telemedicine for Hepatitis C treatment.

      • Many patients have not been treated well in other areas of health care because of stigma around being in MAT, and this grant program is an effort to bring Hepatitis C treatment to them. Some patients are being referred out for Hepatitis C treatment, and some are doing telemedicine at the clinic. Then, the clinic obtains and administers the Hepatitis C medications with the methadone.

  • The clinic does not offer HIV treatment, but every patient is offered testing. There is an infectious disease clinic at the hospital. The clinic does not have a high percentage of HIV+ patients.



Site Name: Maryland Treatment Centers (MTC), Mountain Manor Treatment Center

Location: Baltimore, Maryland

Date Visited: July 9, 2019

Site Description

This SUD treatment and research center provides MAT via buprenorphine/buprenorphine-naloxone (including Sublocade) and long-acting injectable naltrexone (Vivitrol™) medications to people diagnosed with OUD. The program also provides treatment to people with other types of SUD, including those with SUDs related to benzodiazepines, cannabis, stimulants, methamphetamines, cocaine, and alcohol (AUD is particularly common among the older adults). It is offering naltrexone, disulfiram, and gabapentin for AUD. Most of its patients are on medication now, and it credits better public education and reduced stigma for that advancement. It has both for-profit and non-profit arms available to offer treatment to individuals, and it has a research division. Its patient base is about 80-85 percent Medicaid and 15 percent commercial insurance. It also has municipal and state grants to deliver treatment. The program acts as a community partner for Johns Hopkins, the University of Maryland, and other local universities, providing training on addiction for providers.

Its population consists of two subgroups. The young adult subpopulation tends to be whiter and more suburban that the adult population and tends to have more OUD diagnoses than the adult population, which is primarily African-American. However, MTC is finding that the average age of initiation for African-American individuals is dropping. Over time, it has seen its population become more acute (the less acute patients are being seen by other providers, and there is an abundance of providers in the area available to less acute patients).

Unique Aspects of the Site

  • Aspect #1: This site has started a home-delivery program for injectable extended-release Naltrexone (XR-NTX) and has done extensive research to understand the effectiveness of this approach for improving retention in treatment.

  • Aspect #2: This site recently began offering injectable extended-release buprenorphine (XR-Bupe) through its home-delivery program and has plans to conduct research to determine whether, like XR-NTX, the injectable buprenorphine formulation is also more effective at improving retention in treatment in this novel home-delivery intervention. The impact of the XR-Bupe may be different from XR-NTX because XR-Bupe tends to have a more immediate effect on patients than naltrexone, which can take more time to be felt.

  • Aspect #3: MTC is beginning to look at recovery housing as a mechanism for providing a needed structure to support outpatient treatment. It has found that much of the recovery housing available to patients currently is not supportive of the patient receiving medications, which can be a barrier to treatment, and it is often not developmentally specific or able to meet patients' age-appropriate needs (for example, recovery housing may not be supportive of young adults' romantic relationships). MTC is looking into opening its own recovery housing to overcome some of these barriers.

  • Aspect #4: MTC recently began a family advocacy group, which focuses on peer supports for parents and other family members of individuals with SUD. Parents who have lost a child provide support to other parents who have a child or other family member with SUD, and they also provide advice and coaching to help keep other parents from suffering a similar fate.

Information on Study Research Questions

Question 1: What variables affect retention in SUD treatment across disorders? How have these changed with the evolution of drug use patterns?

Site Information

  • Age. MTC reported that all treatment is more efficacious for older adults because they tend to be more engaged in it. This happens for a variety of reasons: young people do not have subjective self-recognition of impairment, they have not encountered many social barriers, they have not suffered as much as older people coming to treatment, there are safety-nets for them, they can be more ambivalent toward consequences, sometimes they are still receiving positive reinforcement from drug usage, they are not as motivated for help, they are pre-contemplative, people give them more room to have delinquent or deviant behavior, experimentation is normative, and parents do not know how to proactively address drug usage and boundary pushing. The Medical Director also mentioned that there is some normative tension between kids and their parents that is exacerbated in a treatment situation; there is a struggle for control between young adult children and their parents.

  • Patient motivation and how it is leveraged. MTC reported that people often come to treatment because they find themselves in a "crisis-driven moment" (e.g., they are going through withdrawal, they become homeless, they have a crisis with a loved one that brings them to treatment). MTC's challenge is how to leverage that touchpoint in order to motivate and engage the patient in sustained treatment. For example, it may start the patient on buprenorphine and engage the patient in the development of a treatment plan to leverage the touchpoint.

    • Motivational barriers to naltrexone include stigma, ambivalence about the treatment, side effects of the medication or a preference for a different medication (the effect of naltrexone is not as quick as buprenorphine), and that all medications may be a reminder that a patient is sick, which is not always appreciated.

  • Retention in treatment. Retention in treatment may produce further retention in treatment. Engagement and therapeutic alliance tend to be reinforcing of help-seeking. The more symptom relief a person experiences, the more a person is retained. On the other hand, once a person experiences symptom relief, the person may have an overconfident sense of "being fixed," with reduced motivation for further care.

  • Proper social support and a supportive environment. As reported in Aspect #3 above, MTC reported that recovery housing can be helpful to the point that it offers patients housing and a new and different environment to begin engaging in treatment. (However, the way that recovery housing is implemented and overseen is not always helpful). Another step that MTC takes to improve retention in treatment is to identify "locators" at the first touch of treatment. Locators are people who can be contacted to help MTC get back in touch with a patient, if needed.

  • Flexibility. MTC has found that there is a population of people who cannot accept the high-intensity treatment for which the system is built (e.g., 10 hours per week of IOP group therapy). For example, patients may need a more individualized or flexible touch than group therapy can provide. In general, MTC emphasized that flexibility and being able to "meet patients where they are at" is important to improving retention in treatment. Counseling also has become more flexible over time as MTC recognizes the need to "meet patients where they are at" instead of trying to get them to fit a preprescribed model.

  • Social determinants. Social determinants that may negatively affect retention in care include lack of stable housing, poverty, sex trafficking, and being a young parent.

Question 2: What are evidence-based methods to address treatment retention in SUD treatment, and how do these apply to treatment of OUD?

Site Information

Evidence-Based Methods

  • MTC has done substantial research on the use of XR-NTX delivered through a home-delivery model, and it is finding statistically significant drops in OUD use over a 6-month period for people engaging in this model of treatment over "usual care."

  • MTC also suspects that medications such as buprenorphine have pharmacologic properties that might encourage retention in treatment because the effects are immediately felt by the patient. This type of effect does not exist with medications for other types of SUDs, and it is not as immediate with naltrexone.

  • MTC also offers motivational incentives (money) for medication adherence specific to the naltrexone initiative (and will be adding these incentives for XR-Bupe), with increased amounts tied to longer retention.

Other Insights Supporting Retention

  • This site believes in a flexible, individualized, and responsive approach to SUD treatment, including the development of a "contract" between the site, the person in treatment, and the person's family members at the first touch for treatment. The contract is then a tool to sustain relationship-building and try to make everyone feel included and supported. It is flexible and tries to be responsive to the individual's treatment needs. The site also uses relatives/family as "locators" to help it remain in contact with the person who needs treatment, and it believes in a high-touch model. MTC said that keeping care out in the open is very important. The family and the patient should be aware of recommended medications and involved in the treatment. The patient and the family also should be aware of the consequences when treatment is not adhered to.

How Do SUD Practices Apply to OUD?

  • MTC emphasized that OUD is different from some other SUD treatment in that it is more urgent. With OUD treatment, the provider does not have the luxury of learning from its mistakes and patients do not hit rock bottom before they start getting better. If you let them hit rock bottom, they will die.

Question 3: Are there promising models of psychosocial support that assist in maintaining an individual in MAT for OUD? Do longer, more continuous durations of treatment result in better outcomes?

Site Information

  • In response to this question specifically, MTC emphasized the importance of helping patients with something else in their life that they want help with--whether it be some sort of personal crisis, family issue, or another problem. This shows patients that MTC can be helpful and helps MTC build a relationship with them.

  • MTC does use motivational interviewing, particularly before a patient is ready to change. Once a patient has committed to a plan of change, there is a shift to more directive behavioral approaches (e.g., the patient-family-provider "contract"). MTC emphasized the need for the psychosocial model to be responsive to the needs of the patient. It offers a flexible approach instead of the structured approach typically offered in group therapy and mentioned the importance of emails, calls, and Facebook messages in particular for its population. Its focus is on leveraging the power of the family member or loved one to retain the person in treatment. MTC talked about how it is using group texts, which include the family member in order to continuously try to engage the member in treatment.

Question 4: How have changes in reimbursement policy impacted the provision of services? Have reimbursement policy changes expanded retention in treatment?

Site Information

  • There have not been specific reimbursement changes that were mentioned, but the site would like to see reimbursement become more flexible to support effective treatment. MTC mentioned that much of what is important to offer is not reimbursed (i.e., high-touch case management, treatment supervision, and outcomes monitoring). MTC also would like to see a pay-for-performance or value-based payment model that pays for outcomes and quality instead of the FFS model under which it is currently reimbursed, which offers the wrong incentives. Much of the naltrexone pilot is grant funded, allowing MTC to provide these supports.

Question 5: What types of settings have seen success in implementation of SUD treatment retention methods, and how do they structure their programs? Have these methods been specifically applied to MAT for OUD, and are these programs structured differently?

Site Information

  • MTC is having a lot of success with its home-delivery of naltrexone program, as described above. This effort targets the OUD population. MTC currently also is looking at the relative effect of home-delivered Sublocade.

Additional Key Information From Visit

  • Provider barriers to administration of naltrexone include that it is more expensive than other MAT, the patient needs to be past withdrawal, and logistical challenges (including needing to have the right resources at the right time; for example, MTC must order the naltrexone, and it takes time to be delivered).

  • Dr. Fishman felt that another pharmacological property of OUD medications that may make them more effective than other SUD medications is that they are "blockers." The patient may feel that "on this medication, I am blocked and I can't get high," which may inhibit them from trying to get high. This is particularly true with XR-NTX, an opioid antagonist.

  • MTC's research and data show that the "treatment as usual" group does particularly poorly, especially in the transition from residential care to an outpatient program. Most patients do not make it from a residential program to a sustained outpatient level of care, and those who do pre-determined that he/she wants outpatient treatment. Most patients discharging from residential treatment are ambivalent about a sustained course of outpatient treatment. At a policy level, MTC feels that this needs to be addressed--there needs to be a more effective bridge from residential care to outpatient treatment.



Site Name: Central City Concern (CCC)

Location: Portland, Oregon

Date Visited: August 14, 2019

Site Description

Central City Concern (CCC) is a multifaceted social service agency that includes SUD treatment, mental health treatment, two federally qualified health centers (FQHCs), and housing and employment services. Close to 90 percent of its client population is homeless. Nearly everyone CCC works with is at or below 200 percent of the Federal Poverty Level. CCC clients are predominantly older and male, although it treats a variety of ages. CCC also offers treatment for pregnant people. The SUD treatment includes the Hooper Detoxification Stabilization Center (Hooper) (Level 3.7, 18 women's beds and 42-45 men's beds), with a bridge program for individuals they cannot place into treatment elsewhere as quickly as needed; IOP services (Level 2); and other outpatient services (Level 1), including MAT for OUD, primarily using buprenorphine, and for AUD. The Letty Owings Center includes 29 beds for women, provides MAT, and allows children under age 5 years to be there with their mother. CCC has domestic violence and driving under the influence programs as part of its SUD treatment. CCC also operates a sobering program in collaboration with the Portland Police Bureau and a Recuperative Care Program with 18 short-term beds for highly acute individuals in need of physical care. The FQHC locations are the Old Town Clinic (OTC) and the new Blackburn Center, the latter of which makes all services available in one building. Both are part of the Healthcare for the Homeless FQHC program. The OTC has an onsite pharmacy and the ability to treat HIV, Hepatitis C, and chronic pain. Housing services include both transitional housing and permanent supportive housing, with approximately 2,400 units, comprising both recovery housing (clean and sober) and low-barrier housing (Housing First). The philosophy of the housing services program is to offer people choices between abstinence-only and low-barrier housing. The employment services program serves between 1,700 and 1,900 individuals a year.

Unique Aspects of the Site

  • The Hooper bridge clinic was created to bridge needed medication or other services for individuals completing treatment at Hooper when some portion of services are not immediately available. It is based on a model pioneered at Massachusetts General Hospital. Previously, people would come to Hooper for withdrawal management, using buprenorphine to get through withdrawal and then be tapered off. It is now maintaining people on buprenorphine and using the bridge clinic to do so where necessary. Individuals can come into the waiting room in the morning for treatment and receive buprenorphine that afternoon or later. If an individual decides to leave, CCC will offer a bridge prescription for a few days. People can stay in the bridge program until needed services are available, subject to insurance coverage limitations. Some have stayed for many months. It was noted that it once took 11 months to obtain needed services for someone at a VA treatment facility.

    Hooper shared retention data from January 2019-July 2019. Of 561 clients with a primary diagnosis of OUD served in that time, 361 (64 percent) completed admission and 188 (34 percent) had at least one completed bridge clinic visit. Hooper used referral tracking for a subset (179) who discharged on buprenorphine maintenance with a follow-up appointment scheduled. Among this subset, 68 percent were engaged in treatment at 7 days and 56 percent at 30 days after discharge from Hooper. Of the subset, 93 percent were discharged to supportive housing and 7 percent were homeless. In that subset, 32 percent were in treatment at CCC, 23 percent went to another large Portland treatment provider (11 percent to the OTP and 12 percent for outpatient treatment). Another 37 percent went to a for-profit buprenorphine provider in Portland. The remainder were in treatment in other settings.

  • CCC offers an integrated set of services, including behavioral health treatment, physical health treatment, and housing and employment services. Until recently, for a client to engage in the variety of services CCC offers, the client may have needed to move between CCC locations across the Portland area. In July, CCC opened the Blackburn Center, which has 300 beds, 60 of which are set aside for Hooper clients. The beds are being filled gradually as the center gets off the ground. A care coordinator at Hooper indicated that the clients she has sent to Blackburn are doing well--they are set up with a PCP and an intake appointment, a mental health appointment, an SUD appointment, and a medication appointment. She can send people to Blackburn with a bridge prescription, and they have all their services taken care of in house. Then clients can come back for the bridge clinic to obtain one more prescription. Out of the 38 or so clients she has sent to Blackburn so far, only one has come back for detoxification treatment.

Information on Study Research Questions

Question 1: What variables affect retention in SUD treatment across disorders? How have these changed with the evolution of drug use patterns?

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Being homeless negatively affects retention, as does inability to access needed care. CCC, in conjunction with the Portland Police Bureau, operates a sobering center that CCC struggles to connect to the rest of its care continuum. Seventy percent of those admitted complete the program, but of those, 15-20 clients a week are discharged with no path to housing or access to care. The most recent Point in Time count found that Portland had 2,900 people sleeping outside, 1,800 of whom were chronically homeless. This capacity issue is regional.

CCC has found that the introduction of buprenorphine into the Hooper facility increased the rate of those leaving stabilized from 1 percent to 70 percent.

Polysubstance use along with opioids is common in the population CCC treats, including alcohol, methamphetamine, cannabis, and benzodiazepine use. SUDs that are not treated with medications can be more difficult to treat, impeding retention.

The most difficult clients to retain in SUD treatment are those with mental health issues or substance-induced mental health issues.

If clients obtain employment that includes health insurance, they sometimes lose the ability to use buprenorphine or naltrexone because some commercial insurance does not pay for it.

The CJS has been slow to embrace buprenorphine or naltrexone treatment for the incarcerated, resulting in people who are in treatment going through painful withdrawal upon entry into jail or prison. Multnomah County is planning to try to continue methadone and buprenorphine for those who enter the system already in treatment. It is now allowing people to be released with naloxone after a series of overdoses immediately postrelease.

Many of CCC's clients do not have reliable phones and can be difficult to contact to ensure that they come to treatment. Many have to bring their children with them to treatment because they lack childcare, which CCC does not offer.

Question 2: What are evidence-based methods to address treatment retention in SUD treatment, and how do these apply to treatment of OUD?

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Some general practices that are believed to help with retention include the following:

  • CCC uses peers and certified recovery mentors with lived experience in the treatment and housing programs. Becoming a peer employed by CCC requires 2 years of abstinence (many are former clients). Becoming a mentor requires 2 years of relevant experience or certification, which takes up to 2 years. CCC conducts internal training and funds part of the activities needed for training and certification.

  • People are allowed in treatment if they are using benzodiazepines. CCC does not prescribe benzodiazepines (other than as part of the alcohol withdrawal protocol at Hooper) but does not keep people out of treatment as a result of use.

  • CCC keeps people when they relapse but helps them get into a higher level of care.

  • CCC avoids doing things that foster shame when someone relapses, and if someone leaves, it has a low-barrier to re-entry.

  • CCC will provide medication continuity for up to 30 days if someone has to leave for another provider.

  • No matter where someone is being seen on a given day at CCC, it seems that the staff uses that as an opportunity to help steer the client toward the client's next meeting.

  • Where it makes sense, CCC provides home induction of buprenorphine.

  • CCC allows walk-in physical or behavioral health appointments, allowing prompt receipt of buprenorphine, and sets a plan for follow-up within 48-72 hours.

At Hooper, the following practices are believed to be helping retention:

  • If there is no place to send someone after Hooper, CCC can: (1) create a medication plan and maintain continuity of medication; (2) vary the amount of buprenorphine supplied by how much support a person needs and has on the outside; (3) allow the person to come in as needed and obtain the medication; and/or (4) set up a PCP appointment at the OTC or Blackburn FQHCs with a bridge prescription until the PCP can see the person.

  • At the Hooper bridge clinic, CCC tracks clients through regular meetings, care coordination, and case management; this allows it to triple the rate of placements from the bridge program.

At the OTC:

  • It is now overbooking appointments because it typically has a 30 percent no-show rate. This allows the OTC flexibility to take walk-ins.

  • The embedded SUD treatment providers:

    • See people 3 days a week when they begin buprenorphine treatment at the OTC.

    • Maintain an open-door policy.

    • Conduct hands-on coordination with other programs.

In the housing program, the following practices have helped with retention:

  • The addition of MAT to housing services helps people stabilize and engage. Traditionally, the housing services were abstinence focused, and MAT use was not considered abstinence.

  • It holds a bed if someone is in jail for less than 30 days; otherwise, it tries to expedite services when someone returns.

  • The housing program holds regular meetings and sends daily rosters within the organization.

Question 3: Are there promising models of psychosocial support that assist in maintaining an individual in MAT for OUD? Do longer, more continuous durations of treatment result in better outcomes?

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As a general matter, CCC requires that individuals be in psychosocial treatment at the Hooper facility to receive buprenorphine as well as in other parts of its care continuum such as housing services. This policy was one reason that CCC opened the bridge clinic at Hooper, to provide a way to meet the need for both those services and buprenorphine delivery until clients can receive treatment in the community. The new Blackburn Center, which is a fully integrated service delivery facility, is encouraging but not mandating psychosocial treatment. The SUD outpatient treatment team integrated into the OTC uses, among other things, motivational interviewing to retain and encourage participation in treatment. Warm hand-offs and an open-door policy also help in that regard. A consistent theme from different people we spoke with was that meeting clients "where they are at" is critical. The facilities incorporate both 12-step and evidence-based approaches.

Related to the topic of psychosocial treatment (as well as medication), a substantial portion of the CCC client population (currently about 740 individuals) has mental health treatment needs in addition to SUD needs. It can be difficult to get clients rapidly into mental health treatment, both because of a shortage of providers and because some providers, including area psychiatric hospitals, turn them away, attributing their symptoms to SUD rather than mental illness. At Hooper, it was estimated that 20 percent come in with a psychotic or bipolar disorder and about 50 percent have another affective disorder. Only about 30 percent do not have some sort of mental disorder. CCC can restart medication at Hooper, but if someone has acute mania or other serious symptoms, it can interfere with the treatment of others. To address the population of chronically homeless people with co-occurring mental health, SUD, and/or physical concerns, it operates the Community Engagement Program (CEP), a multidisciplinary recovery model. CEP services include recovery mentors/case managers, dual diagnosis case managers, social workers, nurse practitioners, acupuncturists, benefits and employment specialists, housing specialists, and a PCP. A program brochure indicates that, for the more than 200 people in the program, 99 percent remained in housing 1 year after enrollment.

CCC offers culturally specific programming. This includes the Puentes program for the Portland Latinx community, which has staff that are bilingual and bicultural, and the Imani Center, which offers Afrocentric and trauma-informed approaches to mental health, SUD treatment, peer support, and case management.

CCC has clinical counselors who can conduct an ASAM assessment within 24 hours.

Question 4: How have changes in reimbursement policy impacted the provision of services? Have reimbursement policy changes expanded retention in treatment?

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CCC is paid a case rate by the Oregon Medicaid Coordinated Care Organization (CCO) for its area. Its CCO does not require prior authorization for buprenorphine treatment, but some other CCOs do, making treatment of people from elsewhere in Oregon more difficult. One area that is not reimbursed is outreach and engagement, and it was pointed out that being reimbursed for these activities could help with getting people into needed treatment. CCC pays for outreach as overhead. Other areas where additional reimbursement would be helpful might include: (1) for services provided during the first month of treatment when people need additional support; (2) for the housing supports that help get people into housing and help them retain it (which are not reimbursed by Medicaid, although Oregon is applying for an 1115 waiver to include this in the services that can be reimbursed); and (3) for complex cases (e.g., where CCC must undertake dual assessments for benzodiazepines and opioids and use dual treatment protocols for withdrawal [approximately 28 percent of current clients]). It was noted that a case rate at, for instance, the Hooper facility, has the perverse incentive of encouraging stays past midnight but no longer than that, because the same amount is paid once midnight passes, regardless of the length of stay. This reimbursement incentive does not cause CCC to reduce stays, but longer stays do reduce net income. Because buprenorphine maintenance was added to Hooper, the percentage of those leaving against medical advice has dropped from 70 percent to 30 percent. People are being stabilized, and that requires longer stays, which result in a reduced bottom line. For people who opt to taper rather than remain on buprenorphine, the case rate incentivizes more rapid tapering, which may undermine recovery. CCC does not taper more rapidly as a result, but this practice also negatively affects net income. For example, the process of connecting a homeless person who has OUD and psychosis to all the needed supports within CCC takes far longer than simply stabilizing the person with buprenorphine and discharging them, although greater reimbursement is not given for CCC's greater effort. CCC has many clients with this level of complexity.

Question 5: What types of settings have seen success in implementation of SUD treatment retention methods, and how do they structure their programs? Have these methods been specifically applied to MAT for OUD, and are these programs structured differently?

Site Information

CCC is a multifaceted service provider that can offer a variety of services and supports that address physical and behavioral health treatment needs, as well as housing and employment services that help address social determinants of health. This allows the creation of a recovery environment.

Additional Key Information From Visit

  • Despite the size and scope of the CCC programs, resources still are limited. Wait times can be challenging for receipt of physical or mental health care, as well as some necessary SUD treatment on the treatment continuum (e.g., intensive SUD treatment). One concrete example involves the need for additional withdrawal management services. Hooper is one of three such facilities in Portland. Hooper served 250 people in July. The demand is so great, however, that it also had to turn away another 250 during that month. Other such programs in the area tend to be smaller and do not treat people on benzodiazepines, nor do they treat pregnant people. Another example involves the Hooper bridge program and the sobering station where they often must discharge people to the street because no housing is available in the area.

  • CCC maintains data related to medication possession ratio (MPR) as an indicator of MAT retention. For the period between February 2018 and January 2019, approximately two-thirds of clients in its OTC had an MPR greater than 0.75 with engagement longer than 30 days. For the same period, in the CEP program, MAT initiation rates were 91 percent, while 55 percent had an MPR greater than 0.75 with engagement longer than 30 days. Also, in the CEP cohort, another 25 percent had engagement longer than 30 days with a moderate MPR of 0.5 to 0.74.

  • CCC has made major progress in the past few years in adopting MAT throughout its services, including housing, all of which were formerly 12-step and abstinence focused.

  • It was noted that compliance with 42 Code of Federal Regulations Part 2 can impede care coordination within CCC and with other providers.