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Colorado Consortium for Prescription Drug Abuse Prevention
Treatment Work Group Meeting MinutesMay 21, 2015
PRESENT
Paula Riggs, MD, UC Denver School of Medicine
Denise Vincioni, Department of Human Services, Office of Behavioral Health Steven Wright, MD, Porter Primary Care
Mancia Ko, Ameritox
Mary Weber RN UC School of Nursing
Katie Wells, Department of Human Services, Office of Behavioral Health Vanessa Fewell, Health District of Northern Larimer County
Rob Valuck, PhD, Skaggs School of Pharmacy; Rosemarie MacDowell, Skaggs School of Pharmacy Guest Presenters:
Mary Hoefler, OBH
Mary Ciambelli, President, Colorado Nurses Association
Angela Bonaguidi,
LCSW, LAC Director of Adult Outpatient, Addiction Research and Treatment Services
(ARTS), University of Colorado at Denver
ABSENT
Lynn Parry, MD, Colorado Medical Society, Marc Condojani, Department of Human Services, Office of Behavioral Health, Emily Schrader, Behavioral Healthcare, Inc., Joanna Martinson, RN, North Colorado Health Alliance; Ellen Price, DO, Mesa County Medical Society; Alia Al-Tayyib, PhD, MSPH, Denver Public Health; Emily Cheshire, Sheridan Health Services.; Jennifer Ziouras, MD, Regional Chief of Internal Medicine, Kaiser Permanente of Colorado; Sania Celio, King Soopers; Paul Scudo, University of Colorado Hospital/CeDAR; Lisa Clements, Department of Human services, Office of Behavioral Health; Art Schut, MD, Arapahoe House; Connie Valdez, PharmD, University of Colorado School of Pharmacy; Joseph Sakai, MD, University of Colorado School of Medicine, ARTS Program; Gretchen Read, Denver Department of Human Services, Child Welfare; Clark Lyda, PharmD, University of Colorado Hospital; Patrick Fox, MD, Interim Director, Office of Behavioral Health; Frank Cornelia, Colorado Behavioral Healthcare Council (CBHC); David Blake, Colorado Attorney General’s Office; Matthew Durkin, Colorado Attorney General’s Office; Stephanie Menke, University of Colorado School of Medicine, ARTS Program; Judith Miller, PhD, Addiction Recovery Treatment Provider; Ken Summers, Colorado House of Representatives; Lisa Raville, Harm Reduction Action Center (HRAC); Irene Lobato, King Soopers; Bob Sammons, MD, PhD, Mesa County Medical Society; David Rogers, RPh, PharmD, Director of Pharmacy
Operations, Safeway Denver Division; Zach Pierce, Colorado Attorney General’s Office, Mark Queirolo, Department of Health Care Policy and Financing, Aaron Miller, Program Manager, CO Alliance for Drug Endangered Children; Whit Oyler, SAMHSA/CSAP Fellow; Carolyn Swenson, Peer Assistance Services
NEXT TREATMENT WORK GROUP MEETING
Thursday, June 18, 2015, from 2:00-3:30 p.m. via GoToMeeting (meeting cancelled 6/15/15) The meeting was called to order by Paula Riggs, Co-Chair, at 2:00 p.m.
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1. UPDATE ON COLORADO MENTAL HEALTH CRISIS LINE (MARY HOEFLER): Paula introduced Mary Hoefler, Director of Colorado Crisis Services. Paula indicated that barriers to treatment have been due, in part, to issues related to the lack of a centralized portal or access to care. Mary reported that the crisis line has been
functioning well and crisis line staff have addiction treatment referral resources. However, she and Denise Vincioni have not yet been able to set up a face-to-face meeting for Denise to specifically train crisis line staff in assessment, triage, and addiction treatment referral.
Mary reported that crisis line staff does not currently track data on inquiries about treatment for prescription opiate abuse. She said that the crisis line currently has a “dashboard” that tracks how quickly calls are
answered (currently between 6 – 8 seconds) and length of calls (currently about 10 minutes/call, consistent with similar national crisis lines). Calls are also categorized (e.g. grief, alcohol-related) and whether or not any
services are provided during the call. Crisis line staff routinely ask for permission to follow up, which is voluntary on the part of caller. She indicated that most of the 5,700 calls received between August and December 2014 have been categorized as consultation calls and 2,600 treatment referrals. She said that crisis line staff also keep a record of follow-up calls and document where the caller is referred. The caller can also initiate follow-up steps if the caller provides permission. There were 4,400 follow-up calls between August – December 2014. Mary did not have a list of additional data tracked by crisis line staff. However, she offered to provide a list to Denise Vincioni who can report to the Treatment Work Group for review. Mary added that she and crisis line leadership would be open to suggestions from the Treatment Work Group regarding additional data that would be helpful to track (e.g. proportion of callers inquiring about prescription opiate treatment resources and outcomes regarding the number who follow through and/or are successful in accessing treatment based on crisis line recommendations).
Paula asked for clarification about what constitutes a “consultation” and other services rendered by crisis line staff. Mary responded that consultations could address a number of issues (e.g. law enforcement on the scene regarding what course of action they should take regarding an individual they are dealing with). Mary said she would have to look into it further to find out more about the nature of consultations. Regarding services offered, Mary reported that these could fall into multiple categories. The caller may also be referred to a walk-in center. Services might also walk-include treatment referral. Denise said she will be able to determwalk-ine the
breakdown once she can connect with the hot line personnel.
All clinicians answering phones have Master’s degrees. Some are licensed or are in the process of obtaining their licenses. There is also a “warm line” with trained peer specialists answering 30 percent of calls. This line provides support rather than clinical intervention and is open from 9 a.m. to 11 p.m. It has proven very helpful for those in crisis.
Steve Wright: Felt it would be useful to have data distinguishing prescription drug or heroin abuse so that a trend could be tracked. He also expressed concern about the nature of referrals as some decisions have to be made based on medical assessment of the patient. In his practice, he has a face-to-face with patients before determining the appropriate treatment recommendation or referral. The patient or a referring clinician doesn’t always know what the patient might require.
Mary responded, saying that the Master’s level clinicians staffing the crisis line are trained to respond in ways that do not require medical decision-making. For example they can refer patients to a methadone clinic for assessment by a clinic physician who can then determine the appropriate level of care and/or medical treatment.
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Steve: He would prefer to see treatment options rather than methadone maintenance and any decision regarding maintenance should be based on a medical decision.
Mary added that all “methadone calls” go to Denise Vincioni and this information is tracked by the crisis line dashboard.
Mary: This information can be provided, but would require that Denise follow up with them. It would also require changes to the tracking system and any change is not instantaneous. The first step towards this goal is for Mary to meet with Denise, Sherry, and Bev to ascertain what is currently being collected.
Denise: We hope to have this meeting within the next couple of weeks.
ACTION ITEM -- Paula: Requested that Denise provide an update to the work group after the above-mentioned meeting occurs. Denise said that she could prepare a report by the next meeting in June. This item will be added to the June 18th meeting agenda.
2. INTRODUCTION OF NEW WORK GROUP MEMBERS:
Introduction of new Treatment Work Group members was deferred as Mary Hoefler provided her presentation at the beginning of the meeting due to her time constraints. Paula introduced the following new Treatment Work Group members: Mary Weber RN, Professor, UC School of Nursing, and Candi Ader with Millenium Health, who was not able to join the call.
3. FOLLOW UP ON ACTION ITEMS FROM PREVIOUS WORK GROUP CALL
The Consortium requested Treatment Work Group recommendations regarding what should be listed on the Consortium’s website to facilitate linking patients with appropriate treatment if requested. In light of significant improvements to LinkingCare.org (by Omni Group), there was consensus that LinkingCare.org be posted on the Consortium’s website as a treatment resource. Dr. Wright expressed concern that LinkingCare.org does not include individual providers for patients with chronic pain and/or prescription opiate abuse/dependence. Group discussion raised concerns that listing individual clinicians/providers could be construed as a mechanism for clinicians to “advertise” and increase referrals. A second concern is the lack of a feasible mechanism for properly vetting individual clinicians/providers as well as concerns about potential legal liability. For these reasons, it was decided that individual providers/clinicians should not be listed on the Consortium’s website. However, there was considerable agreement that treatment referral options need to be broader than those available through LinkingCare.org (e.g. a Medicaid provider list? Crisis Line? NAVID?)
ACTION ITEM -- further discussion of other mechanisms to link patients to providers not accessible through LinkingCare.org and consideration of listing self-help groups such as NA, Pills Anonymous is warranted and deferred to the next Work Group meeting.
4. BARRIERS TO ACCESS AND TREATMENT AVAILABILITY FOR PATIENTS WITH RX AND OTHER OPIATE USE DISORDERS
• Presentation by Angela Bonaguidi, ARTS Outpatient Treatment — Paula invited Angela Bonaguidi, Director of ARTS Outpatient Treatment programs to briefly present on barriers to treatment of patients with opiate use disorders from a community based treatment program perspective. Ms. Bonaguidi
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identified a number of issues that are both barriers and opportunities for positive change in the context of health care reforms/Affordable Care Act including:
o Low level of Medicaid reimbursement for treatment of patients with opiate use disorders o Clinical workforce shortage—the clinical workforce and medication assisted therapy (MAT)
could be significantly expanded by allowing RNPs and PAs to provide MAT and do initial medical evaluations of opiate dependent patients for whom buprenorphine/methadone treatment is appropriate or clinically indicated. OBH rules/policies/procedures are more restrictive than federal law allows. A number of other states have adopted more flexible workforce rules that allow RNPs and Physician’s Assistants to provide clinical services that are currently restricted to MDs only in Colorado. (See attached copy of Ms. Bonaguidi’s presentation for additional details.)
• In the group discussion following Ms. Bonaguidi’s presentation, Denise responded that historically Colorado has not included RNPs and PAs because changes in regulations would impact other areas such as Acute Treatment Units and Regulation 2765 (people held against their will). However, she added that OBH is now open to greater flexibility in these regulations based on stakeholder feedback. Denise added that treatment programs can currently request a waiver to enable mid-level medical practitioners greater involvement in doing intake medical assessments and MAT for patients seeking treatment for opiate use disorders. Paula added that current restrictions appear to have had the unintended consequence of contributing to the clinical workforce shortage in treating opiate use disorders in Colorado. Mary Weber, Professor at UC School of Nursing and Mary Ciambelli, President of Colorado Nurses Association, also voiced strong support for broadening existing regulations to allow RNPs and PAs to have a more meaningful role in MAT/medical treatment of patients with opiate use disorders. They also asked to be added to the stakeholders list to be notified of upcoming stakeholder meetings.
5. UPDATES FROM OBH (Denise Vincioni)
a. Denise said a number of changes have been made or are underway at OBH with the recent appointment of new OBH Director, Nancy Vandermark.
b. The SAMHSA treatment medication grant was submitted May 8th. If awarded ($950,000), the grant will provide much needed additional resources to expand opiate treatment services, especially in areas of the state with unmet needs (e.g. rural areas). She mentioned that mobile units may be used to provide such services in areas with critical workforce shortages and /or lack of available treatment for patients with opiate use disorders. If funded, additional resources will also be allocated to expand case management capabilities. .
c. Preliminary results of OBH’s survey of suboxone-licensed physicians indicate that fewer than 50% of such clinicians are currently providing treatment/MAT for patients with OUD and the vast majority who are in practice do not accept Medicaid.
d. Steve reiterated that current Medicaid reimbursements do not cover actual costs for providing treatment (chronic pain/addiction) for patients with prescription or other opiate use disorders. If reimbursement remains inadequate, then nothing else will fall into place. He added that, in his own practice, he must limit Medicaid clients to only 5% to maintain financial viability. He added that more innovative approaches, such as monthly fees versus the existing “fee for service” model, could also potentially increase the physician workforce providers. He also said that to achieve financial viability, Medicaid fee-for-service reimbursements would need to be more in the range of $120-150 per visit
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ACTION ITEM – Follow-up discussion of these issues and an update on the scheduling of the OBH stakeholders meeting will be continued at the next Work Group Meeting on June 18th.
