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Opioid Management via Group Visits @ Boston Medical Center

Keywords: Opioid, MAT, Groups

Overview

Group visits combining behavioral health therapy and pharmacologic support for patients with substance/opioid use disorder with an emphasis on community support and accountability.

Innovators

Marielle Baldwin MD MPH
Shari Zakim-Yacouby LICSW
Beth Marx MSW, LICSW
Huong Tran MD
Tu-Mai Tran MD
Krystyna Roszczenko, Team Coordinator

Editor

Arambi Eyong

Location

Boston Medical Center Family Medicine Department, Boston, MA

Organizational Context

  • Boston Medical Center is a quarternary academic medical center in Boston, MA.
  •  It is the largest safety net hospital in the New England region.
  • Patients with PCPs in the Family Medicine Department come to the Family Care Buprenorphine/naloxone Group Visits 
  • For patients who are not yet established patients within Boston Medical Center departments, there are several parallel programs addressing addiction treatment open to the public
  •  One particular program called “Faster Paths,” which accepts walk-in patients, operates on an “urgent care”-like model and aims to stabilize patients with point-of-care buprenorphine/naloxone treatment or Vitriol treatment before referring patients to Boston Medical Center Family Medicine for longitudinal care
  • Similar buprenorphine/naloxone treatment group visits are also implemented within the Psychiatry Department
  • The leadership team sought to address a clear patient need within BMC that would supplement aforementioned programs in the Psychiatry Department as well as for walk-in patients. 

Population Served

  • 60% of BMC's patients have public insurance
  • 57% of patients are from underserved populations
  • 32% of patients do not speak English as a first language

Project Leadership

  •  Two physicians, two social workers, and a nurse manager.

Project Tools & Components

  • Structured group activity
  • Prescription distribution
  • Individual assessment protocols for group visits for patients

Training

  • There is currently no formalized system of training for this intervention.
  • Project leadership has engaged with courses offered through the BMC Internal Medicine Department’s Office Based Addiction Training (OBAT) program, a well-resourced, leading hospital-based program in addiction treatment training. 
    • OBAT online courses are accessible to providers across the state of Massachusetts. 

Daily Workflow Steps

Intake

  • Patients are referred to the team of buprenorphine/naloxone treatment group facilitators either by other BMC providers or by providers in the “Faster Paths” program (see above for description), which is located in the same clinic. Some patients self-refer and come to the clinic as new patients.
  •  At each patient’s initial appointment, a social worker conducts a behavioral health intake. This intake appointment includes a thorough social history, medical history, and substance use history. One of the primary purposes of the behavioral health intake is to determine whether the patient is appropriate for group visits or if they need more individualized care.
  • After the behavioral health intake is conducted, the social worker confers with the team to determine whether the new patient is a good candidate for group visits or if they need individual visits.
  • If a patient is deemed appropriate for group visits, an induction is scheduled for one or two days after the first visit with one of the physicians on the group visits team team. Induction includes starting the process of getting the patient on buprenorphine/naloxone treatment and scheduling the patient to start group visits.

Group Visits

  • Group Schedule: There are two hour-long group visits per week with 8-9 people in each group. The group visits are held on Monday and Wednesday afternoons. 
  • Arrival & Testing: On the day of group visits, patients typically arrive at 3pm and undergo urine toxicology testing. 
  • Check In: Each patient speaks to the group regarding their progress since the past group visit and touches on the following topics:
    • Sobriety
    • Taking treatment as prescribed
    • High risk encounters & interactions
  • Group Activity: After the check-in, patients engage in an activity developed by the group leader based on active issues for group participants. 
    • For example, the group talked about self-image and self-love during the Valentine’s Day session.
  • Prescription Disbursal: The RN on the team disburses prepared MAT prescriptions to patients. 
  • Discharge: After 3 months, patients who are stable and have consistently passed urine toxicology screening can be approved by the team to attend group visits every two weeks instead of on a weekly basis. 

Re-Evaluation:

  • Patients are re-evaluated every month afterward.
  • The team’s social workers and clinicians weigh each patient’s unique histories and pattern of behavior and past usage into their recommendations for meeting frequency.

Tech Involved

Epic

Team Members

  • Physician
  • Registered Nurse
  • Social Worker
  • Administrative Assistant

Budget

$0

  • The cost of this intervention to the clinic is not distinct from routine patient care 

Status

The intervention is currently ongoing

Outcomes

  • This intervention has contributed to increased patient satisfaction with encouraging anecdotal evidence of changes in patient behavior and substance use.
  • Several group participants are now experiencing their longest period of sobriety.
     

Unique Challenges

  • There is no current system of data collection to track changes in patient outcomes. 
  • Because the sample size is so small, it has been difficult to determine what kind of data collection would be useful.

Relevant Quality Metrics

2018 MIPS Quality Payment Program (QPP) Measures:
Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Relevant metrics include:

  • Documentation of Signed Opioid Agreement
    • All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record
  • Evaluation or Interview for Risk of Opioid Misuse
    • All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record
  • Opioid Therapy Follow-Up Evaluation
    • All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

More details about measures included in the QPP set can be found here.
 

Patient-Centered Medical Home Metrics:
Establishing a team-based opioid prescribing program may help practices meet a number of NCQA Patient Centered Medical Home 2017 Standards. Potential opportunities include standards such as:

  • KM04: Conducts behavioral health screenings and/or assessments using a standardized tool (such as for a substance use disorder)

More information can be found here.

HEDIS Measures:
A number of HEDIS measures added in 2018 relate to opioid prescribing, and may indicate how other programs will measure quality of care related to opioid prescribing in the future. Related HEDIS measures include:

  • Use of Opioids at High Dosage
  • Use of Opioids from Multiple Providers 

More information can be found here.

Direct Billing:
Depending on how the program is structured, practices may be able to bill Medicare or other insurers for screening, brief intervention and referral to treatment services. More information about billing Medicare for these services can be found here.

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