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How States Are Leveraging Payment to Improve the Delivery of SUD Services

Maryland’s Family Recovery Courts: Successfully Reuniting Families with the Help of Customized Substance Use Disorder Treatment

March 22, 2021/in Policy Maryland Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health /by Mia Antezzo

To reduce substance use as a key cause of children removed from their homes, Maryland implemented a Family Recovery Court program in 2004 that connects parents to intensive treatment for substance use disorder (SUD) and provides case management and incentives. Over a one-year period, program evaluations show the program produced a 25 percent higher reunification rate, reduced days that children spend in non-kinship foster care (252 vs. 346), and produced more than $1 million in savings for the state’s child protective system due to reduced foster care utilization.

Background

Substance use is a major contributing factor in child removals. The rate of removals associated with substance use rose nearly 20 percent between 2000 and 2016 and peaked at 36 percent in 2018 before falling slightly to 34 percent in 2019. To address substance use as a driver of children entering foster care, Maryland uses a Family Recovery Court (FRC) model that connects parents to intensive services, case management, and incentives – all emphasizing SUD treatment as an opportunity to support family reunification.

FRC is a civil court proceeding that works closely with the state’s child welfare/child protection system. Individuals are referred to the FRC when they interact with the judicial system because their abilities to parent have been impaired as a result of SUD. Parents participating in FRCs have an underlying child welfare case in civil family court, where they often face the threat of losing custody following allegations of neglect. Maryland’s FRCs recognize the chronic nature of SUD and that without support and treatment, parents with SUD may continue to struggle. Maryland’s successful model is centered around services and engagement that incentivize the safety, health, and stability of families.

Outcomes of Maryland’s Family Recovery Court Model:

Improved family reunification rates;
Fewer days in non-kinship care;
Increased treatment completion rates; and
Net savings for Maryland child welfare system

Establishing Family Recovery Courts

Maryland’s Code and Court Rules established a formal process for creating “problem-solving courts” that include FRCs. An administrative order from the Chief Judge of the Court of Appeals details the court’s process.

A county circuit court or district court judge is required to lead its development, which includes consulting with and receiving commitments from other government agencies that are willing to participate as partners in the problem-solving court.
Planning must establish community need indicated by SUD rates, child abuse/neglect cases related to parental SUD, rates of SUD treatment retention. The leaders outline program goals, protocols, and an estimated budget.

“The range of services available are so rich and so focused on getting at the source of the medical issue that is driving their use disorder. Not to simply achieve a period of negative urine analysis screenings, but to get to the core causes that will bring them to that ‘I’m done’ day.” – Maryland state official

Maryland established its first FRC in Harford County in 2004, followed by Baltimore City in 2005. Today, the state operates five such courts across the state. To standardize best practices and requirements across jurisdictions, the Maryland Office of Problem Solving Courts released Guidelines for Planning and Implementing Family/Dependency Drug Treatment Court Programs in 2017. These guidelines spell out the process of establishing a FRC, including programming details, target populations, the role of the judiciary, policy issues, and funding strategies.

Eligibility:Parents who participate in Maryland’s FRC programs do so voluntarily, understanding that family reunification is the goal of the program. Eligible participants include:

Parents of infants with positive screens for substances;
Parents with reported neglect;
Parents who maintain custody, but neglect is indicated through a petition; and
Parents who maintain custody following a court’s disposition.

Parents may be referred into the program by child protective services, public defenders, magistrates, and social workers.

Services: Parents participating in a Maryland FRC are provided with an immediate assessment followed by comprehensive SUD treatment services and intensive supports to stabilize the family unit. “The range of services available are so rich and so focused on getting at the source of the medical issue that is driving their use disorder,” noted one Maryland state official. “[The goal is] not to simply achieve a period of negative urine analysis screenings, but to get to the core causes that will bring them to that ‘I’m done’ day.” All parents undergo extensive intake by internal court case managers who develop personalized treatment plans. Plans are closely monitored by the court, which convenes weekly to review open cases and participant progress.

Through the FRC, parents can access:

Psycho-social supports, including counseling, as well as medication for opioid use disorder (MOUD) when clinically indicated;
Peer support;
Assistance in applying for Medicaid;
Linkages to housing and transportation;
Life skills training; and
Continued access to the staff and resources of the FRC to gain continued parenting and SUD support.

FRCs take an incentives-based approach that embraces the reality that SUD is a chronic relapsing disorder – it does not terminate parents from the program solely on the grounds of their return to substance use.

Funding/State Support: Maryland utilizes several funding sources to operate its FRCs. State grant funds from the Office of Problem-Solving Courts, within Maryland’s Administrative Office of the Court, are the primary source of financial support. These grants cover administrative, staffing, training, and drug testing costs, and some ancillary services. In recent years, the state legislature has reduced the judiciary’s budget, but exempted problem-solving courts from any reductions. In 2017, the state’s Heroin and Opioid Prevention Effort (HOPE) and Treatment Act included an ongoing, mandated an appropriation to fund drug courts, including FRCs. FRCs and the Office of Problem-Solving Courts also partner with the Department of Behavioral Health, Department of Social Services, and other agencies to fund and navigate services such as transportation and housing supports. Finally, health care services, such as in- and outpatient treatment, psycho-social therapy, and MOUD are covered by Maryland Medicaid for eligible participants.

Outcomes:While the core goal of this court model is to achieve residential permanency for children, Maryland’s FRCs seek to achieve the often more difficult goal of family reunification by emphasizing holistic rehabilitation. In addition to treatment adherence, parental skill development and engaged participation are critical to the program’s success, and meeting the requirements for graduation from the program can be challenging. As part of annual reporting, the Administrative Office of the Courts routinely reviews all problem-solving courts, including FRCs. The 2020 Annual Report to the legislature indicated that, after adjusting for participants who left for administrative reasons, an average of 19 percent of participants graduated across FRCs in the state; Baltimore County had the highest graduation rate at 34.5 percent.

An external evaluation covering one year in 2008 also showed:

A reunification rate of 70 percent for families participating in FRCs, as opposed to a 45 percent reunification rate among families who did not participate;
Fewer days spent in non-kinship foster care placement (252 days vs. 346 days)
A net savings of over $1 million for the state’s child protection system due to decreased utilization of the foster care; and
A treatment completion rate by participating parents of 64 percent, compared to 36 percent of non-FRP parents.

Further, one FRC in a small jurisdiction was closed as the result of positive outcomes that led to a lack of subsequent need in the community.

Key Takeaways

To establish an FRC in a state, Maryland officials recommend policymakers:

- Seek judicial leadership. Maryland’s Problem-Solving Courts are championed, developed, and supported by leadership within the judiciary, included judges across the state and from various levels of the state’s court system. Critical administrative funding, guidance, and enabling regulation flows from and is overseen by the judicial system, contributing to the program’s overall sustainability and success.
- Frontload a diverse and intensive array of services, and then maintain connections. State officials credit the program’s wraparound approach as an integral part of its success. Maryland’s FRCs provide case management services, short- and long-term family housing and transportation assistance, and employment preparation and life skills development. State leaders view the FRC as a lifelong program. FRCs employ parent locators who seek out FRC alumni and either re-engage them in treatment or encourage their participation in the program as peer support specialists. Parents may continue to receive services in the community after program completion.
Encourage cross-agency collaboration. Maryland’s FRCs and adult drug courts are administered by the Office of Problem-Solving Courts and share an oversight committee, which provides an opportunity for collaboration across criminal and civil dockets. This approach also requires coordination among systems and agencies – the courts work with social services, health and behavioral health/SUD providers, and housing and transportation services to align resources and policies to ensure that the necessary supports are in place to help parents and families remain unified, healthy, and safe.

The National Academy for State Health Policy is providing this fact sheet with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. The authors would also like to thank Richard Abbott, Director, Juvenile and Family Services, Gray Barton, Director, Problem Solving Courts, Lou Gieszl, Assistant State Court Administrator for Programs, and the Hon. Robert Kershaw, Associate Judge, Baltimore Circuit Court, for contributing their expertise and state experiences to this report.

State Policy Center for Opioid Use Disorder Treatment and Access

March 9, 2021/in Policy Featured News Home, NASHP News, Toolkits Behavioral/Mental Health and SUD, Chronic and Complex Populations, COVID-19, Featured Policy Home, Health Equity, Physical and Behavioral Health Integration, Population Health /by Jodi Manz and Kitty Purington

Medications for Opioid Use Disorder (MOUD) Provided in State Prisons, March 2021

March 4, 2021/in Opioid Center Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by NASHP Staff

How States Access and Deploy Data to Improve SUD Prevention, Treatment, and Recovery

January 29, 2021/in Policy Behavioral/Mental Health and SUD, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Quality and Measurement /by Kitty Purington and Jodi Manz

As state policymakers confront the substance use disorder (SUD) epidemic, they require a wide range of data – often found in disparate systems – to understand its impact and craft more effective treatment programs and interventions. This report explores best practices and sources for data gathering and describes how states can help communities access and use data to support local efforts.

Introduction

The nation’s substance use disorder (SUD) epidemic poses unique challenges for policymakers working to understand and apply data – which often exists in disparate systems – to guide their treatment and interventions. States, localities, and organizations need to access and generate reliable data, not just in health and behavioral health care, but in workforce, criminal justice, social services, and other systems to design successful SUD interventions.

This report describes the uses and limitations of commonly available data sets that can stand alone or be used in conjunction with other data to answer common questions posed by state and local leaders. The report reviews common data sources that can help state leaders address key issues, such as preventing SUD and diversion of controlled substances, supporting harm reduction, increasing treatment capacity and service delivery, and understanding the needs of vulnerable populations. The report also highlights best practices at the state level, and notes where state strategies can also assist communities in accessing and using data to support local efforts.

The State SUD Data Landscape

Policymakers have access to data sets that are collected, compiled, analyzed, and maintained by state and federal agencies and other entities responsible for providing or overseeing services related to the prevention, reduction, or treatment of SUD. The following highlights data sets that are commonly used by state policymakers in their efforts to analyze key SUD indicators.

Individual claims and administrative and programmatic data collected by states: Individual-level data sets that tie to the unique experiences of one person through a system can help illuminate the ways that individuals and populations seek and use services. This data is often personally identifiable, which requires either consent, legally authorized use, or systematic anonymization that removes identifying characteristics.

Data	Ownership/Maintenance	Content
Medicaid claims and encounter data	State Medicaid agency Medicaid managed care organization	· Patient demographic data · Diagnostic/service codes · Service utilization data
Prescription drug monitoring programs (PDMPs)	State licensing boards, public health agencies, or free-standing PDMP agency	Patient and prescriber data related to scheduled prescription drugs
Vital statistics, forensic epidemiology, or medical examiner/coroner reports	State public health or vital statistics agencies	· Deceased demographic data · International Classification of Diseases 9-10 codes identifying causes of death · Toxicology reports
Homeless management information systems	State housing or social service agencies	Housing program services and client data, including self-reported diagnoses
Infectious disease data	State public health agencies	Surveillance data on hepatitis B/C and HIV infections
Behavioral health services data	State behavioral health agencies	· Non-Medicaid-funded services for SUD delivered by community behavioral health systems or state hospitals · Provider licensure information
Emergency medical systems data	State public health agencies	Overdose response data, including naloxone deployment
Hospital admissions and discharge data	State public health agencies	Overdoses treated in hospital settings and/or discharges coded as overdose-related
Corrections	State and local corrections agencies	Health and behavioral health assessment and treatment data for incarcerated individuals

De-identified state/federal data sets available to researchers, organizations, and the public: Aggregate data sets can also be helpful to understand system interactions and population trends. These kinds of data are valuable in gauging systemwide behaviors as well as shifts in services, demographics, or activities that indicate the needs of a given region or population.

Data Set	Ownership/Maintenance	Content
All-payer claims databases (APCD)	Independent state or quasi-governmental organizations	Insurance claims from across payer sources
Behavioral Risk Factor Surveillance System (BRFSS)	Centers for Disease Control and Prevention (CDC)	Self-reported health risk factor and health condition data
Census data	US Census Bureau	Self-reported demographic data
National Overdose Report	CDC	Overdose deaths by demographics, states/regions, and substances present
Annual HIV Surveillance Report	CDC	HIV infections by demographics, states/regions, and transmission factors
National Survey on Drug use and Health (NDSUH)	Substance Abuse and Mental Health Services Administration (SAMHSA)	Self-reported substance use, mental health, and treatment services by demographics and state/region

SUD Data Use Cases for State and Community Leaders

The following data use cases and strategies describe how available data can be used, often in innovative ways, to inform and guide state and local policy decisions.

Limit Diversion and Promoting Prevention Use Cases

Prescription opioids are often described as the substances behind the “first wave” of an overdose epidemic that has evolved to now be driven by illicit forms of opioids, such as heroin and fentanyl. In one study, over 80 percent of current heroin users reported that their first experiences with opioids involved diverted prescription pills, suggesting that policy interventions to reduce this diversion should be among state and local leaders’ top priorities. Analyzing available data can help to structure strategies that limit opioid diversion and prevent inappropriate prescribing.

Identify risky prescribing: Forty-nine states and Washington, DC support Prescription Drug Monitoring Programs (PDMPs) that contain prescriber, dispenser, and patient-level data about controlled substances. Policymakers can use PDMP data to develop baselines that help show geographic and individual prescriber averages, as well as aberrations in prescribing and dispensing patterns. Pennsylvania maintains public-facing aggregate PDMP data that can be searched at the county level for a range of measures that indicate risky prescribing patterns, such as:

Number/rate of individuals seeing five-plus prescribers and five-plus dispensers;
Number/rate of individuals seeing four-plus prescribers and four-plus dispensers;
Number/rate of individuals seeing three-plus prescribers and three-plus dispensers;
Morphine milligram equivalents (MMEs);
Number/rate of individuals with an average daily MME of more than 50, 90 or 120;
Number/rate of individuals with overlapping opioid/benzodiazepine prescriptions; and
Number/rate of individuals with more than 30 days of overlapping opioid/benzodiazepine prescriptions.

Similarly, Illinois tracks a “high-risk patient” population using data from its PDMP to better understand trends among individuals who have been:

Prescribed both opioids and benzodiazepines;
Individuals prescribed greater than 90 MME; and
By number of total prescriptions.

Refine prescribing guidelines: States have significant leverage to implement opioid prescribing guidelines in their Medicaid programs and can then use this claims data to support these interventions. Using PDMP and Medicaid service utilization data, state Medicaid agencies can enact and support policies that reduce opioid prescribing and incentivize non-narcotic pain management. Policymakers in Virginia reviewed both opioid and non-opioid prescribing claims in Medicaid, and found the data suggested opioid prescriptions were the default for pain management. Working with stakeholders, including managed care pharmacy directors, the state removed prior authorization for non-opioid pain management and implemented limitations on opioid prescribing among Medicaid providers. Other states, including Ohio, have similarly used PDMP data to track and manage opioid prescribing limits that reduce the availability of pills for potential diversion. Ohio experienced a 41 percent decrease in opioid doses and a 37 percent decrease in prescriptions between 2012 and 2018 as a result of adopting these kinds of regulations.

Understand substance use trends: Massachusetts analyzed death records, state toxicology reports, and prescribing data from its PDMP to better understand substances involved in the state’s overdose deaths. Matching and analyzing these data sets revealed that people dying from overdose were much more likely to have an illegal substance in their system at the time of death, which resulted in a state review of its harm reduction strategy. The report noted that “(a)s a result of these findings, increasing the availability of harm reduction strategies and interventions that target heroin, fentanyl, and polysubstance use (especially benzodiazepine and cocaine use) could significantly reduce the opioid-related death rate.”

Preventing Overdose and SUD-Related Comorbidities Use Cases

Harm reduction interventions can lower the likelihood of both overdose and infectious disease by engaging individuals in active use to mitigate their risks. State-level data sets can help illuminate state- and community-specific needs related to reducing harm from opioid use, and can identify areas for policy intervention that can both improve outcomes for people using drugs and avoid costs related to chronic, comorbid illnesses.

Target resources where most needed: Targeted deployment of key harm reduction resources, such as naloxone, can be difficult to pinpoint:

Lay use of naloxone goes unreported, and
Emergency medical services (EMS) may use multiple doses for one overdose or may use naloxone when overdose is suspected but not present.

Wisconsin took a comprehensive approach in its harm reduction analysis. Policymakers analyzed four indicators across the state to identify areas of greatest need of harm reduction interventions: Incidents of opioid overdose deaths;

Opioid overdose hospitalizations;
Suspected opioid overdose ambulance runs; and
Newly reported cases of hepatitis C in people age 15 to 29.

The state then used data on available resources, such as syringe services programs, naloxone availability at pharmacies through a standing order, medication-assisted treatment, HIV prevention, hepatitis C treatment, and SUD treatment providers to identify areas experiencing acute gaps in harm reduction resources.

To further support harm reduction efforts, Wisconsin also tracks suspected overdose deaths on a monthly basis, enabling the state to provide more timely and actionable data to state and local officials. The state reviews 911 ambulance runs and uses word searches in free-text fields to identify additional details. Data is presented as unconfirmed.

Push out actionable data to clinicians to treat common comorbidities: The Louisiana Public Health Information Exchange (LaPHIE) was first implemented in 2008 as a partnership between its Office of Public Health and Louisiana State University Health Care Services Division. The OPH maintains comprehensive HIV surveillance data that is updated daily through lab reporting. If a patient enters a participating hospital and a provider opens that patient’s electronic medical record to provide services, the provider will be notified if the patient has not received timely HIV care and prompted to take appropriate action. LaPHIE is bi-directional, any action taken by the provider with respect to the patient, whether it be a referral or a link back into care, is incorporated into the patient’s electronic medical record (EMR) and returned to the OPH, which then updates the state’s HIV surveillance data.

Identify critical intervention points: Several states have used comprehensive, cross-agency strategies to identify patterns and opportunities for intervention, and the Delaware Drug Overdose Mortality Surveillance report is one such example. This report uses data to illuminate the experiences of individuals in the months prior to their deaths and includes information from a broad scope of data sets, including hospital and health system interactions (including EMS and emergency department visits for overdoses), corrections engagement, and interface with the behavioral health system. By looking at non-fatal overdoses and interactions with EMS, officials can understand the systemic interplay and individual experiences of individuals who fatally overdose in order to better target opportunities for intervention, including treatment in emergency departments.

Similarly, in Massachusetts, the state linked ambulance data with state hospital data to identify individuals who had experienced a non-fatal overdose. By leveraging access to data afforded by the state’s opioid data-sharing initiative, Chapter 55, analysts were able to:

Link information about this subset of individuals to other state data systems;
Identify individuals’ prescription drug patterns through the state PDMP;
Chart their contact with the health care and behavioral health systems through the state’s APCD; and
Document their involvement with corrections.

The state used this information to identify opportunities for intervention and outreach on SUD treatment. A similar data exercise in West Virginia identified that 81percent of those who died from overdoses had interacted with at least one of the state’s health care systems.

Improving Treatment and Recovery Supports Data Use Cases

Ensuring an adequate treatment infrastructure is a high priority as states work to develop access to evidence-based services in the face of this epidemic. By investigating the current treatment landscape in a given state or region, policymakers can analyze unmet need and address gaps in care. Understanding the actual inventory of existing treatment providers through various data sources can help states develop gap analyses and understand workforce needs.

Quantify and optimize current capacity: The Substance Abuse and Mental Health Services Administration (SAMHSA) established a public list of buprenorphine-waivered providers by state and a list of opioid treatment programs (OTP) that provide methadone, also searchable by state. These are helpful starting points when assessing state and local needs, but can be misleading as only a small percentage of waivered providers deliver care to the full extent enabled by the waiver process, and providers can choose to opt out of the listing. Policymakers can compare state-level claims data (Medicaid, APCD) to identify waivered providers who are not providing treatment or maximizing waiver treatment capacity limits. Through this additional step in analysis, state and local policymakers can drill down to better understand which providers may need support in engaging in the medication for opioid use disorder (OUD) provision. Referring these prescribers to tools such as the SAMHSA Provider Clinical Support System can provide additional tools and supports for those providers who are reluctant to maximize their capacity.

Indiana used state workforce survey data to identify which regions of the state lacked a sufficient amount of SUD treatment providers. The Indiana State Department of Health was one of several funders that supported the development of a user-friendly Health Workforce Information Portal that allows members of the public to create maps and reports to review both current workforce and educational pipelines for emerging professionals. Based on survey data, state, county, and local leaders could identify the number of full-time equivalents across areas of the state for a range of professionals, including psychiatrists, clinical social workers, and addiction counselors.

Understand cost and utilization patterns within Medicaid: Looking at existing cost drivers of SUD in Medicaid claims and encounter data within a state’s Medicaid Management Information System (MMIS) can be a helpful starting point for states seeking opportunities to both reduce costs and realign reimbursement structures with service needs. Creating service delivery systems that prioritize a continuum of care in which services can be provided in community clinical settings presents an opportunity for Medicaid programs to reduce costs. In order to better coordinate care and potentially realize cost savings, states can use their Medicaid cost data to develop a range of options that support behavioral and physical health integration and promote team-based care. Virginia’s Addiction and Recovery Treatment Services (ARTS) waiver aligned SUD services to the American Society of Addiction Medicine’s (ASAM) criteria, and encouraged those services to be provided in primary care settings and office-based outpatient treatment facilities. In doing so, Virginia Medicaid experienced a 32 percent reduction in emergency department visits related to OUD during the second year of the program.

Support real-time access to treatment: In addition to the SAMHSA provider locator mentioned above, states can use self-reported provider data to maintain their own state-level treatment locators, and those can include a range of filters to identify particular information, similar to the tool developed by Kentucky using federal grant funding. Through a diverse partnership, the Kentucky Department for Public Health (via the Kentucky Injury Prevention and Research Center) engaged with the Kentucky Office of Drug Control Policy, the Kentucky Department for Behavioral Health, Intellectual, and Developmental Disabilities, and Operation Unite to pull together provider data and develop a short screening that could connect the user to an available treatment provider. Providers have the necessary access and ability to update their facilities’ information daily, and are encouraged to do so. Some states are also employing “bed registries,” tools that track availability of inpatient hospital services, many of which are specific to detox and/or treatment and may serve to help providers in accessing real-time data about available treatment space.

Data Use Cases for At-risk and Underserved Populations

States can also analyze Medicaid service utilization data for specific populations or eligibility categories in order to tailor policy approaches to support vulnerable or underserved populations.

Racial and ethnic disparities: West Virginia, Minnesota, and other states that have analyzed overdose deaths through a racial/ethnic disparity lens have found higher rates of death from overdose among these populations. Minnesota released data analysis focused on the racial disparities it found by reviewing state death certificates and coroners’ reports. The state concluded that the overall low drug mortality rate masked significant racial disparities: Blacks were twiingce as likely to die from a drug overdose than Whites and American Indians were almost six-times more likely to die of a drug overdose than Whites. While drug overdose mortality rates increased for all groups, racial disparities in overdose mortality also increased.

Pregnant women: Through collaborative efforts across state and private agencies, West Virginia identified and addressed a surge in neonatal abstinence syndrome (NAS) and developed a programmatic response. The effort began by standardizing definitions for neonatal withdrawal and providing guidance to clinicians explaining how to use and track diagnostic criteria. The data informed the development of DrugFree Moms and Babies, a program that provides early intervention, treatment, and recovery supports to women and their newborns. The program has improved identification of families at risk and created a structure to support them.

Individuals with corrections involvement: The SUD crisis has highlighted the need for cross-system collaboration between health, behavioral health, and criminal justice systems. A 2017 Special Report from the Bureau of Justice Statistics detailed substance use patterns among individuals incarcerated in state prisons and jails between 2007-2009 and indicated that more than half of incarcerated individuals meet criteria for SUD. Kentucky’s Office of Drug Control Policy, in conjunction with the Kentucky Agency for Substance Abuse Policy, publishes a combined annual report that helps policy makers drill down to specific trends or patterns in charges that may indicate SUD, which can then be used to target the development of incarceration-based treatment programs and pre-arrest diversion programs such as the Law Enforcement Assisted Diversion (LEAD) initiative in Louisville. In Massachusetts, the state Department of Corrections and county-level corrections agencies provided a complete list of people who had been released during one analysis period. The state found that people recently released from corrections facilities were 56-times more likely to die of an opioid overdose than the general public. Moreover, data indicated that those who had received treatment while incarcerated did not have a significant reduction in their risk of overdose. The analysis noted that additional attention should be paid to be individuals leaving corrections facilities, and that treatment should be standardized, regardless of setting.

Individuals without stable housing: Data on housing and homelessness is collected and maintained in Homeless Management Information Systems (HMIS) and can often be accessed directly from the Communities of Care (CoC) that operate regionally to provide a host of services that support housing. CoCs collect and report both housing inventory count (HIC) and point-in-time (PIT) counts of individuals who are homeless, information that can also be accessed at the CoC and state levels through the federal Housing and Urban Development Exchange website. Matching HMIS data with Medicaid utilization data through a state’s MMIS can provide opportunities to develop specific interventions for individuals who are homeless and have received services related to SUD. In Connecticut, the state matched HMIS and Medicaid data and identified a subset of Medicaid enrollees with complex and high-cost health care needs. The state used this data to develop program strategies to better support these individuals, and has since documented improved housing retention, decreased use of emergency departments, and improved connection to preventative services.

Supporting recovery: States are increasingly building peer supports into the continuum of care for SUD. While definitions and services provided vary, 39 states currently reimburse for peers in some capacity through their state Medicaid programs. North Carolina, in addition to tracking access data such as buprenorphine prescriptions and enrollment in opioid treatment programs, also includes access to peer recovery as a key metric on that state’s opioid dashboard. The state has demonstrated a significant increase in the number of certified peer support providers in the state, and provides the data by county.

Best Practices in Using Data to Support State and Local Policy Development

Comprehensive data – often gathered from across state, local, and federal resources – enables state and local leaders to tailor their prevention, treatment, and recovery responses and make the most of scarce resources. However, effectively using available data, matching or comparing complementary data sets, and identifying what should be the focus of analyses can be complicated. The following are key considerations for states seeking to improve data quality, explore data-sharing opportunities, and analyze existing data sets across systems.

Leadership is critical: Sharing data across state silos is challenging – many agencies generally prefer not to release data. Encouraging the sharing of health care and related data sets requires unifying leadership and a vision that can maintain momentum through many programmatic, legal, and technical hurdles. In some states, such as Pennsylvania, the governor used a disaster declaration to bring agencies to the table to create and sustain that state’s multi-agency data capacity. Other states, such as Massachusetts, made significant progress in cross-agency data sharing through legislation. That state’s Chapter 55 public law, passed in 2015, provided the impetus and structure needed for that state’s many SUD data innovations.

Engage both technical and policy expertise to make the most of existing data: While technical expertise in essential, policy and programmatic expertise is also a critical factor in successfully using data to support SUD prevention, treatment, and recovery. Data insights help state policymakers understand and explain variances in eligibility groups, interactions between specialty programs, and flag anomalies in the data due to program idiosyncrasies. Data also helps guide analysts in shaping metrics that will have value for policy decision-making.

Allow time and resources to address data governance: How substance use data is stored and shared is covered by both the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2 – the latter is specific to SUD data and imposes privacy standards that are often more stringent than those found in HIPAA. With few exceptions, providers and stewards of SUD data must obtain consent before sharing personally identifiable information that is protected by 42 CR Part 2. States can make the most of sharing data across agencies by building in time and resources to manage data governance issues:

Data use agreements help to clearly articulate how organizations will use data, and specifically how it supports policy development. This Centers for Medicare & Medicaid Services fact sheet on DUAs outlines necessary components, helpful tips, and includes state example documents. Recognizing the limitations of all data sets included in a DUA also helps to expedite work. Confidentiality issues can be addressed clearly and completely, eliminating onerous approaches to de-identification or aggregation that may not ultimately be necessary. State agencies may have existing DUAs in place that can support new/emerging uses.
Massachusetts was able to combine protected data from across ten disparate state agencies through a project-specific de-identification process that assigned random identifiers to each record. The state also developed a series of legal agreements that covered how data would be linked, shared, hosted, and accessed.

Expect challenges:

Timeliness of data in a rapidly shifting substance use epidemic can be a challenge for virtually all data sets, as very few reporting systems offer real-time data. Longer lags, however, particularly those that pass more than a year from collecting data to reporting, make some data sets better used for understanding the landscape in retrospect rather than as a planning tool. Some states use unconfirmed data when necessary to track particularly urgent indicators, such as drug overdose deaths.
Completeness of data sets – and the lack thereof – can also pose limitations for policymakers and is a major factor in data quality. State Medicaid enrollees, for instance, may move on and off the program as individual eligibility fluctuates, creating gaps in coverage and in key data points, such as current addresses. Encounter data from Medicaid managed care plans can also be problematic – states can improve encounter data quality through contract incentives, regular communication, and guidance. State-level guidance to providers and/or managed care organizations may be required to improve completeness of data

Conclusion

Many data sets produced by state and federal agencies have value when used individually, but when data can be shared and presented in new ways, it begins to tell a more comprehensive story of the particular and highly localized impact of SUD across systems and populations. There has been unprecedented activity at the state level in recent years to identify and use data sources to better understand and address state and local needs to prevent SUD, reduce the harms caused by SUD, and promote treatment and recovery. While states adopt indicators and metrics that meet specific state needs, there is an increasingly innovative menu of options to support their efforts.

Acknowledgements: The National Academy for State Health Policy provided this report with the ongoing support of JBS International and the federal Health Resources and Services Administration (HRSA). The authors would like to thank Lisa Patton, PhD, Vice President of Health Optimization Program and RCORP-TA Project Director at JBS International, and Marcia Colburn, MSW, Program Analyst in the Federal Office of Rural Health Policy at HRSA, for their continued guidance and expertise in supporting this work.

Q&A: How Louisiana Has Retooled its Harm Reduction Services for Vulnerable Populations during COVID-19

November 23, 2020/in Policy Louisiana Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Health Equity, HIV/AIDS, Physical and Behavioral Health Integration, Population Health, Safety Net Providers and Rural Health, Social Determinants of Health /by Eliza Mette, Mia Antezzo and Jodi Manz

As drug overdose deaths accelerate during the COVID-19 pandemic, states are working to ensure that a continuum of services, including access to harm reduction programs, remain available to people with substance use disorder (SUD). The National Academy for State Health Policy (NASHP) recently spoke to Louisiana’s Viral Hepatitis Coordinator Emilia Myers and STD/HIV/Hepatitis Program Deputy Director Anthony James to learn how the state is continuing to provide harm reduction services during the pandemic.

Louisiana authorizes cities, including New Orleans, Baton Rouge, Shreveport, and Alexandria, to operate syringe services programs (SSP). The state has helped maintain these programs by targeting federal grants and through close cooperation between state and community partners.

How have the challenges posed by COVID-19 impacted the day-to day operation of harm reduction services in Louisiana?

Louisiana has six active SSPs across the state. They have stepped up to the challenges of this pandemic and have continued to provide their services, essentially without interruption. They’ve been able to do so through some very innovative approaches, such as hotlines and mail-based naloxone services, and by moving away from brick-and-mortar SSPs. The Louisiana Department of Health (LDH) has worked to improve its relationships with SSPs and link them with their respective local health departments. One result of this manifested in New Orleans where, right when COVID-19 started to ramp up, the city started providing residences for folks who were experiencing homelessness. SSPs went out to the hotels that were housing people to bring harm reduction services to them.

We are also using federal State Opioid Response (SOR) grant dollars in collaboration with the Office of Behavioral Health to fund SSP navigators and federal Opioid Overdose Data to Action (OD2A) dollars in collaboration with the Bureau of Community Preparedness to fund Linkage to Treatment Coordinators (LTCs), who prioritize people who inject drugs (PWID) who have fallen out of hepatitis C treatment. If they are also willing to talk about their drug use, the LTC will conduct a Screening, Brief Intervention and Referral to Treatment (SBIRT). We’ve also been using OD2A funds for our marketing campaign to raise awareness of integrated and co-located care for OUD (opioid use disorder), hepatitis C, HIV, and SSPs to reduce harms associated with substance use disorder, which we hope to continue.

Luckily, there is buy-in to this work. About a year ago, together with the Office of Behavioral Health and Bureau of Community Preparedness, we developed a state health department-wide, harm-reduction crosswalk, which was an environmental landscape analysis of who’s doing what in infectious disease, who’s doing what in OUD, and how we can create no-wrong-door systems of care. We’ve had some modest gains as a result, including braiding select government funds, scaling up SSP-based OEND (overdose education and naloxone delivery), increasing opt-out hepatitis C testing at select human service district agencies and cross-training OBOT (office-based opioid treatment) providers statewide to deliver both medication-assisted treatment for OUD and treatment for hepatitis C and we are looking to build on our momentum. Our state agencies have innovative leaders that make connections for more effective public health and behavioral health collaboration and care touch points, and we’re fortunate to have trailblazers that keep this work moving along.

How have people with comorbid HIV and hepatitis C diagnoses been affected by COVID-19, and how has the state responded?

We know folks who are coinfected are one of the populations most vulnerable to unemployment, poverty, lack of access to health care, and they generally have a lot of competing priorities between trying to take their medications and live their lives. Anecdotally, we are seeing more people accessing SSPs and needing supplies, and SSPs are trying to accommodate that increased demand. With an increase in utilization of SSP services, we hope there will not be an increase in overdoses and or increases in HIV and hepatitis C transmission. I think COVID-19 has really turned access into a challenge and created additional burdens for vulnerable populations, so we have to look at the issue through a health equity lens. There are a lot of systemic challenges and barriers that have been exacerbated by the pandemic, and people’s health has become a lesser priority because they’re trying to survive day to day.

Within our Hepatitis C Elimination Plan activities [featured in an April 2020 NASHP case study], we have seen decreases in testing and treatment as a result of the pandemic. Before we launched our program, 61 people per month were starting curative treatment. After implementation, we were seeing on average 478 people per month starting treatment. At the start of the COVID-19, that number dropped back down to an average of 155 people per month, but since September 2020, testing and treatment utilization has picked back up. This has forced us to learn how to get testing and treatment outside of brick and mortar treatment facilities, because people are anxious of going into health care systems. Because of funding reductions and other impacts of COVID-19, we revisited our hepatitis C strategy to ensure we were focused on realistic and achievable objectives for the second year of the plan, and reassess what Years 3 through 5 will look like. COVID-19 has forced us to pivot and continuously innovate hepatitis C service delivery. We will use this as an opportunity to leverage our response and facilitate a larger push in harm reduction.

How does Louisiana’s harm reduction approach support health equity and reduce disparities?

In both the LDH and STD/HIV/Hepatitis Program mission statements, we focus on addressing health equity and racial disparities across the board. Disparities in health care exist and are associated with worse health outcomes, for example the HIV/HCV coinfection diagnosis and prevalence rates are disproportionally higher among Black males primarily in the Baton Rouge and New Orleans areas. Looking at the mono-hepatitis C surveillance data, there hasn’t been a lot of variability in who’s being diagnosed by race. We see disparities in rates of infection by age – we have baby boomers and people who inject drugs getting infected, so we have this bimodal distribution. In an effort to address these disparities in the context of the current hepatitis C/OUD syndemic, we have to pinpoint shortcomings in hepatitis action towards people who actively use drugs and expand primary prevention through harm reduction because treating your way out of a hepatitis C epidemic isn’t feasible. PWID are increasingly researched, but their ability to tell their own stories and provide input into the programs and services they utilize has been historically limited due to stigma. Louisiana is changing that by leveraging community wisdom through community advisory boards to inform evidence-based service delivery. We move this work forward through a core set of values to help us ensure that the services that we and our community partners provide are moving in an equitable direction.

How has the pandemic necessitated or encouraged new strategies or partnerships?

One of our strategies has been offering provider training. We’ve leveraged Project ECHO to train providers how to leverage telemedicine to treat and manage hepatitis C virtually, revamping remote care. There has been a lot of engagement from clinicians.

There was also a decline in hepatitis C and HIV testing at the start of COVID-19. Our community-based partners have conducted risk mitigation strategies to safely re-engage people in testing. Now that they’ve been able to get PPE, they are able to conduct testing in community settings again.

We are also prioritizing data sharing and maximizing opportunities to form strong partnerships, because the syndemic of hepatitis C, HIV, and drug overdose is really intertwined, and COVID-19 has only made things more challenging. Reinforcing our partnerships and leveraging data sharing, in addition to amplifying the voices and wisdom of community members, is helping us make these programs work for the people who rely on them.

What would you say are your greatest lessons learned from COVID-19?

We really need to lean into interdisciplinary telemedicine for comprehensive care, especially for the hard-to-reach communities in high-burden regions of the state. COVID-19 has caused so much slow down, but also additional time to re-assess what we’re doing. In this context, developing robust telemedicine programs will be critical. The next challenge will be how to integrate offerings into clinical care beyond the COVID-19 pandemic so that a “one-stop-shop” PWID service bundle will become an increasingly ordinary part of care with movement towards the goal of reducing disparities in infectious diseases and opioid use disorder treatment access.

Harm Reduction in the COVID-19 Era: States Respond with Innovations

October 19, 2020/in COVID-19 State Action Center Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Population Health /by Mia Antezzo, Eliza Mette and Jodi Manz

Despite COVID-19 workarounds, such as telehealth and virtual recovery programs enabled by flexible federal guidelines, more than 40 states have reported increases in drug overdoses during the pandemic, underscoring the importance of keeping state harm reduction programs as accessible as possible.

As COVID-19 upends the nation’s health care systems, treatment for substance use disorder (SUD) has shifted to telehealth environments and recovery programs have gone virtual as state and federal policymakers adjust regulations and guidance to maintain access to services. But the unique risks facing people with SUD during this time of isolation and mandatory social distancing are also becoming more clear.

State-authorized harm reduction programs that provide syringe exchange services, testing for infectious diseases and referral to treatment, and connections to treatment for opioid use disorder and other SUDs provide a critical intervention. Despite the challenges of implementing COVID-19 protocols for what have traditionally been in-person services, states have developed flexibilities and innovative approaches to ensuring that these programs continue to provide critical, ongoing support to people with SUD until they are ready for treatment.

State guidance for harm reduction providers in response to COVID-19:

The guidance that state officials and agencies have developed recognize the unique challenges that face harm reduction providers during the COVID-19 pandemic. Many states acknowledge harm reduction as an essential service and some have temporarily loosened program restrictions to ensure the continuity of services during the pandemic.

The Oregon Health Authority (OHA) authorized its Syringe Service Programs (SSP) to provide curbside services and phone orders for syringes, naloxone, and other supplies. OHA also suggested operational shifts in staffing, distancing protocols, and volunteer management to mitigate COVID-19 transmission among staff, volunteers, and clients. OHA included messaging in support of people who use drugs (PWUD) in order to maintain their safety during the pandemic. The messaging emphasized the increased respiratory risks associated with drug use and COVID-19 and provided guidance on how to reduce the risk of COVID-19 infection as well as the risk of overdose during the pandemic.
In Maine, Gov. Janet Mills issued an Executive Order on March 30, 2020, suspending an existing one-to-one syringe exchange rule, thereby increasing the number of syringes individuals can take home at once. The order also allows flexibility in mail delivery services, needle exchange site locations and operational hours and provided on-site social distancing protocols.
The Missouri Department of Mental Health issued comprehensive COVID-19 guidance in mid-March, which featured published resources from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Harm Reduction Coalition, and the National Health Care for the Homeless Council (NHCHC), as well as best practices from other states and programs. Missouri’s guidance includes operational directives for treatment and harm reduction providers, as well as practical harm reduction guidance for PWUD, particularly individuals who use drugs alone.

Adaptations in harm reduction services:

Harm reduction programs are making policy shifts to develop practices that respond to the specific needs of their communities. As states and municipalities have responded to the COVID-19 pandemic at varying degrees of restrictiveness, harm reduction programs have also tailored their programs to respond to the pandemic.

Operational changes. Programs in Washington and other states have shifted services outdoors. They now provide curbside or mobile services and have closed their fixed sites entirely and instead rely on delivery services. Many Washington State SSP programs have limited hours and scope of services. In New York, SSPs have been operating with skeletal staff and reduced resources. In response to the new limitations on in-person service, 22 of 23 of New York’s SSPs now rely on some form of peer-delivered syringe services.
Shifts in testing priorities. In addition to continuing to provide harm reduction services, some SSPs in Washington now provide COVID-19 screening and testing at their program sites. West Virginia’s harm reduction programs have reduced the amount of non-COVID-19 infectious disease testing they’re conducting and the amount of hepatitis A and B immunizations they administer, in order to focus on COVID-19 and the immediate needs of individuals with SUD.
Emphasizing naloxone distribution. As overdose rates continue to rise during the pandemic, states are increasing access to the overdose-reversal drug naloxone. Pennsylvania’s Secretary of Health signed an updated standing order that allows community organizations to distribute naloxone through mail. Ohio’s Department of Mental Health and Addiction Services has provided official guidance to all community programs through its statewide Project DAWN overdose reversal initiative to maintain minimal contact with individuals who need services while maximizing naloxone distribution as a strategy to mitigate overdoses. Additionally, the US Department of Health and Human Services has published guidance for first responders to safely administer naloxone during the pandemic.

Looking Ahead

As states begin to consider the impact of COVID-19 on their budgets, programming, and future planning, maintaining harm reduction programs may become more challenging. Harm reduction programs are often supported by multiple funding streams, and program administrators and policymakers may consider leveraging federal grants and other non-state funds to maintain these services. In addition to ensuring access to infectious disease prevention and life-saving treatment and recovery services, harm reduction programs offer a mechanism to maintain engagement with people who have SUD and reduce their risk of overdose, which results from isolation.

This work was funded by the Foundation for Opioid Response Efforts (FORE). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE. FORE is authorized to reproduce and distribute reprints for foundation purposes notwithstanding any copyright notation hereon.

Three Approaches to Opioid Use Disorder Treatment in State Departments of Corrections

September 2, 2020/in Policy Kentucky, Maine, Pennsylvania Featured News Home, Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Coverage and Access, Medicaid Expansion, Population Health, Social Determinants of Health /by Jodi Manz and Eliza Mette

As drug overdose fatalities continue to rise and incarceration rates remain high nationwide despite recent declines, states are increasingly developing opportunities for incarcerated individuals to access evidence-based opioid use disorder (OUD) treatment in state prison facilities.

While the forced abstinence during incarceration can temporarily pause substance use itself, providing comprehensive treatment that includes medications for opioid use disorder (MOUD) during incarceration is shown to result in better treatment engagement as well as long-term recovery upon re-entry. Providing this kind of treatment during incarceration represents a shift in criminal justice approaches to substance use disorders (SUD), one that relies on partnerships between state agencies and providers, as well as the adoption of an understanding of OUD as a chronic-yet-treatable disorder with effective medical interventions.

Any discussion of this shift toward reframing people with OUD as individuals in need of Treatment – including those incarcerated as a result of their substance use – must also recognize that racial bias across systems affects sentencing policies. While Black people use illicit drugs at similar or lower rates than the rest of the population, they are incarcerated at over five times the rate of White people. Black Americans have also been disproportionately affected by recent increases in overdose fatality due to synthetic opioids, underscoring inequitable systemic responses to prevention, treatment, and recovery for Black individuals with OUD. The incarceration-based treatment approaches emerging today stand in stark contrast to the policy response to the crack-cocaine epidemic and subsequent sentencing guidelines of the previous generation that saw millions of Americans, approximately 80 percent of whom were Black men, incarcerated without a similar focus on treatment.

Policymakers are currently charting a different course by offering evidence-based treatment that is initiated alongside incarceration, recognizing that systems can work together to support people with SUD. These programs represent an opportunity to address both the SUD that may be at the root of criminalized behavior, and the racial disparities in sentencing that foster health disparities.

Developing programs that emphasize treatment instead of incarceration ultimately requires not just a shift in perspective about the nature of SUD, but also the will of leadership to implement new policies and clinical practices – and the funding to do so. The National Academy for State Health Policy (NASHP) talked to leaders from three states – Kentucky, Maine, and Pennsylvania – about their approaches to SUD treatment within their state prison populations and how these approaches are evolving.

Maine

In early 2019, the Maine Department of Corrections (ME DOC) developed a pilot program to begin providing MOUD, starting in one secure state facility and two pre-release state facilities. Part of the impetus for this program was a 2018 lawsuit filed by the American Civil Liberties Union (ACLU) on behalf of an individual with OUD who was entering a Maine state prison and was going to be denied treatment, despite having been in recovery for five years with the assistance of prescribed medication.* ME DOC ultimately settled the case, agreeing to continue providing the individual with necessary medication. Prior to this, the state’s correctional facilities focused on providing residential and out-patient level of substance use treatment and continuity of care in the community upon release, but had no internal, evidence-based program that provided MOUD. In 2019, a new governor and administration initiated different priorities, including new approaches to address Maine’s opioid epidemic. Additionally, the state had just expanded Medicaid, which helped ME DOC to develop protocols that would ensure continuity of care upon release by enrolling participants in Medicaid coverage immediately upon re-entry.

To inform its planning process and learn about successful incarceration-based MOUD programming, Maine’s corrections leadership visited Rhode Island, a leading state in SUD treatment with incarcerated populations. ME DOC launched its buprenorphine pilot in July 2019 by engaging 50 individuals in the program, each of whom was three months from release. The size and scope of the initial pilot phase were intentional, as the state was limited to operating within its existing budget, staffing, and medical services contract. By November, with additional funding, a second facility was added, expanding the program to 75 to 90 participants, and by the end of that year, 115 individuals had successfully initiated treatment while incarcerated and transitioned back into the community.

In 2020, ME DOC expanded the program to all secure and pre-release state facilities and has nearly 200 participants enrolled in the program on average. ME DOC continued to expand eligibility policy over time. Currently, if a behavioral health or medical provider refers an individual for induction, regardless of entry or release date, ME DOC is able to provide MOUD. All program participants are released with a naloxone kit and a continuity of care plan in place, and internal data has shown that 84 percent of program participants attended their initial treatment appointment post-release.

Pennsylvania

Pennsylvania’s Department of Corrections (PA DOC) began offering injectable naltrexone in 2014 through a small pilot with women who were re-entering the community from one state correctional facility. Within two years, PA DOC had expanded this program to other facilities, identifying individuals at risk of overdose and providing injectable naltrexone prior to re-entry, as well as connections to Medicaid enrollment to support continued treatment in the community.

On June 1, 2019, PA DOC continued this development of treatment services through a formal policy change that supports provision of buprenorphine to anyone coming into state custody who was on a verified prescription upon entry, though not yet to other incarcerated individuals with OUD. While this did not replace the naltrexone program, it did introduce a second form of MOUD into the state corrections system, creating entirely new protocols and challenges and with them, opportunities. PA DOC also began inducting those individuals who entered prison due to technical parole violations on injectable buprenorphine before they returned to the community as an alternative to detoxing onsite. Buprenorphine provision, however, experienced serious disruption with the temporary loss of a provider to prescribe the drug, followed by the emergence of COVID-19, which has affected clinical and procedural protocols across the board for PA DOC.

Pennsylvania also brought on a full time medication-assisted treatment (MAT) coordinator for corrections in 2016, a move that led to planning and exploration of expanded treatment provision development, bringing significant growth to the program. In the first year, the state had fewer than 80 individuals receiving MOUD, but participation has grown annually and is on track to include over 1,000 people in all 24 state prisons in 2020.

Kentucky

Kentucky’s Department of Corrections (KY DOC) currently maintains about 6,000 SUD treatment beds within the state’s correctional facilities, though most of those do not include the provision of MOUD and instead promote an abstinence-only approach. In 2018, the state developed the Substance Abuse Medication Assisted Treatment (SAMAT) project in which at-risk individuals are identified pre-release and provided injectable naltrexone or buprenorphine. While still incarcerated, they are connected to Kentucky Medicaid and enrolled in a managed care plan, and prior authorization is completed for necessary continuity of medication upon re-entry.

In 2020, looking for ways to further support and sustain comprehensive treatment in state prisons, the Kentucky legislature passed a budget that included language directing the state Medicaid agency to develop and submit an 1115 demonstration waiver to the Centers for Medicare & Medicaid Services (CMS). This waiver is intended to create a mechanism for Medicaid coverage of SUD treatment while an individual is incarcerated, an approach that is currently prohibited by language known as the “inmate exclusion” in the Social Security Act.

This means that policymakers in Kentucky are simultaneously designing a DOC treatment program and the mechanism to administer and fund it. State leaders are currently exploring proposals to amend the current 1115 waiver to address anticipated clinical and policy challenges to providing MOUD, especially buprenorphine, to people who are incarcerated. All of this must be done while maintaining the budget neutrality required by 1115 waivers. This process also raises questions about when Medicaid coverage would begin, and what services would be absorbed by the DOC budget as opposed to those that would be reimbursable by Medicaid. A mechanism to provide Medicaid coverage to individuals within a 30- to 60-day window prior to release may mitigate some of these concerns. This approach would ultimately increase resources for KY DOC to improve its quality of services by moving toward a more evidence-based approach that includes MOUD.

Considerations for States

All three of the featured states started small, beginning their DOC-based MOUD provision in pilot programs, and with initial success and additional funding, scaled those programs up to meet demand. States had to account for multiple factors in deciding which forms of MOUD to use in their programs, including the expectations of DOC clinical providers, security within facilities, and community treatment supports upon re-entry.

Widespread concerns among corrections officials about potential diversion, as well as stigma about using agonists and partial agonists for treatment, has resulted in a slower adoption of their use in incarceration-based treatment. Though naltrexone has been more widely embraced by correctional facilities than agonists and partial agonists like buprenorphine and methadone, each state has included or is working to include at least two forms of MOUD. Beyond this, state officials also developed clinical protocols and program components based on state resources and needs, and certain experiences and design elements were common across the states.

Decisions around specific forms of MOUD. Maine’s program currently primarily utilizes buprenorphine, recognizing that methadone provision would require significant administrative and clinical policy change. Federal methadone treatment regulations require accreditations and standards that are challenging to meet for an existing correctional facility. ME DOC is, however, exploring opportunities to expand the program to include methadone over time. Additionally, because naltrexone has limited availability in the community for individuals upon release, policymakers were concerned that a program utilizing naltrexone may make connections to ongoing treatment challenging.

While Maine has had success with buprenorphine, current PA DOC policy does not provide for induction on buprenorphine to most incarcerated individuals with OUD – a challenge that is both clinical and administratively-based. Like many states, Pennsylvania contracts for medical care in state prisons, and the current contract was not written to include the provision of MOUD, particularly buprenorphine, which can be clinically intensive and comes with provider waiver requirements.

Per the Request for Applications (RFA) issued by PA DOC, the next iteration of the contract will include a requirement that the state’s corrections medical provider provide MOUD. The RFA stipulates that:

An Addiction Specialist, certified through the American Board of Preventative Medicine, be identified among the contractor’s leadership to support SUD treatment needs;
All providers are educated in SUD treatment;
The contractor must register each correctional institution in the Risk Evaluation and Mitigation Strategies (REMS) program in order to safely order, store, and administer buprenorphine.
Subcontracts are developed with opioid treatment programs to provide methadone at certain facilities; and
A sufficient number of provider staff hold a waiver to prescribe buprenorphine.

Regardless of current challenges, Pennsylvania is prioritizing buprenorphine induction for individuals with OUD who are re-entering communities, similar to the way in which they are currently providing naltrexone. Further, there is a push to be able to induct those who are using contraband opioids, often as a means of harm reduction, while incarcerated. While the state uses injectable buprenorphine for a small minority of program participants, state leaders are awaiting the late 2020 release of a shorter-acting, non-refrigerated formulation that may be less cumbersome to administer.

Attention to correctional workforce needs. Recognizing that addressing staff concerns about the provision of MOUD, including issues of security and diversion, would be necessary for the program to succeed, ME DOC leadership arranged a second site visit specifically for security staff to meet with their counterparts in Rhode Island. To gauge staff culture, ME DOC leadership also conducted an internal survey among staff to assess the general understanding of MOUD, the results of which were used to tailor subsequent staff training and education prior to program implementation.

Kentucky is contemplating the development of new workforce protocols to provide these services as part of the state’s proposed Medicaid waiver. The current approach uses KY DOC counseling staff who are not licensed as behavioral health professionals. The state may consider developing a new provider type of DOC-based professionals, requiring new or amended professional licensing regulations, reimbursement policy changes, and facility licensure changes if needed. The state is also deliberating what utilization of peers may look like in such a program, as well as what supervision for unlicensed staff would include.

Ensuring continuity of care upon re-entry. Individuals leaving incarceration face a host of risk factors for return to substance use and potential overdose, including lack of access to treatment and limited financial resources. In recognition of this, all three states ensure that program participants are enrolled in Medicaid coverage, safeguarding their access to continued treatment in the community. The ME DOC also contracts with Groups Recover Together, a community recovery organization that helps to ensure that individuals are connected to and engaged in recovery services upon re-entry.

Pennsylvania is also considering how individuals progress with treatment upon re-entry based on the treatment provided to them while still incarcerated. Currently, PA DOC is providing up to three naltrexone doses prior to release and is reviewing state Medicaid treatment data to understand the impact of multiple doses versus one dose on treatment outcomes in the community.

Coordination between state leadership. Because these programs often emerge from previously existing social or abstinence-based approaches, the development of protocols and resources must be coordinated under the direction of high-level state leadership. Officials in all three states indicated they had leaders who not only authorized but championed treatment in incarceration settings. These leaders were critical to developing treatment policy, and their continued focus on OUD-related initiatives was a key component to maintaining services. In 2018, Pennsylvania’s governor declared the overdose epidemic a statewide disaster, and he continues to renew that declaration to ensure that initiatives it supports – including treatment within PA DOC – are maintained. The declaration established a cross-agency Opioid Unified Coordination Group composed of cabinet-level health and public safety officials that meets weekly.

Kentucky is one of few states to have a dedicated Office of Drug Control Policy, which led the charge for them to be among the first states to fund and implement an incarceration-based naltrexone program in corrections. The state legislature is unique in the nation in its decision to direct the state Medicaid agency to explore and submit a Medicaid waiver to provide SUD treatment to incarcerated individuals.

Maine’s current governor appointed a cabinet-level State Opioid Response Director, and she included incarceration-based treatment among her top priorities for the state upon assuming office. The governor’s second Executive Order, signed less than a month into her term, directed the development of OUD treatment in criminal justice settings, and the state’s DOC commissioner was working to implement this within the first few weeks of her administration.

Funding and Support for Incarceration-Based Treatment Sustainability

Because of the inmate exclusion that prevents correctional facilities from receiving Medicaid reimbursement for services in incarceration settings, states are relying primarily on federal grant funding to support these programs.

Maine launched its pilot program without using any additional funds beyond its internal budget, receiving an additional $1 million in funding from the Maine Office of Behavioral Health’s federal substance abuse block grant to support the program later in 2019. Concurrently, ME DOC realized savings in its health care budget as a result of the state’s recent Medicaid expansion. With these additional funding streams, Maine was able to make its final program expansion by adding its last remaining correctional facility to the program and expanding program eligibility to allow individuals who entered a facility from a local jail to continue on a course of MOUD that had been established previously. This also allowed Maine to expand treatment to individuals who are 180 days pre-release.

Kentucky’s initial provision of naltrexone was supported through state legislation that allocated $3 million to the program, and the current program is supplemented through federal State Opioid Response funds provided via the Kentucky Opioid Response Effort (KORE). Pennsylvania similarly uses their SOR funding to support current programming.

Looking Ahead

States are looking to the future as they plan what OUD treatment services for incarcerated populations will look like, as well as how to fund such services with increasingly limited resources and current reliance on federal grants. There may be an emerging appetite to address the inmate exclusion and develop new approaches through Medicaid, though as the COVID-19 pandemic increases Medicaid enrollment and drives state revenues down, any new Medicaid-funded services will be challenging to state budgets.

Even in successful corrections treatment programs, lack of insurance coverage upon re-entry is a barrier to long-term treatment and recovery outcomes. A House bill introduced in 2019, known as the Re-entry Act, was written to allow states to reinstate eligibility for Medicaid for incarcerated individuals in jails and state prisons up to 30 days prior to re-entry. Recognizing that the COVID-19 pandemic has disrupted, if not altogether halted, re-entry services across the country, the bill’s language was integrated into pandemic response legislation as a part of the Heroes Act, which has yet to be passed.

Treatment programs in incarceration settings are helpful tools that states are using in hopes of reducing opioid overdoses, but also in reducing the stigma around SUD and the racial disparities in health outcomes for people with OUD. As states continue to take steps to tackle the opioid epidemic, state corrections settings are proving to be an innovative access point for evidence-based treatment.

*See Smith V. Fitzpatrick, et al. The lawsuit argued that the DOC was violating the Constitution and the Americans with Disabilities Act by denying treatment to prisoners with OUD. At the time, the Maine DOC had a policy generally prohibiting medication-assisted treatment, under which Smith would have been prevented from taking his medication and forced into acute withdrawal.

Acknowledgements: The National Academy for State Health Policy is providing this case study with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. Further, the authors would like to thank Allen Brenzel, medical director of the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities; Steven Seitchik, Statewide Medication Assisted Treatment Coordinator for the Pennsylvania Department of Corrections, and Ryan Thornell, Deputy Commissioner of the Maine Department of Corrections for contributing their expertise and state experiences to this brief.

Q&A: How West Virginia Uses Partnerships to Increase Opioid Use Disorder Treatment

August 24, 2020/in Policy West Virginia Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Kristina Long, Eliza Mette and Jodi Manz

The National Academy for State Health Policy (NASHP) recently spoke to Robert Hansen, executive director of West Virginia’s Office of Drug Control Policy, to learn how the state is expanding opioid use disorder (OUD) treatment access and capacity through strategic partnerships that support its Substance Use Response Plan’s goals.

West Virginia has made expanding access to medications for opioid use disorder (MOUD) a priority. How are you doing this?

In an experiment, conducted by the West Virginia Drug Intervention Institute at the University of Charleston, to locate a treatment provider willing to accept a new patient immediately, we found that access was dismal – no messages or voicemail and no appointments available until seven to ten days, or three weeks, or a month down the road. If you look at a listing in Kanawha County, you’ll see a lot of providers and you might assume that means a lot of treatment. But can you get in when you need help? West Virginia has had a growth in medically assisted treatment availability throughout the state. At last look, we have had a 59 percent increase in the number of waivered providers, but access is still an issue. Our state is very rural and most providers are available 9 to 5, Monday through Friday.

If we know anything about substance use disorder (SUD), we know people need access to treatment as quickly as possible. So, how do you do that in a state with many transportation challenges? West Virginia is tackling access issues by working with Bright Heart Health, which is helping the state expand MOUD availability. This national, for-profit organization specializes in using telehealth to provide round-the-clock treatment as well as rapid access to virtual assessment, enrollment, and crisis intervention. Through this partnership, people living in West Virginia can access care and treatment when they need it and regardless of where they are located, so long as they have access to a phone, tablet, or computer, and a reliable internet connection.

You’ve indicated that West Virginia’s expansion of Medicaid has been crucial in facilitating access to treatment in the state, how is Medicaid supporting this particular partnership?

Medicaid is very central to paying for ongoing services. We have three managed care companies that were just re-awarded contracts to work with our bureau of medical services. All three of them were able to fast track BHH’s application and enrollment, ensuring that these services could be implemented for Medicaid coverage quickly. Sometimes credentialing gets very bogged down, but I think all three companies in West Virginia have embraced this concept and this company.”

How have the state’s emergency departments supported access to OUD treatment? Is COVID-19 a factor?

Increasing access to treatment has to be a goal for addressing not only the COVID pandemic, but the opioid epidemic. We have several emergency rooms in our state that were [providing buprenorphine] before COVID, and that’s why we’ve made it a big initiative and worked with Mosaic to build out assessment, identification, and linkage to SUD services. Mosaic’s approach is multifaceted and involves working with ERs to screen all patients for SUD and develop clinical pathways to address individuals’ treatment needs, including incorporating peer recovery coaches into ER settings in order to fast-track people into treatment. There’s still stigma within the medical community, as there is in the community at large. I think that we lost momentum in [some of our initiatives] since mid-March, and now we’ve got to pick it back up.

How will West Virginia ensure that individuals remain engaged in treatment once they have been linked to treatment?

We are working on measuring [treatment] retention and continuous engagement, and I think we’re making strides – but, we have a long way to go. [Soon], as part of the Shatterproof ATLAS pilot initiative, we plan to go live with a webpage about West Virginia’s providers and how well they’re doing in delivering services according to Shatterproof’s National Principles of Care for addiction treatment. Through this pilot, West Virginia will be working with Shatterproof’s data partner to review Medicaid claims data and determine how providers are performing on a variety of key indicators, including treatment retention. These data will be available to state officials, as well as to managed care companies and individual providers.

How will West Virginia measure the effectiveness of these initiatives?

There are two big benchmarks that I live and die by – one is the number of overdose fatalities and two is the number of suspected overdose incidents. If you look at the national CDC (Centers for Disease Control and Prevention Centers) data on West Virginia fatalities, our rate per 100,000 is so much higher than the national average. [These projects] are just starting to hit the ground in West Virginia, and it’s going to be an evolutionary process, but the more individuals [we] engage, the better.

This blog is funded through a two-year grant awarded by the Foundation for Opioid Response Efforts (FORE). NASHP would like to thank Catherine Dunne, court accounts and special projects manager with Bright Heart Health, for her valuable contributions.

New Jersey’s Project ECHO Builds Provider Capacity to Support Maternal and Child Health during COVID-19

June 29, 2020/in Policy New Jersey Blogs, Featured News Home COVID-19, Health Coverage and Access, Health Equity, Health IT/Data, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health, Workforce Capacity /by Eddy Fernandez

Confronted with a pandemic that impacts the health of women and children – ranging from pregnancy and delivery to access to substance abuse treatment – a consortium of New Jersey state and health care experts launched a Project ECHO (Extension for Community Healthcare Outcomes) initiative to share COVID-19 expertise between specialists and primary care to meet the needs of women during the crisis.

Originally, the Rutgers Project ECHO partnered with the Robert Wood Johnson Medical School, New Jersey’s departments of Health, Human Services, and Attorney General, Division of Consumer Affairs, Rutgers Medical School, and The Nicholson Foundation to develop a Project Echo that focused specifically on maternal and child health (MCH) and opioid use disorder (OUD). This ECHO was to be funded through a federal Substance Abuse Prevention and Treatment Block Grant, but with COVID-19’s increased demands on community providers, New Jersey’s Department of Mental Health and Addiction Services agreed to postpone that effort and refocus on a COVID-19-specific ECHO.

Using interactive technology, the ECHO Model™ connects groups of community providers with specialists in regular collaborative sessions. The sessions, with case-based learning and mentorship, help local workers gain the expertise required to provide needed services, especially during a public health emergency.

This temporary change enabled the Rutgers team to address treatment issues, access to health care services, and how to meet the needs of specific populations of women during the crisis. The initiative has increased the workforce’s capacity to address the impact COVID-19 on pregnant and parenting women and advanced best care practices.

How Project ECHOs Work

Project ECHO, initially developed by the University of New Mexico to address hepatitis C, is a national model that focuses on building provider capacity across a region or state by connecting experts/specialists to local providers. This model, funded through a mix of public and private funds, encourages a virtual, bi-directional exchange of information between peers and subject matter experts on a particular topic. University hospitals are often the convening entity, with providers registering to join the events. Project ECHOs can allow any provider join in order to maximize local capacity building.

Discussion topics can be determined in collaboration with other stakeholders, such as the state Medicaid or public health agencies. Creating a Project ECHO for primary care providers, obstetricians, midwives, and others allows for informative discussion about maternal and child health and COVID-19 topics. For example, some providers may be particularly concerned about increases in maternal depression and/or anxiety and the intersection of COVID-19 and maternal mortality.

How New Jersey’s Project ECHO Works

New information continues to emerge about the impact of COVID-19 on pregnant women, strategies for limiting infection exposure during labor and delivery, and telehealth and other strategies to address SUD treatment during a time of physical distancing. Federal and state agencies are continuously releasing new guidance for providers and hospitals about billing and coding, telehealth, access to services, and most recently, guidance to medical facilities to allow non-emergency procedures. Maternal and child health (MCH) providers may want to seek additional support from other providers about limiting COVID-19 exposure and understanding the latest state-specific provider guidance for serving pregnant or postpartum women during this pandemic.

Responding to COVID-19, New Jersey’s Project ECHO devoted seven sessions between April and the first week of June 2020, to support MCH providers. It created the opportunity for participants to discuss interventions and increased their ability to respond to emergent needs. With support from the Nicholson Foundation, these Project ECHO sessions provided a forum to disseminate and share information and an opportunity for providers to ask questions and learn from each other.

During these sessions, providers heard from a number of experts who offered guidance and policies to address emerging issues.

Representatives from the Division of Mental Health and Addiction Services explained guidance on 28-day supplies of take-home medication and the impact of COVID-19 on opioid treatment programs;
Representatives from Cooper University Health Care discussed SUD treatment for pregnant and parenting women;
Medicaid representatives discussed the enhanced telehealth flexibilities the state was offering;
Experts discussed birth and delivery protocols, a concern in many states as providers seek to limit potential COVID-19 exposure to mother and child;
Social determinants of health, such as food security and housing, and their role in health outcomes; and
The potential impact of COVID-19 on the maternal mortality

These sessions provided an opportunity for providers to discuss challenges and share solutions to best support pregnant and parenting women. Other states can use a similar model to disseminate information and scale innovative practices to improve care for maternal and child health populations.

Funding opportunities for Project ECHOs have been identified through existing programs, philanthropic partnerships, as in the case of New Jersey, and with university support. Emergency Section 1135 and Section 1115 waivers can also be used to authorize matching federal Medicaid funds for Project ECHO sessions. Medicaid agencies can also work with managed care organizations to use or adjust existing contracts to explicitly provide financial support for these instructive sessions.

State Medicaid, public health, behavioral health, and social service agencies can leverage Project ECHO, in addition to state and federal guidance on COVID-19, to disseminate timely information and to facilitate the scaling of practices that are beneficial for women and children. The potential exchange of knowledge and information with other peers and subject matter experts can be beneficial as states open their economies and allow for non-emergency medical procedures. Sharing approaches that promote infection control and other safeguards for prenatal and postpartum care appointments can help them resume as states develop procedures to encourage these critical appointments.