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Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder

Summary 
  • Need: Increase access to medication-assisted treatment for opioid use disorder in Vermont.
  • Intervention: Statewide hub-and-spoke treatment access system.
  • Results: Increased treatment capacity and care coordination.
Description

With over 9,000 square miles, Vermont has a significant rural population with 8 of 14 hospitals designated as Critical Access Hospitals and 11 Rural Health Clinics. Though in the past Vermont was a leader for a number of waivered providers for office-based opioid treatment (OBOT) of opioid use disorder (OUD), providers were treating limited numbers of patients because of treatment-related challenges and lack of behavioral health partners.

Additional treatment barriers to medication-assisted treatment (MAT) for OUD were provider concerns for reimbursement as well as drug diversion problems, the transfer of one individual’s legally prescribed controlled substance to another for illicit use. To mitigate these issues for rural areas as well as the entire state, the Care Alliance for Opioid Addictions Initiative (2012-2016) was created by addiction medicine specialists and public health leaders. This approach is unique in linking OBOT and hub-based opioid treatment programs (OTP). As of 2017, Vermont has the highest capacity in the U.S. for treating OUD.

Central to the project was replicating chronic disease management principles, similar to congestive heart failure clinics staffed by cardiologists or HIV clinics with infectious disease specialists. In the Care Alliance model, addiction medicine specialists and specialty clinics were matched to initial treatment or relapse management of OUD using a coordinated hub-and-spoke treatment model that adapted a continuum of care model embracing collaboration and integration efforts.

Also built into the model was a unique bidirectional transfer process: the hub could transfer care to the spoke, and vice versa. Patients were transferred into hub for assessment and initial medication induction and medication stabilization. Once stable, patient care was transferred to the spoke. If the patient relapsed/destabilized, the spoke transfers the patient back to the hub.

A learning collaborative was a key element to the dissemination and implementation of this robust, comprehensive, statewide program.

Vermont Hub & Spoke Care Alliance map
Image credit: Vermont Department of Health.

The Care Alliance designated 5 geographic hub clinic areas where outpatient methadone treatment programs were given additional prescriptive authority for buprenorphine, an opioid blocking drug. Coordinated transfers between the hub and spoke was an intentional goal. Specifically, once patients were stabilized, they were transferred from the OTP to their primary care provider or a medical home for further OBOT.

Funding for the treatment leveraged reimbursement through aspects of the Affordable Care Act’s Home Health Services’ Community Health Teams. The National Institutes of Health and the National Institute of General Medicine Science also provided grant support for this project.

Services offered

Hub:

  • Specialty clinics with board-certified addiction specialists
    • Perform comprehensive physical and mental health evaluations
    • Treatment with buprenorphine or methadone, depending on patient assessment
  • Referrals to the hub originate from hospitals, emergency rooms, residential treatment programs, correctional facilities, and community mental health programs
Spoke:
  • Spoke-located Care Alliance MAT team
    • The Vermont Chronic Care Initiative provides 1 full time RN and 1 master’s-level licensed behavioral health provider/100 treated patients providing clinical, logistical and administrative duties that increased spoke provider prescribing efforts
    • Provides interested physicians with waiver-training information
    • Waivered providers are provided with on-going support when needed
Diversion Prevention: At both hub and spoke locations, patient medication dosing is observed to prevent diversion.
Results

Pre-implementation MAT wait times varied within the state. However, during 3-year implementation phase:

  • 2 regions eliminated treatment waiting lists
  • 2 regions nearly eliminated treatment lists
  • 1 region decreased waiting list from 6 months to 2 months

Waivered physician increased from 2012-2016, from a total of 173 to 283 providers. Additionally, there was a 50% increase in providers caring for more than 10 patients. By Sept 2015, 23% of spoke providers were caring for more than 30 patients and 10% caring for more than 50 patients

For more program details:

Brooklyn, J.R, Sigmon, S.C. (2017). Vermont Hub-and-Spoke Model of Care For Opioid Use Disorder: Development, Implementation, and Impact. Journal of Addiction Medicine; 11(4):286–292.

Richard A. Rawson. Vermont Center on Behavior & Health, The University of Vermont. Vermont Hub-and-Spoke Model of Care for Opioid Use Disorders: An Evaluation. December 2017.

Vermont Hub & Spoke
Image credit: Blueprint for Health
Barriers
  • Staffing shortages
  • Data collection across treatment network
Replication

To replicate this project’s success in other states or regions:

  • Involve passionate physician leaders
  • Understand that spoke MAT teams are integral to achieving success
  • Provide education for policy makers:
    • Chronic disease aspects of OUD
    • MAT waiver training is not equal to addiction medicine certification
  • Use Learning Collaborative to promote common language central to achieving project goals
  • Entertain Medicaid expansion as necessary for overall success
  • Partnering with a state health department that’s committed to providing comprehensive MAT access
Contact Information
John R. Brooklyn M.D., Clinical Assistant Professor
Department of Psychiatry, The University of Vermont
johnr.brooklyn@gmail.com
Topics
Access
Illicit drug use
Prescription drug abuse
Service delivery models
Substance abuse
States served
Vermont
Date added
June 13, 2018

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.