Emergency Department and Bridge Clinic Services (C2319) - KORE/SOR Supplies

Kentucky Opioid Response Efforts (KORE) Proposed Scope of Work Emergency Department and First Bridge Clinic UK HealthCare & Center on Drug and Alcohol Research Draft Background Kentucky is at the epicenter the most pressing public health crisis facing the United States today: opioid use disorder (OUD), overdose, and death. This treatable disease, along with secondary complications such as Hepatitis C and HIV, is destroying lives and our communities. Access to effective FDA-approved therapies and harm-reduction interventions are needed now. UK HealthCare acknowledges that millions of dollars are required to staff and equip new programs in the Emergency Departments (ED) at Good Samaritan and Chandler; the outpatient Bridge Clinic in the Center on Drug and Alcohol Research; and opioid overdose education with naloxone training/distribution programs, as articulated in the State's KORE directive. UK HealthCare and the Center on Drug and Alcohol Research (CDAR) propose a plan to invest the $500,000 from the CURES funding for new patient care by linking those presenting for overdose at the ED (highest priority population) to medication-assisted treatment at the First Bridge Clinic, a new outpatient transitional care clinic staffed by licensed professionals and offering evidence-based treatment. By leveraging work and infrastructure that is currently underway at UK, the CURES allocation will expand capacity to treat patients and save lives in the Bluegrass Region and surrounding areas. Initial Operational Plan We are proposing to launch First Bridge Clinic, to be located at 845 Angliana Avenue in current CDARoccupied space. At launch, the hours of operation will be during regular business hours, Monday through Friday. The First Bridge Clinic will specifically support the emergency departments at Chandler and Good Samaritan Hospitals. Patients presenting to those emergency departments with opioid overdose (highest priority) or other sequalae of opioid use disorder will be identified through screening by health providers and existing social work staff within the hospitals. The social work staff is available 7 days a week, from 7AM to 11PM. The social work staff will initially complete a structured standard screening tool and a locator instrument to ascertain best methods of contacting patients (e.g., phone, text, email, etc.). Those patients who express interest and/or willingness to consider outpatient treatment will then be linked to First Bridge Clinic. This linkage can occur by phone or fax to clinic staff. All of these contacts will be captured in a database. All patients will be offered a naloxone prescription in the ED. The First Bridge Clinic will hire a peer support specialist (PSS), who will initially have immediate access to patients through video-conferencing on a secure iPad or other mobile device approved for use in the emergency department at UK Healthcare. Initially, virtual interaction between patients and PSSs will occur during regular business hours. For those patients presenting outside of business hours, the ED will collect information from all qualified patients and transmit this information to the First Bridge Clinic in order to initiate peer support services as quickly as possible. Patients will also receive a contact card with the PSS information. Appropriate consent for release of information that falls under HIPAA and the Code of Federal Regulations for substance abuse services will be incorporated into the initial screening process. The PSS will attempt to make regular contact with potential patients daily for five business days, at ~14 days and ~28 days after the ED visit. These outreach efforts and outcomes will be documented. Once patients are connected, the PSS will mentor, guide and encourage patients to initiate treatment and assist in their other recovery support needs. Peer support specialists require regular, intensive, face-toface supervision by a qualified licensed professional whom the same employer employs. A licensed qualified Social Worker or other professional at First Bridge Clinic will supervise the PSS. Patients interested, willing and qualified for outpatient treatment will be evaluated on an outpatient basis at the First Bridge Clinic by licensed professionals, including x-waivered physicians and possibly Nurse Practitioners as this group becomes certified to practice and other staff as appropriate. Transportation from the ED to First Bridge will be provided as needed, and this may include vouchers for car service, payment to Uber, the hospital shuttle or other methods. Patients may be offered treatment with buprenorphine or naltrexone formulations approved for the treatment of opioid use disorders. Ongoing treatment will include counseling, urine testing, health referrals, and other ancillary services. All care will be evidence-based and compliant with KBML and federal regulations. Patients will remain in treatment until an appropriate transfer to another provider for ongoing care can be made. Other high-risk patient groups may qualify for care in the First Bridge Clinic, including patients who are hospitalized at UK for complications related to their OUD (osteomyelitis, endocarditis) and post-partum women (e.g., exiting Pathways Program at UK). With regard to estimated numbers of contacts for opioid overdose presentations specifically; we are relying on estimates from reporting by the Kentucky Injury and Prevention Research Center. The most recent publicly available data are from 2014 and report over 500 OD presentations to Chandler and Good Samaritan emergency departments. Those numbers have risen since that reporting year and suggest that OD presentations are occurring at a rate of ~2/day. The largest emergency department intervention to date (D'Onofrio et al., 2017)1 identified individuals suitable for treatment and less than 10% of the cohort was patients presenting with opioid overdose specifically. Anecdotally, physicians indicate that overdose patients are often uncomfortable from naloxone-precipitated withdrawal and anxious to leave the hospital. Thus, it is difficult to predict, of the total presenting cohort, how many will be interested in pursuing treatment. Our goal will be to make contact with ALL overdose patients to assess willingness and interest in treatment. Program outcomes will include, but not be limited to, the number of ED contacts/referrals, the number of patients screened at First Bridge, the number of patients entering treatment, treatment responses, and the number of patients successfully transitioned to permanent care. These outcomes will help to inform future interventions and guide practice. 1D'Onofrio, Chawarski, O'Connor, Pantalon, Busch, Owens, Hawk, Bernstein, Fiellin (2017) Journal of General Internal Medicine, 32 (6): 660-666. FREEMAN ¡V SCOPE OF WORK Expanding Access to VivitrolÆÊ using a Community Pharmacy Practice Model: A one.year Pilot Project Center for the Advancement of Pharmacy Practice Scope of Work for KORE June 20, 2017 Background and Rationale: Pharmacists are highly trained healthcare professionals with great ability to impact patient and public health, yet remain grossly underutilized within the healthcare community. Community pharmacists offer unparalleled access points for OUD treatment, overdose prevention and related harm reduction services, with at least one community pharmacy located in 119 of Kentucky¡¦s 120 counties. Pharmacists are participating in VivitrolÆÊ programs currently at two sites in KY ¡V Bluegrass Community Health Center in Lexington and St. Matthews Community Pharmacy in Louisville. and have established successful collaborative relationships with drug court officials and OUD treatment providers that we can use to develop our care delivery model. UK¡¦s CAPP has relationships with community pharmacists across the state and led the development of the training program required by the Board of Pharmacy to implement SB 192 which since May, 2015, has been used to train more than 1700 pharmacists and student pharmacists. In this pilot project, we will partner with pharmacists from Bluegrass Community Health Center in Lexington (Tera McIntosh) and St Matthews Community Pharmacy in Louisville (Chris Harlow) to integrate and build on their existing VivitrolÆÊ programs to develop the community.pharmacy care delivery model for VivitrolÆÊ. Training for administration and management of Vivitrol and implementation of the pharmacy.based care delivery model will be developed by the Center for the Advancement of Pharmacy Practice (CAPP). Once the care delivery model is developed and select pharmacists trained, we will facilitate collaborations between community pharmacists and local opioid use disorder (OUD) treatment providers offering psychosocial interventions, including Kentucky¡¦s 15 Community Mental Health Centers, as well as between local prison and drug court officials to identify individuals in need of VivitrolÆÊ therapy as they transition from criminal justice settings. Pharmacists implementing care delivery model would purchase and maintain VivitrolÆÊ inventory and would bill Medicaid MCOs or other third.party payers for the medication and its administration as appropriate. Individuals who are uninsured or whose insurance plan does not adequately cover the costs of VivitrolÆÊ could receive VivitrolÆÊ purchased by grant funds. As take.home naloxone is indicated for any individual with a history of OUD, pharmacists would also dispense and educate on use of naloxone. Once the care delivery model is established and implemented in select pharmacy sites, the program could be scalable to include additional community pharmacies in areas of highest need. FREEMAN ¡V SCOPE OF WORK Project Goals: We propose to increase access to VivitrolÆÊ by: 1) developing a community.pharmacy care delivery model for VivitrolÆÊ.based MAT 2) training community pharmacists to appropriately administer and manage VivitrolÆÊ therapy and implement the care delivery model 3) facilitating the establishment of collaborative relationships between officials overseeing release of incarcerated individuals, drug court officials, community pharmacists and practitioners who provide psychosocial interventions (CBT) for delivery of quality MAT for individuals re.entering the community following incarceration or drug court Project Timeline: July 1 ¡V Aug: Review practice models at St Matthew Community Pharmacy and Bluegrass Community Health Center to identify implementation successes and challenges and identify community partners from correctional and other rehab facilities in targeted areas as defined by CHFS Sep ¡V Oct: Refine community pharmacy practice model and develop pharmacist training for program implementation Nov¡V Dec: Recruit and train pharmacists/pharmacies for participation in VivtirolÆÊ administration program in targeted areas as defined by CHFS and facilitate collaborations between community pharmacists and local opioid use disorder (OUD) treatment providers offering psychosocial interventions and drug court officials Jan . June: Implement practice model at 4 sites and assess impact of practice model on VivitrolÆÊaccess