Division of Alcohol and Drug Abuse Programs
Vermont Hub and Spoke model for OTP’s as Health Homes
March 29, 2015
Tony Folland
Vermont SOTA
Vermont Department of Health
Vermont
Population 626,562
1. Northwestern Hub
HowardCenter Chittenden Clinic
Chittenden, Franklin, Addison &
Grand Isle
2. Northeastern Hub
BAART Behavioral Health Services
Essex, Orleans & Caledonia
3. Central Vermont Hub
Central Vermont Addiction Medicine
Washington, Lamoille & Orange
4. Southwestern Hub
Rutland Regional Medical Center
Rutland & Bennington
5. Southeastern Hub
Southeast Regional Comprehensive
Addictions Treatment Center (Habit
OPCO & Brattleboro Retreat)
Windsor and Windham
Brief Evolution of MAT Services
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Late entering MAT services, 1st OTP opened in October
2002
Opened Buprenorphine Induction Hub in 2004
Quickly became #1 nationally in per capita DATA 2000
waivered physicians
OTP expansion to 5 in state clinics and 1 out of state clinic
with significant Vermont utilization
In 2012 650 individuals treated in OTP’s and roughly
1500-1800 in OBOT programs.
2011 Development of MAT treatment rules to regulate
DATA 2000 waivered physicians with 30+ patients
3
Vermont Department of Health
Integrated Health System for Addictions Treatment
Corrections
Probation &
Parole
Family
Services
Residential
Services
Spokes
Nurse-Counselor Teams
w/prescribing MD
HUB
Mental
Health
Services
Spokes
Assessment
Care Coordination
Methadone
Complex Addictions
Consultation
Spokes
Substance
Abuse OutPt Treatment
Nurse-Counselor teams
w/prescribing MD
Medical
Homes
Vermont Department of Health
Spokes
In Patient
Services
Pain
Management
Clinics
Care for Complex Addictions – the “Hub”
“HUB”
A Hub is a specialty treatment center responsible for coordinating the
care of individuals with complex addictions and co-occurring substance
abuse and mental health conditions across the health and substance
abuse treatment systems of care. A Hub is designed to do the following:
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Provide comprehensive assessments and treatment protocols.
Provide methadone treatment and supports.
For clinically complex clients, initiate buprenorphine or antagonist
treatment and provide care for initial stabilization period.
Coordinate referral to ongoing care.
Provide specialty addictions consultation and support to ongoing care.
Provide ongoing coordination of care for clinically complex clients.
Vermont Department of Health
Developing The “Hub”
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Engaged stakeholders regionally, statewide and within the state system
Introduced concept to community providers and sought participation in
committees
 Pregnant women, Children and Families Workgroup
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Physician Workgroup
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Identify resources, services and connections for women and family supports
Clinically driven algorithm development for matching patients with
pharmacotherapy agents and clinical treatment settings
Guidelines for medical screening and comprehensive assessment
Guideline development for patient structure, if medication other than
Methadone (eg. Daily dosing vs. multitude of OBOT structure options)
Clinical Workgroup
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Behavioral health screening, admission, assessment, and treatment planning
procedures for the hubs
Operationalizing “Health Home” language/definitions with behavioral health
supports (eg. Health Promotion=Treatment and Patient self-management)
Care for Complex Addictions – the “Spoke”
“SPOKE”
A Spoke is the ongoing care system comprised of a
prescribing physician and collaborating health and
addictions professionals who monitor adherence to
treatment, coordinate access to recovery supports, and
provide counseling, contingency management, and case
management services. Spokes can be:
 Blueprint Advanced Practice Medical Homes
 Outpatient substance abuse treatment providers
 Primary care providers
 Federally Qualified Health Centers
 Independent psychiatrists
Vermont Department of Health
Spoke (OBOT physicians with support)
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Polled OBOT physicians regarding most significant
concerns/barriers to expansion or perceptions of
optimal care
Consistent feedback: patients may require more
time/coordination of care than physicians had in
their schedules
Using existing VT Health Home infrastructure
(Blueprint for Health) Community Health Team
model physicians were offered in-office supports
Spokes continued
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Any willing provider
any structure of OBOT provider
New or existing providers
Vermont Department of Health
Health Home Services Defined
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Comprehensive care management
Care coordination
Health promotion
Transitions of care
Individual and family support
Referral to community services
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Vermont Department of Health
Comprehensive Care Management
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Comprehensive care management includes
activities undertaken to identify patients for
MAT, conduct initial assessments, formulate
individual plans of care, and manage patient
care across the health, substance abuse and
mental health, social services and long term
systems of care.
Vermont Department of Health
Care Coordination and Referral to Community Supports
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Once an individualized plan of care is developed,
the Health Home RNs and licensed clinician case
managers are primarily responsible for monitoring
its implementation (with patient engagement)
through appropriate coordination, referrals, and
follow up of services and supports across treatment
and human services providers.
Vermont Department of Health
Health Promotion
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Health promotion activities are part of every plan
of care and include activities that promote patient
activation and empowerment for shared decisionmaking in treatment, healthy behaviors, and selfmanagement of health, mental health, and
substance abuse conditions. Depending on the needs
of the individual, the patient may elect to engage in
one-on-one activities or group educational health
promotion programs.
Vermont Department of Health
Care Transitions
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Care transitions focus on streamlining the movement
of patients from one treatment setting to another,
between levels of care, and between health,
specialty mental health and substance abuse, and
long term care providers.
Vermont Department of Health
Individual and Family Supports
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The RNs and licensed clinician case managers are
primarily responsible for supporting the resilience
of patients and their families through various
activities, including but not limited to: advocacy,
assessments of individual family strengths and
needs, education about the Agency of Human
Services resource systems, and facilitating
participation in the ongoing development and
revision of care plans.
Vermont Department of Health
Payment Methodologies In Hubs
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Under ACA 90/10 split for up to 8 quarters (2
years) for health home related services
Overall estimated that 30% of Hub services met
criteria for 90/10 funding
Monthly bundled rate payment to providers
$ 493.37 PMPM with 1 documented health home
service
345.36 with TAU
Note: If Buprenorphine or Naltrexone products are the pharma, meds are
paid outside of this PMPM rate
Vermont Department of Health
OBOT Health Home Supports
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ACA funding for 2 FTE, non-billing responsible staff
per 100 patients 90/10 funding split in Spokes
(ACA section 2703 VT SPA)
1 FTE licensed behavioral health provider
1 FTE nurse provider
Any configuration of service providers/service
areas to provide Health Home Services
Vermont Department of Health
Data Considerations
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Physician visit planners/panel management
guidelines developed consistent with other chronic
illnesses
Standard OTP documentation requirements and
physician chart notes
Standardized releases across hubs
Standardized waitlist reporting
Accreditation Requirements
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NCQA PCMH requirements (specialty care) mirror the primary
care standards: over 86% of all Vermonters in PCMH practices
Blueprint for Health support: project manager and embedded
staff supports
First Hub (Chittenden Center) has completed its baseline
assessment of data
Vermont Child Health Improvement Program (VCHIP) doing
evaluation assessing program adherence and cost impacts
Vermont Department of Health