Addressing Opioid Use in California by Investing in the Hub & Spoke Model

Between 2015 and 2016, the number of drug overdose deaths increased by 22%, with more than 64,000 deaths nationwide. Opioids are responsible for more than 66% of these fatalities. California is home to more people with opioid use disorders (OUDs) than any other state in the country; and some small counties in California have higher rates of overdose deaths than most states.

Image from:

http://www.uclaisap.org/ca-HubandSpoke/html/project-info.html

In an effort to address the opioid crisis, the California Department of Health Care Services (DHCS) is taking advantage of funding available through the 21st Century Cures Act. With $90 million in new federal grant funds over two years, the state is implementing the Medication Assisted Treatment (MAT) Expansion project, which has three components:  1) the California Hub and Spoke System (CA H&SS); 2) the Tribal MAT Project; and 3) Prevention and Treatment Activities.The goals of the MAT Expansion Project are:

Improving access to MAT services in at least 30% of counties with the top ten highest overdose rates;Expanding access to integrated MAT services in urban areas; andIncreasing access to Narcotic Treatment Programs (NTP) and/or Medication Units (MUs) in underserved areas by three clinics.

The largest component of the MAT Expansion, the California H&SS, is modeled after the Vermont Hub and Spoke Model, which had shown promising results to date.

Vermont Hub and Spoke Model

Results of Vermont Hub & Spoke Evaluation

96% decrease in opioid use92% decrease in injection drug use89% decrease in emergency department visits90% reductions in illegal activities and police stops/arrestsZero overdoses in 90 days prior to being interviewed while receiving treatment through the Hub and Spoke system, versus 25% who had overdosed before entering treatment

Vermont’s Hub and Spoke Model is made up of five regions, each with a “Hub,” which is defined as a licensed outpatient treatment program (OTP) authorized to dispense buprenorphine and methadone. Each Hub is connected to a network of “Spokes,” which are medical practices that provide office-based opioid treatment with buprenorphine. This system is beneficial to individuals being treated with OUDs who are able to transfer easily between a Hub and a Spoke based on their needs and clinical assessments.A recent evaluation conducted by the University of Vermont demonstrated that the H&SS is resulting in positive outcomes for patients. Hub and Spoke patients noted that the most important part of their treatment was their relationship with their providers, increased access to counselors, and the role that the Spokes play in destigmatizing treatment. Participants reported that they “benefitted from receiving MAT in the same setting as their medical care” and in-depth interviews demonstrated that “the Spoke environment was a powerful positive influence on participants’ self-esteem and attitude toward treatment.”

California MAT Expansion

California hopes to achieve similar success through its MAT Expansion project, and the H&SS in particular. The connected and complementary roles of Hubs and Spokes (see table below) will allow for patients to begin receiving services at either a Hub or Spoke (as deemed appropriate) following a clinical assessment, and transfer easily between the two when the level of care they need changes, enabling more consistent and sustainable treatment over time. The CA H&SS currently has 19 Hubs throughout the state, and a growing number of Spokes associated with each.

Figure 1: California Hub & Spoke Roles

Hubs

Spokes

Licensed Narcotic Treatment Programs or Medication Units

Serve as the regional consultants and subject matter experts on opioid dependence and treatmentProvide care to clinically complex patientsManage buprenorphine inductionsSupport Spokes that need clinical or programmatic advice

A federally waivered prescriber,

or

one or more federally waivered prescribers and a MAT team

Provide ongoing care for patients with milder addiction (managing induction and maintenance) and for stable patients on transfer from a HubMonitor adherence to treatmentCoordinate access to recovery supportsProvide counseling

By leveraging its existing payer programs, such as Medi-Cal (California’s Medicaid program) and private insurance, California took a sustainable approach to financing the H&SS. Grant funding is available to pay for services under the CA H&SS only after all other sources of funding and revenue are utilized. Grant funds are also used to support learning collaboratives for the Hubs and Spokes and to provide mentoring and other educational resources to providers within the system, especially prescribers.

Harbage Consulting’s Role

Harbage Consulting is providing implementation support to DHCS for the California MAT Expansion project. We are helping to design materials to inform stakeholders about the new opportunities available through the CA H&SS and working to ensure that the system is complementary and inclusive of other efforts to combat the opioid epidemic across the state.Harbage is working closely with DHCS and the University of California, Los Angeles (UCLA), which is running the CA H&SS Learning Collaborative and conducting the HS&S evaluation, to develop and disseminate materials, including resources for prescribers and community system partners, such as emergency rooms and poison control. Lastly, we are facilitating a quarterly Learning Collaborative open to all states implementing the Hub and Spoke Model. We are proud to be working on this project that will help Californians with OUDs access live-saving care.To learn more about the CA H&SS and the MAT Expansion project, click here.

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Authors

Lucy Pagel [Director]