Problem Addressed

In 2017, Pennsylvania (PA) accounted for the third-highest rate of drug overdose deaths in the country.² Prior to the implementation of this innovation, the Geisinger system had disparate foci and approaches to caring for its substance abuse patients, depending on the care setting. Outpatient services were focused on reducing opioid prescribing, but not on the use of MAT for the treatment of the addiction. Geisinger has operated the 91-bed inpatient rehab and detox facility, Geisinger Marworth, for the past 38 years. However, inpatient treatment alone is often inadequate to address opioid addiction because of the chronic nature of this brain disorder. Unfortunately, prior to implementation, the treatment culture in PA focused on an inpatient abstinence-only model rather than integrating the use of medication-assisted treatment across all care settings.³

The team at Geisinger sought to develop an outpatient addiction medicine specialty program that incorporated MAT, peer support, and connection to community counseling services that uses data-driven insights to monitor and improve patient outcomes.³

Description of the Innovative Activity

Geisinger’s outpatient addiction medicine clinics primarily focus on MAT, including buprenorphine or naltrexone, to manage maintenance of substance use disorders. However, the clinics additionally provide a more holistic approach to patient care and focus on care coordination related to social determinants of health, peer support, and connecting individuals to community counseling resources. One of the critical components of the initiative is that the patient’s specific substance use disorder treatment information is embedded into Geisinger’s electronic health records (EHR) system. This allows for treatment information to be seen by providers across the health system, for the abstraction of key performance indicators (KPI) in a dashboard that tracks clinical and operations trends, and allows for data-driven decision making and policy development to support clinical outcomes and patient engagement.³

In addition to these services, Geisinger designed a color-coded patient acuity scale that classifies patients into two different treatment objective categories:³

• Functional improvement: Goal of gradual cessation of substance abuse
• Harm reduction: Goal of keeping the patient engaged and alive while mitigating the spread of infectious disease via intravenous injection

The objective of this acuity scale is to define clinical criteria which can standardize practice according to best practice guidelines for common clinical presentations. A downstream impact is the ability to cohort patients for purposes of clinical outcome tracking on objectives such as increasing patient engagement and decreasing overdose mortality. 

Those in the “harm reduction” category are required to attend fewer clinic visits and counseling verification requirements are less stringent than for those in the “functional improvement” category. This policy decision is based on evidence that even some patient engagement is better than no engagement. It is designed to not only keep more patients in the program, but also to make more clinic time available for access by all patients. With physician agreement, patients can choose to move from the “harm reduction” to the “functional improvement” category at any time.³

Geisinger’s addiction medicine clinics are staffed by addiction coordinators who are familiar with local patient resources and have backgrounds in substance abuse treatment. Multidisciplinary teams are led by addiction specialists. The team maintains close relationships with community resources, which provide many of the counseling services offered to patients.³

Context of the Innovation

In 2016 the Governor of PA created the Centers of Excellence for Opioid Use Disorder (COE) within the PA Department of Health and Human Services to tackle the opioid abuse crisis in the state.² Through this program, Geisinger received a grant to support and fund care managers to coordinate and manage patients, with a focus on connecting individuals to MAT. Geisinger created its own services embedded within its integrated delivery network and placed them in communities with the greatest need.

Results

The innovation has been successful at the following:³

• Reduced all-cause mortality. The all-cause mortality rate among individuals in the program is 81% lower than in individuals with untreated substance use disorder. Data has stabilized at 9-deaths per 1,000 engaged patient-months.
• Increased patient engagement. Maintaining patient engagement in substance abuse programs is an ongoing concern. However, the introduction of the harm acuity scale to evaluate patient disease and the creation of two categories of patient-program objectives has increased patient engagement in the program from 130 days to 218 days.
• Decrease in quantity of controlled substances. Geisinger has observed a decrease of 34% in the quantity of substances with a medium to high risk for abuse prescribed after 90 days.

Planning and Development Process

While this type of initiative does work best within an integrated delivery network with EHR data that can be tracked, measured, and shared across settings, the core of the innovation continues to be beneficial for other institution types. When planning for implementation it is critical to work with the IT team to ensure access to the right data for KPIs of interest. 

Resources Used and Skills Needed

In both the initiation and sustainment of this innovation, it is critical to ensure the involvement of a multidisciplinary care team that can address a variety of patient needs. While the exact size and composition of the team may vary, typically a team consists of an Advanced Practice Provider, a nurse, and a care manger. An addiction specialist physician should oversee this team. In addition to staffing by a multidisciplinary care team, the clinic should establish and maintain connections to community resources available to meet different counseling needs. As the Geisinger model does not attempt to address the multitude of different psychosocial needs of a patient within the clinic itself, these connections to outside community resources are critical.

Funding Sources

An initial grant provided the funding necessary to support upfront costs associated with the innovation. However, since establishing the innovation, clinical operations are now sustainable through reimbursement contracts with different patient insurance companies. These include some bundled contracts associated with providing the coordination, oversight, and treatment of patients, as well as some reimbursement from Medicaid.

Getting Started with This Innovation

When launching this innovation, the Geisinger team recommends keeping in mind the following:

• One size does not fit all, and while this model may serve as guidance, it should be modified to fit your organization, ensuring that it is flexible enough to evolve over time.
  • Treatment of substance use disorders is a relatively new field and a new specialty. As evidence evolves and you determine what works best within your setting, you may need the ability to refine your program over time.
  • Ensure consideration of system-specific intricacies and nature of the local community.
• Work to establish strong partnership with champions in care settings that frequently encounter individuals with substance use disorders, in particular the emergency department (ED).

Sustaining This Innovation

Geisinger has found that by establishing reimbursement contracts both with private insurance and Medicaid, that they were able to overcome the biggest barrier to sustainment – funding. However, funding is only one component and the team identified a number of other factors as critical to the ongoing success of the program: 

• Education. There is a great deal of stigma associated with substance use disorders. As evidenced by the limited number of MAT facilities in PA prior to implementation of this intervention, substance use disorder has frequently been treated as a choice rather than a disease. Education for the community that this is a disease that requires specialized treatment helps to alleviate some of this stigma and encourage individuals to seek care when they need it.  
• Advocacy for behavioral health. Behavioral health may not fall within traditional funding and reimbursement mechanisms within your facility. Additionally, advocacy efforts may be needed to receive buy-in from the executive level to prioritize and implement an innovation in behavioral health.  
• Identification of ROI. It is critical to identify tangible benefits of the program that can be measured to demonstrate ROI and a sustained business case for continuing the program. For example, reduced ED visits or reduced readmissions demonstrate that the program is not only self-sustaining from a funding perspective but is also saving the system money in other areas.

References/Related Articles

Barbour JS, Jarvis MA, Withers DJ. How Geisinger Dramatically Reduced Deaths from Opioid Use Disorder. NEJM Catalyst Innovations in Care Delivery. 2020;1(2). DOI: https://doi.org/10.1056/CAT.20.0018.

Footnotes

1. Alaigh P, Zander G, Pringle JL. Pennsylvania’s Novel Public-Private Approach to Combatting the Opioid Crisis. NEJM Catalyst Innovations in Care Delivery. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0302. Published October 1, 2020. Accessed January 15, 2021.
2. Centers of Excellence. Pennsylvania Department of Human Services. https://www.dhs.pa.gov/Services/Assistance/Pages/Centers-of-Excellence.aspx. Accessed January 15, 2021.   
3. Barbour JS, Jarvis MA, Withers DJ. How Geisinger Dramatically Reduced Deaths from Opioid Use Disorder. NEJM Catalyst Innovations in Care Delivery. 2020;1(2). DOI:https://doi.org/10.1056/CAT.20.0018.

Original Publication

February 10, 2021

Date Verified by Innovator

February 8, 2021