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Digital Health Transformation and Alternative Delivery Models

Part one of a two part blog series on Care for Substance Use Disorder Populations during COVID-19.

Content provided by Jill S. Warrington, MD, PhD. Blog edited by Alexa De Vivo.

The COVID-19 pandemic has led to unprecedented changes globally, in our communities and in health care. Like a latex balloon that has been stretched and never bounces back to its original form, health care delivery will never be the same as we navigate through and past this emergent crisis.

The silver lining in this challenging global emergency has been the ingenuity and innovation across our country and our world. We have seen remarkable collaborations, accommodations and accelerated transformations.

Changes in health care delivery have spanned five domains of medical care. We have seen a transformation of digital health, ingenious alternatives to traditional care delivery models, adjustments in regulatory and payor strategies, an adoption of a population health approach to care and an increasing recognition of our patients’ unmet social and behavioral health needs. If progress continues in each of these domains, long-existing care gaps can be obliterated.

Digital health transformation and alternative delivery models are helping to pave the way for the future of healthcare, post COVID-19. While telehealth was being offered at most healthcare establishments in the pre-COVID-19 world, the spread of mandated stay at home orders prompted telehealth across the globe.

Large health systems such as Geisinger Health System and the Cleveland Clinic have reported a 5-10-fold increase in use of telehealth services (1). We’ve also witnessed adoption of novel strategies in surveillance and triage such as the use of Chat Bots to support patient symptom identification and facial scanners in hospitals to recognize fevers (1,2). Anecdotal reporting for the Substance Use Disorder (SUD) population suggests digital health solutions have reduced numbers of missed appointments (3).

Alternative delivery models were used before the introduction of COVID-19 but many health systems sped up the process of developing take home or remote methods for medical testing.

Prior to and in response to COVID-19, laboratory services were innovating in alternative care delivery models such as at-home blood draws (4), drone use in medical product delivery (5) and at home monitoring programs (6). Further development of these types of innovations will only be aided by COVID-19.

Part two of this blog series, "How is COVID-19 Redefining Care Delivery for the SUD Population?", will discuss regulatory shifts and population health adaption. It will also go over recognition of unmet social and behavioral health needs.

References:

1) Paddy Padmanabhan, 3-27-2020, How the COVID-19 pandemic is reshaping healthcare with technology, CIO. https://www.cio.com/article/3534499/how-the-covid-19-pandemic-is-reshaping-healthcare-with-technology.htm [last accessed, 5/5/2020].

2) Greg Nichols, 3-27-2020, Coronavirus: Business and technology in a Pandemic. Robotics. https://www.zdnet.com/article/overhead-scanners-screen-bystanders-for-signs-of-covid-19/, [last accessed, 5/5/2020].

(3) Mindy Miller, personal communication.

(4) https://www.northwell.edu/northwell-health-labs/labfly, [last accessed, 5/5/2020].

(5) Paavola A. 6 things to know about WakeMed’s drone delivery program. 2-24-2019. Becker’s Hospital Review https://www.beckershospitalreview.com/supply-chain/6-things-to-know-about-wakemed-s-drone-delivery-program.html, [last accessed, 5/5/2020].

(6) American Society of Addiction Medicine, COVID-19 Adjusting drug testing protocols. 4-29-2020. https://www.asam.org/Quality-Science/covid-19-coronavirus/adjusting-drug-testing-protocols, [last accessed, 5/5/2020].

Medication-Assisted Treatment (MAT; also known as Medications for Opioid Use Disorder; MOUD) is a lifeline for so many in treatment with Opioid Use Disorder. In particular, the combination product of buprenorphine-naloxone (Suboxone) has saved lives by preventing overdoses, reducing IV heroin-associated infectious diseases - such as HIV and Hepatitis C - and by improving patient's chance of staying in treatment.

Given the importance of buprenorphine treatment, patients at times can feel pressure to demonstrate that they are staying on the medications, even if they haven't been able to stick with the treatment plan. This can result in feelings of shame, fear of repercussions, or a desire to not disappoint their provider. As part of the disease process, patients may even be motivated by the desire to divert or sell some of their medications.

Due to these pressures, patients can occasionally engage in a practice where they "spike" the original drug directly into their urine. In this case, buprenorphine will be detected in a patient's urine, but it will not have been actually consumed. This practice will be missed on any common immunoassay-based screening method. However, if confirmation testing is ordered, both the original drug (also known as the parent drug) as well as the drug's metabolite (norbuprenophrine) will be detected.

Providers have increasingly relied upon the ratio of the metabolite norbuprenorphine to the original drug (buprenorphine), known as the N:B ratio, to identify this practice of spiking urine samples with drug. Since naloxone is also part of the Suboxone combination product, there has been some speculation that naloxone levels can also be used to highlight this practice.

Aspenti conducted a study to determine if elevated naloxone levels can be used to flag possible cases in which patients have spiked their urine with drug. Though only a small case study, this was the largest evaluation of urinary naloxone concentrations to date. We found that naloxone levels (>2000 ng/ml) may be useful clinically to flag cases of possible urine spiking with Suboxone.

To learn more about this recent study, please see the article here: https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-020-0178-9.

[post_title] => Using Naloxone Levels To Detect "Spiked" Urine Tests [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => using-naloxone-levels-to-detect-spiked-urine-tests [to_ping] => [pinged] => [post_modified] => 2020-01-27 13:38:12 [post_modified_gmt] => 2020-01-27 18:38:12 [post_content_filtered] => [post_parent] => 0 [guid] => http://aspenti.com/?p=60244 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 59345 [post_author] => 13 [post_date] => 2019-01-09 15:01:47 [post_date_gmt] => 2019-01-09 20:01:47 [post_content] => Imagine waking up one day and deciding that you are going to rob a store to purchase enough dope to kill yourself, and if you don't make it that far and get caught....at least you'll get the help you need. That is how Jennifer Clay woke up on Easter Sunday of 2015. Clay had been in a car accident when she was 18 and was prescribed pain medication that she quickly developed an addiction to. Once her prescription ran out, she turned to illicit pills and then, heroin. She had been maintaining a job at a hospital, her house, bills, and her car. However, Clay’s addiction continued and led to her ultimately robbing a Walgreens and a friend turning her in to the police. While incarcerated, a state treatment facility inquired if Clay would be interested in beginning addiction treatment. Through group counseling sessions, she began to recover, and requested to be put into an inpatient program when she was released. Staying at a women’s recovery house following her stay in rehab, helped Clay become 100% sober. Today, she has a job, a home, and a 6-month old son. Although it’s a sad statement, Jail truly saved Clay’s life. Many women in recovery face multiple barriers due to stigma, and an upstanding role that society plays in them being the prime caretaker of their children. Barbara Rachelson, a Representative on the House Judiciary Committee, says that there is still a big stigma that people assume these women were out partying. The stigma can be so alarming that many women won’t openly speak out about their addiction, worsening their issues. Adding onto the fact that many of these women have experienced various kinds of trauma, and do not have access to affordable counseling or other mental health treatments. “Its easier to stay sober when you have more resources at your disposal than if you’re homeless or struggling”, Rachelson added. References: Katie Wedell (2018). Local Mom in Recovery: Jail 'best thing that ever happened to me'. https://www.daytondailynews.com/news/local/local-mom-recovery-jail-best-thing-that-ever-happened/9l17VWsAqnYzbHdRhkBTGK/ Jess Aloe (2018). Opioid addiction: Mothers in recovery face a unique set of barriers. https://www.burlingtonfreepress.com/story/news/2018/12/31/opioid-addiction-recovery-mothers-face-unique-challenges/2312346002/ [post_title] => Why Did This Mom Say Jail was the Best Thing to Ever Happen to Her? [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => moms-in-recovery [to_ping] => [pinged] => [post_modified] => 2019-10-21 16:30:50 [post_modified_gmt] => 2019-10-21 20:30:50 [post_content_filtered] => [post_parent] => 0 [guid] => https://aspenti.com/?p=59345 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 59325 [post_author] => 13 [post_date] => 2018-12-05 13:37:30 [post_date_gmt] => 2018-12-05 18:37:30 [post_content] => Methamphetamine has always been an issue in more rural states, but recently Massachusetts has seen an influx of meth overdoses in the Boston area. In a recent study from the National Emerging Threats Initiative (NETI), most of the meth sold in the United States is produced in Mexico, then shipped through suppliers that are also dealing in cocaine, fentanyl, and heroin. It was once thought that the arrest of "Chapo" Guzman in 2016 would create a substantial decline in methamphetamine manufacturing. However, the emergence of the Jalisco New Generation Cartel and the re-organization of the Sinaloa Cartel increased the problem within the last 2 years. “New initiates of methamphetamine use (people who had not previously used methamphetamines) increased by 47% from 133,000 in 2010 to 195,000 in 2017. At the same time, HIDTA seizures of methamphetamine increased from 256% from 8,021kg in 2011 to 28,558 kg in 2017.” [caption id="attachment_59335" align="aligncenter" width="600"]

The above graph reflects the change in methamphetamine/ice seizures, in terms of amount seized (in kilograms) and the total number of incidents (reported in Kg, dosage units and liter forms) within all HIDTA counties from 2011[/caption] Individuals usually start with heroin that is being cut with meth, and then move on to straight meth. Meth users don’t feel as sick when they are coming down from the high and meth is cheaper than heroin. However, despite meth being an easier option for it’s users, it is not for treatment options within hospitals and clinics. Meth overdoses have increased across the United States, and while we may not see the full impact of the influx of meth in Boston right now, it'll show up in a few years. The meth issue is compounding the opioid epidemic, because while patients addicted to fentanyl or heroin are usually prescribed a medication to curb cravings, patients have been trying to use meth while in treatment for their opioid addiction to help cope. It appears the opioid epidemic has set itself on a larger scale, with cocaine and methamphetamines and is becoming more of a drug epidemic. References: Martha Bebinger (2018). Meth Use Is Rising In Boston, Intensifying The Opioid Crisis. http://www.wbur.org/commonhealth/2018/11/21/meth-worsening-opioid-epidemic National Emerging Threats Initiative (2018). Emergening Threats Report 2018: Status and Factors Affecting the United States. https://d279m997dpfwgl.cloudfront.net/wp/2018/11/1120_emerging-threats-report.pdf [post_title] => Why is Meth Use on the Rise in Boston? [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => meth-in-boston [to_ping] => [pinged] => [post_modified] => 2019-10-21 16:31:06 [post_modified_gmt] => 2019-10-21 20:31:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://aspenti.com/?p=59325 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 1 [filter] => raw ) [4] => WP_Post Object ( [ID] => 57752 [post_author] => 13 [post_date] => 2017-10-04 16:01:12 [post_date_gmt] => 2017-10-04 20:01:12 [post_content] => I am not a scientist and I am not a counselor. I am not an expert, but I have learned to be a good listener. I am the Social Impact Coordinator for Aspenti Health, a toxicology lab in Burlington, Vermont which provides substance use testing, a critical part of a patient’s treatment plan. We are much more than a traditional lab. We are patient centric, offer community impact through alliances and partnerships, and we embrace the responsibility of social stewardship to affect positive change. My position is newly created, and my first task was a needs assessment and one of inquiry. I endeavored to listen and learn of needs – those of our patients, clients of community organizations and the organizations themselves – to identify community challenges, emerging trends and ways to partner. On my drive home one evening, I was reminded of a blessing in disguise presented during my first-year internship as a Master of Social Work graduate student. I was assigned to an Area Agency on Aging which was an hour from home, a demographic I hadn’t considered working with, and quite honestly, I went into it with a bad attitude. The Central Vermont Council on Aging utilized “Options Counseling” (OC). It assumes that if we can engage the client in exploring ways to feel more secure in their world, then we can support them in remaining fulfilled. OC allows us to do so in a way that shifts from the “we know what’s best for you” approach, to one that engages the client in exploring their goals and helping to achieve them. It is deeply respectful and highly collaborative. Eventually, I was given the unique opportunity to meet with older adults in their homes, learn of their needs and try to find a solution. I had studied the many programs available to assist Vermonters, and I was eager to impart my knowledge and better their lives. Oh, how wrong I was. Truth be told, I was not the expert on anything – my clients were. They knew their situation, they knew where they wanted to be, and what they needed was the information necessary to make the best decision possible. With this approach, they remain the true stewards of their destiny, buoyed by the knowledge of what is available. As I became a little more proficient, I learned that Options Counseling has three parts:

Engagement Through Relationship Building
Identifying Client Preferences
Introducing Participant-Directed Options in an Unbiased Manner

Individuals in early recovery, like the elder community, are often unaware of available programs and resources. They may be juggling drug testing, Medication Assisted Treatment, counseling, and probation and parole appointments as well as 12-step meetings. Schedules are often so heavily laden with imposed commitments, individuals don’t have the opportunity to explore available social service options. Utilizing what was learned during my internship, we have incorporated a Collaborative Helping Model pilot which utilizes Options Counseling in one of our Patient Service Centers. It is an opportunity to develop deep connections with our patients, understand their concerns and challenges, and when directed, present available options. Out of respect, we present available options only in an unbiased manner, and based on patient preference, we can serve as a potential warm hand-off to those who provide the services our patients desire. We’ve come to realize and value that social service support for patients with Substance Use Disorder’s need not be restricted to traditional or primary therapeutic relationships; laboratories may be an effective mechanism for increasing awareness to address social needs of individuals. “Who are you as a person?” I’ve wondered often how many never get asked that question. They may be asked what they need and they may be judged for having that need. When an individual finds the courage to ask for help and who they are is not validated, the message received is the assumption they have nothing of value to offer. My hope is that we will want to know who they are, what they value, and what makes them valuable. Discovering who they are can help us discover who they may need to know, not just based on their needs but even more based on their talents and abilities. Listening is an art. Compassion is a virtue. Respect for individual vision, however, is perhaps one of the greatest gifts we can give. [post_title] => You Can’t Help Me If You Don’t Hear Me First [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => cant-help-dont-hear-first [to_ping] => [pinged] => [post_modified] => 2019-10-21 16:34:59 [post_modified_gmt] => 2019-10-21 20:34:59 [post_content_filtered] => [post_parent] => 0 [guid] => http://localhost/aspenti/?p=57752 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 5 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 60300 [post_author] => 13 [post_date] => 2020-05-14 15:25:27 [post_date_gmt] => 2020-05-14 19:25:27 [post_content] =>

Digital Health Transformation and Alternative Delivery Models

Part one of a two part blog series on Care for Substance Use Disorder Populations during COVID-19.

Content provided by Jill S. Warrington, MD, PhD. Blog edited by Alexa De Vivo.

Alternative delivery models were used before the introduction of COVID-19 but many health systems sped up the process of developing take home or remote methods for medical testing.

References:

(3) Mindy Miller, personal communication.

(4) https://www.northwell.edu/northwell-health-labs/labfly, [last accessed, 5/5/2020].

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