Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact

Abstract

A B S T R A C TAs part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid use disorders, and decrease overdose deaths. Expanding access requires expanding knowledge and intensive implementation support of new practices. This paper describes the rationale, specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.

The impact of project ECHO on physician preparedness to treat opioid use disorder: a systematic review

“…However, it is impossible to tell how many became waiver certified as a direct result of ECHO. This means that more physicians are able to treat patients with OUD, which will increase the opportunities for patients with OUD to receive treatment [ 10 ].…”

“… Other outcomes? Katzman et al [ 5 ] 7 Five-hour long courses on seven different dates 1315 attended, 1079 gave consent to participate in the study Yes Yes No No No N/A Kawasaki et al [ 6 ] Not specified Varies based on survey Yes Yes Yes No No Shorter wait times for patients and decreased sense of professional isolation for physicians Komaromy et al [ 7 ] Two-hour session every week Varies based on survey No Yes No 77% of physicians changed patient care plan No ECHO participants rated input 5/5 Komaromy et al [ 8 ] Two-hour sessions every week 654 unique partic-ipants attended at least one clinic No No Yes No No N/A Miele et al [ 10 ] One-hour session every month 30–50 per session No No Yes (*prelim. results*) No No N/A Salvador et al [ 16 ] 12 one-hour sessions for 12 consecutive weeks 24 partici-pants from 13 primary care clinics No …”

Misalignment of Stakeholder Incentives in the Opioid Crisis

“…Expanding capacity of treatments and providers: Adequate monetary incentives and reimbursement for providers, reducing regulatory burdens, providers’ education, private insurance coverage, and utilizing state subsidies are reported to impact the successful recruitment of providers [ 89 , 90 , 91 ]. Real-world instances of initiatives include the Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration (SAMHSA-HRSA) joint project on expanding the use of medications in safety-net settings [ 92 ], SAMHSA’s Addiction Technology Transfer Center Network [ 93 ], CVS Pharmacy providing naloxone without prescriptions in most states [ 94 ], California implementing a state-wide hub-and-spoke model to improve access to OUD treatments [ 95 ], improving the rate of follow-up treatments among Medicaid enrollees in Pennsylvania by offering incentives to providers [ 96 ], and the SUPPORTAct expanding Medicare coverage to include bundled payment for treatments [ 97 ]. By contrast, in the first three year implementation of Global Payment and Accountable Care by Blue Cross Blue Shield of Massachusetts, no significant impact on using treatments was observed [ 98 ].…”

Preliminary results of the evaluation of the California Hub and Spoke Program

“…The model is designed to reach those who may not have a local OTP available, or who do not otherwise seek treatment in specialty care, by making MOUD available in office-based opioid treatment (OBOT) settings, like primary care clinics. California has adapted the H&S model to fit its unique geographic, demographic and clinical landscape (Miele et al, 2019). This paper examines preliminary evaluation data from the first fifteen months of implementation activities (August 2017-October 2018).…”