Electronic health records (EHRs) are needed when opioid treatment programs (OTPs) work in coordination with other health care providers─which isn’t very often. But that’s starting to change. Kenny House, LCAS, CCS, vice president of clinical services for Coastal Horizons Center, an OTP based in Wilmington, North Carolina, has been in the thick of EHRs since his program started treating medical conditions and mental health problems, in addition to substance use disorders (SUDs). In fact, treating those conditions in-house has proven superior to sending patients to external providers, because confidentiality issues don’t arise as much. Patients are more willing to consent to record-sharing when the other providers are under the same roof as the OTP.
For many OTPs, the issue is simple: they don’t want to be involved with health records. “But we’re not treating SUDs in isolation anymore,” Mr. House told AT Forum. OTPs are trying to connect patients to treatment “in the world of health services,” he said. As that happens, it becomes clear that the general medical community isn’t as comfortable with patients on medication-assisted treatment (MAT) as OTPs are. “Something that is normal to us might not be as welcome to a care provider outside of our sphere.”
Medical Home
So Coastal Horizons is trying to overcome that problem by bringing medical care to patients within the OTP. Funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) and private sources has made it possible to build the infrastructure for providing what are referred to as “medical home health services,” he said, with the OTP being the medical home for the patients.
But there are some situations, such as pregnancy, where the OTP has to work with outside providers. “We have been very aggressive in educating the hospital,” said Mr. House. “We’re part of a hospital task force on pregnancy.” He added that the OTP recently trained care providers on the hospital staff on MAT during pregnancy.
Before this kind of communication can take place, the patient has to sign a consent form. “We need to get the patients to realize that we’re not just asking them to sign a consent and leave it at that─we’re helping with coordinating care.”
With the patient’s consent, the medical director or program director typically would write a letter or have a phone conversation) with the medical professional treating the OTP patient. “That way there’s a comfort level” about the case for the non-OTP provider, who may not be educated about MAT.” Over time, patients have become more comfortable about sharing information about their care, as long as the OTP providers are helping with the coordination, said Mr. House. “There may still be some patients who refuse [to sign the consent], but most are much more willing when they know we’re on their side.”
42 CFR Part 2
Individualized signed consent is required under 42 CFR Part 2, the regulation governing the confidentiality of alcohol and drug abuse treatment records. SAMHSA is considering making changes in this regulation, but OTPs are adamant in protecting the confidentiality of their patients, with stigma for MAT─especially methadone treatment─still very high. But there are drawbacks─in particular, physician time.
Because of 42 CFR Part 2, there are “huge limitations” on communications about patients, so the OTP can’t participate with “true health information exchange in the general medical world. We have to do it patient by patient, and that means we get calls from doctors,” Mr. House said. “It’s more work.” So while 42 CFR Part 2 protects patients from stigma and discrimination, it also prevents patients from being treated in the general mainstream, a goal of SAMHSA. “Right now, it’s just very labor-intensive” for the OTP, he said. On the other hand, he doesn’t want to drive patients away from treatment.
That’s why having medical care provided within the OTP overcomes barriers. “It’s when patients get their care externally” that problems start─either discrimination, or a lot of extra work and time from OTP physicians.
SAMHSA Grant
Mr. House has bypassed some of these integration problems by turning his facility into a full health clinic, staffed with mid-level providers who are supervised by physicians. There are health coaches. The grant for the program comes from SAMHSA’s Primary Care and Behavioral Health Integration (PCBHI) grant program. The four-year grant, which started in October of 2012, is meant to be self-sustaining when it ends. “We’re developing our system to be sustainable, but it’s very challenging,” said Mr. House. “We need to provide these services as billable services, and the financing is different for everyone.” In North Carolina, which didn’t expand Medicaid, there are still many patients who are uninsured─therefore, there is no payer to sustain those medical services. “We’re hoping that will change,” said Mr. House, referring to the Medicaid expansion issue.