2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Through Health Care System Integration

In many communities, harm reduction programs have helped prevent overdoses, lower HIV risk and hepatitis transmission and open the door to treatment for substance users. Originally started in the late 1980s, harm reduction approaches introduced syringe exchange initiatives with the goal of reducing the transmission of blood-borne infections.

Yet, treatment gaps resulting from uncoordinated care remain a serious challenge for many substance users. A simple example: an individual receives a prescription from provider X for suboxone to treat his opioid addiction disorder, while continuing to take the opioid prescribed by provider Y.

The problem of uncoordinated care, of course, is endemic across our health care system. Fragmented care leads to doctor shopping in some cases, medication non-adherence, poor outcomes and high costs for any given population, particularly among those with co-morbidities.

It is not uncommon for substance users to also suffer from other conditions such as HIV, Hepatitis C, and sexually transmitted infections. They may also have hypertension, asthma, diabetes, liver disease, and depression. For example, approximately 8 million U.S. adults have a co-occurring mental illness and substance use disorder. These conditions are often poorly understood by patients and inadequately managed by providers.

There are several reasons why these conditions are poorly managed. Much like the broader Medicaid population, substance users are typically under financial constraints, often with minimal or no health insurance coverage. Additionally, given the acute shortage of addiction specialists, primary care doctors with little training in identifying and diagnosing substance abuse find themselves on the front lines. The nationwide shortage of psychiatrists also exacerbates the problem. All this – while the nation’s opioid crisis is at epidemic proportions – often leads these patients to seek crisis oriented, episodic, high cost care in emergency rooms.

The health care industry is increasingly recognizing that social determinants of health have a major impact on outcomes, particularly for vulnerable populations. According to research complied by the County Health Rankings, “40 percent of the variation in health status can be traced to social and economic factors – twice as much as can be attributed to clinical care”.

The five percent of the population that accounts for roughly half of total health care spending are typically very sick, but just as important, they are often very hard to help due to poverty, mental illness, inability to travel and other factors. For many of these people, fulfilling basic needs such as food and housing is just as powerful as any medication to treat their condition.

Managing social determinants of health is fundamental to harm reduction. Many with substance abuse disorders suffer from inadequate housing, food insecurity, job instability, and lack of mobility, all of which adversely impact their health and ability to access care.

According to recent ODH research, however, the industry has a lot of catching up to do. Many health plans struggle to collect social determinants of health data and convert it to actionable insights. While nearly all payers say that integrating social determinant data is important to realizing better outcomes for their members, only six out of ten actually collect such data.

To some degree, harm reduction programs have evolved in recent years to become de facto community based care managers that address the physical, behavioral, and social care gaps of substance users – a highly chronic, disadvantaged and underserved population.

Harm reduction programs approach substance use addiction like any other chronic illness and manage it in a comprehensive, non-judgmental fashion. They typically provide referrals to primary and mental health care services and medication-assisted or other drug treatment services; support and education; case management and care coordination; Medicaid enrollment; food and nutrition services; and personal grooming services.

Harm reduction programs, in fact, could serve as a model for delivering value-based care to this population – and help contain costs – if they were more tightly integrated with other aspects of the health care ecosystem.

To make that a reality, however, requires four key steps:

  1. Closely tie harm reduction services to primary and specialty care services. A study by the New York Academy of Medicine found that health care and harm reduction providers are forming partnerships to co-locate clinical and pharmacy services at a harm reduction center, and teaching hospitals are providing part-time clinic hours at nearby harm reduction centers. Harm reduction staff are often able to build trust and engage substance users in their care in a way that other healthcare providers cannot. When coupled with consistent primary, behavioral, and specialty care, harm reduction programs can provide holistic care that improves chronic health condition management.
  2. Leverage technology to help assess and treat substance users, especially those with multiple co-morbid conditions and facing social barriers that impact their health. Solutions include: telehealth for prescribing and delivering information to substance users, particularly those in rural areas or with an inability to physically travel to a clinic or physician’s office; shared information systems that facilitate coordination and communication across providers; sophisticated analytics, risk stratification and predictive modelling to identify patients most at risk; and integration of multiple patient data sets – including medical, behavioral, pharmacy and social determinants – onto a single platform to enable care managers to assess clinical complexity, identify care gaps and recommend appropriate treatment.
  3. Improve access to primary care services. Substance users suffer the same shortage of primary care services as does the general Medicaid population. Further, very few primary care physicians are well versed in addiction and treatment options. Thus, more training about the signs, symptoms and treatment of addiction is needed, both in medical school and via continuing medical education.
  4. Create payment delivery models that incentivize providers to cooperate with harm reduction programs. As the industry migrates to a value-based care environment, these programs can play a vital role in educating substance users about addiction, supporting recovery efforts and encouraging healthier behaviors and ultimately, helping to promote the “triple aim.”

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