Traction or just spinning wheels?

N.H. Hub and Spoke system aims to help in opioid battle

Editor’s Note: This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. Part 2 of this report will publish in Saturday’s edition of The Telegraph, with additional stories coming on Sunday and Monday. For more information, visit Next week’s story will focus on the issue of Medicaid reimbursements and what’s being done to address the issue.

By June 2018, 107 Granite Staters had already died from opioids. That month, 70 more cases were pending toxicology confirmation, so there would surely be more. But June 2018 was also the month when officials at the New Hampshire Department of Health and Human Services saw an opportunity.

There was a federal grant available, a pretty big one, for opioid use disorder programs such as the Hub and Spoke model used in Vermont for the last five years.

“We knew when we were looking at it, that this would be a great opportunity to organize a system that was somewhat disorganized,” said Katja Fox, Director of the DHHS Division for Behavioral Health. “So while we have many treatment providers, we have many recovery centers and we have lots of services across the board, we didn’t have a central point to coordinate it and to really make sure that individuals were not falling through the cracks. And so this was an opportunity to do that.”

Serendipitously, around the same time, Gov. Chris Sununu had been doing some Googling.

“He wanted to know how people were accessing services,” Fox said. “He decided he would sit down and say, ‘I’m a family member who’s looking information about how to help somebody who is struggling with opioid use disorder.’ So he Googled that and it just was an explosion of information that was all over the place.”

DHHS officials set to work devising a plan and laying out their proposal in the grant application for what would become New Hampshire’s Hub and Spoke system. It was a model that would set up nine doorways, or hubs, across the state for people seeking opioid addiction treatment to enter the system. Once through the door, they would get referred to “spokes” where they could receive treatment and other recovery support and social services.

Six weeks after they read the federal announcement of the grant, they sent out the proposal. They received word that they got the grant in the fall, at which point providers were told they had three months to pull together and roll out the two-year, $45 million, statewide program.

According to DHHS spokesman Jake Leon, the State’s application to SAMHSA anticipated the system would serve about 5,000 individuals per year. The projection was based on past utilization of established programs that serve people with an Substance Use Disorder.

The Granite State News Collaborative contacted Department of Health Commissioner Jeffrey A. Meyers directly and through Leon, requesting an interview about Hub and Spoke. He declined that interview through an email from Leon, citing a “booked schedule” for the foreseeable future.

Meyers and other officials did go out to several public forums around the state shortly after the Hub and Spoke program began on January 1, to explain the program and answer questions. The response was a mix of skepticism and confusion, often leaving people with more questions than answers.

What would happen, for instance, to Safe Station, the popular and – according to data – effective program in Manchester and Nashua? [See sidebar] Who are the spokes? What about Medicaid reimbursements? Are there enough services, beds, providers to get this done? What happens when the money runs out?

Questions were often met with some variation of “the details are still being worked out.” Critics murmured about a giant program hastily put together and thrown out as a costly Band-aid on the hemorrhage of the opioid crisis that wouldn’t amount to much.

But that’s not the only way to look at it.

“I have a perspective perhaps unique from a number of other folks on this thing,” said Nick Toumpas, Executive Director of Connections for Health, the Integrated Delivery Network for the Seacoast and Strafford County areas. He also served as NH DHHS commissioner from 2007-16.

“It’s really easy for people to take any initiative that you’ve put forward and poke holes at it,” he said. “But what we have to ask ourselves, when you look, when you consider what’s at stake for the individuals that are dealing with an issue of mental illness or substance use, for their families, for their communities, for the providers that are serving these folks, we’ve simply got to put some of that, ‘this crap can’t work’ type of thing away and say, ‘all right, let’s look at what’s working and what can we do in order to build on that.’ And If it’s not working, what do we need to do? Let’s just not say, ‘well, it’s not working.’ …Let’s say, ‘yes it can work if we do the following type of things.'”

Hub and Spoke is not meant to be a silver bullet, officials have said, although the price tag might carry with it some assumptions that it is. In reality, Fox said, it was meant to be a start. In other words, a step toward a solution on a path littered with inherent challenges to its success.

While this report aims to outline those challenges, over the course of the next several weeks, The Granite State News Collaborative partners will publish stories that take deep dives into each of these seemingly intractable problems confronting Hub and Spoke NH, and analyze possible solutions everyone from practitioners to legislators are coming up with to make it work.

Reinventing the Wheel

Hub and Spoke as a model is not without precedent. After years of planning, study and changes in the law, Vermont Health officials rolled out their version of Hub and Spoke in 2014 and it is still in place.

Fox said NH DHHS officials knew of the Vermont model because, “we had attended multiple presentations on it, as well as webinars and that kind of thing.” They also knew that it was a standard that the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal agency offering the grant, was looking to replicate.

“We knew that Vermont had a different model,” Fox said. “We knew that we had to make it a New Hampshire model.”

Fox said the goals in this round of funding were to help people seeking help with opioid addiction receive access to medication-assisted treatment and other clinically appropriate services, as well as reduce opioid fatalities by 10 to 15 percent by the end of the funding period.

But they had another goal as well.

“Our objective in creating this system was to use the federal funding as an opportunity to organize our substance use system,” Fox said. “And so we wanted to have an infrastructure that was built that would not only address opioid use disorder, which as you know, this particular funding source is focused on, but to address other types of issues that individuals who are struggling with addiction have.

“And so it’s evolving.”

In the Vermont model, the treatment starts in the hubs, and once a person is considered “stable” they are transferred to a spoke, where they can receive other social services and primary care help. If they relapse, they can go back to the hub and get stable again through medication-assisted treatment.

In New Hampshire, the hubs are more the coordinators of the treatment the patient will receive at the spokes in the community.

“So we knew that would work because we had to implement this quickly,” Fox continued. “And we just didn’t have those centralized specialty services [treatment in the hubs] geographically across the state.”

Additionally, they knew they wanted to implement the governor’s ideas of having one number people could use to access treatment information and that this initial entry into the system would be no more than an hour’s drive away from anywhere in the state.

“We were losing people in the system because we made it so complicated,” Fox said, of the way treatment information and systems were organized and disseminated before Hub and Spoke.

She said they wanted to create a system where “people knew where to go, what type of help they would get – knowing to call one number, knowing that within an hour’s drive they had a place where they could go when they were ready to start a recovery process, that they would have walk-in service.”

In New Hampshire, most of the hubs are run in conjunction with hospitals: Dartmouth-Hitchcock Medical Center in Lebanon; the Concord Hospital; Androscoggin Valley Hospital in Berlin; Wentworth-Douglass Hospital in Dover; Cheshire Medical Center in Keene; Lakes Region General Hospital in Laconia; Littleton Regional Healthcare in Littleton.

In Nashua, the hospitals are not participating. Instead, the nonprofit Granite Pathways, which has a presence in Manchester but is lesser known in Nashua, is taking the reins as hub coordinator.

The hubs are designed to provide screening, clinical evaluations, counseling, and case management. Some can also start medication-assisted therapy.

From the hubs, patients are referred to existing services in the communities, such as inpatient detoxification, housing, or recovery centers.

Say, for example, that a person is ready to get treatment for opioid addiction. They can call 211 to find out where to go or they can walk into a hub. Once inside they receive an extensive assessment of their physical condition and what sort of treatment they might need.

“We knew that that was something that was missing because people were calling and getting appointments that were three days away and that was too long a gap in time – and they never showed up or they were lost in the system,” Fox said. “And this way was a way to organize that.”

Peter Evers, CEO of Riverbend Community Mental Health Center in Concord, which is operating the Concord Hospital hub, said once a person is assessed they receive case management, which is there to provide a bridge to the spokes, aka, the treatment providers.

“If there is a wait for treatment the case manager checks in every day with the person waiting and will arrange for the person to be seen for individual or group treatment before the referral is completed,” Evers said. “The idea is that no one just waits alone for treatment, and if they have to wait, the hub can tide them over with clinical interventions.”

Once a person is in a spoke, the hub still keeps in contact. Fox said the state is required to collect the data that tracks a person in the system at 30-, 60- and 90-day intervals and report it quarterly to SAMHSA.

Another difference between the New Hampshire and Vermont hub and spoke systems is that in Vermont, hubs begin patients on medication-assisted treatment immediately and are the ones who continue to administer that part of the program throughout recovery. In New Hampshire, some but not all hubs have providers who are allowed to prescribe those medications, but the ongoing medication-assisted treatment continues at the spoke level.

Fox acknowledges that DHHS didn’t reach out to Vermont officials or mine any of their data when constructing the New Hampshire plan.

“We knew what we knew on the ground in New Hampshire and what wasn’t working and what would benefit our individuals,” she said. “We did not do a compare and contrast with Vermont and do a deep dive there. We did use our experience from having to address this explosion of opioid epidemic and we made it work for New Hampshire.”

Bumps in the Road

But even with its successes and planning, Vermont still had its challenges, as does and will New Hampshire. The following are some major roadblocks:

Medicaid Reimbursements

Even with an infusion of federal dollars most of the spokes are community mental health centers which are funded almost entirely – about 85 percent of patient revenue – by Medicaid reimbursements.

“(Community mental health centers] really are the safety net for people with mental illness and substance abuse,” said Riverbend’s Evers. “And they are paid for with Medicaid.”

Reimbursement rates, which have been among the lowest of all states and well below the national average, have not risen since 2006. In fact, during the 2008 recession, when services were trimmed or eliminated, rates were reduced. Currently New Hampshire Medicaid reimburses mental health providers at about 58 percent of the rates paid by commercial carriers, and Medicaid and commercial rates in New Hampshire are less than those in neighboring states.

The American Academy of Pediatrics surveyed Medicaid reimbursement rates in 2015. In New Hampshire a psychiatric evaluation was reimbursed at $87.82, compared to $117.42 in Massachusetts and $104.13 in Vermont. An evaluation with medical services was reimbursed at $65.00 in New Hampshire – the lowest rate in the country – but $95.06 in Massachusetts and $115.63 in Vermont. And 30 minutes of therapy in New Hampshire was reimbursed at $32.50, but $48.53 in Massachusetts and $51.55 in Vermont.

Although the community mental health centers primarily serve those enrolled in Medicaid, commercial insurers reimburse mental health providers at lower rates than those paid to other medical practitioners, despite a federal law requiring that mental health and substance abuse be treated on a par with medical and surgical procedures.

This story is by Melanie Plenda, Rob Greene, Sheryl Rich Kern, Ryan Lessard, Barbara Tetreault and Michael Joseph, for The Granite State News Collaborative. See Part 2 in Saturday’s edition of The Telegraph.