State's opioid treatment system has had hiccups

Across the state, addiction treatment providers — the spokes in the hub-and-spoke service delivery system — agree the Doorway is working. People are entering treatment and services are better-coordinated, even if there have been some hiccups in rolling the Doorway system out. 

With one year left on the two-year federal grant, such hiccups are symptoms of a greater systemic dysfunction, something providers say needs to be addressed before the money runs out, including:

• The need for brick-and-mortar treatment centers, especially in northern New Hampshire;

• A more robust public awareness campaign about the Doorway;

• More long-term prevention initiatives;

• More statewide affordable housing options. 

 Entering the Doorway

“It really helps us [at Concord Hospital] because we are able to have a place to send for additional referrals or if a person needs more services such as housing,” said Monica Edgar, APRN, director of substance use services at the hospital. She is also a care provider at the CHOICES program, which is part of Riverbend Community Mental Health Center (both are spokes), and sits on the Governor’s Commission on Alcohol and Other Drugs.

“It’s been able to create this access,” she said, which is a big improvement over how it used to work. 

Before, if someone came into the hospital needing treatment, the front-line staff had to manually look up providers and hand out phone numbers, Edgar said. Now, thanks to The Doorway, there is a coordinated assessment, tracking, and referral system. 

Each Doorway assesses individuals, assigns a case manager, and refers those who enter to a treatment provider. They are also responsible for tracking each person’s progress and reporting on it at intake, six months in, and at discharge. Should someone go directly to a treatment provider, that provider refers them to The Doorway to get the process started.  Providers have different types and levels of care, and The Doorway keeps track of those options and determines which are appropriate for each individual. 

“The Doorway program is great, but there is always work to be done to make it better in terms of workflow,” said Noel Cassen, manager of peer support and admissions coordinator at CHOICES in Concord. 

For example, a Doorway may make a couple of referrals and send the person where they can start treatment instead of being on a wait list. Sometimes a patient may then be referred elsewhere and that initial provider doesn’t always know what has happened.

However, Cassen said, the main point is that the person is in the system and is being treated. 

Need for more resources continues

Edgar understands the state had to move quickly to launch the Doorway system because the money came so quickly, but a shortage of qualified staff is a significant factor.

“I’m down two counselors right now at the hospital. Staffing is a big piece for the Doorways,” Edgar said.

Denise Elwart, director of operations for Southeastern New Hampshire Alcohol & Drug Abuse Services in Dover, said there aren’t enough spokes in the system. 

“That’s where the big hangup is. It’s hard to find programs that have openings,” she said. “There’s not a lot of funding for brick and mortar — this [SOR grant] is short-term funding. “

Elwart commended Peter Fifield, program manager for The Doorway-Dover, for his work finding staff and launching The Doorway. 

“I know they weren’t given a lot of time to get it up and going,” she said. “Kudos to him. He’s done yeoman’s work getting it running.”

Overall, providers say regional Doorways have simplified the process, which takes the burden off emergency room staff and primary care providers because they just have to remember one number (The Doorway) for patient assessment and treatment.

“It’s been a great partnership. We’ve been able to make referrals back to The Doorway, and it’s nice to have that resource,” said Edgar. 

Tym Rouke, director of New Hampshire Tomorrow at the New Hampshire Charitable Foundation, is a member of the Governor’s Commission on Alcohol and Other Drugs, said that, thanks to the Doorways, thousands of people have been able to find a place to go and ask for help in a more equitable way across the state.

Tracking where people go for help and what the services they need — even beyond treatment for opioid addiction — informs the state about what services are needed.  

“I’ve said all along that many people choose to leave their community of origin to find recovery. We never want to force a person to stay,” Rouke said. “We want to protect patient choice, but, at the same time, how do we build effective services for those who don’t want to leave their community?”

Nancy Frank is chief executive officer of the North Country Health Consortium that works with the Doorways in Littleton and Berlin.

“What this has provided for us is another avenue for our community health workers,” she said. “They are already working with the population that would access the Doorways, and now we receive referrals from them, and we provide referrals to The Doorway.”

It is, Frank said, a challenge for those who are farther north in towns such as Colebrook, because the closest Doorway is an hour away, in Berlin. While there are some transportation services through Tri-County Transit and others, and some Medicaid reimbursement, it can still be difficult to access a ride. 

Getting the word out

Additionally, awareness of the Doorway system among the public and even treatment providers is still lacking. Frank and other providers said any kind of marketing or promotional campaign was slow to get out. 

“I think I just recently saw something the state put out,” Frank said. 

She said she understands the program had to be launched quickly, but the promotional campaign wasn’t there.

“In my opinion, I still think providers have no idea what it is, or a lot of providers have heard of it but don’t know what it is,” she said.

Rourke said DHHS and Doorways deserve a lot of credit for getting the Doorway system up and running in three months.

“This [SOR funding] was the biggest amount of money the state has ever received in one fell swoop and they had three weeks to figure out how to spend it,” he said. “I’ve never seen anything like it.”

Rouke explained that, once the state was notified SOR funds were available, it had three weeks to submit an application saying what it would do with the funds. When the funds were received, the state had three months to get that money out into the community. 

Awareness and understanding of The Doorway and services available is critical, not just for the providers but for individuals, businesses, and community organizations across the state.

 “There is nothing easy about this,” said Eric Spofford, CEO of Granite Recovery Center in Concord. “It’s good that, after years and years, we have the public’s attention. Nothing has gone perfectly, but lots of people are finding help and getting treatment.

“It has certainly expanded the system of care, but this is a problem that took a very long time to get like this,” Spofford said. “We’re not going to fix this in a year or two or an election cycle. This is going to be over decades or generations.”

Edgar agreed, especially since New Hampshire has been “last” when it comes to treatment and prevention. 

“We are talking about chronic illness,” she said. “It’s not going to go away in 10 years.”

Long-term investment is needed. The system of care in New Hampshire is still fragmented, and one of the biggest issues — Spofford calls it a bottleneck — is the waiting list for inpatient treatment beds. 

“We get 500 calls a month just from New Hampshire Medicaid patients [for in-patient beds]. That’s just people from New Hampshire,” he said.

Those callers are referred to the Doorways for services, and Spofford said there are about 40 to 60 people a day on a waiting list.

Granite Recovery Centers has nine drug rehab facilities across New Hampshire, including two inpatient residential programs. Spofford and others are working on solutions to increase inpatient treatment beds for people in need that have New Hampshire Medicaid.

One of the most significant issues providers face is not knowing whether the federal funding, which is set to expire in September of 2020, will be renewed. Providers are hesitant to invest in additional capacity such as expanding services or adding beds because the funding for treatment is uncertain.  

The contracts related to funding the Doorway program are reliant on federal funding, and it is noted in the contract language that, “In the event that the Federal Funds become no longer available, [state] General Funds will not be requested to support this program.”

In November, an additional $2,111,500 was awarded through the State Opioid Response grant to provide crisis respite beds for men, which fills a gap identified by the Doorways. Granite Recovery was awarded $1,003,570, which Spofford said will mean an additional 11 respite beds; and $1,107,750 was awarded to N.H. Respite LLC in Nashua for 12 respite beds. Other centers received an increase in the amount they received per day for Medicaid patient beds, although it still doesn’t cover the whole cost.

While the current investment in treatment is helping, Spofford said the state needs to do a much better job at prevention. Opioids became a problem in the late ’90s, but only on the radar of the media and general population within the last five years.

“New Hampshire has very high addiction rates with very low rates for addiction treatment,” he said.

Beyond treatment: Is a self-sustaining system possible?

Sara Lutat, executive director of Dismas Home of NH in Manchester, said the three-year-old nonprofit does get some referrals from The Doorway. However, Dismas Home only serves women who have been in a substance-use disorder program while incarcerated and need additional treatment upon release.  

Dismas Home has six beds (soon to be eight) and provides several months of transitional programming after those 90 days. 

“We do have SOR funding, but it is only for opioid [addiction treatment]," she said. “There’s a whole big picture beyond just the addiction. There isn’t enough money to fund building the infrastructure that is needed.”

One of the biggest needs, Lutat said, is housing. The women she sees at Dismas Home have felony convictions, are recovering from underlying trauma, and compared to men, usually only get low-paying jobs, which isn’t enough to afford decent housing —- even if it existed. Child care adds another challenge for that population.

“There are so many issues tied to this population,” she said. “They need a whole spectrum of services.”

Rouke agreed. “Grants, no matter how big, don’t hit the fundamentals, like housing, transportation, and child care. The real question is how scalable the system is to meet the needs not just of people seeking recovery today, but in the future.”

Frank expressed a need for more infrastructure in The Doorway, such as agreements between the hubs and spokes. “It would be good to know who the spokes are and what services they are providing.” 

A list of all the providers is not readily available, or on the state’s Doorway website. 

“Any resources we can get are great,” Frank said, adding that, even if The Doorway went away, the relationships that have been built through this process would remain, and that is a benefit to her organization and other health workers. 

“It’s all about the relationships,” she said. 

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This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org. Follow on Twitter @NewsGranite and like facebook @collaborativenh.