By June 2018, 107 Granite Staters had already died from opioids that year. 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 NH 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.” [See sidebar]
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.”
But even with its successes and planning, Vermont still had its challenges, as does and will New Hampshire. The following are some major roadblocks:
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
Medicaid reimbursements play a role in the next big challenge, which is a shortage of practicing behavioral health workers nationally and in New Hampshire.
The issue of workforce has been a challenge for a number of years and it's driven by a couple of factors, said former commissioner Toumpas, who also sits on the state’s behavioral health workforce task force with Evers.
One is a simple matter of demographics: Practitioners in the field are aging and retiring. But even more than that, Toumpas said, “Specifically in the area of the mental health and substance use issues, the ability for many of these organizations to hire people are really pegged to the level of reimbursement that they get for those particular services. And what's happened over a period of a decade or more is that those rates and that reimbursement has declined at the state level.”
At the same time, costs went up and there were a number of other, more lucrative, alternatives for people looking to get into the medical fields.
“Vascular surgeons get paid around $600,000 a year,” Evers said. “And a psychiatrist gets, you know, probably, you know, a quarter to a third of that.”
Over the past year, the Community Mental Health Association has tracked the number of vacancies that exist with the 10 mental health centers and it shows they are down about 200 people, Evers said.
“Most of those vacancies are clinical positions and case management, the people that actually do the work, who are seeing the people in need,” Evers said. “So that to me really speaks to the workforce shortage best.”
“So that's a significant number of clinical and case management positions to fill, which means there’s a little bit of circling the drain if you like that. When you don't have physicians, you have the demand, then people unfortunately have too many cases to deal with. And then they get burned out and then they really don't want to be in that job.”
Fox said in an interview that she was happy to report that the nine hubs had staffing to meet the current need. GSNC requested from Fox and Leon current and projected staffing numbers and as well as the number of people expected to access NH Hub and Spoke from DHHS.
“The minimum staffing requirements are spelled out in the contracts,” Leon said in an email response to questions. “However, each hub has at least one clinician. The contract requires each hub to have sufficient staffing levels based on the services provided and the number of people served. ...The hubs would be able to provide you with their staffing plans.”
People in the hubs who spoke to reporters from GSNC indicated that staffing was a work in progress.
Vermont health officials credit the statewide push to get medication-assisted treatment to people as one of the single biggest drivers of their success.
In Vermont, only the regional-care centers, or hubs, can prescribe both buprenorphine and methadone (a synthetic opioid with a milder but longer-lasting high than heroin). Spokes – usually primary caregivers – can only prescribe buprenorphine and then only by taking an eight-hour course and getting a waiver from the federal Substance Abuse and Mental Health Services Administration. The process is the same in New Hampshire.
Before 2016, doctors could serve no more than 30 medication-assisted treatment patients in the first year of their waiver and, by request, up to 100 patients after that. The Comprehensive Addiction Recovery Act, passed in 2016, raised the maximum to 275 patients and allowed nurse practitioners and physician assistants to get waivers, too.
The 2017 Vermont Blueprint annual report says that “60 new nurse practitioner and physician-assistant prescribers have obtained their waivers and are now prescribing medication for Vermonters with opioid-use disorder.” Nurse practitioners and physician assistants must pass a 24-hour course to get a waiver.
Between 2012 and 2016, the number of waivered physicians in Vermont increased from 173 to 283, reflecting a 64 percent increase. Density of buprenorphine patients per provider also improved, with a 50 percent increase in those prescribing for more than 10 patients. By September 2015, 23 percent of spoke providers had more than 30 patients and 10 percent had more than 50. From January 2014 to December 2015, 225 “stable” patients had transferred from hubs to spokes.
In an initial interview with Fox, she said some of the federal money would be going toward training providers in medication-assisted treatment and then tracking who is using it and how many patients they are seeing.
GSNC asked DHHS how many total practitioners can prescribe buprenorphine in the state, how many more are needed, how many patients can currently be treated and what efforts are underway to get waivers.
Neither Fox nor Leon provided these numbers, but Leon said that State Opioid Response contract, the NH Medical Society is creating a tracking system to determine which providers have received the waiver (whether or not the provider is affiliated with one of the Hubs or Spokes).
Leon also pointed out that providers authorized to prescribe buprenorphine can voluntarily register with SAMHSA.
SAMHSA tracks the number of practitioners newly certified per year by state who are eligible to provide buprenorphine treatment for opioid dependency.
According to that database, the number of providers seeking a waiver to be able to prescribe to 30 patients jumped from about a steady dozen or 14 per year in 2015 to 21 to 64 in 2016. Since then, an additional 345 providers have been newly certified to prescribe to a maximum of 30 patients and another 60 have been certified to provide buprenorphine to up to 100 patients.
That said, according to a SAMHSA provider locator database for New Hampshire, there are only 173 providers across the state who can prescribe to between 30 and 100 patients. The bulk of those providers are concentrated in the more urban areas of Hillsborough, Rockingham and Merrimack counties. For example, Hillsborough County has 50 providers who can prescribe buprenorphine listed in the SAMHSA database. In contrast, Coos County has four providers listed within the county.
Vermont still has challenges with people accessing care in the more rural parts of the state, said Vermont Health Commissioner Mark Levine, although these areas still can boast of no wait times and the number of people getting treatment has continued to go up in remote regions, as they have in the rest of the state.
Similar situations are bound to arise in the more rural regions of New Hampshire as well, where access to treatment is already an issue.
For example, the Berlin hub serves Coos County and part of northern Carroll County. Littleton covers parts of Grafton and Coos County.
For someone in Pittsburg, the Berlin center is a 120-mile round trip, while Littleton is about a 70-mile round trip for someone in Bartlett. Under the new system it is possible some arrangements could be made for them to be able to get at least some services in Colebrook at either Upper Connecticut Valley Hospital or Indian Stream Health Center, cutting the travel time in half, according to North Country health officials.
However, the lack of public transportation and the vast distances involved still make transportation the No. 1 problem in the North Country. Many seeking help may not have vehicles or be able to drive to receive services.
Paving the way forward
Fox said it’s still too early to know the details of what the state will do after the two-year grant runs out, but they are thinking about the future.
“We're one month in or, you know, we're just getting – we can't really make plans for a future state until we know what the current status and that won't be when there's full implementation, which I think we'll see over the coming months,” Fox said in early February. “But the idea of having individuals being able to access services no matter what their issues are, being centralized and being regionalized, they can get their needs met is something that is being discussed in a bunch of arenas as you know.
“We don’t believe this is a problem that is going to go away in two years,” she said. “We don't believe that the federal funding is done, but we also want to leverage other resources and other opportunities to be able to continue and sustain the services.”
Toumpas, for his part, says while the state could have taken more time to roll out a program, that could be said of any program. He said he believes the state was responding to the urgency of the opioid crisis and, rather than sit back and doing nothing, they figured they’d at least take an opportunity to do something.
“We gotta do something because it's impacting everyday people,” Toumpas said. “It's impacting kids, its impacting adults, it's impacting innocent people who are impacted by somebody else who has a problem with substance abuse — it’s an overall sense of urgency. They basically said it's better to do something fast and then correct it as we go along, as opposed to stepping back and looking at it in a more measured way.”
And Evers said the providers on the ground so far are willing to roll with it. One of the benefits of this new system is that the heads of all the hubs are now collaborating and regularly meeting to talk about what is working and what is not in the hopes that they can help shape a more integrated system that works for patients.
“Look, this is a population that we've neglected for years,” Evers said. “This is a state where it's very difficult to get people to pay more taxes than they pay. People don't like to use general funds for anything. So what I would say is we have leveraged matchable money from the feds and we will use it as, if you like a, a first step to the solution.
“This is not the solution, but it is a network of willing participants who were saying we need to make it easier for people to get in the front door.”
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.)