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POLICYPROFILE

RAND-USCSCHAEFFER

OPIOIDPOLICYTOOLSAND

INFORMATIONCENTER

CORPORATION

Hub-and-SpokeTypePolicies

Directstateand/orfederalfundingtoimplementmultiplegeographicallybasedcoordinatedcarenetworksinwhichpatientsreceiveshort-termintensiveinpatientoroutpatientcareuntilstabilized,thenarereferredtootheroutpatientpracticesforsupportiveservicesandmedicationforopioidusedisorder(MOUD)inprimarycaresettingsorcommunity-basedpractices.Eachnetworkformsa

systemofcarewithaprimaryorganizingagency(hub)thatidentifies,collaborates,andsubcontractswithanetworkofsubstanceuseandmentalhealthtreatmentproviders(spokes)toprovideintegratedmedicationtreatment.

Apanelofexpertsratedhowtheyexpectthistypeofpolicytoaffectfouroutcomes:opioidusedisorder(OUD)treatment

engagement,OUDtreatmentretention,OUDremission,andopioidoverdosemortality.Anotherpanelofexpertsratedthepolicyonfourimplementationcriteria:acceptabilitytothepublic,feasibilityofimplementation,affordabilityfromasocietalperspective,andequitabilityinhealtheffects.

POLICYRECOMMENDATIONACCORDINGTOEXPERTRATINGS

OPPOSE

UNCERTAIN

SUPPORT

SUMMARYOFEXPERTRATINGS

OUTCOMES

EFFECTRATING

OUDTreatmentEngagement

HARMFUL

LITTLE-TO-NO

BENEFICIAL

OUDTreatmentRetention

HARMFUL

LITTLE-TO-NO

BENEFICIAL

OUDRemission

HARMFUL

LITTLE-TO-NO

BENEFICIAL

OpioidOverdoseMortality

HARMFUL

LITTLE-TO-NO

BENEFICIAL

CRITERIA

IMPLEMENTATIONRATING

Acceptability

LOW

MODERATE

HIGH

Feasibility

LOW

MODERATE

HIGH

Affordability

LOW

MODERATE

HIGH

Equitability

LOW

MODERATE

HIGH

SUMMARYOFEXPERTCOMMENTS

?

ExpertsexpectthesepoliciestoincreaseOUDtreatmentengagementandretentionbyimprovingaccess,

coordination,comprehensiveness,andcarequality,thusincreasingOUDremissionanddecreasingoverdose

mortality.

?

?

Moderatefeasibilityisduetogeographicvariabilityininfrastructure,cooperationamongdifferenthealthcareprovidersandorganizations,andexistingresources.

Althoughcost-effective,thesepoliciesareresource-intensivetoinitiateandsustain.

?

Expertsbelievethepublicsupportsincreasingaccesstocareandcontinuityofcaretoaddresstheoverdoseepidemic.

?

Highratingforequitabilityreflectsexperts’perceptionsofimprovedcoordinationandgreateraccesstocare,aswellasbettercommunityengagementasaresultofthesepolicies.

THEPANELSANDRESULTSINFORMINGTHISPOLICYPROFILEAREFULLYDOCUMENTEDIN

Smart,R.,Grant,S.,Gordon,A.J.,Pacula,R.L.,&Stein,B.D.(2022).Expertpanelconsensusonstate-levelpoliciestoimproveengagementandretentionintreatmentforopioidusedisorder.JAMAHealthForum,3(9),e223285.AsofJuly31,2023:

/t/EP69031.html

Grant,Sean,RosannaSmart,AdamJ.Gordon,RosalieLiccardoPacula,andBradleyD.Stein.(2023).Expertviewsonstatepoliciestoimproveengagementandretentionintreatmentforopioidusedisorder:Aqualitativeanalysisofanonlinemodified-Delphiprocess.JournalofAddictionMedicine.AsofDecember4,2023:

/t/EP70324.html

ForacompletelistofOPTICPolicyProfiles,visit

/policy-profiles.

ToviewthisPolicyProfileonline,visit

/t/RBA3054-23.

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POLICYPROFILE:HUB-AND-SPOKETYPEPOLICIES

OutcomesSummaries

OUDTREATMENTENGAGEMENT

PercentageofpeoplemeetingthecriteriaforanOUDdiagnosiswhoreceivetwoormoreOUDtreatmentservices(includingmedicationforOUD)within34daysofinitiatingtreatment.

EFFECTRATING

SUMMARYOFEXPERTOPINION

REPRESENTATIVEQUOTATIONS

BENEFICIAL

Fundingforshort-termintensivecare,easieraccesstooutpatienttreatment,andexpandedpathwaystocarewouldincreasetreatment

engagement(e.g.,startingMOUDand

coordinatedcare),especiallyinunderservedareaswithpreviouslyscarcepathwaystocare.

“Thispolicygenerallyincreasesaccesstotreatmentandalsofacilitateslong-term,coordinatedcare”

LITTLE-TO-NO

Dependsontheimplementation(e.g.,

appropriatesubcontractingandreimbursementmechanisms,accesstohub,outreachand

handofffromhubtospokes).

“Dependsontheimplementationandbuy-infromhubs”

HARMFUL

N/A

N/A

OUDTREATMENTRETENTION

PercentageofpeoplemeetingthecriteriaforanOUDdiagnosiswhoremaincontinuouslyenrolledinOUDtreatmentservicesforatleastsixmonths.

EFFECTRATING

SUMMARYOFEXPERTOPINION

REPRESENTATIVEQUOTATIONS

BENEFICIAL

Increasedtreatmentengagementwilllead

toincreasesintreatmentretention.More

comprehensiveandcoordinatedcare(e.g.,

sharedmedicalrecords,opportunityforpatientsnotdoingwelltoreturntothehub)willincreaseretention.

“Thehubandspokemodelallowsformore

access/optionsfor[treatment],andcanbe

especiallybeneficialinruralareas.Isee

accessibilityandcoordinatedcaregoinghandandhandwithretention”

LITTLE-TO-NO

Limitedevidencetoratepoliciesasharmfulorbeneficial.Costs,treatmentaccessibilityandquality,andtheavailabilityofsocialsupportsmayinfluencetreatmentretention.

“Thecaveatisimplementationwithgoodfidelity,thedataisnotasrobustonthesespecific

outcomes,especiallylongterm”

HARMFUL

N/A

N/A

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POLICYPROFILE:HUB-AND-SPOKETYPEPOLICIES

OutcomesSummaries

OUDREMISSION

PercentageofpeoplemeetingthecriteriaforanOUDdiagnosiswhodonotexperienceOUDsymptoms(otherthanacraving,desire,orurgeforopioid)foratleast12months.

EFFECTRATING

SUMMARYOFEXPERTOPINION

REPRESENTATIVEQUOTATIONS

BENEFICIAL

IncreasedtreatmentengagementandretentioncouldleadtoincreasesinOUDremission.Morecomprehensiveandcoordinatedcare(e.g.,

accesstovariouslevelsofcare,individuallytailoredcare)couldincreaseremission.

“Havingconnectionstospecialized,

comprehensivetreatmentprogramsthatcan

addressongoingdrugusethroughawiderangeofservicesandreferralsmaymakeasignificantdentonremission”

LITTLE-TO-NO

Population-levelimpactsonOUDremissionarechallengingtoachieve,andthereislimited

evidencetoratethesepoliciesasharmfulor

beneficial.AvailabilityofrecoveryservicesmayinfluenceOUDremission.

“VeryfewhubandspokemodelsIhave

witnessedincludecommunity-basedpeer

supportservicesfocusedonrecoveryratherthantreatmentcontinuation”

HARMFUL

N/A

N/A

OPIOIDOVERDOSEMORTALITY

Percapitaratesoffataloverdoserelatedtoopioids,includingopioidanalgesics(e.g.,oxycodone),illegalopioids(e.g.,heroin),andsyntheticopioids(e.g.,fentanyl).

EFFECTRATING

SUMMARYOFEXPERTOPINION

REPRESENTATIVEQUOTATIONS

BENEFICIAL

Moreaccessible,comprehensive,coordinated,andevidence-basedcare(includingMOUDandnaloxonedistribution)shoulddecreaseoverdosemortality.

“Forpatientsstruggling,havingeasyaccess

tothehubwillhopefullyincreaseretentionin

vulnerablepatientsandallowthemtoremainintreatment.Leavingtreatmentisatimeparticularlyhighriskforoverdose”

LITTLE-TO-NO

Thereislimitedevidencetoratethesepolicies

asharmfulorbeneficial.Theywouldnotimprove

accessforthosewithouttheabilitytopayforcare.

“Thereisnotalargeliteratureonthisoutcomeforhub-and-spokemodels,andtherearealsoalotofinterveningfactorsthatimpactmortalityoutcomes,sothedecreaseinmortalitymaynotbeverylarge”

HARMFUL

N/A

N/A

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POLICYPROFILE:HUB-AND-SPOKETYPEPOLICIES

ImplementationCriteriaSummaries

ACCEPTABILITY

Theextenttowhichthepolicyisacceptabletothegeneralpublicinthestateorcommunitywherethepolicyhasbeenenacted.

IMPLEMENTATIONRATING

SUMMARYOFEXPERTOPINION

REPRESENTATIVEQUOTATIONS

HIGH

Generalpublicisfavorabletoincreasing

accesstocareandcontinuityofcareto

addresstheoverdoseepidemic(especiallyinrural/remoteareas).

“Forthemodelsthatareoutthere,itseemstohavebeenembracedbythepublic.Ithinkthegeneralpubliccanseehowitcreates

opportunityinareasthatmaybedidn’thaveaccessinthepastordidn’thaveaccesstospecialistthroughthehub.”

MODERATE

Generalpublicislikelynottobefamiliarwithorhavestrongopinionsaboutthesepolicies.Amongthosewhoare,somemaynotlikethecost.

“Noobviousreasonwhythiswouldbeviewednegatively,exceptthatitisprobablynot

familiartothegeneralpublic”

LOW

N/A

N/A

FEASIBILITY

Theextenttowhichitisfeasibleforastateorcommunitytoimplementthepolicyasintended.

IMPLEMENTATIONRATING

SUMMARYOFEXPERTOPINION

REPRESENTATIVEQUOTATIONS

HIGH

Usecasesdemonstratefeasibility,given

sufficientinfrastructure,leadership,andresources.

“Thereisgrowingevidenceonimplementationofthesemodelsonwhichtobuildpoliciesinsystemsthataddressfeasibilityconcerns”

MODERATE

Geographicvariabilityinfeasibilityduetopotentialimplementationdifficultiesrelatedtoinfrastructure(e.g.,localcapacityfor

hubsandspokes,telemedicine,technicalassistance,trainedproviders),cooperationamongdifferenthealthcareprovidersandorganizations(e.g.,willingnessofprimary

careproviderstoparticipate),andexistingresources.

“ThisrequiresMUCHmoreinfrastructure

support,funding,training,andtechnical

assistancethanmoststateshaveanticipated.Everyonewantstosaytheyareofferinghub

andspoke,butfew(outsideof[Vermont])

haveactuallygivenadequatesupporttothe

spokesites(intermsoffunding,infrastructuredevelopment,ortraining/technicalassistance).Itisfeasible,buttakesalotmorethanmost

stateshaveanticipated”

LOW

Limitedfeasibilitybasedonreal-world

evidencethattheVermonthub-and-spoke

modeldidnotreplicateinotherstates.Difficulttoimplementgivenfragmentedhealthcare

system,siloingofbehavioralhealthcare,andthestigmasurroundingMOUD.

“ThisdidnotworkthatwellwhenimplementedinCaliforniabasedonVermontmodel—theylackedthedynamicindividualsthatmade

Vermontwork—notsurewhattheansweris—theideaisgreat”

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POLICYPROFILE:HUB-AND-SPOKETYPEPOLICIES

ImplementationCriteriaSummaries

AFFORDABILITY

Theextenttowhichtheresources(costs)requiredtoimplementthepolicyareaffordablefromasocietalperspective.

IMPLEMENTATIONRATING

SUMMARYOFEXPERTOPINION

REPRESENTATIVEQUOTATIONS

HIGH

Highupfrontcostswouldbeoffsetbylong-termcost-effectivenessthroughmore-efficientcareandreductionsinmorbidityandmortality.

“Upfrontcostswillberequired,dependingonstate,butdatashowsthatthereisacostsavingswhenhubandspokemodels[are]implemented(e.g.,Vermont)”

MODERATE

Concernsaboutpoliciesbeingresource-intensivetoinitiateandsustain.

“Thesecaremodelstendtoberesource

intensive,althoughit'scommensuratewiththeneedofthepopulation”

LOW

Failedreplicationshavebeenextremelycostly.

“The[Vermont]modelwasanepicfailurein[LosAngeles]County.Tensofmillionsofdollarswerewasted”

EQUITABILITY

Theextenttowhichthepolicyisequitableinitsimpactonhealthoutcomesacrosspopulationsofpeoplewhouseopioids.

IMPLEMENTATIONRATING

SUMMARYOFEXPE