The opioid crisis has been driven by high rates of uninsured patients, unintegrated treatment facilities, disparities in medication access, stigma and insufficient educational opportunities for providers. As a result, innovative approaches are required to expand care.
One innovative approach is the hub and spoke (H&S) treatment model, in which anchor sites (or hubs) such as VUMC provide comprehensive and specialized care to patients with opioid use disorder (OUD), and partner sites (or spokes) offer more limited services.
So far, H&S models have mostly been described in Medicaid expansion states. However, David Marcovitz, MD, assistant professor of Psychiatry and Behavioral Sciences and director of the Division of Addiction Psychiatry along with a group of co-authors have published what they believe to be the first description of hub-and-spoke partnership in a Medicaid non-expansion state.
“Working with spoke sites allows us to connect our patients to clinics and agencies that play an important role in communities that may have been historically underrepresented in OUD treatment,” Marcovitz said. “It allows us to reach more patients with even more treatment options.”
VUMC’s hub for addiction treatment falls under the Vanderbilt Integrated Services for Treatment of Addiction (VISTA) umbrella. The state-funded hub designation from the Tennessee Department of Mental Health and Substance Abuse Services includes funding for dedicated multidisciplinary staff salaries and for reimbursement for uninsured patients to get clinical care at VUMC.
VISTA is also home to the department’s Addiction Consult Service, Bridge Clinic, the Vanderbilt Recovery Clinic, and several other addiction recovery programs where hub-funded staff work with patients.
VUMC is currently funded to serve as a regional hub site through a federal State Opioid Response grant, which pays for integrated care to support treatment of patients with OUD and other complex conditions. To date, the hub has enrolled 110 uninsured patients.
Through this grant, VUMC partners with eight regional nonprofit spokes which offer residential services, outpatient services and dispersal of methadone and buprenorphine. Spoke partners were selected for their history serving uninsured populations and working with underrepresented minority groups and peripartum women. These partnerships have helped launch an important step toward addressing health disparities in Middle Tennessee through resource sharing.
Marcovitz has observed Tennessee hubs and spokes working together to troubleshoot, handle referral challenges and communicate about grant-related matters. Through their partnerships, Tennessee hub and spoke sites gained a mutual understanding of treatment philosophy and implementation processes, with many spoke sites revising policies and transitioning to lower-barrier harm-reduction approaches to closely align with national treatment guidelines.
Marcovitz’s analysis, published in the American Psychiatric Association’s Psychiatric Services Journal, has important implications for policymakers and other medical centers in non-expansion states.
“We want to help shape the policy discussion by detailing how much more expensive it is to provide care in this way — and how many fewer medical benefits patients get — when you’re trying to provide grant-funded care versus comprehensive care that’s funded by health insurance,” said Marcovitz. “We’re creating parallel systems to administer these grants instead of doing the thing that makes more sense, which is paying for co-occurring medical and psychiatric disorders all as part of medical care.”
Co-authors on the column included Mariah Pettapiece-Phillips, MPH, Kristopher Kast, MD, Katie White, MD, PhD, and Carolyn Audet, PhD, from Vanderbilt, and Heather Himelhoch, PhD, MPH, from Northwestern University.
