QUERI – Quality Enhancement Research Initiative

Making Medication Assisted Treatment (MAT) Available at CBOCs Using Telemedicine

VA Connecticut Healthcare System, West Haven, CT

Overview:

More than one-third of Veterans live in rural communities, where rates of overdose exceed the national averages and life expectancy is lower. In FY2016, the fatal overdose rate in Maine was nearly 50% greater than the national average (25.2 lives lost per 100K vs. 13.3 per 100K) with most overdoses involving opioids. Medication Assisted Treatment (MAT) decreases mortality and improves treatment follow-up. However, many rural Veterans have limited access to MAT and there is a shortage of practicing MAT prescribers at rural community-based outpatient clinics (CBOCs). Prescribing MAT using telemedicine has the potential to bring treatment to these at-risk rural Veterans.  Telemedicine prescribing is effective for a range of mental illnesses but its use for MAT has been hampered by legal issues about prescribing controlled substances remotely, and a lack of standardized procedures for such issues as medication delivery in rural areas, and materials for staff who deliver much of the day-to-day care at CBOCs.

This VISN PII Start-up project’s overarching aim is to develop and pilot-test materials and procedures that facilitate MAT delivery via telemedicine to Veterans at CBOCs.

This project builds on an existing infrastructure connecting Telemental Health (TMH) Regional Hubs to CBOCs. VISN 1 (VA New England Healthcare System) is home to one such Telemental Health Hub (funded by VA’s Office of Rural Health), which delivers  psychotherapy, medication management, and other services to Veterans in rural Maine. 

The project involves both External Facilitation by experienced addiction providers from the TMH and the VA Connecticut Healthcare System, and Internal Facilitation by VA Maine Healthcare System primary care and pharmacy staff. The primary measure of program outcomes will be the SAIL (Strategic Analytics for Improvement and Learning Value Model) Substance Use Disorder 16 measure of medication-assisted treatment (MAT) use for Veterans with opioid use disorder.

Aims:

The objectives of the VISN PII pilot phase are to:

• Implement telemedicine prescribing of medication-assisted treatment at rural CBOCs in Northern Maine that lack on-site MAT providers.
• Develop and refine a TeleMAT implementation toolkit that will include an implementation guide, legal background and regulations, education materials, and instructions on how to increase TeleMAT to Veterans at rural CBOCs.
• Gather feedback from CBOCs staff and various stakeholders with the goal of improving TeleMAT future projects—nationally and at additional VISN 1 sites.
• Prepare to disseminate the above procedures nationally.

Expected Impacts

The protocol, toolkit and experienced gained during the pilot phase of this project will help other facilities and VISNs across the VA healthcare system to implement medication-assisted treatment via telemedicine targeting all Veterans with OUD in the future. The toolkit is available at https://vaww.portal.va.gov/sites/OMHS/SUD/SUDfiles/Medication%20Treatment%20for%20SUD .

Principal Investigators: Marc I. Rosen, MD (marc.rosen@va.gov); VISN 1 Project Lead: Lisa Lehmann MD, PhD, MSc, Executive Director or VHA National Center for Ethics in Health Care (lisa.lehmann@va.gov); and David Moore, MD, PhD (David.Moore2cdbc8@va.gov), Content Expert.

Operations Partner(s): Office of Mental Health and Suicide Prevention (OMHSP), VISN 1 Telemental Health Regional Hub, VISN 1 Health Care Network Leadership Team, and VA Maine’s Mental Health and Primary Care Service Lines.