Federally qualified health centers (FQHC) form the largest primary care system in the United States. They play a vital role in providing comprehensive primary care services to their patients, including integrated substance use and behavioral healthcare, but less known is their role in caring for older Americans (older than age 50), who make up 27 percent of their patients. This requires an integrated healthcare team that can provide screening and brief intervention to ongoing medical and behavioral health treatment, including medication assisted treatment (MAT) for opioid use disorder. FQHCs are positioned to play a vital role in addressing substance use disorders (SUD) in older adults in a community context.
FQHCs, integrated care, MAT, older Americans, SUD, OUD
All forms of substance use are significant issues of concern in older adults, and this is certainly true of the population of patients cared for in the country’s federally qualified health centers (FQHC), formerly called community health centers, or simply health centers. With 1,395 FQHCs serving 29.8 million individuals in thousands of rural, urban, and underserved community primary care sites across the United States, the country’s largest primary care system is recognized for its focus on access and affordability.
Also, it is a leader in innovations such as the integration of behavioral health and primary care, data-driven quality improvement, and a focus on vulnerable populations. Today, 76 percent of all health centers are recognized as patient-centered medical homes (PCMH). Health centers serve a population that is disproportionately (greater than 90 percent) low income, has a high percentage (62 percent) of members of racial and ethnic minority groups, and of people (24 percent) who prefer to speak in a language other than English.
Perhaps unique to this system of care is the longstanding requirement for annual and consistent data reporting on patient demographics, services and utilization, health workforce staffing, and clinical outcomes for the Uniform Data System (UDS), from which the preceding 2019 data was obtained (Health Resources and Services Administration, 2020).
This data provides an opportunity to look at health centers nationally and on an individual level to gain an appreciation of the older population seen in FQHCs, the impact of substance use disorders (SUD) on this population, and the ways health centers respond by using integrated, multidisciplinary, and interprofessional teams.
Today, individuals older than age 65 make up 9.6 percent of the total patient population seen in health centers; if we consider all individuals older than age 50, this group of patients makes up 27 percent (8.26 million people) of the total health center population. National UDS 2019 data highlights the overall picture of SUD screening, diagnosis, and treatment. Health centers are expected to screen for depression at least annually and to screen adult patients using SBIRT (Screening, Brief Intervention, Referral and Treatment) at least annually.
In 2019, only 1.3 million people, or 4 percent of total health center patients, were reported to have received SBIRT screening. The reasons vary. Clinicians have expressed concerns with the challenges of conducting screening in light of competing priorities. Patients have indicated support for universal screening, but some cultures are less accepting of the method. There are documented concerns about stigma, lack of sufficient clinical knowledge and training, and lack of referral and treatment resources to follow positive screens (McNeely et al., 2018; Rahm et al., 2015). National data on substance use by age group in health centers is not readily available, but the UDS 2019 reports 389,951 patients with an alcohol use disorder (AUD), 636,988 with other substance use disorders, and 1.23 million people with tobacco use disorder—as tobacco continues to be a formidable health scourge.
SUD Prevalence Increasing in Older Adults
The prevalence of SUDs in older adults generally is increasing, with alcohol, prescription drugs, and illicit drugs being top causes. High-risk drinking and AUD are the leading SUDs in older adults and may be difficult to recognize due to medical comorbidity, functional decline, and cognitive impairment (Seim et al., 2020). AUD is a growing problem among older adults, with an analysis of trends from 2004–2017 using multiple data sets showing a significant increase in the proportion of older adults seeking treatment, with an average annual percent change of 6.8 percent (Huhn et al., 2019).
Given the paucity of treatment options available for AUD, Rehm and colleagues recommend that AUD be treated in primary care as a chronic illness like hypertension, with regular checks for consumption, advice for behavioral interventions, and pharmaceutical assistance if behavioral interventions are not successful (Rehm et al., 2016).
SUD does not discriminate among its victims; it afflicts men, women, and individuals of all races and ethnicities, with social determinants of health exerting a major influence on the health and social consequences of SUD. Data from the National Epidemiologic Survey of Alcohol and Related Conditions-III on individuals ages 18 to 90 show SUD prevalence is generally higher for men than women, until relatively late in life (70s). White participants report higher rates of most SUDs in young adulthood and Black participants report higher or equal rates to white participants in midlife (Vasilenko et al., 2017).
Across America the communities and populations cared for by health centers have been hit hard by the opioid crisis. As a critical element of the nation’s safety net, health centers are charged with ensuring access and high-quality care to vulnerable and underserved communities and populations, and are expected to respond to the opioid use disorder (OUD) crisis.
‘In 2016, 18.4 percent of all opioid-related deaths in the United States were in those ages 55 and older.’
The Health Resources and Services Administration (HRSA) has recognized the importance of bringing together primary care, behavioral/mental health care, and treatment for OUD within an integrated system. Since 2016, HRSA also has supported health centers with additional funding, as well as technical assistance and training to provide SUD services, including medication-assisted treatment (MAT) and integrated primary care along with telehealth, particularly in rural areas. HRSA also has supported workforce training for behavioral health professional and paraprofessional students for practice on multidisciplinary teams (Steinberg, Azofeifa, and Sigounas, 2019).
As a result, since 2014 the number of health centers providing SUD services has steadily increased and the number of patients who received MAT has increased as well, from 100,328 in 2014 to 168,508 in 2019, based on the UDS 2019 report.
Health centers recognize that OUD may well exist in the presence of other SUDs, chronic and infectious diseases such as hepatitis C (HCV), and HIV, and all other chronic illnesses, requiring a multidisciplinary and integrated approach (Rich et al., 2018). A study of the impact of mental health and SUD integration with primary care in health centers found lower rates of ER visits and hospitalizations for patients with SUD, primarily associated with the use of medical enabling services such as case management (Pourat et al., 2020).
The threat to health for older adults with opioid use disorder is severe. In an analysis of 14,000 adults older than age 50, comparing individuals with no lifetime history of prescription opioid misuse vs. any past use, vs. use in the past year, older adults with use in the past year showed significantly higher ER use, higher rates of major depression, and a dramatically higher rate of overnight hospitalization (Schepis and McCabe, 2019).
Further, a fifteen-year study of 335,123 opioid-related deaths between 2001 and 2016 in the United States showed that the largest relative increases over those years occurred among adults ages 55 to 64 (a 754 percent increase) and those ages 65 and older (a 635 percent increase). In 2016, 18.4 percent (7,762 of 42,245) of all opioid-related deaths in the United States were in those ages 55 and older (Gomes et al., 2018).
One Health Center’s Experience
It may be instructive to look at one community health center‘s experience in addressing the OUD crisis in all populations, including older people. Community Health Center, Inc. (CHCI) has adopted the core principles of a robust interdisciplinary, team-based care model. This includes: ongoing workforce training and education; a data-driven approach to high performance care as it concerns access, treatment, risk reduction, and ongoing support; and applying the foundational principles of primary care, which include delivering care close to where people live, work, and pray and in the context of continuous healing relationships.
CHCI is one of the country’s largest FQHCs, serving more than 100,000 patients annually from primary care centers in cities and towns across Connecticut, and is also home to the Weitzman Institute, its research, innovation, and education arm.
Although integrated behavioral health and primary care have been part of CHCI’s model since its 1972 inception, a combination of crises: dangerous prescribing of opioids by healthcare providers, the longstanding scourges of heroin and other illicit drugs, and most recently, the advent of deadly fentanyl in the street drug supply and the resulting death toll; has made the effective assessment and treatment of pain, the prevention of narcotic dependence, and timely, readily available SUD treatment issues of utmost concern. This shift in priorities also demands significant resources, including new competencies and a willingness to engage in SUD treatment across all primary medical care and behavioral healthcare providers and their team members, not just specialists.
Scope of Problem and the Importance of an Integrated, Team-based Care Approach to Treatment
Given disparities in life expectancy when factoring in race and income, CHCI considers patients ages 50 and older as older patients, which includes 22 percent of all patients seen in 2019. Of this group, 6,141, or 27 percent, had one or more of the following disorders: alcohol related disorders, nicotine use disorder, opioid related disorders, or other SUDs. The largest group by far, 62 percent, were between ages 50 and 59. In the 50 and older age group, 1,400 individuals were diagnosed with OUDs, with the majority (68 percent) in the 50- to 59-year-old group, but continuing right up to persons older than age 75. Of the 1,400 individuals with OUD, men outnumber women almost two to one (64 percent and 36 percent, respectively).
SUD in older adults is a chronic condition that affects every aspect of health and is considered in light of the prevalence of other chronic health problems. The team-based model of care is likely to be the most effective in meeting the needs of this population (Parchman et al., 2017; Wagner et al., 2017). CHCI’s model of care brings to bear multiple components of an effective and integrated team-based system of care, including the core team of primary care provider (physician, nurse practitioner, or physician assistant), medical assistant, registered nurse, behavioral health specialist and the extended team of psychiatrist/psychiatric nurse practitioner, clinical pharmacists, registered dieticians, and chiropractors—each fulfilling a unique role.
While the priority for individuals seeking immediate help with OUD is induction and initiation of MAT, once engaged and stabilized it is imperative to address all other healthcare concerns, which have been obscured by the immediate and life-threatening concern of OUD. This requires an elegant choreography of timely access, appropriate screening, “warm hand offs” between medical and behavioral health, a range of individual and group treatment, detailed clinical process pathways for medical assistants to follow, and complex standing and delegated orders and protocols for RNs. The key to success is a robust team of healthcare providers who are licensed, trained, confident, and competent in their skills. Of course, it also demands administrative and clinical leadership support in treating OUD and providing MAT services.
Recognizing that any delay, from the moment an individual reaches out for help with OUD, may mean the difference between life and death, CHCI added a new role to its team, the recovery care coordinator. Originally one position that supported the entire organization, the immediacy and size of the need now requires four full-time individuals. Recovery care coordinators are singularly focused on saving lives by minimizing any delay between initial contacts and connecting patients to treatment at CHCI. If treatment is not immediately available, they are charged with connecting patients directly via a warm hand off and closed loop referral to another source of care in the community. The recovery care coordinator maintains contact at least until such time as they are well and safely established with a primary care team and have initiated treatment. They also address and resolve barriers related to lack of insurance or financial means, and facilitate the patient’s engagement with a behavioral health group or individual treatment.
From there, the choreography of team-based care can play out over time, following the urgencies and priorities of the patient and the care team. The medical assistant is responsible for ensuring that all required lab tests and screenings are completed, old records secured, necessary referrals and eConsults made, and referral loops closed. The RN initiates complex care management, with in-person and telehealth visits to manage the space between PCP visits. The RN also educates, supports, and monitors response to treatment, and completes drug testing as indicated. Of critical importance in the care of older patients, the team also attends to all other pressing healthcare concerns, including smoking, alcohol, and illicit substance use such as cocaine or methamphetamines.
Commonly occurring disorders such as diabetes, hypertension, cardiovascular disease, obesity, and dental decay, as well as major and persistent mental health disorders, may be further complicated by disorders such as HCV, HIV, and the consequences of too many years of adverse lifestyle choices and delayed or deferred preventive care. The recovery care coordinator is there to assist with resolving the often present social determinants of health: unstable housing, food scarcity, isolation, insufficient income, lack of insurance, and sometimes personal safety.
Older adults who have struggled with addiction their whole lives often take on the role of patriarch or matriarch in counseling and support others in treatment.
While it is not always possible to engage and maintain this high-risk population in the full team-based model, of CHCI’s 1,400 patients older than age 50 with OUD-treated in the most recent twelve-month period, 35.4 percent were actively engaged during that period with behavioral health services and 36.5 percent were actively engaged with nursing visits outside of a visit with a medical or psychiatric provider. These high levels of engagement of patients with team members other than the PCP hold true for patients with any SUD, not just OUD.
What Does it Take to Make a Team-based Model of Primary Care Work for Patients with OUD?
This is not easy work. CHCI’s team-based model of care has been critical to its success in improving performance for prevention and chronic illness management, as well as OUD, but this requires the “building blocks” of team-based care to be in place: leadership support, detailed and coherent practice policies, clear patient understanding and agreement about the treatment plan, or registry systems, a “planned care” approach to routine preventive care, and additional resources for complex patients such as eConsults or specialty referrals (Parchman et al., 2017).
CHCI has recognized this through several key actions, of which perhaps the best known is the work of CHCI’s Weitzman Institute in developing its Project ECHO-Weitzman programs. Project ECHO-Weitzman was adapted by CHCI in 2012 from the first Project ECHO model developed at the University of New Mexico to support primary care providers in treating HCV (Arora et al., 2011).
The ECHO model generally includes weekly or biweekly 90-minute virtual sessions between a team of multidisciplinary clinical experts and a community of providers focused on a specific high-volume, high-burden, or high-complexity topic. Of relevance to the issue of treating OUD are three CHCI-Weitzman Institute Project ECHOs: Project ECHO-Pain, Project ECHO-MAT, and Project ECHO-RN Complex Care Management.
New primary care providers must participate in Project ECHO-Pain in their first year of practice and are encouraged to participate in Project ECHO-MAT. All sessions include elements of didactic education, case presentations from the enrolled providers, and group discussion and sharing. All new PCP and psychiatric providers are expected to secure a Drug Enforcement Administration (DEA) X waiver and be credentialed and privileged in providing MAT for SUD. This has carried through to CHCI’s postgraduate nurse practitioner residency program, which allows nurse practitioners a full year of practice in this area with intensive support and education from expert providers.
Expert, seasoned, and committed clinical leaders and practitioners are key to success. Dr. Marwan Haddad, family physician, HIV specialist, MAT provider, and Medical Director of CHCI’s Center for Key Populations, is one such leader. He observes that among all of the SUD/OUD patients, perhaps the most stable group of all are the older patients—patients in their 50s and 60s who bring the wisdom often associated with aging to the subject of their lived experience with addiction, benefitting others in treatment.
Haddad notes these often are people who have struggled with addiction, usually heroin but often in combination with other drugs, for their entire adult lives. Having survived this long, some have finally sought out MAT as they witnessed the deaths by overdose from Fentanyl-contaminated heroin of friends and other community members struggling with addiction. Haddad notes that he has seen these individuals in their 50s and 60s, in men’s and women’s groups, take on the role of patriarch or matriarch in counseling and supporting other members in treatment.
Daniel Bryant, LPC, CCTP, CHCI’s Clinical Director of Substance Use Disorder Services, oversees the development of CHCI’s group treatment program. He notes that in many ways, these older individuals are the remaining survivors of OUD—with many younger addicts having suffered its fatal consequences. Both of these clinical leaders agree that the urgency of addressing OUD and its very real risk of immediate death can crowd out the ability for patients to focus on their other major health risks—other drugs, particularly cocaine and methamphetamine, AUD, tobacco use, and other chronic medical illnesses.
CHCI’s fully integrated model is one in which patients can not only be treated and supported in their response to their SUD, but also in all of their other complex health and social needs. These patients present great challenges, but caring for them has offered great professional reward and meaning to staff. Dr. Mary Blankson, Chief Nursing Officer of CHCI, notes these are patients who figure prominently in case presentations by the nursing staff as part of Project ECHO-RN Complex Care Management. The combination of social needs like housing, food insecurity, and isolation coupled with chronic illnesses present opportunities for nurses to make strong connections and a profound difference in the lives of their patients.
Despite all efforts, and CHCI’s ability to muster resources to address virtually all social needs either directly or indirectly, relapse is not uncommon and death at an earlier age than statistically expected by age, gender, and race/ethnicity, is sadly not unusual. This work requires full institutional support at the executive and clinical leadership levels but also peer-to-peer support. CHCI’s Chief Medical Officer, Dr. Veena Channamsetty, sets medical policy for the organization and leads the organization’s Opioid Review Committee, setting opioid-specific policies, reviewing provider prescribing patterns and identifying needs for intensified training, establishing priorities for treatment, and supporting providers in carrying out this challenging work. All clinical leaders actively participate in ongoing performance improvement activities to reduce risk, enhance health, and deliver on the promise of fully integrated, comprehensive primary care.
COVID-19 unleashed a new potential for disaster for people with OUD on multiple levels, including disruption of social and emotional connections and support, financial hardship, and loss of access to some healthcare services. The allowance by Medicare of both telephonic and audiovisual telehealth services, followed by Medicaid in many states, including Connecticut, has been a life saver for the healthcare consumer. Haddad and Bryant note, however, that group therapy—a critical element of supportive treatment—has not been as successful via visual telehealth platforms, and individual medical, nursing, and behavioral health visits—mostly via telehealth—are currently the norm. We are maintaining a vigilant eye on the impact of COVID-19 on morbidity and mortality related to SUD as data begins to emerge.
SUD is common in older adults, and this is seen in the nation’s largest primary care system of community health centers. OUD in older adults requires particular focus due to its potential lethality and the burden of other health problems associated with aging and other SUDs. The fully integrated, team-based model of care is an important contribution to ensuring timely access, comprehensiveness of care, and the potential for dramatic improvement in overall health status through full integration of clinical services. Clinical leadership and engagement are critical, as is a focus on training current healthcare team members and the next generation of providers. Just as primary care team members need the ongoing expert training, education, and support that can be provided through a modality like Project ECHO, so, too, can patients of all ages with OUD and other SUDs benefit in group treatment from the hard-earned wisdom and insights of the older individuals who struggle with SUD, particularly OUD.
Margaret Flinter, PhD, APRN, is senior vice president and clinical director of the Community Health Center, Inc., and is a family nurse practitioner in Middletown, Connecticut.
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