Adherence to and Retention in Medications for Opioid Use Disorder Among Adolescents and Young Adults
Adherence to and Retention in Medications for Opioid Use Disorder Among Adolescents and Young Adults
Abstract
The volatile opioid epidemic is associated with higher levels of opioid use disorder (OUD) and negative health outcomes in adolescents and young adults. Medications for opioid use disorder (MOUD) demonstrate the best evidence for treating OUD. Adherence to and retention in MOUD, defined as continuous engagement in treatment, among adolescents and young adults, however, is incompletely understood. We examined the state of the literature regarding the association of age with adherence to and retention in MOUD using methadone, buprenorphine, or naltrexone among persons aged 10–24 years, along with related facilitators and barriers. All studies of MOUD were searched for that examined adherence, retention, or related concepts as an outcome variable and included adolescents or young adults. Search criteria generated 10,229 records; after removing duplicates and screening titles and abstracts, 587 studies were identified for full-text review. Ultimately, 52 articles met inclusion criteria for abstraction and 17 were selected for qualitative coding and analysis. Younger age was consistently associated with shorter retention, although the overall quality of included studies was low. Several factors at the individual, interpersonal, and institutional levels, such as concurrent substance use, MOUD adherence, family conflict, and MOUD dosage and flexibility, appeared to have roles in MOUD retention among adolescents and young adults. Ways MOUD providers can tailor treatment to increase retention of adolescents and young adults are highlighted, as is the need for more research explaining MOUD adherence and retention disparities in this age group.
Recording Available: Virtual Hill Briefing – Using Telehealth to Address the Coronavirus Public Health Emergency
During this event, telehealth leaders spoke to what their systems are doing and how they are using new flexibility created by Congress to deliver telehealth during the COVID-19 pandemic. A couple of teaser screenshots are included below. Presentation PDF.
Dr. Ethan Booker, Medical Director at MedStar Telehealth Innovation Center
“In February, we thought we had a decent month, with about 240 telehealth video visits delivered to people’s homes. Since March 13, we have completed more than 12,000 video visits and now have approximately 1000 providers in our health care system using telehealth to provide care.”
“We used to do about 5-6 of [scheduled outpatient visits] a week, as you can see here, we did more than a 1,000 Friday and it has continued to grow through the early part of the week.”
Dr. Todd J. Vento – Medical Director for the Infectious Diseases Telehealth Service at Intermountain Healthcare
Intermountain is leveraging its longstanding telehealth expertise to respond to the COVID-19 pandemic and increased requests for virtual communications and triaging.
Dr. Lawrence “Rusty” Hofmann, Medical Director of Digital Health at Stanford Health
In two weeks Stanford Health Care scaled video visits from less than 1% to more than 40% of all ambulatory visits, screening patients with URI symptoms, reducing unnecessary exposure, minimizing community spread and maximizing medical resources.
Stanford also strongly encourages participation in their National Daily Health Survey — which will learn and predict which geographical areas will be most impacted by coronavirus based on patient-reported data.
Emergency Management Assistance Compact (EMAC) for Telehealth
Emergency Management Assistance Compact (EMAC) for Telehealth
The National Emergency Management Association released guidance on using the Emergency Management Assistance Compact (EMAC) to facilitate telehealth across state lines. EMAC is a national disaster-relief compact ratified by all 50 states, the District of Columbia, Puerto Rico and all U.S. territories.
On April 1, The National Emergency Management Association sent all 50 state governors a telehealth template for a gubernatorial executive order, which will create more consistency across state lines in implementing telehealth services and solving interstate licensure issues during the COVID-19 emergency. The Alliance for Connected Care and the National Governor’s Association called on Governors to use their authority under EMAC in March. Through this executive order, states can enable private sector telehealth in their state to assist health care workers.
If adopted, the template directs governors to waive interstate licensure for the duration of the emergency period, so that any health provider licensed, registered, or certified in good standing in another U.S. jurisdiction may deliver services in their state, including through telehealth, as long as those services are within the provider’s authorized scope of practice. This solves the existing telehealth barrier of interstate license permits and certificate reciprocity between states using existing EMAC state law. In the executive order template, governors can also mandate that no municipality, county or any other agency of the State can enact or enforce any order, rule, regulation, ordinance or resolution that would contradict the provisions included in the executive order.
EMAC Best Practices for Telehealth
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Open in new tab CMS COVID-19 Interim Final Rule Summary and Code Chart
As part of its announcement on “Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge the Administration included significant additional Medicare telehealth changes, including:
- CMS will now pay for more than 80 additional services when furnished via telehealth. These include emergency department visits, initial nursing facility and discharge visits, and home visits, which must be provided by a clinician that is allowed to provide telehealth.
- CMS finalized CPT codes 98966-98968 and CPT codes 99441-99443 for prolonged, audio-only communication between the practitioner and the patient.
- Virtual Check-In services, or brief check-ins between a patient and their doctor by audio or video device, could previously only be offered to patients that had an established relationship with their doctor. Now, doctors can provide these services to both new and established patients.
- Clinicians can provide remote patient monitoring services for patients, no matter if it is for the COVID-19 disease or a chronic condition. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry.
- CMS is allowing telehealth to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice and home health. During the pandemic, individuals can use commonly available interactive apps with audio and video capabilities to visit with their clinician.
- Home Health Agencies can provide more services to beneficiaries using telehealth, so long as it is part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care.
- Hospice providers can also provide services to a Medicare patient receiving routine home care through telehealth, if it is feasible and appropriate to do so.
- If a physician determines that a Medicare beneficiary should not leave home because of a medical contraindication or due to suspected or confirmed COVID-19, and the beneficiary needs skilled services, he or she will be considered homebound and qualify for the Medicare Home Health Benefit. As a result, the beneficiary can receive services at home.
- CMS is allowing for physician supervision requirements to be provided virtually, using real-time audio/video technology. Other changes to supervision requirements as well.
- Licensed clinical social worker services, clinical psychologist services, physical therapy services, occupational therapist services, and speech language pathology services can be paid for as Medicare telehealth services.
Please find a more detailed summary and a chart of the newly covered services below.
*Note that this interim final rule does not reflect several of the statutory changes achieved for telehealth in the “Coronavirus Aid, Relief, and Economic Security Act,” which was signed into law on March 27. That law altered preexisting relationship requirements for telehealth in Medicare and altered the telehealth payment structure for Federally Qualified Health Centers — among other changes.
For information on the COVID-19 waivers and guidance, and the Interim Final Rule, please go to CMS COVID-19 flexibilities webpage: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers.
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RSVP NEEDED – Using Telehealth to Address the Coronavirus (Alliance Virtual Hill Briefing)
View this past event at Recording Available: Virtual Hill Briefing – Using Telehealth to Address the Coronavirus Public Health Emergency
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Telehealth in the Third COVID Legislative Package
The President has signed the Coronavirus Aid, Relief, and Economic Security Act (H.R.748). The language is a significant advancement for the telehealth community. Here is a topline of the key telehealth provisions in the bill –
Sec. 3212. Telehealth network and telehealth resource centers grant programs.
- This section would amend the current Telehealth Network and Telehealth Resource Centers grant program to specify that it will support evidence-based projects, to extend grant period funding to five years, rather than four, and assuring that 50 percent of funds shall be for projects in rural areas. Provides $29M for each of FY21-25.
Sec. 3701. Exemption for telehealth services.
- This section would allow a health plan or employer to provide pre-deductible coverage of telehealth and other remote care for individuals with health savings account (HSA) eligible high-deductible health plans (HDHP) for plan years beginning on or before December 31, 2021. This could be either discounted or fully covered care.
Sec. 3703. Increasing Medicare telehealth flexibilities during emergency period.
- This section would eliminate the requirement in Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020 (Public Law 116-123) that limits Medicare telehealth expansion authority during the COVID-19 emergency to situations where the physician or other professional has treated the patient in the past three years. The “qualified provider” requirement would instead be replaced with a Secretarial ability to waive all requirements under 1834(m).
Sec. 3704. Enhancing Medicare telehealth services for Federally qualified health centers and rural health clinics during emergency period.
- This section would allow, during the COVID-19 emergency, Federally Qualified Health Centers and Rural Health Clinics to furnish telehealth services to beneficiaries in their home or other setting. Medicare would reimburse for these services at a composite rate similar to payment provided for comparable telehealth services under the Medicare Physician Fee Schedule.
Sec. 3705. Temporary waiver of requirement for face-to-face visits between home dialysis patients and physicians.
- This section would eliminate a requirement during the COVID-19 emergency that a nephrologist conduct some of the required periodic evaluations of a patient on home dialysis face-to-face., allowing these vulnerable beneficiaries to get more care in the safety of their home.
Sec. 3706. Use of telehealth to conduct face-to-face encounter prior to recertification of eligibility for hospice care during emergency period.
- This section would allow hospice providers to conduct a face-to-face encounter required for recertification of eligibility via telehealth.
Sec. 3707. Encouraging use of telecommunications systems for home health services during emergency period.
- This section provides the HHS Secretary the flexibility to consider ways to encourage the use of telecommunications systems and other communications or monitoring services, consistent with the care plan for the individual, as appropriate.
Appropriations:
Federal Communications Commission
- $200 million to remain available until expended, to prevent, prepare for, and respond to coronavirus, domestically or internationally, including to support efforts of health care providers to address coronavirus by providing telecommunications services, information services, and devices necessary to enable the provision of telehealth services during an emergency period
Dept of Agriculture
- $100 million for the costs of construction, improvement, or acquisition of facilities and equipment needed to provide broadband service in eligible rural areas
- $25 million for the Distance Learning, Telemedicine, and Broadband Program (DLT) –The DLT grant program supports rural communities accessing telecommunications-enabled information, audio and video equipment, and related advanced technologies for students, teachers, and medical professionals
Indian Health Services
- $1,032,000,000 to prevent, prepare for, and respond to coronavirus, domestically or internationally, including, but not limited to, funding for surveillance, testing capacity, community health representatives, public health support, telehealth, Purchased/Referred Care, and other health service activities necessary to meet the increase in need of services and to protect the safety of patients and staff
- Up to $65,000,000 is for electronic health record stabilization and support
Public Health and Social Services Emergency Fund
- $27,014,500,000, to remain available until September 30, 2024, to prevent, prepare for, and respond to coronavirus, domestically or internationally, including the development of necessary countermeasures and vaccines, prioritizing platform-based technologies with U.S.-based manufacturing capabilities, the purchase of vaccines, therapeutics, diagnostics, necessary medical supplies, as well as medical surge capacity, and related administrative activities, addressing blood supply chain, workforce modernization, telehealth access and infrastructure, initial advanced manufacturing, novel dispensing, enhancements to the U.S. Commissioned Corps, and other preparedness and response activities
- $180,000,000 of the funds appropriated (under the Public Health and Social Services Emergency Fund) shall be transferred to ‘‘Health Resources and Services Administration—Rural Health’’ to remain available until September 30, 2022, to carry out telehealth and rural health activities under sections 330A and 330I of the PHS Act and sections 711 and 1820 of the Social Security Act to prevent, prepare for, and respond to coronavirus, domestically or internationally.
Health Resources & Services Administration (HRSA)
- $275 million to remain available until September 30, 2022 for Ryan White programs, rural health programs, and telehealth programs.
Department of Veterans Affairs
- $14.4 Billion to supports increased demand for healthcare services at VA facilities and through telehealth, including the purchase of medical equipment and supplies, testing kits, and personal protective equipment. Also enables VA to provide additional support for vulnerable veterans, including through programs to assist homeless or at-risk of becoming homeless veterans, as well as within VA-run nursing homes and community living centers.
- The Secretary of HHS may enter into contracts with telecommunications providers in order to provider mental health services to isolated veterans during the emergency
- Creates flexibility for telephone or telehealth renewals in the Veteran Directed Care program
- Secretary of VA shall ensure telehealth capabilities are available to homeless veterans participating in HUD-VA programs
Secretary Azar Calls on Governors to Allow Telemedicine Across State Lines
On March 25, Department of Health and Human Services Secretary Alex Azar sent a letter to Governors calling on them to take a number of actions to strengthen the healthcare workforce as it faces the COVID-19 pandemic, including:
- Allow licensure across state lines – either in person or through telemedicine
- Waive state-level regulatory barriers to telehealth
- Relax scope of practice limitations
- Allow more telehealth and remote supervision
- Allow rapid certifications
- Develop and share a list of state-level liability protections for healthcare providers
- Modify any laws to allow signature-less delivery of pharmaceutical products.
Please find the full letter below:
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NGA Memos on State Licensure Requirements
National Governors Association Memorandum to Governors on Telehealth and State Licensure Requirements
On March 20 and 24, the National Governors Association (NGA) issued memorandum to State Governors on “Gubernatorial Strategies for Telehealth” and “Gubernatorial Strategies for Health Care Workforce and Facility Capacity.”
The first memo noted the many state actions that have already been taken to increase access to telehealth services – including increasing the types of reimbursable covered services, reducing consumer costs, reducing participation requirements and barriers for providers, and increasing the modalities trough which services may be offered via telehealth. It also provided several recommendations for Governors to consider:
- Ensuring that individuals have coverage of telehealth services with limited or no cost sharing for those services.
- Waiving state specific professional licensure requirements or granting temporary licenses to enable cross-state in-person or telehealth services in states that have declared a state of emergency and activating the Emergency Management Assistance Compact (EMAC).
- Coordinating with health systems and hospitals to ensure capacity and capabilities to deliver telehealth services.
- Streamlining and simplifying provider participation in telehealth.
- Expanding how and where telemedicine can be delivered and still qualify for reimbursement.
- Facilitating continued access for individuals receiving medication-assisted treatment (MAT)
The second memo recommended that Governor’s respond to workforce challenges by:
- Expanding access to out-of-state licensed health care providers and telehealth.
- Maintaining and increasing the number of providers by easing in-state licensure requirements.
- Using state emergency funding to support enhanced training and recruitment efforts.
The Alliance for Connected Care is pleased to contribute to this effort. Please see the full document below:
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Stakeholder Letter – Telehealth for People with High-Deductible Health Plans
On March 20, a group of leading organizations called on Congress to pass legislation that amends the Internal Revenue Code of 1986 to allow employers and health plans to cover telehealth services pre-deductible in Health Savings Account-eligible high deductible health plans during this health care crisis.
This legislation would build on efforts by Congress to ensure access to telehealth during this emergency, when access to care and treatment is more important than ever.
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