Expanding Your OBOT Program: Considerations and Strategies

You’ve done it!  You’ve moved past the initial hurdles of beginning your office based opioid treatment (OBOT) program.  Patients are getting the medications they need to support their recovery journey, and the program is growing.  But now you’re at that perilous point of figuring out how to expand because you can no longer meet demand.  Where do you start?! This can be a challenging question, and there really isn’t a one size fits all answer.

The first thing to consider is your established success metrics.  From day one, you want to have some way of evaluating what “success” means.  These metrics may be different across OBOT programs, and they will be impacted by your philosophy of care, but there should still be something that tells you, “Yes!  We are doing what we set out to do, and we are doing it well.” (And if you aren’t, doing it well that is to say, that’s ok. That’s the whole point of an evaluative process).  But before you think about expanding, what is the problem you’re trying to solve, what are the contributing factors, what are the potential solutions, and how does this align with those success metrics you’re measuring your program against?

As I’ve said before, the best way to keep people alive, and ultimately on the road to recovery, is to keep them coming back. So for me, the north star metric has always been patient engagement, and not measuring abstinence. I need to know what percentage of my patients are coming back at 7, 14, 30, and 90 days after medication initiation: 6- and 12-months post medication initiation? And then I need to know why.  Is there some organizational, programmatic, or care team contributor to why we see drop out rates at key points of treatment, and how do we address those barriers to increase patient retention?  By understanding WHY patients are dropping out of treatment, I can make a more informed decision about WHAT needs to be done to mitigate the problem.  This will also inform HOW I make changes, which could include increasing support staff, adding new types of team members, increasing the number of prescribers or the times in which services are offered, or adjusting a policy that deters patients from attending their appointments. And in my experience, each of these factors has proven to be true at some point or another.  So, what do you do about it?

Each factor will require its own strategy, and there are administrative and operational hurdles to consider.  In many cases, advocating for a new provider is a smaller lift than advocating for non-revenue generating positions, like care coordinators and peer recovery specialists (PRS).  The reason is simple, provider revenue keeps the doors open.  But, as we will talk about in our next blog on burnout, an overwhelming theme of provider reported burnout is the administrative workload that detracts from the provider-patient relationship. Your administrative burden is to “prove” the quality and cost saving impact of these non-revenue generating positions.  Can providers see more patients?  Do patients remain engaged for longer?  Do we see lower SUD related ED visits and fewer hospital readmissions that can be attributed to these new or expanded roles?   Your operational burden…in the not-for-profit world, sometimes it’s as simple as, where are these new people going to sit?

We must also consider the policy and procedural impactors on engagement.  Are no-show or late policies deterring patients from attending their appointments?  If so, how would adjustments in your OBOT program impact the larger organizational policies?  How about the frequency of visits or the requirement for behavioral health engagement?  While likely well intentioned, requiring appointment attendance too frequently, or requiring engagement in behavioral health may result in patients self-selecting out of treatment.  And to what end?  Because this will only increase their potential for overdose.  But, how would changes to these policies impact your team cohesion and other treatment protocols?

And a big one to consider, is the cost/benefit analysis of hiring peer recovery specialists, and the impact on HR policies around substance use and criminal justice involvement. In my opinion, and I suppose your reading this to hear it, is the benefits always outweigh the risks in this area.  The insights, advocacy, and supports that peer recovery specialists bring to your interdisciplinary team are beyond compare, and, in my experience, a main reason that patients remain engaged in services.  And I have to say, the changes to the P&Ps have the potential to extend far beyond your OBOT program and peer recovery specialists.  Consider the opportunities that community health centers have to impact the communities they serve. The ability to change the types of policies that continue to disenfranchise individuals with substance use and/or criminal justice histories opens the door for community members in all kinds of recovery to improve their lives and their communities.

Sources

1. Agarwal, S. D., MD. (2020, March 1). Professional Dissonance and Burnout in Primary Care: A Qualitative Study. Psychiatry and Behavioral Health | JAMA Internal Medicine | JAMA Network.