Archives for May 2018

How to Mitigate an Epidemic When it isn’t an Epidemic: MAHEC’s Efforts to Serve a Country in Crisis

The United States opioid crisis has been titled the “Opioid Epidemic” by the CDC and picked up by media drawing attention to the growing number of 600,000 people who have died from drug overdoses in the past 10 years. Vox has even claimed it as the, “epidemics of epidemics” attributing this largely to the over prescription of prescription opioids and now deadly impact of synthetic opioids like Fentanyl1. 100 times more potent than morphine, Fentanyl, which is mixed with heroin because it is a cheaper and stronger alternative, has led to increasingly to more overdoses and subsequent deaths.

MAHEC is among healthcare clinics across the country attempting to address this crisis that is seemingly out of control. As a healthcare education center, MAHEC serves the 18 westernmost counties of North Carolina and trains providers and community members on safer opioid prescribing, teaches how to treat opioid use disorder (OUD), and leads community discussions on the current state of the opioid crisis, amongst many other talks. As part of the education team, I help speakers comb over new literature on opioid and pain treatment to be disseminated to learners of our programs. Most of the literature is from 2017 and 2018 indicating the recent push from the medical community to more adequately address the crisis, but there is still so little we know about adequately helping patients with pain and addiction.

Aiming to use best opioid treatment practice, MAHEC has two substances use specific treatment services –the perinatal substance use program which treats pregnant women who have substance use disorders and the office based opioid treatment services which provides family medicine patients with medication assisted treatment (MAT) for opioid use disorders. Both of these programs provide behavioral health services as well as medication in order to help patient’s combat addiction by reducing cravings and withdrawal symptoms. As part of the clinic teams, I help with program logistics, development, and research. These roles include community outreach, creating education materials for patients and other providers, and scribing patient documentation.

MAT helps patients curb their withdrawal symptoms, it eases their nervous symptoms anxiety and urges to use. The analogy we use in clinic is that MAT is to people with substance use disorders like insulin is to people with diabetes. It helps regulate your body to a normal state. This analogy has helped me combat my own harbored bias and medicalize addiction as a disease. The providers a work with state, almost as a mantra, that addiction is a “chronically relapsing disease.” Relapse is part of the disease—it is expected that patients will struggle for the first few months while in treatment because this disease is so difficult to combat.

The biological, medical model for addiction is only one piece of understanding addiction. People who struggle with addiction are also surrounded by others who are using. Even if you are on MAT you may go home to your parents or partner using, which can be incredibly triggering and stressful. Evidence has shown that addiction also has an unclear but definitive genetic component, meaning that if you have a family history of addiction, you have a greater chance of having addiction yourself. And historically addiction has existed disproportionality in communities of color and in poverty. While the opioid crisis initially impacted poor, rural, white communities, it has grown to have broader implications in urban areas and across racial groups2. Medicalizing the rise in opioid addiction and opioid related deaths is incredibly important because it emphasizes the notion that addiction is a chronic relapsing disease that can be helped through medication and therapy. But more broadly addiction stems out of communities harboring significant trauma, stress, and other social determinants of health.

Many of our patients have extensive trauma histories and family histories of addiction. Trauma causes anxiety and fear, putting your body in fight or flight mode. When the body is in constant fear, maybe because of an unstable family situation or even insecure housing or nourishment, the body can get stuck in fight or flight mode. High stress, high anxiety mode. Especially if someone has never been taught healthy coping mechanisms, they can often turn to substances to help calm their nervous systems and get a break. Patients have told me that their first time using an opioid was “the first time the felt normal.” This trauma often exists in communities of poverty and can carry on through generations.

Unlike other “epidemics,” the opioid one isn’t virally catching. And going into this fellowship and as I learned more extensively about addiction as a disease, I did not fully grasp why the language of “epidemic” could be problematic. But providers, researchers, and patients themselves have shown me that addiction cannot be solved by a cure all medication or even a simple behavior change like washing your hands. In order to more fully support patients with addiction, within the medical setting, patients must, at minimum, be provided with behavioral health and social resources that mitigate their psychosocial stressors. Using the word Epidemic can leave out the psychosocial pieces of addiction –its existence due to poverty, trauma, stress, anxiety.

MAHEC has shown me how one organization can target the crisis through different avenues like clinical practice, population health, community and provider education, and community engagement. However, the opioid crisis is another crisis in a long time of addiction crisis that have persisted throughout United States history. We need more robust efforts that target systemic inequalities so that we don’t see another crisis in ten years.

 

  1. Nilsen, E. (2018, March 06). America’s opioid crisis has become an “epidemic of epidemics”. Retrieved from https://www.vox.com/2018/3/6/16453530/america-opioid-crisis-epidemic-bacterial-endocarditis-hepatitis-c
  2. Peñaloza, M. (2018, March 08). The Opioid Crisis Is Surging In Black, Urban Communities. Retrieved from https://www.npr.org/2018/03/08/579193399/the-opioid-crisis-frightening-jump-to-black-urban-areas

An Intro to Grant Writing at CCHC

Charlotte Community Health Clinic (CCHC) relies on a significant amount of grant funding from diverse organizations. These include local faith groups, national non-profits, and the state and federal government. During my year at the clinic, I was given the chance to work on a number of these grants. Here’s three things I’ve learned as a result of my foray into grant writing:

Know your audience: It’s important to think about exactly who the funder is, in terms of what you write and how you write it. When I wrote a request to a local church, there was more flexibility to talk about individuals and their stories, express our organization’s belief in the right to access care and the inherent worth of individuals we care for. While that’s all well and good, when writing a grant request to the NC Office of Rural Health, they tend to care more about things like, well, money. In that grant request, we were careful to emphasize ROI, calculating potential community savings brought about by prevention of unnecessary ER trips. Different outcomes constitute impactful results for different audiences.

It’s a team effort: For some of the more formal grants I worked on this year, as many as five or six people would be involved in their writing. Typically, I would get to take a first stab at the narrative and work to find any clinical, local, or national data we might need to support our request. Requests for general operating funds were pretty straightforward because I could use fairly similar wording across grants. However, when writing for a new program, like when we wanted one of our providers to work onsite at a public housing location, I needed information from clinical staff to understand what the program would actually look like. Often times, the individuals that would know this (namely, our Chief Operating Office), would be busy with other things, like you know, keeping the clinic running, so I would take a stab at outlining the program. Then, when I had a chance to sit down with the COO she’d provide input as to what resources would be needed for the program to succeed and what I missed in the narrative. She would also help come up with reasonable objectives, usually with support from our data analyst. This would then get passed on to my supervisor, the Director of Development, who would work on the detailed budget and make my narrative sound a lot nicer (despite my Writing 101 professor’s best efforts, I’m the queen of unnecessary commas). When she was done, it would go back to the COO and CEO for final approval.

Outcomes are really, really tricky: Outcomes are what support the worth of your work. They give the grantor an idea of the tangible results that we anticipate coming if they fork over the money. However, there are a lot of things that make coming up with these objectives tough. Sure, we know that having a nurse who coordinates the care of our patients with chronic disease improves outcomes for them, but how do we measure that? 150 unnecessary ER trips avoided? Lower A1c levels for our diabetics by 1? A 25% increase in access to a patient care team? Are these objectives too broad, do they have too little direct correlation to the nurse coordinator, or are they too hard to measure? Even if we already track this data, do we have the capability to export it from our Electronic Health Records system? Additionally, what we think are significant goals may not seem that impactful to funders. For example, when we say the hire of a nurse coordinator will improve outcomes for our diabetics by 5%, we’re taking into account the many social determinants that impact our patients and the comorbidities that they often present with. But for some funders who may not understand our patient population as well, a 5% improvement may hardly seem a worthy investment.

It has certainly been a challenge to attempt to convey the value of our work to those who will never have the chance to meet our patients, but one I have very much enjoyed. It’s also been pretty great to start seeing the results of our efforts. Over the last two weeks we have received notice of having been awarded more than $170,000 for various grants we wrote earlier this year. While this may seem like a drop in the bucket, for us it means kick starting our effort to provide onsite services in public housing, buying medical supplies for our pediatric patients, providing health education workshops for seniors, and covering the cost of part of our nurse care coordination team. As I’m currently finishing out my final weeks here at the clinic, I won’t be around to see these funds in action. However, I’m grateful to have been given a chance to play a small part in tracking down the resources needed to let our clinic staff do more of their incredibly important work.

In the Pursuit of a Seamless Network of Care

Since the implementation of the Affordable Care Act (ACA), the number of insured people in the United States has increased; however, 12.2% (Q4 2017) remain without insurance in many communities. Healthcare safety nets continue to provide essential, community-based services to the remaining underinsured and uninsured people. Some of these individuals lack employee-sponsored coverage and their income is too high for Medicaid, some might be recent immigrants or seasonal workers, some might hold multiple jobs and still cannot afford marketplace coverage, and some might just have too low of a health status, are unemployed, and still are not Medicaid-eligible. Just navigating the complex system of government and local agencies takes a toll in the health of individuals and their families. The greatest issues still remain: access to care, affordability of care, and delivery of care.

According to the Small Area Health Insurance Estimates (2015), there are approximately 23, 317 uninsured adults between ages 18 – 64 in Cabarrus County, of which 42.1 % are below or at 135% of the Federal Poverty Level. More than one in seven (15.7%) adults report being unable to see a doctor in the past year due to cost (County Health Rankings, RWJF, 2015). I have been a Fellow at the Community Free Clinic since June of last year. To give you some context, we serve chronic working-age adult patients at 125% or below the Federal Poverty Level, with an annual re-certification process. As a central hub for HealthNet Cabarrus and the Pink Card Program, we provide access to on-site primary care, laboratory, behavioral, and pharmaceutical services, as well as specialty, diagnostics, and medical referrals. We have been serving the unmeet health needs of the county and its uninsured residents since our foundation in 1994. Currently, the Clinic has full time and part time staff, hundreds of volunteers including physicians, nurses, pharmacists, lab technicians, and many more. Our funding has come from several sources over our years of service: United Way of Central Carolinas, The Cannon Foundation, The Kate B. Reynolds Trust, Office of Rural Health Community Health Grants, The Leon Levine Foundation, Atrium Health/Carolinas HealthCare System – NorthEast, and private donations.

I have been involved in a series of meetings in order to develop a pathway for community members to more easily navigate our local system of care. The HealthNet task force has met for 18 working sessions, logging over 720-person hours to date to create a seamless system that serves the uninsured within Cabarrus County. Various health care and community organizations are involved in this endeavor: the Community Free Clinic, the Rowan Cabarrus Community Health Centers, Community Care of Southern Piedmont, Atrium Health/Carolinas HealthCare System – NorthEast, Carolinas HealthCare System – NorthEast Physicians Network, Cabarrus Health Alliance, Daymark Recovery Services, Cooperative Christian Ministry, and Cabarrus County Department of Human Services. All of us have the same goal in mind: to strengthen and revitalize the current health safety net for the uninsured population.

In a partnership with a team of consultants from Care Share Health Alliance, an organization that provides strategic support to other organizations forming coalition and safety nets in counties of North and South Carolina, we have strengthened our referral and enrollment system by implementing a web-based software, FHASES, to include multiple referral points and common data elements across partner agencies. Our principal goal is to increase the patient population accessing our services by 1000 within the next 12 months. With that in mind, we also want to increase individual trackability of referrals and appointments to make sure they do not get lost in the “black hole”. The collaborative has also focused in tracking population and individual data on social determinants of health. However, we will not only assess for SDOH, but also make the necessary referrals to local partners ranging from temporary housing to food pantries. This will be done using the Community Resource Hub, a platform established by Atrium Health using Aunt Bertha, that provides referral specialists the ability to close the loop.

Perhaps one of the most impactful experience has been working with these local, community leaders in the efforts to strategize and continue to meet the unmet needs of the Cabarrus community. The health care environment has shifted in the last 10 years with funding and policy becoming unstable and highly politicized. It has been fantastic to see the synergy among these organizations and leaders that continue to provide the necessary services to the community, and it has been a privilege being able to support them in this effort.

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