Delivery of Care

A report from the front lines of telehealth

An interview with Linda Hurley, president and CEO of CODAC Behavioral Healthcare in RI

Image courtesy of CODAC Behavioral Healthcare

Linda Hurley, right, president and CEO of CODAC, with Sen. Sheldon Whitehouse

By Richard Asinof
Posted 7/20/20
An in-depth interview with Linda Hurley, the president and CEO of CODAC, talking about how the paradigm has shifted to telehealth amidst the coronavirus pandemic.
What has become of Sen. Joshua Miller’s Senate commission to study the issue of insurance reimbursements in Rhode Island? Why has Neighborhood Health Plan of Rhode Island chosen to oppose parity in reimbursements for telehealth services? What kinds of applications of the new digital texting platform developed by Healthcentric Advisors might be adopted for use in schools in response to tracking students who may have become infected with the virus? What kind of data mining is being done in preparation of the second annual Rhode Island Life Index? When will Rhode Island have a complete dataset linking the diseases of despair – alcohol, suicide and drugs? How much is the Governor willing to invest in Health Equity Zones in Rhode Island?
In an effort to continue to meet the unmet needs around behavioral health services for Rhode Islanders struggling to cope with the stress of the crisis caused by the coronavirus pandemic, as a result of job loss, social distancing and continuing health problems, the Rhode Island Foundation awarded last week an additional $1.7 million for behavioral health services. The services funded include counseling to survivors of domestic violence to help for children coping with the stress of the pandemic through telehealth services.

PROVIDENCE – Far, far below the media radar screen, during a hearing held on Wednesday, July 15, before the House Finance Committee, overwhelming testimony was heard in favor of enacting legislation, under a budget article “Relating to Telemedicine,” to extend the enhanced practice of telemedicine for a year, instead of depending upon monthly extensions of an executive order by the Governor.

The practice of telehealth has emerged during the past five months as an innovative necessity during the coronavirus pandemic, in order to continue to deliver health care in a timely, efficient and cost-effective manner, when in-person visits have become impossible and no longer feasible, both for the safety of the patients and the providers.

From behavioral health services for young mothers to the distribution of methadone, from digital platforms connecting patients and providers who may have been infected by the coronavirus to consultations with specialists around treatment of neurological conditions, telehealth has emerged from being a novelty to becoming a necessity. [See link below to ConvergenceRI story, “From a novelty to a necessity.”]

One of the key provisions would be to continue providing full parity reimbursements from insurers for telehealth services, as well as the creation of a stakeholder group to be convened by the R.I. Office of the Health Insurance Commissioner to analyze the delivery of services under telemedicine.

There were some 98 written letters of testimony in support of the legislation and only five against. But one of the letters opposing the legislation, from Peter Marino, the president and CEO of Neighborhood Health Plan of Rhode Island, a managed care organization for the delivery of Medicaid services as well as a commercial health insurer, took many health care advocates by surprise. [The only in-person testimony opposing the legislation came from the Rhode Island Business Group on Health.]

Marino’s suggested that OHIC was overstepping its authority, that parity was not desired outcome, and that the emergency expansion of telehealth be sunset. Translated, Marino appeared to be arguing for the preservation and return to the status quo.

What the evidence tells us
Linda Hurley, the president and CEO of CODAC Behavioral Healthcare, the largest nonprofit outpatient provider for opioid treatment in Rhode Island, was recently featured in a July 15 story in Crain’s HealthPulse New York, written by Jennifer Henderson, talking about her organization’s focus on maintaining access to care during the COVID-19 crisis.

“The primary goal was to mitigate exposure to the virus,” Hurley told Henderson. To help do so, between April 1 and May 15, the organization provided nearly 160,000 doses of methadone to be self-administered outside of the clinic. The medication went to those who usually visited daily or several times a week, had been released early from prison, were in a homeless shelter or had been self-isolating.

Some 60 percent of the doses would not have been distributed outside of the clinic before the pandemic, Hurley said. However, less than 1 percent of the medication was not managed well, with people losing it or taking too many doses.

Translated, it appears that eased regulations for take-home doses and the virtual initiation of medication-assisted treatment have been part of the efforts to safely maintain access to care for a vulnerable population. A study is being conducted in coordination with the School of Public Health at Brown University to measure the efficacy and patient satisfaction with telehealth services.

ConvergenceRI recently reached out to Hurley to ask about a number of pertinent issues surrounding the delivery of care during the coronavirus pandemic. Here is the ConvergenceRI interview.

ConvergenceRI: What have been the most important things learned in the past five months of crisis?
HURLEY:
We have learned very clearly three things:

• One, that our field has been both over-regulated relative to methadone and under-regulated relative to the use of buprenorphine as a medicine for opioid use disorder.

Both of these conditions are very clearly the result of historic fears, bias and discrimination. In other words, stigma.

In Rhode Island, the relaxation of regulation and the ability of patients to self-manage their medications has not resulted in an increase in diverted medications in the community. This perception of those who come to us for care for substance use disorder is not supported by the facts.

Importantly, we have learned that these regulations actually have become a barrier to care for many, many individuals.

• Two, we have learned that telehealth is an incredibly effective component of a menu of services for the treatment of substance use disorder and other behavioral health care disorders. We have learned that it is effective and has met with a great deal of patient satisfaction.

• Three, telehealth creates increased utilization that creates more revenue. Within the context of Rhode Island having one of the lowest Medicaid rates in New England and the Mid-Atlantic states, this becomes even more vitally important.

Most importantly, we have been permitted to prove that our patients are courageous responsible individuals who have come together with us as their medical providers and their communities in order to help to navigate together through this pandemic.

ConvergenceRI: How important has telehealth become as a tool in responding to patients’ and providers’ needs?
HURLEY:
Telehealth has become a critical component of our care during this COVID-19 crisis. Our goal has been to mitigate exposure to the virus for our staff, our patients and the community, at the same time that we are enhancing services due to the stressors resultant of the social upheaval.

We were forced very quickly to adapt. Utilizing telehealth services has become a foundational component of this adaptation. All aspects of telemedicine have been utilized with patients.

Face-to-face medical assessments and crisis interventions as well as behavioral health interventions have been available to our community and patients throughout this pandemic and continue to be available.

However, routine medication management medical questions and behavioral health interventions have been conducted telephonically or by both audio and visually.

The response has been remarkable. Patients and staff alike report both patient satisfaction and clinical efficacy. Utilization of counseling time has increased. The utilization of medication management services has increased.

The historic access issues that often resulted in up to a 50 percent no-show rate are now practically eradicated, as a result of individuals being able to access care in their home.

Transportation, time constraints, childcare and other barriers to access have now been mostly [removed] by these models. Post-COVID pandemic, telemedicine needs to continue in order to provide optimum service for those who come for care.

ConvergenceRI: What are the stressors most prevalent in the communities and patients you serve?
HURLEY:
Across the board, what we are seeing – just as is being reported nationally – are the outcomes related to isolation, uncertainty and fear. Whenever any of us are challenged in these ways, we very often respond with some of our earliest coping mechanisms, which most often are ineffective or harmful in our adult lives.

Just as relationships are critical for healing from the disease of substance use disorder, isolation often exacerbates the symptoms.

In addition, job insecurity and housing insecurity are social determinants that frequently impact an individual’s recovery. During the initial phases of COVID-19, we saw very little increase or no increase in relapse and overdose.

As we have moved into June we are seeing a marked increase – just as is being seen nationally. This increase is not as remarkable as the national numbers, we are presuming, because the population [here at CODAC] that we are measuring are individuals choosing to be in treatment.

Our patients are particularly vulnerable to the social and medical risks of COVID-19. Many of our staff members suffer from the worry about “what happens next.” There has been no real reassuring routine. The post-event response and support for staff needs to be ongoing. The psychic fatigue of all this is a critical stressor.

ConvergenceRI: Has anyone in government reached out to your to learn more about the concept of recovery and what it means for a post-pandemic world?
HURLEY:
Sen. Sheldon Whitehouse’s office has reached out to understand needs of those in recovery as well as those not yet in treatment. He and his staff have been not just interested but responsive.

On a state level, the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals has been timely and supportive of the developing needs and has supported us in requesting ongoing federal relaxation for take-home medication and induction protocols – many of which do not support science and appear to be regulatory demonstrations of stigma.

The R.I. Department of Health has been supportive through PPE supplies, dollars for crisis and counsel.

To date, I have to say that there have not been “too many” meetings. This pandemic changes daily so our community needs and methods to do so need to remain fluid. Communication is critical and so far well worth the time.

Gov. Gina Raimondo has signed executive orders every 30 days that require any telemedicine or telehealth or telephonic service that reflects a face-to-face service ordinarily provided to patient, is to be paid and paid at the same rate by all third-party payers whether public or private.

The most recent executive order expires on August 30. Our governor has suggested that the components of her executive orders for telehealth remain in effect until June 2021. She’s doing this to assure optimum care for the residents of Rhode Island.

So continued payment for telehealth services is supported by the Governor’s office and by the state Senate, leaving the R.I. House as the final barrier.

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