Tackling the Opioid Crisis in New York State

Nearly 9 million opioid prescriptions were dispensed in New York State in 2015. Between 2011 and 2014, approximately 145,000 New Yorkers annually abused or were dependent on opioids.

The opioid crisis in New York State is multifaceted, and solving it will require a whole range of interventions. Among other approaches, curbing the epidemic will involve: analyzing and sharing data to demonstrate the scope and diversity of the problem; educating health care providers and giving them tools to address prescribing patterns; encouraging public health departments to screen for opioid use and refer users to treatment; and working with law enforcement to emphasize treatment over incarceration.

NYHealth is supporting a number of activities to combat the opioid crisis.

Analytic Work

Follow the Money: Pharmaceutical Manufacturer Payments and Opioid Prescribing Patterns in New York State
This report examines how payments from opioid manufacturers to physicians may have influenced opioid prescribing in New York State. Financial relationships between physicians and drug manufacturers are common, including payments for speaking and consulting fees, as well as for various gifts such as meals. Between 2013 and 2015, drug manufacturers spent more than $3.5 million in opioid promotion activities with thousands of New York State physicians. The report finds roughly 1 in 10 physicians who prescribe opioids received a payment, and physicians who prescribe more opioids got more opioid-related payments.

Targeting an Epidemic: Opioid Prescribing Patterns by County in New York State
To better understand the scope of the epidemic, NYHealth produced this data snapshot examining trends in opioid prescriptions and opioid abuse in New York State. The analysis examines prescribing trends by county in New York State from 2010 to 2015, using publically available data from the Centers for Disease Control and Prevention. Most research on the opioid epidemic has focused on state-level data, which masks important differences between smaller geographic areas. Understanding geographic variation within New York State is essential to ensure that resources and interventions are targeted appropriately.


A Coordinated Response to the Opioid Epidemic in North Country
In 12 upstate New York State counties alone, the number of heroin overdoses jumped 417% between 2009 and 2013. In response to this emerging crisis, Essex County Public Health established the Essex County Heroin and Opioid (ECHO) Prevention Coalition, a multiagency collaboration to prevent and reduce heroin and opiate use and addiction. A top priority for the coalition is to launch a Screening, Brief Intervention, and Referral to Treatment (SBIRT) program in Essex County and beyond. An evidence-based, effective approach to combat substance use disorders, SBIRT can reduce health care costs, decrease severity of drug and alcohol use, and reduce risk of trauma. With a 2016 NYHealth grant, Essex County Public Health is introducing and implementing SBIRT in Essex County, and eventually in other North Country counties.

Women, Pregnancy, and the Opioid Epidemic in New York: A Health Care Provider Educational Approach
Health care clinicians often lack familiarity with key guidelines related to opioid use and safety, knowledge about opioid addiction, and the necessary skills to address the unique needs of these patients. With a 2016 NYHealth grant, the American Congress of Obstetricians and Gynecologists (ACOG) is working to improve obstetricians’ and gynecologists’ knowledge and awareness of opioid use and safety in pregnant women. The project will focus on engaging women’s health care providers in rural and upstate regions of New York State. ACOG will organize a multidisciplinary town hall meeting in upstate New York to gain a local perspective on the issue, as well as assemble a workgroup of experts to help develop, vet, and implement clinical education. Based on these meetings, ACOG will develop and implement hospital-based provider toolkits that include best practices on the care management of pregnant women who use opioids, targeting five upstate academic medical centers and their affiliate locations as pilot sites for training and education. ACOG will publish a final report on the implementation process, outcomes, and lessons learned from the pilot as a guide for how to best replicate the program.

Addressing the Opioid Epidemic by Improving the Electronic Health Record Prescription Process
One of several critical factors causing the opioid epidemic is physician-prescribing practices. Misused prescription opioids contribute to the epidemic of heroin use and heroin and fentanyl fatalities. In 2017, NYHealth awarded Weill Cornell Medicine a grant to encourage physicians at hospitals and federally qualified health centers (FQHCs) to prescribe opioids at levels consistent with Centers for Disease Control and Prevention (CDC) guidelines. Under this project, Weill Cornell Medicine will adapt a successful electronic health record (EHR) prescribing interface for generic drugs and modify it specifically for opioid prescriptions. This modified EHR will default opioids to CDC-recommended short-duration and low-dose formulations, but allow those defaults to be overridden by providers to ensure that clinical judgment is not constrained. The adapted EHR will be piloted first in a small setting to ensure that the system performs as expected, and then it will implemented at primary care sites within Weill Cornell Medicine’s system. Based on provider experiences with and evaluation of the EHR, a freely shareable implementation procedures toolkit will be developed and disseminated throughout the State. The toolkit will be used to replicate this intervention at the Institute of Family Health, an FQHC with 19 sites in New York City and rural regions outside of the City.

Replicating the Law Enforcement Assisted Diversion (LEAD) Model in New York
LEAD is an evidence-based, harm reduction-oriented program designed to reduce low-level arrests and recidivism and promote better health outcomes. Instead of making an arrest for certain criminal offenses (such as low-level drug charges), police officers, prosecutors, and defense attorneys work together to divert individuals directly to a case manager, who then facilitates access to a comprehensive network of services for drug addiction, alcoholism, mental illness, and other health-related issues. These individuals receive intensive case management and targeted social services, with greater coordination among systems of care. In 2014, the City of Albany, with NYHealth support, launched its own LEAD program, making it the first jurisdiction on the East Coast and only the third in the nation with this program. In 2016, NYHealth awarded a grant to the Katal Center for Health, Equity, and Justice to help replicate LEAD in other communities in New York State that are struggling with the devastation of the opioid epidemic. Katal will convene government agencies, policymakers, private funders, and other stakeholders, providing them with technical assistance to establish LEAD planning teams in their communities. Project staff will also facilitate peer-to-peer guidance and develop strategies for collaboration among police officers, prosecutors, service providers, community public safety leaders, and case managers to familiarize them with the concept of diversion and the LEAD model and protocol.


Better Balance for a Better Future

Carol Rock, a senior citizen and a resident of the small rural town of Windsor, N.Y., had trouble with her balance and struggled with risk of falling.

Elderly residents of Broome County had one of the highest rates of falls in New York State. NYHealth awarded Broome County a grant to support the State’s Prevention Agenda goals, which designated falls prevention as the highest priority for the county.

An NYHealth grant to Broome County Health Department supported the Better Balance for Broome Fall Prevention Project, a program that includes several interventions for older adults to identify those at risk for falling, refer them to appropriate programs, and build their strength to help them maintain their independence and quality of life.

Through her senior volunteering program, Carol learned about a Tai Chi program offered through Broome County Health Department. She liked the Tai Chi classes so much that she decided to train to become an instructor herself. “Everyone enjoys the classes,” says Carol, who has been teaching Tai Chi class twice a week since 2014. “They feel like they’re receiving a great benefit from it in not only improving their balance, but also for the emotional benefits and relaxation.” The Tai Chi program draws in members of the senior community in Windsor, as well as those who are involved in other exercise programs through the Broome County’s retired seniors program. Carol’s class has 10 members who attend each week. “Teaching these classes has been wonderful because it’s so motivational to exercise in a group,” said Carol. “It just benefits everyone physically and mentally. I’ve seen a lot of people come in that were depressed, and because of the comradery of these classes, they feel better.”

The Better Balance for Broome also incorporated provider training for fall screening at United Health Services Hospitals (UHS). Dr. Frank Floyd, a practicing internal physician at UHS, noted that prior to Better Balance for Broome’s involvement, fall screening for individuals was not commonly performed in the hospital setting. UHS providers now screen all patients over the age of 65, many of whom have benefitted from the program’s classes. “We proactively prescribe the program to prevent falls,” said Dr. Floyd, “in turn helping the health of the community.”

Vulnerable Children Receive Vital Oral Health Services

WIC Smiles

With support from an NYHealth grant, Albany Medical Center has co-located pediatricians at upstate WIC sites to provide oral health services to Medicaid-eligible preschool-age children in areas where access to dental care is limited. At the sites, mothers receiving WIC benefits also are able to bring their infants and children (up to five years old) to the on-site pediatrician for a basic dental screening and a fluoride varnish application—an important tool in cavity prevention.

Noah’s mother, Becky, first learned about the oral health services during a routine nutrition appointment at her WIC site in downtown Albany. Becky’s WIC counselor told her about the free fluoride varnish and asked if she wanted to make an appointment for her son. One week later, Noah saw the on-site pediatrician and underwent the procedure, which was over in less than a minute. Without the WIC Smiles program, “I wouldn’t have known the varnish was in existence, let alone helpful,” said Becky.

Although Noah didn’t have any discernible tooth problems, he had not received any dental care up until his WIC visit. “It’s good to know he has that extra level of protection now, and it’s a good precedent for kids that sets them up for future dental success,” said Becky.

The vision behind WIC Smiles is to reach children at high risk for oral disease before the onset of cavities or tooth decay. “Prevention is much easier because once they have established tooth disease, it’s hard to reverse,” said Melinda Clark, a pediatrician with Albany Medical Center and initiator of WIC Smiles. “The earlier and more aggressive you are on the prevention side, you can make a huge impact in lessening the risk for oral disease in these children down the road.”

The program, which is sustained through Medicaid reimbursement, also helps lower health care spending in the long run: delivering preventive services to the youngest and most vulnerable patients lessens the need for costlier (and more painful) dental procedures later on.

Pediatricians at the WIC sites see infants and very young children whose teeth are just beginning to emerge. In many cases, these patients do not have regular access to dental care because few private dentists accept Medicaid-enrolled children. The pediatricians also are trained to provide families with oral health education, recognize oral health problems in children, and refer patients to a network of dental providers for additional treatment.

WIC Smiles has been established in four upstate counties—Albany, Cortland, Saratoga, and Tioga—and Albany Medical Center is in talks with four other counties to add sites.

…and Beyond

Albany Medical Center now also has an opportunity to move beyond WIC sites and have an even greater impact on children’s oral health in New York State, thanks to two major policy shifts in 2014. First, the U.S. Preventive Services Task Force (USPSTF)—an authority on prevention and evidence-based medicine—released recommendations that primary care providers apply fluoride varnish to the teeth of all infants and children up to the age of five. The American Academy of Pediatrics then endorsed the USPSTF directives, releasing guidelines for all pediatricians to perform not only fluoride varnishing but also oral hygiene and dietary counseling as preventive primary care services.

As a result, pediatricians across all payers—not just those accepting Medicaid—can provide the varnish and other oral preventive services to their patients and be reimbursed. “This is now a mandate,” said Dr. Clarke. “You will get paid to do this, and it’s good for children’s health.”

Dr. Clarke recognized the policy changes as a critical moment to move beyond the WIC sites and make a statewide push for a wider standard of care for children’s oral health. She approached NYHealth staff with the idea to broaden the grant’s original scope of work to include two new key elements: (1) educating pediatricians and other health care professionals across the State on the guidelines and insurance billing changes and (2) training those providers to deliver oral health services.

With NYHealth’s go-ahead, Albany Medical Center now is working with Community Health Care Association of New York State (CHCANYS) and other statewide and regional primary care provider networks to train providers on how to properly apply fluoride varnish and integrate oral health services into primary care settings—especially in rural health areas where such services have been scant.

While WIC Smiles has improved the oral health of Noah and other Medicaid-enrolled children like him, Albany Medical Center’s collaboration with NYHealth to expand its grant activities is helping many more children across the State obtain access to proven preventive services.

House Calls Help Homebound Patients Reconnect with Primary Care

Dr. Kevin Dooley uses a silver 2006 Volkswagen Jetta as his office.

It’s not that Dooley, a family physician for more than 15 years, can’t find the office space in the Albany region—rather, his vehicle is what gets him to the homes of the 15–20 patients he sees each week through the Home Visiting Physicians program administered by St. Peter’s Health Partners Medical Associates (SPHPMA) and its affiliate, the Eddy Visiting Nurse Association (EVNA).

The program, funded in part by NYHealth, sends health care providers on medical house calls to visit homebound, chronically ill patients who can’t get to a physician’s office for primary care services. Without regular care, many of these patients end up cycling in and out of emergency rooms or are frequently admitted to hospitals—a costly and inefficient use of the health care system.

In contrast, the Home Visiting Physicians program—serving Albany, Rensselaer, and Saratoga counties—reconnects patients with a primary care provider to receive at-home care and services, which in turn improves their quality of life, reduces unnecessary hospital visits and readmissions, and lowers health care costs.

“This model provides a beautiful bridge for people who can’t get to an office or just don’t know how to use the health care system efficiently and they end up in the emergency room instead,” said Dr. Dooley, who is part of a small team of doctors and nurse practitioners that has treated nearly 300 patients since the program began operating in November 2013. “What we’re doing every day is a huge solution to this problem.”

Participating patients—many of whom are elderly—are homebound and struggle with a host of chronic conditions that keep them from easily accessing outside primary care, including Alzheimer’s or dementia; Parkinson’s disease; multiple strokes; diabetes; respiratory illnesses, such as COPD and pneumonia; spinal injuries; and cardiac issues, such as congestive heart failure.

Dr. Dooley recalled visiting Anne*, a patient with an autoimmune disease who had not been feeling well. Lab work revealed very high blood sugar levels, which would have required Anne’s hospitalization if left unchecked. Instead, Dr. Dooley put together an action plan with Anne’s pharmacist and visiting nurse to give her insulin. Anne stabilized and remained at home, thus avoiding a trip to the hospital.

Another patient, Tara*, had been struggling with a serious lung disease for some time. Prior to being accepted into the Home Visiting Physicians program, she had been to the emergency room six times in six months for her condition. After Tara came under his care, Dr. Dooley discovered through a home visit that she did not have a nebulizer and arranged for one to be brought into the home. In the ensuing seven months, Tara’s hospital trips dropped off dramatically, with no returns at all during that time period. She has since become more emotionally calm in addition to feeling physically better.

The house call team provides a full range of primary care services to homebound patients from the routine, such as checking blood pressure and other vitals and refilling medications, to the more complex, such as administering ultrasounds, EKGs, and X-rays using a mobile imaging unit. The house call team can bring much of the equipment and instruments typically found at a primary care office or hospital directly into the home, according to Dr. Christopher Domarew, one of the program’s physicians.

Through regular home visits and proper primary care, providers can keep health problems from spiraling out of control and prevent unnecessary hospital visits and readmissions—major drivers of health care costs. (The average cost of a U.S. hospital stay in 2010 was $9,700, according to the Agency for Healthcare Research and Quality.) Eight months after its launch, the Home Visiting Physicians program has led to 84 averted emergency room visits and hospitalizations. If a patient does go to the hospital, the house call provider immediately works with the hospital to develop a care plan to get the patient back home as quickly as possible.

“This is serving the need of a population that has fallen to the wayside, but that also utilizes a major part of the health care system,” said Dr. Domarew. “We’ve made a major reduction in hospital readmissions, and if we can avoid even just one admission, that’s a huge impact.”

Home visits also allow the house call team to evaluate the safety of the home or observe any hazardous circumstances that can have a negative effect on patients’ health, such as pest infestations, pets, mold, or unused prescriptions—all issues that would otherwise go unnoticed but can now be rectified, according to Dr. Domarew.

SPHPMA and EVNA are putting in place expansion plans for program and also intend to share the model with other upstate health systems.

“We have so many sick, disabled, disadvantaged people; this has to be the new model of care to deal with this and it’s part of the solution to address the disconnect between primary care providers and the hospitals,” said Dr. Dooley.

*Name changed to protect patient’s privacy

What Makes the Model Work

Strong communication and collaboration among the house call team and area hospitals, visiting nurses, physical therapists, and other health care professionals involved with the patients are key to the model’s success. The house call team regularly checks in with their patients’ other health care providers to streamline care and learn more about how a patient is eating, sleeping, and taking medications, and other health indicators. The program also helps to alleviate some of the stress of family members and caregivers struggling to care for loved ones.