The American Association for the Treatment of Opioid Dependence (AATOD) is an association of, mainly, opioid treatment programs (OTPS), the only providers in the United States who can legally treat opioid use disorder (OUD) with maintenance methadone. AATOD met last week in Philadelphia for its meeting which occurs every 18 months. This meeting’s them was “The evolving field of opioid treatment.”
A highlight of the meeting was a presentation by Linda Hurley, president/ CEO of CODAC Behavioral Healthcare, on “one-stop shopping.”
Hurley has brought “integrated care,” a buzzword that is often used but rarely practiced, into reality. “You can’t have functional health and wellness if we don’t look at the whole picture,” she said at the October 7 workshop.
Integrated care means coordinating methods and models across:
The purpose of this integration is to “build connectivity, alignment, and collaboration between the cure and care sectors,” said Hurley. The goals are to:
The first step, for an OTP, is to integrate primary care, said Hurley. It may sound easy, but it’s complex. Breaking down the frameworks can help. There are two types of integration:
• Horizontal integration is focused on a demographic and links health, social, and care providers through teams or networks to support specific groups (one such group is people with OUD)
• Vertical integration is focused on sectors and connects services across all care levels (primary, community, hospital, tertiary) using best-practice pathways or smooth care transitions, and is based on a single sector (such as OTPs)
It’s important to focus on the person, not the demographic, and not the provider – that is the point of integration, said Hurley. But this is “changing the culture of care.”
For example, when someone comes to CODAC, “we don’t say ‘we know what you need, let us help you,’” said Hurley. “We ask, ‘Are you hungry? Do you need food?’ And we’ll take care of that. When they have enough courage to come to us [for treatment], we will be there.” It’s not just a matter of earning trust – it’s practical. Someone with an OUD doesn’t just need medication.
“If I am an opioid treatment provider and you come to me for care, one of the ways I provide integrated treatment is I can give you bus passes,” said Hurley.
Hurley recalled a patient who was experiencing extreme anxiety waiting for his methadone at a window – it was not only the medication, but that he needed to report to probation and that he didn’t have his Medicaid information updated. “He was starting to get worked up, to get loud,” said Hurley. “We have six dosing windows, but they’re not always all open. We were able to get him his medicine in 3 minutes. Then the peer recovery support specialist took him down the hall to his probation officer. And then, because he didn’t have his documentation for continued Medicaid, we took him down the other hall to the Medicaid office. He went from highly anxious – not well – to sitting calmly with a glass of water,” she said.
Below are the medical services provided by CODAC as part of integrated care:
All FDA-approved medications for treatment of all substance use disorders are utilized.
Below are the mental health services provided as part of integrated care:
Below are the critical social service collaborations provided as part of integrated care:
CODAC has the benefit of operating in the small state of Rhode Island, where the bureaucracy isn’t as cumbersome as in, say, New York. It also has the benefit of support from the state government, which can help with the integration of many state services, including probation and parole, child services, Medicaid, SNAP, WIC, and more.
There is a critical mass as far as patient census before other organizations, such as the state, will come into the building, said Hurley, responding to a question from the audience. “It will be community-specific,” she said. “We guaranteed 350. And we’re marketing to the whole community, not just the OTP, so the partner will have access to a primarily Medicaid population with high need. We’re also going to let the neighborhood know you’re here.” The state wants to get more people healthy, so wants to get more into Medicaid.
CODAC’s building is large enough to be able to provide many services under one roof. Hurley acknowledged that most OTPs are in smaller facilities which couldn’t do what CODAC does logistically. “But we have to make this integration more efficient.”
Coordination and collaboration can be difficult when various sectors are fighting over the same shrinking pie of funding. Many hospitals, Federally Qualified Health Centers, and Certified Community Behavioral Health Clinics (CCBHCs) have created services for buprenorphine, Hurley noted. “Suddenly every CCBHC is an expert in opioid treatment, and because they financially need to have that service, they will not refer” patients to an OTP.
CCBHCs are funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), or Medicaid.
Only OTPs can prescribe and dispense methadone for OUD, so it’s natural that Hurley’s integration of care begins with methadone and the OTP.
Hurley is aware of the financial pressures on OTPs. One of the ways CODAC makes money is by renting space, to Brown University, to the University of Massachusetts Chan Medical School.
She asked for a show of hands of how many attendees work in a Medicaid-funded system. Most of the attendees raised their hands. In January 2027, this Medicaid money will most likely go away, thanks to H.R. 1. “We’re going to need to think about how we continue to provide care,” said Hurley. “We need to be creative. What do you offer? Can you sell trainings?”
Certainly, OTPs, the experts in treating OUD, can train other providers.
“Twenty-five years ago, we would say ‘Keep your heads down, don’t make any noise,’” said Hurley. “With the opioid epidemic, it was time for us to say ‘We’re the experts, we know how to do this.’ We aren’t used to bragging, but everyone here [at AATOD] is an expert. We know what this disease is. So sell your trainings.”
There are many things OTPs can do that others can’t, said Hurley. For example, motivational interviewing is a key counseling skill.
Also present within CODAC – training by the Department of Labor. When the new work documentation requirements for Medicaid kick in, “we will know right away what they are,” said CODAC. And it’s important for OTPs to know what these are, so they can keep their patients enrolled in Medicaid – and keep getting paid. “’As soon as anything happens we can provide these forms for you,’” CODAC tells patients, she said. “Our goal is to do this in all eight sites, because it’s going to happen,” she said of Medicaid cuts.
It’s the same with managed care Medicaid organizations, said Hurley, noting that they want to keep patients enrolled as well. They don’t want to lose any of their premiums.
Mobile units are another way of creating revenue, said Hurley. “We are getting new patients for whom we can bill, who normally would not be coming into our building, and at the same time, we are able to take care into the community, which is critical.”
"You can’t have functional health and wellness if we don’t look at the whole picture."
"We don’t say ‘We know what you need, let us help you... We ask, ‘Are you hungry? Do you need food?’ And we’ll take care of that. "
“Twenty-five years ago, we would say ‘Keep your heads down, don’t make any noise. With the opioid epidemic, it was time for us to say ‘We’re the experts, we know how to do this.’ We aren’t used to bragging, but everyone here [at AATOD] is an expert. We know what this disease is. So sell your trainings.”
