California Health Care Improvement Projects (CHIPs)

Beyond the X-waiver: Normalizing MAT Prescribing in Primary Care

In January 2023 the DEA and SAMSHA announced elimination of the X-waiver as a requirement to prescribe Suboxone (buprenorphine/ naloxone) for opioid use disorder which presented an opportunity to reduce one barrier to treatment, access to X-waivered providers, among patients at a suburban community health center. This project looked at the willingness of primary care providers not previously X-waivered to begin prescribing Suboxone for patients on a stable dose before and after a peer-led training. It further assessed if there was a difference in willingness to prescribe buprenorphine for chronic pain vs opioid use disorder. Prior to the training, 60% of providers indicated they were likely to prescribe buprenorphine for an indication of chronic pain or opioid use disorder and 40% of providers responded they were not likely to prescribe for either indication. After a one-hour peer training and the creation of a reference guide the number of providers likely to prescribe for an indication of chronic pain was 71% while the percentage likely to prescribe for opioid use disorder was 57%. Those not likely to prescribe for chronic pain dropped to 28%, but the number not likely to prescribe for opioid use disorder remained nearly the same at 43%. During the three months between the peer training and data collection one provider began sending Suboxone prescriptions for a patient with opioid use disorder. In the post-training survey, a question was asked about the new DEA license renewal requirement to complete 8 hours of education on substance use disorders which started in June 2023. Out of the two providers who completed the new requirement one felt it increased their willingness to prescribe MAT and one reported it had no effect.

Trauma Informed Care Transformation and Universal Screening for ACEs/Toxic Stress in a Student Health Setting

My CHIP project is Trauma Informed Transformation of a Student Health Center and Universal ACEs screening. I am currently an Assistant Professor of Clinical Obstetrics and Gynecology in USC Student Health. Prior to joining USC in 2018, for 10 years I was Chief physician of an Ob/Gyn department in a Federally Qualified Health Center in South Los Angeles. Our service planning area had some of LA County’s highest rates of STIs, Teen pregnancies, Preterm deliveries, Low birth weight babies, and all cause morbidity and mortality rates. Exposure to toxic stress and adverse childhood experiences are higher in racial/ethnic minorities, women, immigrants, LGBQT+ individuals, people with disabilities, those living in poverty, and other historically marginalized groups, and within these groups there is an increased risk of being adversely affected by trauma; our patients represented many of these groups. We universally screened all OB patients for depression with PHQ9s; although a great screening tool, it wasn’t the optimal screen for our patient population.

Many of my current patients, college students, are experiencing high levels of stress; this coupled with histories of ACEs and toxic stress may negatively affect mental health and academic performance. According to SAMHSA, in community samples more than two thirds of people have experienced a traumatic event by age 16; other studies note more than one third of adults in the general population have experienced at least two ACEs. Newer cohorts report more ACEs than older cohorts indicating the incidence of ACEs may be increasing1. Even students without overt signs of stress may have histories of toxic stress. Toxic stress can have significant impact on academic performance, physical, and mental health outcomes, so universal screening of patients can provide opportunities for early interventions to mitigate toxic stress, prevent academic barriers to success, and increase positive health-related outcomes.

I am the Chair of USC Student Health’s Trauma Informed Steering Committee, Co-Chair for the American College of Ob/Gyn’s District IX DEI Committee, a member of ACOG’s National DEI Delegation, USC Department of Family Medicine’s Anti-Racism Task Force, and USC Student Health’s DEI committee. My professional, clinical, and personal experiences have cultivated a perspective that considers the intersections between toxic stress and the lived experiences of persons from marginalized groups. The Trauma Informed Steering committee identified ACEs as a screening tool that could be used with our patient population to assess for toxic stress. The original ACE Study was conducted in the late 1990’s (by Kaiser Permanente and the CDC) among a clinical population of 17,337 middle-class insured adults, 79.4% were white, had a mean age of 56.1 years, and 43% percent had graduated from college. The study identified a set of 10 categories of common, adverse experiences occurring in the first 18 years of life, and confirmed ACEs are highly prevalent and demonstrate a strong dose response relationship with numerous negative health and social consequences in adulthood2 . With a DEI lens and guided by the SAMHSA principle of gender and cultural awareness, we created a hybrid ACEs questionnaire to reflect the diversity of our population and their experiences. Our modified ACEs is 18 questions and is an amalgamation of the original 10 ACEs with additions from the Expanded Philadelphia ACEs and the ACEs IQ (International) to include other items that focus on community ACEs (discrimination, poverty, community violence, foster care, and neighborhood safety).

Implementing CalAIM Community Supports to Create a System of Safe Discharge Options for Challenging Patients from Acute Care Facilities to Decrease Administrative and Denied Days

Medicaid patients remain in acute care settings (acute hospitals, long term acute care hospitals, skilled nursing facilities) because there are no safe, clinically appropriate discharge options. This results in an increased number of administrative or denied days because the patients are no longer clinically acute and are just awaiting placement. Patients who could be in an inpatient bed or in a skilled nursing facility are instead stuck boarding in the emergency department or an inpatient bed. This leads to crowding both in the emergency department and the inpatient setting, which is both bad for the patient and costly for the health care system.

Enhanced Care Management (ECM) and Community Supports (CS), as offered through California Advancing and Innovating Medicaid (CalAIM), can address this problem by increasing the number of safe, clinically appropriate discharge options. The challenge is weaving the discrete benefits and funding streams offered under CalAIM into a system of care that augments the existing discharge options.

This project focuses on the implementation of CalAIM Community Supports by translating CalAIM’s vision into a concrete approach through nontraditional partnerships. The project expands the capacity of existing service providers (personal care services providers, shelters, recuperative care/medical respite, transitional housing, sober living environments, board and cares, assisted living facilities, residential care facilities for the elderly (RCFEs), etc.) through using CalAIM CS to pay for these services and makes them directly accessible to acute care facilities as Medicaid funded discharge options.