Communities that adopt a coordinated response to the opioid epidemic can have a greater impact on treatment access than a single organization can achieve independently. Fostering collaboration across diverse community partners can support prevention efforts, connect patients to comprehensive treatment services, and build broader opioid response efforts for the community at-large. Such partnerships expand access to care in rural areas with limited treatment options and provide opportunities to better address health-related social needs.  

This case study explores implementation of medications for opioid use disorder (MOUD) at a federally qualified health center (FQHC) in rural California that engages with the broader community to address the opioid epidemic. The Center for Health Care Strategies developed the case study drawing from a series of interviews with FQHC staff and leadership at the community’s opioid coalition.

Background

El Dorado Community Health Centers (EDCHC) is an FQHC founded in 2003 with support from the El Dorado County Board of Supervisors and approval of a local hospital. EDCHC, which serves almost 11,000 patients annually, is the only FQHC in a county designated as a Primary Care Health Professional Shortage Area. As the main health center in its rural service area, EDCHC provides care for a fast-growing population, the majority of whom have incomes below the federal poverty level. EDCHC helps ensure access to care for low-income, homeless, and uninsured populations by collaborating with local programs and social service agencies. EDCHC provides care for all ages, including primary care, behavioral health, pharmacy, dental, podiatry, eye care, telemedicine for primary care and select specialty services, nurse case management, health education, and patient advocacy.

EDCHC offers an MOUD program known as Supportive Treatment Empowering Personal Success (STEPS). A physician champion created the MOUD program in 2016 within EDCHC’s primary care-based complex care clinic. In 2018, the program grew into STEPS, when staff recognized a need to treat a wider array of substance use disorders (SUD) such as alcohol and stimulants. In 2021, STEPS became a distinct program from primary care, and is currently part of El Dorado’s behavioral health department. STEPS serves between 300 and 350 patients at any given time, 60 percent of whom have opioid use disorder (OUD), while the remainder have other SUD like alcohol and stimulant use disorder.

Impetus

Veronica Velasquez, MD, a primary care provider (PCP) at the health center, championed and created the MOUD program after case reviews demonstrated that many patients with chronic pain had underlying OUD. Around 2015, Velasquez secured implementation grants from the California Health Care Foundation (CHCF) to build the program, including paying for provider time and the services from a nurse expert in substance use disorder, who provided in-person consultation twice weekly. The leadership team at EDCHC supported efforts to design the program. By 2016, the complex care clinic began offering MOUD, which later evolved into the STEPS program. In 2018, the program diversified to treating other SUD in addition to offering MOUD.

From the beginning, the MOUD program at EDCHC embraced a team-based approach. Initial staffing included providers, two nurse case managers, two medical assistants, and behavioral health clinicians who ran group therapy sessions. A nurse practitioner served as a program manager in the early stages of the program. While it took time for the MOUD program to gain momentum, EDCHC’s efforts to bring in the right staff and encourage team‑ and culture- building over time facilitated its evolution.

EDCHC participates in El Dorado’s Coalition for Overdose Prevention and Education (COPE), which started in 2017. The coalition’s mission is to address the overdose epidemic by reducing opioid use in the county. COPE is a multisector coalition with representation from 150 individuals and 50 agencies such as law enforcement, schools, faith-based communities, counseling agencies (e.g., family and youth counseling centers, counseling centers for justice-involved youth), and local businesses. Any organization interested in creating more seamless care for community members is welcome to join.

Engaging with the Broader Community to Address the Opioid Epidemic

COPE’s efforts focus on strategic planning and short-term interventions, such as a survey to better understand treatment engagement disparities among the Latino population. COPE also creates data dashboards to track progress in addressing identified disparities. The coalition initially sought to bring medications for addiction treatment (MAT) into the community, which involved offering physician education and continuing education units to encourage more providers to get their X‑waiver, which was required at the time to prescribe buprenorphine. COPE, which coordinated the training effort, used some of its own funding to cover training costs along with funds from other community partners. Within the first year of training, the number of local physicians with an X-waiver increased, significantly expanding access to MAT. Another early COPE effort supported cross-organizational training on best practices for treating OUD based on Centers for Disease Control and Prevention guidelines. Local treatment providers, including EDCHC, created buy-in among providers for a set of community-wide shared agreements, such as not removing a patient from treatment if they were using opioids and streamlining intake paperwork to initiate treatment more quickly. This approach placed more accountability on providers to offer the same standard of care. COPE also provides community education to residents, including a bi‑monthly virtual educational speaker to combat stigma and increase understanding about the complexity of substance use. Additionally, COPE provides culturally relevant OUD-related information for patients whose primary language is not English.

EDCHC is COPE’s contracting and fiscal agent, meaning that all of COPE’s finances run through EDCHC. The health center is one of COPE’s greatest champions and the coalition acknowledges that they would not be as robust without EDCHC’s involvement. COPE has partnered with EDCHC on several key initiatives. For example, COPE helped EDCHC create a formal referral feedback loop with Marshall Medical Center’s Emergency Department (ED) Bridge program. This process offers MOUD to patients presenting in the ED with symptoms of opioid withdrawal and then refers these patients to MOUD programs in the community. Referral data was being reported verbally to EDCHC, and patients were responsible for arranging their own follow-up care, making it difficult to track whether referrals resulted in ongoing treatment. COPE successfully created a formal referral feedback loop, which standardized connection points and follow-up processes between community providers receiving referrals from the Bridge program.

COPE also hosted workshops to bring together MAT providers in the community to discuss successes and barriers to effective treatment. For example, Barton Health in South Lake Tahoe was experiencing challenges due to a lack of resources and fewer ancillary services, such as counseling and groups. Through a recent COPE coaching workshop, EDCHC offered mentoring and technical assistance to Barton Health to support them in developing their MOUD program. The workshop included case study presentations by medical directors from other MOUD programs to facilitate shared learning.

COPE prioritizes health equity in its work, particularly focusing on disparities in the Latino population’s participation in MOUD services throughout the county. EDCHC staff noticed similar disparities within STEPS, with fewer Latino patients receiving MOUD as compared to other services at the health center. COPE conducted a survey to better understand why this population was not accessing MAT services at EDCHC or other programs in the county. The results showed that many Latino community members lacked knowledge about the benefits of Narcan (e.g., naloxone) and dangers of fentanyl. COPE is now seeking to establish an advisory board of Latino community members to improve access and engagement in MAT for this population.

How We Built This

Community Partnership

COPE’s parent organization, Access El Dorado (ACCEL) started 21 years ago as part of a Health Resources & Services Administration (HRSA) grant requirement for a community collaborative when EDCHC was established. After the HRSA requirement was fulfilled, the community found value in keeping the partners together as a health advisory committee. In 2016, a community partner asked ACCEL if they would form an opioid coalition in response to the local opioid epidemic. This led to the creation of the El Dorado Opioid Coalition in 2018, later renamed to COPE. ACCEL has been the primary driver of building effective community partnership linkages, spurring discussions to increase MAT access throughout El Dorado County.

The coalition is financially sustained by five major health entities in the county including two hospitals, the county’s health and human services department, EDCHC, and the tribal health center. Additional grant funding also helps support COPE, including grants from the California Departments of Health Care Services and Public Health. COPE recently applied for opioid settlement dollars through the county for continued funding.

Infrastructure for the MOUD Program

The STEPS program has two physical locations, both co-located within facilities providing primary care and other services. STEPS offers all buprenorphine and naltrexone products, including injectable options. Both locations also have pharmacies providing MOUD medications.

EDCHC uses eClinicalWorks as its electronic health record. Patient information for those receiving MOUD through STEPS is limited to the program’s medical team and behavioral health clinicians working with patients who have a co-occurring mental health condition. Internally, there is a firewall which makes STEPS documentation inaccessible to all treatment team members, meaning PCPs cannot access MOUD treatment information unless a patient provides consent to share it with primary care. Patients can revoke their consent at any time.

When patients enter STEPS, they sign a release of information for the county SUD department, which streamlines care coordination and referral processes. Patients who are transferred from the Marshall Medical Center’s MOUD program, called the Clinically Assisted Recovery and Education Services (CARES) clinic, sign a release to share information. For patients entering STEPS via a Marshall ED Bridge referral, STEPS nurses can access EPIC, the electronic health record used at Marshall, to pull the patients’ discharge summary from the ED.

Philosophical Approach to MOUD

STEPS follows an individualized and patient-centered approach. Patients with OUD who are stable in their treatment have the option of continuing their regimen within STEPS or transitioning treatment back to primary care. Patients who receive primary care services elsewhere, typically stay with STEPS for their MOUD treatment. In addition, patients with more complex behavioral health needs typically continue to receive treatment within STEPS.

In addition, some patients with OUD who stabilize on medication continue with STEPS but do not necessarily need to follow through with behavioral health services. Patients interested in receiving behavioral health services can attend group sessions led by certified addiction counselors. One group is focused on meditation and self-awareness while another group has a more flexible agenda that enables patients to participate in an open group discussion.

Staff reflected that the curriculum is not as important as the personalized attention given to each patient. STEPS takes a non-judgmental, low-threshold approach that supports the patient throughout their recovery journey and has a strong culture of patient-centered care and interdisciplinary collaboration. This approach requires staff with effective interpersonal skills who are passionate about serving individuals with OUD. Successful staff members are open to change, adapt to adverse circumstances, value open communication, understand the need for role clarity, demonstrate the ability to maintain boundaries, and can self-reflect on both a professional and personal level.

Training and Capacity Building

Initial trainings for new STEPS staff consist of online education through American Society of Addiction Medicine (ASAM) as well as resources from Boston Medical Center’s Grayken Center for Addiction. These trainings cover ASAM Levels of Care, current best practices in addiction medicine, and different types of SUD including their severity ratings. New primary care providers at EDCHC also receive training on addiction medicine and spend time with STEPS providers to better understand the program and further their education on addiction. EDCHC’s culture supports ongoing learning with leadership highly encouraging staff to take advantage of continuing education opportunities.

EDCHC emphasizes the importance of team building, acknowledging that the role of every staff member is important. Monthly meetings provide a relaxed and emotionally safe environment for staff to process difficult circumstances, further empowering them to provide the best possible patient care. Ongoing efforts to work collaboratively include daily huddles and a monthly Quality Interdisciplinary Review Committee, as described below:

• During daily morning huddles, STEPS staff gather to review patients on the schedule. During interviews with CHCS, a nurse case manager noted that everyone who interacts with the patient has valuable insights to share. Medical assistants and front desk staff may have conversations with patients that other staff are not aware of. Therefore, the huddles provide a comprehensive picture of the patients on the schedule.
• The Quality Interdisciplinary Review Committee is a monthly meeting where STEPS and primary care staff come together to conduct case reviews. Providers and nurses can submit complex cases (de-identified as necessary) to discuss during the meeting. Staff examine the patient’s history and collaboratively develop a plan for how they can best support the patient. These meetings support providers, particularly those earlier in their careers, provide education on treating patients with addiction, and ultimately help provide better care to the patient.

Staffing and Services

The MOUD care team includes:

• Two physicians, responsible for medical oversight of each patient care plan, prescribing medications, psychiatric care for patients with lower acuity behavioral health needs, referring patients to EDCHC psychiatrists for higher acuity behavioral health needs, and recommending follow up with primary care as needed. PCPs can also fill-in as needed to prescribe medications.
• Two nurse case managers, responsible for completing the initial intake with new patients (including the ASAM assessment, assigning a level of care, and collecting background information), setting patients up for their initial induction and follow-ups, coordinating care related to refill needs and patient complications, administering buprenorphine and naltrexone injections, and linking patients to primary care services as needed.
• Two medical assistants, responsible for rooming patients, taking vitals, administering urine drug screens, preparing exam rooms, and calling patients for initial telehealth screenings.
• One drug and alcohol counselor, responsible for meeting with all patients receiving MOUD at least once, seeing patients for weekly or bi-weekly appointments, and providing extra support to patients who may be struggling with their sobriety or other SUD.
• One embedded behavioral health clinician who is an associate clinical social worker (ACSW) working toward independent licensure and has a strong background in trauma therapy. This clinician is responsible for taking on most behavioral health referrals from STEPS. There are 12 behavioral health clinicians in total in EDCHC’s behavioral health department. Some STEPS patients see other clinicians, who are a mix of ACSWs, associate marriage and family therapists (AMFTs), licensed clinical social workers (LCSWs), and licensed marriage and family therapists (LMFTs). These clinicians run individual and group sessions with patients.
• One peer-support intern offers lived experience as a former patient to share what was helpful for them when they were going through the MOUD program. The intern has been in recovery for quite some time and is currently in school.
• Front-office support services coordinators, responsible for scheduling appointments, answering phone calls, and checking patients in and out for their appointments.

EDCHC staff focus on treating the whole person and provide wraparound services beyond traditional medical care. The health center’s CEO shared that they encourage staff to commit to five core behaviors — service, appreciation, inclusivity, positivity, and doing your best, which helps to ensure a positive patient experience. Patient advocates working in the patient support services department have referral relationships with community organizations that they can connect STEPS patients to as needed. For example, this department acts as a liaison to connect patients with housing providers in the community. STEPS can also provide gas cards for its patients as needed, which is made possible through a broader effort in California to expand access to MAT.

Financing

Like other FQHCs, EDCHC receives a Section 330 grant from the federal government each year to cover patients without insurance. EDCHC also bills insurance, with 59 percent of patients on Medi-Cal (Medicaid), 18 percent on Medicare, and 11 percent on private insurance plans. Six percent of the FQHC’s patients are on a sliding scale, and an additional six percent with no ability to pay are covered through grant funding. The ASAM assessment is not billed for, as STEPS cannot reimburse or bill for nurse visits. In addition, EDCHC cannot bill for medical and mental health services on the same day, so they either use grant funding to cover any services provided on the same day or they absorb the loss. Due to the specialty services involved with MOUD, EDCHC has secured additional state-based grant funding to support the needs of their patients as follows:

• State Opioid Response (SOR) Grant. This federal grant is the primary funding that EDCHC receives to cover MOUD services. The costs associated with support staff who provide nonbillable services including nurses, medical assistants, and front office staff are covered by the SOR grant. EDCHC’s Behavioral Health and SUD Director emphasized the importance of team-based care and acknowledge that it is cost-intensive. A smaller portion of the SOR funding provides additional coverage for uninsured patients and those with insurance-related barriers to access. The cost of fentanyl test strips given to patients is also covered through this grant. EDCHC is currently on their third round of SOR funding.
• Health equity grants from Direct Relief. These are smaller grants that cover stipends to support interns entering the behavioral health and SUD field. Integrating the STEPS program within the larger behavioral health department made it easier for EDCHC to secure these types of behavioral health-focused grants.

SPOTLIGHT ON THE PROSPECTIVE PAYMENT SYSTEM

The Prospective Payment System (PPS) rate that EDCHC receives is the same for all services including MOUD treatment and behavioral health care. To be financially viable, EDCHC staff stated that it is important to factor in all costs associated with delivering services when building out the PPS rate. The PPS rate is site-specific, and includes all costs associated with delivering services, including front office, medical assistants, and nursing staff. This rate covers the actual provider encounter, and other services associated with MOUD treatment including the nurse visit, front office support, drug and alcohol counseling, and therapy for co-occurring mental health conditions. Counseling and therapy services must be provided by a billable provider (e.g., LCSW, LMFT, ACSW, AMFT) to be billable under the PPS rate. Services provided by licensed advanced alcohol and drug counselors are not billable to PPS. In California, SUD treatment is paid through separate mechanisms than primary care services. At EDCHC, PPS revenue covers the program’s operating expenses.

FINANCIAL SUSTAINABILITY

Case management services are incorporated into EDCHC’s PPS rate. EDCHC seeks to supplement its STEPS program with grant funding to ensure they can cover non-billable services, such as case management and patient support services.

STEPS is working to become an Enhanced Care Management (ECM) provider through California Advancing and Innovating Medi-Cal (CalAIM) to better serve patients with complex needs, such as those with SUDs, co-occurring mental health conditions, and health-related social need concerns such as housing. Billing as an ECM provider covers services that would not be billable under the PPS rate. ECM contracts structure payment based on deliverables and performance metrics related to patient care. Staff expect to be able to respond to health-related social needs more rapidly once becoming an ECM provider. If successful, STEPS plans to add an additional care team nurse and social worker to partner with its physicians.

Successes and Challenges

Successes

The nurse case managers noted that the recent removal of the federal X-waiver requirements have helped improve access to MOUD within the STEPS program. EDCHC PCPs who did not receive their X-waiver and were previously unable to prescribe MOUD, can now initiate buprenorphine treatment for new patients with support from STEPS providers, and have them follow up with STEPS during subsequent visits. PCPs feel supported to do so through the education received from STEPS providers. Having more prescribing physicians at EDCHC has enabled faster treatment initiation for new patients.

Staff also shared some of the benefits that EDCHC’s participation in COPE, for both the health center and the community. For instance, through COPE, the health center has been able to facilitate a strong referral relationship with Marshall Medical Center’s ED Bridge program to better serve those with OUD in the community. Through attending coalition meetings, staff have developed a better understanding of resources that the county can provide to patients who require services of a higher level. This may include services provided at residential treatment centers such as WellSpace Health, Granite Wellness Centers, or Progress House, or intensive outpatient programs such as Recovery in Action or Granite Wellness Centers. COPE has also helped all the MOUD programs in the county to work together to better educate the community about services to enhance access to care. As a forum for shared learning, COPE facilitates case conferences for MOUD treatment providers that provide an opportunity to share clinical information and emerging issues of relevance. A recent case conference covered the increase in kratom use, which was new to most providers in the area. Now providers across the county who attended the case conference know how to assess for kratom use.

Challenges

POLICY AND PRACTICE LEVEL

Administrative burden in accessing injectable buprenorphine. The STEPS program has been administering more buprenorphine injections to patients over time, with about 45 injections provided every month. This form of MOUD must be obtained from a specialty pharmacy. As a result, the nurse case managers need a substantial amount of dedicated administrative time for ordering the injections and ensuring that the medication arrives to the clinic in a timely manner.

Attrition rates from referral to intake and from intake to the six-month mark. STEPS staff acknowledges that there is a 50 percent drop-off rate between initial referral and actual intake as well as a 50 percent attrition rate for patients who come in for their first induction visit and continue receiving treatment for at least six-months. While staff noted that these rates are standard for MOUD treatment nationally, they are working to facilitate continued engagement and improve retention in treatment. STEPS is aiming to hire a peer support specialist to stay in touch with patients who have not remained in the program and share harm reduction strategies to reduce adverse outcomes. For example, they would like to offer food or gas cards support to individuals and provide informal support via check-in calls. Staff hope this approach could help impact readiness for change among those who have not continued with the program.

Connecting patients to methadone. Some STEPS patients could benefit from a referral to an OTP, but it is often difficult for patients to follow through with such referrals given the lack of resources in the rural area. The closest methadone clinic is about an hour away where patients need to go for an evaluation and to initiate treatment. Once in treatment, there is a closer satellite clinic that patients can go to for daily dosing. While an abbreviated version of the California Hub & Spoke System, a model that creates strong referral pathways between OTPs and health centers for patients with OUD, is in place at EDCHC, staff noted that their rural environment makes implementation challenging. More specifically, transportation is often difficult for patients due to socioeconomic barriers.

Policy concerns about the sustainability of telehealth prescribing. If the Public Health Emergency’s relaxed standards for telehealth prescribing that are still in place were removed, challenges could result since STEPS prescribes MOUD via telehealth for stable patients who have difficulty attending in-person appointments. The flexibility in “where” care is provided is particularly important in a rural area where transportation barriers are common.

STIGMA

EDCHC has engaged in ongoing efforts both at the community and clinic levels to combat stigma around SUD and MOUD. STEPS staff shared that El Dorado County has a politically conservative climate, and stigma around SUD and MOUD is a substantial challenge. Participation in COPE has enabled better coordination across organizations and among community members, particularly regarding education. For example, some staff members at EDCHC initially thought that harm reduction was enabling addiction behavior until they received stigma training through Marshall Medical Center. STEPS staff also work closely with new patients to combat any internalized stigma that could interfere with treatment. This may involve speaking with patients about how OUD is a chronic illness, comparing it, for example, to diabetes.

COPE is involved in additional efforts to combat stigma as well. The coalition hosts a bi‑monthly series called Community Awareness Substance Use Education where an expert from a local agency talks about a service-oriented project they were involved with and how they addressed stigma. The sessions are hosted as lunch-and-learn sessions and are well attended, with between 40 and 50 participants per event.

While these efforts have resulted in some improvements, staff acknowledge that more education and training around stigma is needed, particularly across health care providers in the community. EDCHC has already identified some providers in the community that they can meet with to address stigma and seeks to continue making improvements in this area.

Recommendations

EDCHC leadership identified the following foundational elements of success:

• A provider champion;
• Executive leadership buy-in;
• Business acumen necessary to achieve financial sustainability; and
• Organizational buy-in to combat stigma.

In addition, EDCHC’s CEO recommended starting small when building out a new program and emphasized the importance of considering your location, including the services that are already available in the community. From there, start identifying problems and care gaps in the community and build a program around that.

At EDCHC, staff have adopted a different approach to MOUD from other health centers that integrate their programs within primary care. The STEPS program is separate from primary care but involves communication and coordination with PCPs. Velasquez, the founding provider champion of STEPS, shared that filling the demanding role of a PCP in addition to providing MOUD is a “recipe for burnout.” In her view, SUD treatment and primary care sometimes needs to be separate. She acknowledged that doing both would be more feasible if providers were able to spend more time with each patient.

For provider champions seeking to approach their clinic’s leadership about starting an MOUD program, EDCHC’s CEO offered the following recommendations:

• Approach the conversation with the mindset that the health care system is under strain and that there are not enough PCPs to meet the needs of the patient population.
• Remind leadership that PCPs are already seeing patients with OUD even if they are not directly treating them for it with MOUD.
• Frame the creation of an MOUD program as an opportunity to remove strain from PCPs. While PCPs could do a portion of the work themselves, they could use the support of a separate program to address the complex needs of MOUD patients.

EDCHC also encourages other health centers to develop strong relationships with the local EDs and additional organizations that provide higher levels of care for people with SUD including residential programs, county SUD services, and intensive outpatient programs. Staff emphasized the importance of considering the continuum of care for SUD services in one’s community and coordinating with organizations that provide different levels of care. Staff also encouraged other health centers to develop positive relationships with law enforcement, particularly correctional facilities, as referral relationships can be particularly beneficial in getting individuals being released from incarceration connected with MOUD treatment. Patients receive more timely care that effectively meets their needs when collaborative relationships are formed with other SUD services and partners in the community.

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