Community-Based MAT+ Treatment for Vulnerable Philadelphians

Nature of the Problem

Philadelphia has the tragic distinction of having some of the cheapest and purest heroin and one of the highest drug overdose death rates in the nation (Philadelphia Department of Public Health, 2017). Philadelphia experienced approximately 1,200 fatal overdoses in 2017, nearly four times the number of deaths by homicide. Philadelphia’s overdose rate is three times that of Chicago and four times that of New York (Larson, Padron, Mason, & Bogaczyk, 2017), and the opioid epidemic has touched all neighborhoods and socio-economic levels in the city. Project HOME’s services target people who are homeless, people in recovery from homelessness, and low-income individuals in Lower North Philadelphia, one of the city’s poorest ZIP codes. The opioid epidemic has been one of the main drivers of increased numbers of unsheltered homeless in Philadelphia (City of Philadelphia, 2018; Shaw, 2018). Images of encampments of hundreds of people with opioid use disorder living under the bridges in the Kensington neighborhood have captured international attention. In 2017, there were approximately 70,000 people who used heroin in Philadelphia alone. However, data from SAMSHA indicates the entire state of Pennsylvania had the capacity to treat only 27,490 people with medically assisted treatment using buprenorphine. We can help more.

Program Description

Significant capacity and service gaps exist for medically assisted treatment for people with opioid use disorder (OUD) in general, and specifically for people with current or past experiences of homelessness and trauma. Traditional drug and alcohol programs do not always adequately serve the needs of people with experiences of homelessness and complex prior trauma because of difficulties with logistics such as restricted intake times, location in areas that can be triggers for substance use because of local drug traffic in close vicinity, settings that are isolated and stigmatizing, and punitive procedures such as zero tolerance for co-occurring substance use disorders. Community-based, primary care, office-based treatment for opioid addiction, integrated with Project HOME’s comprehensive housing and services, is what we are calling Medication Assisted Treatment PLUS (MAT+). This approach holds significant promise for highly marginalized populations with marked medical and psychiatric co-morbidities (Cantone, Fleishman, Garvey, & Gideonse, 2018). Integrating treatment of OUD into community-based primary care represents a paradigm shift from isolated, stigmatized MAT treatment facilities. Our holistic approach makes MAT accessible and normalizes this form of treatment in a primary care setting.

Disruption

Since 2016, we have provided primary care office-based MAT with buprenorphine-naloxone and naltrexone. In 2017, COE support enabled the addition of an MAT case manager and a licensed clinical social worker to the integrated care team and expansion of access to care by establishing a group MAT program. The group format succeeds in supporting patients in reaching their goals of recovery; of the initial 54 patients in our group program, 70% remain in active treatment after 4 months, a 20% increase over treatment retention rates generally reported in the literature. Our low barrier MAT+ group model improves access to MAT and primary care, offers the opportunity to recognize and address issues of transportation/housing/food insecurity, and provides peer support from other group members with similar experiences. This leads to greater opportunities to discuss self-management and education, ongoing support from a multidisciplinary team that includes peer specialists, and improved quality of life.

Leadership

Project HOME Health Services (PHHS) offers fully integrated, trauma-informed primary care, behavioral healthcare, addiction/recovery support, dental care, pharmacy, and wellness services serving people experiencing homelessness and the local neighborhood with over 22,600 visits for 5,500 patients annually in four sites including our Federally Qualified Health Center (FQHC) and a medical street outreach team. Project HOME also improves health among people with experiences of mental illness and co-occurring substance abuse through other services such as 24/7/365 street outreach, over 800 units of entry-level and permanent supportive housing, adult learning, and employment opportunities. As a Center of Excellence for treatment of opioid use disorder, we are a model for other FQHCs for integrated behavioral health in opioid therapy groups in primary care. We know what works, and are always looking for opportunities to partner with other organizations doing other levels of the work, to connect to us in the continuum of care.

Scalability

Under our FQHC designation, PHHS currently provides primary care services at two partner agencies: Prevention Point Philadelphia and Pathways to Housing; and at the Hub of Hope, Project HOME’s drop-in engagement center in the Philadelphia subway system. Locally, our MAT+ program could be integrated into our supportive housing’s residential programs, and nationally, it could be reproduced at other FQHCs. We leverage funding that supports our operations as startup money for fee for service work so it can become self-sustaining, and to further develop relationships with additional prospective funders. We have a strong track record of securing private and public funding, as well as a track record of fiscal responsibility. Charity Navigator recently awarded Project HOME its sixth consecutive 4-star rating, which indicates that we adhere to sector best practices and execute our mission in a financially efficient way. Fewer than seven percent of charities rated have received this distinction, nationally.

Results/Outcomes

We will increase access to person-centered, trauma-informed MAT in combination with comprehensive OUD psychosocial services and access to housing, education and employment (MAT+) to vulnerable populations with experiences of homelessness and complex medical and psychiatric co-morbidities in Philadelphia, whose needs are not being served by the existing system. Retention in MAT services is on par with expected results as we continue to engage people with primary care. Shared outcomes may help educate the public and our funders about Project HOME’s efforts to end and prevent homelessness in the City of Philadelphia, as well as the role that access to health and wellness care plays in that work. We have received state and federal recognition for our program, get regular feedback from peers about their excitement of the program, have presented our results at a national conference, and received requests from across the city, state, and county for program replication advice.