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Vermont’s Hub-and-Spoke Approach to Opioid Treatment Catching On

May 22, 2018
by David Raths
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Portland-area providers follows model toward ‘no-wrong-door’ approach to medication-assisted treatment

The scale of the opioid crisis cannot be overstated. Every day, more than 115 people in the United States die after overdosing on opioids, according to the National Institutes for Health. The Centers for Disease Control and Prevention estimates that the total "economic burden" of prescription opioid misuse alone in the United States is $78.5 billion a year. But some states and regions are finding ways to shape their treatment response. For instance, a promising “hub-and-spoke” approach developed in Vermont is now being put in place in Portland, Ore., as well.

In a recent webinar put on by the Substance Abuse and Mental Health Services Administration (SAMHSA), John Brooklyn, M.D., the medical director of opioid treatment programs in Vermont, described how the Hub and Spoke Model was developed and some of the results the state has seen. Then Alison Noice and Justine Pope of the Wheelhouse Program in Portland described their effort to replicate some of Vermont’s successes with their own hub and spoke.

Brooklyn described how the Hub & Spoke Program enhances the provision of medication-assisted treatment (MAT) by adding new healthcare staff to both Hub designated providers, which are centers of excellence for opioid use disorder (OUD) treatment and the Spokes to provide health home services. Some teams are embedded in the practices. Other teams visit practices, meet patients at alternative sites, or speak on the phone. These new staff link OUD treatment with primary care practices and community health teams to provide care that is evidence-based and integrated.

“No Vermonter has to wait for opioid treatment,” Brooklyn said.  “We have eliminated waiting lists with a systemic program developed by the state. With this approach, there is no wrong door into treatment.”

Brooklyn and colleagues developed a Treatment Need Questionnaire to help providers triage patients and determine where they should go for treatment. They also developed a learning collaborative. Each participating entity had measures to report on at each session to measure progress toward goals such as waiting list reductions and retention in treatment.

The hub-and-spoke model supported a substantial increase in Vermont’s OUD treatment capacity and has shown 6 to 7 percent in cost savings by 2014 by treating OUD in the Hub and Spoke Model.

Alison Noice and Justine Pope from CODA Oregon followed Brooklyn’s presentation by talking about how they are replicating the hub-and-spoke model in the Portland area with a coordinated collaborative model of care delivery. They started out by noting that there are significant treatment gaps in Oregon, and they cited several reasons, including a continued stigma around the use of medications in support of recovery, and artificial and the lack of integration between physical and behavioral care systems.

Wheelhouse is sponsored by Health Share of Oregon, which serves approximately 300,000 Medicaid members in the Portland area. increase availability and access to MAT. CODA and another organization, Central City Concern (CCC) make up the hub. One effort involved working with spoke providers to create and implement a standardized referral process  to better coordinate services.

Wheelhouse has also followed Vermont’s approach of creating a learning collaborative to support the spread of best practices.

“One of our goals is to create a high-functioning and integrated system of care,” Noice said. “It is not just about expanding MAT,” she said. Providers who are used to being competitors in the fee-for-service world are being asked to behave like a meaningfully organized system, and not a series of separate organizations.

“It is quite exciting watching systems change and for providers to see themselves as part of a larger system of care.”

The goal is getting to that “no wrong door” to accessing to MAT.

Looking forward, Noice said, Wheelhouse is looking at implementing standards of care, and leveraging alternative payment models and common quality improvement metrics.




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