San Francisco Chronicle - (Sunday)
Program to help drug users is threatened
Health providers and addiction experts warn the funding structure is unstable for a California initiative that steers patients with substance use disorder into long-term treatment after they are discharged from emergency rooms, which has already led some critical employees to leave their jobs.
Supporters of CA Bridge’s behavioral health navigator program, which started in 2022, say its reliance on one-time money makes it hard for hospitals to retain navigators amid a growing drug crisis. In 2022, the most recent year for which data is available, 7,385 Californians died from opioid-related overdoses, of which 88% involved fentanyl, a synthetic opioid that can be 50 times as strong as heroin.
“This should be very basic, 101 first aid for opioid use disorder, and we are truly struggling to sustain it,” said Andrew Herring, an emergency medicine physician at Highland Hospital in Oakland and a co-founder of CA Bridge. “Everyone is looking at everyone else to pay for this. The doctors, nurses, social workers and care managers are standing by, ready to do work that is inherently compelling and wonderful, but they’re simply not being paid to do it.”
The navigator program is just one component of CA Bridge, a multilayered program intended to expand the use of medications for substance use disorders in ERs. CA Bridge pays for training for doctors and nurses to increase the use of prescription medication, and its navigator program pays hospitals up to $120,000 to contract with behavioral health workers.
Currently, 284 navigators have been assigned to place patients into long-term treatment after they are discharged from an ER. Once a year is up, hospitals have the option to bring navigators on staff or allow those contracts to expire. CA Bridge officials confirmed more than a hundred navigators have left their positions.
In response, state officials say they are trying to expand the use of Medi-Cal, the state’s Medicaid program, which covers low-income people, to help pay for navigators by nudging managed-care plans to cover such services. Officials said the state is also trying to secure additional federal grants through March 2025. However, Democratic Gov. Gavin Newsom did not include new state funding in his latest budget in the face of a $38 billion deficit.
CA Bridge started in 2018 and has since received almost $100 million in federal and state money as it has expanded across California. As of January, 265 hospitals with emergency departments, or 83% of those in the state, are participating in the program and about 100 hospitals have hired navigators as permanent staff. According to a January 2023 CA Bridge report, 76,801 patients have been prescribed buprenorphine, and an estimated 34,560 were connected to follow-up care.
Hospital industry representatives say more of their members would join the program if they knew it would have sustainable long-term funding.
The program raises doctors’ awareness of the benefits of prescribing medications such as buprenorphine, which works by binding to the same brain receptors as more dangerous opioids, reducing withdrawal symptoms. Buprenorphine, naltrexone and methadone are the only medications approved in the U.S. to treat opioid use disorder. Only 10% of Californians with substance use disorder received appropriate treatment in the previous year, according to a 2022 analysis by the California Health Care Foundation.
Meanwhile, CA Bridge navigators, who are trained in harm reduction, behavioral health and community outreach, help place patients into long-term treatment after discharge, a step that can be lifesaving and that the behavioral health system often struggles to complete. A study of patients in England found they were four times as likely to die from an opioid overdose within 48 hours after a visit to the ER versus other times.
Patients who received help from a navigator were more than three times as likely to be in treatment within 30 days after they visited the ER than those who did not receive the assistance, found a study conducted from September 2021 to January 2022 in three public hospitals, including Highland.
Even though hospitals that hire navigators can be reimbursed by billing Medi-Cal for community health care services, few hospitals have negotiated that benefit with Medi-Cal’s health plans. David Simon, a spokesperson for the California Hospital Association, said that the service is new and that the state has yet to provide guidance on how to bill health plans.
In the past, supporters of the navigator program have suggested reducing barriers to billing Medi-Cal and tapping various state funds.
“A statewide funding mechanism to sustain the navigators’ services on an ongoing basis has yet to be solidified,” a coalition of dozens of health providers and advocates wrote last year.
Aimee Moulin, a principal investigator and co-founder of CA Bridge, said the program needs momentum to stem an epidemic of overdose deaths. While the program has helped expand the use of medications for opioid addiction, she said, there is still work to do to bring in additional hospitals and persuade them to incorporate addiction care.
“For opioid use disorders, we have highly effective medications,” Moulin said. “It’s not like we don’t know what works. It’s just a matter of getting them out there.”
“Everyone is looking at everyone else to pay for this. The doctors, nurses, social workers and care managers are standing by, but they’re
simply not being paid to do it.”
Andrew Herring, emergency medicine physician at Highland Hospital