Introduction:

The misuse and abuse of alcohol, over-the-counter medications, illicit drugs, and tobacco affect the health and well-being of millions of Americans. North Carolina reports 8.5% of the total population use illicit drugs and unfortunately we rank 20th compared to other states in drug overdoses. Western North Carolina communities are actively working to implement solutions that address the impact of substance use disorders by increasing access to treatment and recovery services, increasing prevention and education efforts and examining the impact of substance use on the overall health and economic development as a result of lost productivity of workers. Coordinating and collaborating these local level efforts can result in positive outcomes in addressing the problems associated with substance use across the Vaya Health catchment area, including the stigma of substance use disorders and treatment. By legislative statute, Vaya Health is responsible for the planning of community efforts such as this.

Guiding the work of the Western Region are two recently released reports.  The Governor’s Task Force on Mental Health and Substance Use released their report on May 1, 2016.  The report can be found at www.ncdhhs.gov/mhsu.  The report contains recommendations and implementation strategies that address factors impacting substance use issues across adult and child populations.  In 2016, the first-ever Surgeon General’s Report on Alcohol, Drugs, and Health reviews what we know about substance misuse and how you can use that knowledge to address substance misuse and related consequences.  It speaks to prevention through treatment and recovery (https://addiction.surgeongeneral.gov).  These reports, along with other literature and data will be used to drive the recommendations and solutions of the WNC SU Alliance.

Scope:

The WNC SU Alliance will leverage existing efforts and work to create or replicate solutions across the region in order to address substance use from a regional perspective.  The purpose of the Alliance is to formulate a comprehensive SU strategic plan, reflective of the grass root, community efforts across the twenty-three (23) counties.  The WNC SU Alliance Steering Committee will provide oversight and guidance for 4 subcommittees.

Goals:

The goals of the Comprehensive SU Strategic plan include:

• Increase collaboration across agencies and stakeholders to coordinate efforts addressing the problems associated with substance use.
• Leverage resources to maximize efforts across the Vaya Health 23 county catchment area.
• Reduce unnecessary duplication of efforts to address substance use.
• Establish intervention priorities for the region that will result in positive outcomes and increase sustainability for all populations, regardless of payment source.

Recommended Approach:

The WNC SU Alliance Project will be guided using an Executive Steering Committee, chaired by project sponsor, Brian Ingraham, Vaya Health CEO.  The Steering Committee will consist of representation from across the Vaya Health twenty-three (23) county region.  This committee will receive recommendations and other deliverables from four subcommittees.  The Subcommittees are:

• Safe Opioid Prescribing & Medication Assisted Treatment (MAT)
• Adult SU Treatment Continuum/Crisis
• Child SU Treatment Continuum/Prevention
• Women and Perinatal SU Treatment

Project and Governance Structure:

Roles and Responsibilities of Steering Committee and Subcommittees:

The Project Sponsor, Brian Ingraham, acts as a vocal and visible champion, legitimizes the project goals and objectives, keeps abreast of major project activities and is, with the assistance of the Executive Steering Committee, the decision maker for the project.  The project sponsor activates project activities through the four (4) subcommittees once the approval of the project charter is obtained.  Project manager, Tara Larson, with Cansler Collaborative Resources (CCR), will staff the Executive Steering Committee and along with Vaya and CCR staff, assists the subcommittee structure with identifying major issues, problem solving, policy conflicts, removes obstacles, approves significant changes in project scope, schedule, cost, quality and risk and achieving the goals of the project.

Each subcommittee has a chair and a Vaya staff person assigned to carry out the specific subcommittee scope.  The subcommittee chairs will report on the progress of their work monthly at each Steering Committee meeting.

Subcommittee Scopes:

Safe Opioid Prescribing & Medication Assisted Treatment (MAT) (Chair: Dr. Blake Fagan, MAHEC)

• Develop plan for implementing appropriate opioid prescribing and pain management techniques, to include interventions without medication
• Expand timely access to MAT, integrated/coordinated with adjunct specialty evidence based behavioral health treatment, for all 23 counties
• Identify best practice MAT models initially for opioid use disorders and then for alcohol/other drugs
• Develop education and consultation strategies regarding MAT for providers including crisis response, emergency services, pharmacists, inpatient care and outpatient medical and behavioral health, recovery community, and other stakeholders
• Increase collaboration with primary care, comprehensive and specialty providers through evidence based strategies and activities, including strategies to educate consumers regarding the impact and possible consequences of pain medication
• Define, educate, and identify relapse and overdose prevention strategies for consumers, families, providers, primary care, law enforcement, etc.
• Create protocol for use of Naloxone prescriptions for opioid overdose and recommended follow up services (includes protocol for maintaining data regarding successful use of Naloxone)

Adult SU Treatment/Crisis Continuum (Chair: Chad Husted, October Road)

• Move system/community from reactive to proactive recovery focused/resiliency based
• Increase use of primary & secondary care as opposed to crisis focused care
• Development of comprehensive continuum of care beyond basic outpatient
• Define roles of ADATC, other residential, and transitional step down services within the continuum
• Reduce unnecessary use of ED for substance use crisis events
• Develop education campaign to reduce stigma, increase knowledge of the continuum of care, and move culture from criminalization to treatment
• Develop a chronic disease management approach (including relapse as part of the disease)
• Educate providers and practices about diagnosis protocol (e.g. ask “how many drinks do you have in a week?” vs. “do you have a problem?”), and brief intervention implementation (i.e. use the opportunity to determine interest in behavior change); encourage full implementation SBIRT (including appropriate brief intervention strategies)

Child SU Prevention/Treatment Continuum (Chair: Danielle Arias, RHA)

• Increase proper identification of Substance Use Disorder criteria in adolescents; coordinate with systems (schools, juvenile justice, primary care) to appropriately identify the need to refer youth for comprehensive behavioral health assessments (MH/SU) through effective and evidence based screening strategies
• Increase development of comprehensive continuum of services for child/adolescent SU
• Increase understanding and acceptance of child SU issues in the schools
• Define substance use prevention for children and adolescents
• Identify EBP prevention/intervention/treatment models to increase resiliency in children/families
• Coordinate with Medication Assisted Treatment (MAT) subcommittee to identify strategies to address pain medication prescribing practices for children and adolescents
• Develop strategies to integrate child/adolescent SU evidence based and best practice models with primary care (specifically pediatrics); specifically evidence based screening and brief intervention to include trauma screening
• Identify successful treatment strategies/models for youth involved with juvenile justice, while monitoring current efforts in North Carolina to enact legislation to raise the age of juvenile court jurisdiction to include youthful offenders aged 16 and 17 years

Women and Perinatal SU Treatment (Chair: Leslie McCrory, Vaya Health SU Consultant)

• Increase engagement of substance using women (preconception, pregnant or with young children) to attend to primary care, perinatal care and accessing SU treatment, including strategies to address barriers such as transportation, child care and the impact (emotional and financial) of separating children from mothers
• Increase gender specific treatment models for substance using adults (men and women) with children (address impact of parental SU on children and skills to improve parent/child bonding)
• Develop an efficient and effective integrated whole person care approach to SU treatment for pregnant women and women with infants (including parent/child bonding)
• Integrate education, counseling, and engagement strategies regarding preconception and perinatal care issues related to substance use across behavioral health, primary care and OB/GYN providers
• Emphasize a family focused approach to treatment (including addressing fears of losing custody of children in order to engage in treatment)
• Coordinate with MAT subcommittee in order to address the impact of MAT for women during preconception, pregnancy and with infants

Project Deliverables:

The Comprehensive SU plan will consist of two parts:

Phase I

The Phase I work product is for each subcommittee to identify 5 priorities to be integrated into a comprehensive regional SU strategic plan.  Each priority must address or take into account:

• Stigma associated with substance use disorders and treatment participation (including MAT)
• Utilize trauma focused lens while also being recovery focused and resiliency based
• Provide strategies on how to achieve integration across settings, including primary care offices, community partners of health and other social determinants
• Take into account the role of social determinants of health into the recommended priority
• Be reflective of all 23 counties needs or strengths, recognizing that strategies and implementation may vary in approaches and timing.
• Identify possible barriers to addressing each priority

Phase II

The Phase II work product is a design of the Implementation Strategy.

Critical Timelines:

• January 24, 2017
  • Subcommittees will report on committee scope and membership commitment
• February 28, 2017
  • Subcommittees will report on the identification of the 5 priorities
  • Presentation of a draft global Communication Strategy for the WNC SU Alliance
• March 28, 2017
  • Subcommittees will confirm the 5 priorities for each group, and strategies to address the priorities across the 23 counties
  • Subcommittees will report on existing efforts/initiatives across the 23 counties that address the subcommittee priorities
• April 25, 2017
  • Subcommittees will identify strategies for coordinating efforts and initiatives across the 23 counties to address the identified priorities
• May 23, 2017
  • Subcommittees will present draft report outlining Phase I activities and findings
• June 1, 2017
  • Final Phase I subcommittees report due; report should include initial implementation strategies to address the 5 priorities across the 23 counties

Assumptions that may impact the critical timing and project planning:

The General Assembly begins meeting in January, 2017 for the long session.   Budget preparation and the LME/MCO funding is expected to be a topic of attention.  The WNC SU Alliance interim and final reports can influence the activity of the General Assembly.  Funding for substance use has historically been a challenge.  Sustainability of programs and solutions is a key element in strategic planning and implementation.

Steering Committee

Meets 4th Tuesday of each month, 6-8pm, at Vaya Health

Name	Organization
Dr. Blake Fagan	Assistant Director, Family Medicine Residency Program, MAHEC
Sonya Greck	Sr. Vice President, BH Services, Mission Hospital
Dr. Jim Hartye	Behavioral Health Medical Director, Mission Hospital
Mandy Stone	Assistant Buncombe County Manager
Jim Holland	Business Officer, Buncombe County
Alice Salthouse	CEO, High Country Community Health (FQHC)
Judy Johannsen	Vaya Health Board Member  (CFAC representative)
Fred Brason	Executive Director, Project Lazarus
Jeanne Duncan	President, RHA Health Services, Vaya Health Board Member
Ronnie Beale	Macon County Commissioner, Vaya Health Board Member
Steve Smith	Health Director, Henderson County Health Department
Leslie McCrory	Vaya Health SU Consultant
Danielle Arias	Child SU Tx/Prevention Sub-Committee, Director & ESTR Program, RHA
Chad Husted	Adult SU Tx/Continuum/Crisis Sub-Committee, Regional Director, October Road
Dr. Craig Martin	Chief Medical Officer, Vaya Health
Christina Dupuch	Chief Operating Officer, Vaya Health
Brian Ingraham	Chief Executive Officer, Vaya Health
Doug Trantham	Director of Behavioral Health Service, Cherokee Indian Hospital Authority
Kristi Case	Recovery Services Manager, Cherokee Indian Hospital
Jennifer Wehe-Davis	CCWNC
Tom Wroth	Medical Director, CCNC
TBD	Representative of Judicial System/Criminal Justice or Law Enforcement

Sub-Committees

Focus Area	Name
Medication Assisted Treatment Meets 1st Tuesday of each month, 5:30-7pm, at MAHEC	Blake Fagan, MD, Chair Elizabeth Fleming Rob Fields, MD Jim Haaga, MD Linda Davidson, FNP Steve Crane, MD Miriam Schwarz Will McClean, MD Fred Brason Eric Christian, MA, LPC Don Teater, MD Stephanie Almeida Peggy Weil Leslie Gray Courtenay Wilson, PharmD Matt Holmes, MD Cliff Feingold, PA (retired DDS) Jesse Smathers Placeholder
Pregnant SU Services Meets 3rd Monday of each month, 5-7pm, at Vaya Health	Leslie McCrory, Chair Erin Bowman Carol Coulson Julie Lovingood Nivee Roy Todd Wallenius Jim Holland Sonya Greck Susan Mims Kellett Letson Ann Absher Jeff Heck Vicki Lewis Todd Berchen Celeste Ordiway Ariel Thomas Shelly Foreman Christina Dupuch Craig Martin
Adult Treatment Continuum/Crisis Services Meets 3rd Thursday of each month, 2-4pm, at October Road	Chad Husted, Chair Erin Bowman, LCSW, LCAS, CCS Jon Marbois-Segall John Sanders, LCSW, LCAS, CCS Kevin Mahoney , NCCPSS, NAADAC-A Caroline Carter, LPCS, LCAS, CCS James Hartye, MD Jana Aitken, LCAS
Child Treatment Continuum/Prevention Meets 2nd Tuesday of each month, 1-3pm, at RHA	Danielle Arias, Chair Vernetta Eleazer Michelle Geiser Jenni Irwin Suzanne Mizsur-Porter Heather Sharp Jeff Spargo Liz Thomas Patti Tiberi Carson Ojaama Paige Stephens Great Metcalf Kristen Gentry Brenda Chapman Alice Elio Beth Nelson