Table 3.
Overview of MAT models of care for OUD in primary care (including rural or other underserved settings)
| Model | Summary | Pharmacological Component | Education/Outreach Component | Coordination/Integration of Care Component | Psychosocial Component | Other Component(s) |
|---|---|---|---|---|---|---|
| Practice-Based Models | ||||||
| 1) Office-based Opioid Treatment (OBOT) | Glue person (typically nurse) with expertise in buprenorphine working in collaboration with primary care clinician | Primarily buprenorphine/naloxone | Not a major component | Glue person (typically nurse) instrumental for coordinating and integrating care, including primary care and mental health | Physician counseling monthly; some psychological services provided on-site by glue person or other staff. Other psychosocial services vary, including integrated CBT, Motivational Enhancement Therapy; some psychosocial services offsite | |
| 2) Buprenorphine-HIV Evaluation and Support (BHIVES) Collaborative Model | Chronic care model for providing buprenorphine/naloxone in HIV primary care clinic setting | Buprenorphine/naloxone | Patient and provider educational material available online | Treatment for OUD and primary care, including HIV care integrated in same setting. Clinical coordinator “glue person” coordinates care; works in conjunction with primary care provider. Provision of HIV care may be by the primary care provider or another provider working with the primary care provider | On-site psychological services variable, including individual and group counseling | Coordination with OTP for patients switching to or from methadone |
| 3) One Stop Shop Model | Integrated model based in mental health clinic to provide “one-stop” shopping including management of HIV/HCV infection and plans for MAT in progress | Primarily naltrexone | Education to increase number of waivered physicians | Treatment for OUD, mental health, and primary care (including HIV/HCV care) provided in same setting. Peer navigators and social workers provide coordination with primary care providers | Centered in mental health clinic that provides comprehensive psychological services; psychiatrist once a week | Syringe exchange and other services also available |
| 4) Integrated Prenatal Care and MAT | Model providing prenatal care to pregnant women who are treated with buprenorphine | Buprenorphine | Not a major component | Primary care clinic provides MAT, as well as prenatal and post-partum care; care continued in office-based setting for 1 year after birth. In some programs women can work with doulas | Services provided on-site or via partnering OTP | |
| System-Based Models | ||||||
| 5) Hub and Spoke Model (Vermont) | Centralized intake and initial management (buprenorphine induction) at “hub” and then patients connected to “spokes” in community for ongoing management | Primarily buprenorphine/naloxone | Outreach to prescribers in the community to increase number of buprenorphine-waivered physicians. | Coordination/integration between hub and spoke as well as within each primary care site “spoke.” Registered nurse clinician case manager, and/or care connector (peer, behavioral health specialist) for coordination/integration of care at spokes. | Embedded in spoke sites, including social workers, counseling, and community health teams. | Hubs provides consultative services and available to manage clinically complex patients, support tapering off MAT, or prescribe methadone, if needed |
| 6) Medicaid Home Model For Those With Opioid Use Disorder | A flexible model that provides MAT in combination with behavioral health therapies and integrated with primary care. | Primarily buprenorphine/naloxone | Provider and community education emphasized to increase uptake and decrease stigma | Required component, but mechanism of coordination varies | Six core psychosocial services are required: comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow-up, individual and family support and referral to community and social support services. | Some telehealth services offered |
| 7) Project Extension for Community Healthcare Outcomes (ECHO) (New Mexico) | Model of care for linking primary care clinics in rural areas with a university health system, emphasizing nurse practitioner or physician assistant screening and MAT (physician prescribing) combined with counseling and behavioral therapies. | Primarily buprenorphine/naloxone | Mentored buprenorphine prescribing for providers, including Internet-based, audiovisual network for provider education. Free buprenorphine training provided several times a year. ECHO staff provide patient education one-to-one or in group setting. | NP/PA performs initial evaluation and screening educate patient and refer to collaborating physician for treatment. NP/PA performs monitoring treatment and followup appointments including labs, urine testing, monitoring, patient education and support and other coordination (e.g., vaccinations) | Counseling and behavioral therapies offered from all ECHO team members including CHWs, although CHWs and NPs provide education/support, psychosocial support including 12 step programs, crisis counseling, referrals, and relapse-prevention plans. | Refer any patients with high or moderate risk scores for opioid use to NP for further assessment and/or referral to OTP |
| 8) Collaborative Opioid Prescribing (Co-OP) Model (Maryland) | Links opioid treatment programs with office-based buprenorphine providers; initial intake, induction, and stabilization performed at OTP then shifted to primary care clinic | Buprenorphine/naloxone | Outreach performed by counselors to community physicians | Initial assessment, psychosocial treatment, and expert consultation initiated in drug treatment program and patients transitioned to primary care in federally qualified health center following stabilization | Provided concurrently via OTP, including ongoing counseling and monitoring | In Baltimore, supports to facilitate access to health coverage through Medicaid and to coordinate care through HealthCare Access Maryland |
| 9) Massachusetts Nurse Case Manager Model | A primary-care based model that teams nurse care managers with primary care physicians; nurse care managers generally perform initial screening, intake, education, observed/supports induction, followup, maintenance, stabilization, and medical management with the physician and team. | Primarily buprenorphine/naloxone, with integration of extended-release naltrexone in last two years | A training program exists to get more physicians, especially residents, and also faculty on board. Department of Public Health trains staff on best practices. Nurse care managers receive 8 hours of training in MAT, shadowing in model MAT site, site visits, email and phone support, case review, quarterly trainings, and addiction list server. | Nurse care managers (RN or FNP) manage 100 to 125 patients alongside primary care clinicians, with assistance from a medical assistant. Alternatively, care partners (usually Master’s level individuals) who assist the primary care staff with screening, brief intervention, and referral to treatment. | Psychological services are integrated on-site or nearby | Patients who require higher level of care can be expedited into an OTP, assistance with transfers of care, day support programs |
| 10) Emergency Department (ED) Initiation of OBOT | Model involving ED identification of OUD; buprenorphine/naloxone induction initiated in ED; coordination with OBOT, nurse with expertise in buprenorphine working in collaboration with primary care clinician | Buprenorphine/naloxone | Not a major component | OUD identified in ED and patients started on buprenorphine and connected to ongoing OBOT provided by physicians and nurses for 10 weeks, then transferred to office-based ongoing maintenance treatment or detoxification. | “Medical management” counseling visits with physician and nurse | |
| 11) Inpatient Initiation of MAT | Model involving identification of OUD in the hospital and connecting patients to office-based MAT and primary care | Buprenorphine/naloxone, naltrexone | Not a major component | MAT started by multidisciplinary addiction consult service during medical hospitalization and connected with primary care. Treatment continued in primary care; some programs have buprenorphine “bridge” clinic prior to transition to primary care. | Provided at primary care site | |
| 12) Southern Oregon Model | A local and informal model for delivery of MAT in a rural primary care network | Almost exclusively buprenorphine/naloxone | A group of local stakeholders from many perspectives who prescribe opioids (Oregon Pain Guidance) meets regularly to develop guidance and provide education. | Relatively limited support for coordination/integration of care | On-site licensed clinical social worker with experience in treating patients for pain and addiction, not necessarily in MAT. | Access to OTPs for complex patients not formally integrated. |
Abbreviations: CBT = cognitive behavioral therapy; CHW = community health worker; DPH = Department of Public Health; ED = emergency department; FNP = family nurse practitioner; HCV = hepatitis C virus; MAT = medication-assisted treatment; NP = nurse practitioner; OTP = opioid treatment program; OUD = opioid use disorder; PA = physician assistant; RN=registered nurse.