Integration of Care – Minutes – 5/4/22

Minutes of the 

INTEGRATION OF CARE COMMITTEE

Veronica Fortunato & Donald Powell, IOC Co-Chairs

Wednesday, May 4^th, 2022, 10a-12p

Zoom Meeting

Video link

Attendance:

Guests: Samuel Kelton Roberts, Allan Clear, Elizabeth Schady

DOHMH/PHS Staff: 

Agenda Item #1: Welcome/Introductions w. Pronouns/Moment of Silence/Review of Minutes

Introductions and moment of silence conducted. Intergalactic Star Wars Day was honored.

Agenda Item #2: Drugs, Politics, and Pariahs Or, How to Think Historically About Race and Harm Reduction during (and after) the War on Drugs with Dr. Samuel Kelton Roberts

Dr. Imani Woods, original cadre of harm reduction activists. Two key issues for her – who should lead the Black harm reduction movement. Today harm reduction has been centered – many thoughts this would never happen.

Well-meaning efforts to design programs for Black people – create suspicion in Black community. White harm reductionists tend to mimic the dominant in interactions.

Still see remnants of the cultural aversion among Black people to concept of harm reduction. Dr. Woods was often accused of supporting genocide.

Espoused need for a standardized harm reduction definition. Only in past 5 years have definitions of harm reduction become more critical. 

What is harm reduction and what does it have to do in this moment – especially thinking about the structural factors.

Imani Woods talked about a basic needs approach – addressing social and political issues. You see an epidemiologic flip among new HIV infections in the mid 90’s. The Fullilove’s documented these syndemics. Hysteria about Black men on the down low. High degrees of stigma. Started seeing Black movements mobilizing against HIV.

A critical and radical vanguard composed of a structural analysis of individual and community health and autonomy. Do what doesn’t work until you find something that does. Public health experts have considered many of these actors to be pariahs. What is the formula for making someone a pariah?

Historical roots – within the longer history of struggle in the Black community. A critical Black approach has long been present. For more see the work of  Sarah Haley. Recommended reading:

The Boundaries of Blackness

North Carolina and the Problem with AIDS

Not Straight, Not White

To Make the Wounded Whole

The function of stigma in legitimizing structural violence: Blaming people for inability to access regular healthcare. Retraction of social and economic support over past 25 years. Idea of welfare queens to reduce a robust welfare state. Lack of protection for sexual minorities.

Pariah centered approach: stigma has been an effective means by which to rationalize oppression of the vulnerable. Anti-stigma work is central to a pariah centered approach. Different from “user” centered – pariah centered forces thinking about the structural forces which produced these social categories. 

Future work in harm reduction should pay attention to the political organization of these communities.

Can have harm reduction be a national policy – and still see Black communities treated as pariahs. Must consider the maintenance of structural racism in how programs operate.

How is recovery and addiction being defined inside of the community – many of these definitions were given to us. Must seize the power to redefine these concepts.

Historically the measurement is a drug test – not – how is your relationship with yourself or with your family? Any positive change is not usually part of the diversion deal.

Q&A

1. There are men who will characterize their use as crack when its crystal meth. Crack is more acceptable. There is a lot of stigma about crystal meth – people who are in crystal meth are included in groups, while people overmedicated on methadone are not. Harm reduction requires humility. 
   1. In public policy, everyone is lumped together. But within that, there are differentiations – can see the pariah making of one group misnaming a drug. Humility is key to this work. 
2. How to implement a pariah centered approach? 
   1. Concept of humility is the secret sauce. There are excellent trainers in this work – cannot underestimate power of teaching people. Many people cannot teach – very special to be able to do the work and teach it – cherishing of people who can do that. Peers do this work all over the country. 
3. What are the layers of stories that people carry? 
   1. Addiction policy and mental health policy have been viewed as separate for too long. We don’t treat people holistically – important to think about hierarchy of needs and consider what people interpret as their most pressing need.
4. Appreciate Imani Woods being centered in this talk – she was a brilliant thinker and trainer. She had no fear of talking to political leaders. Black Panthers were defending their communities. It has taken 30 years for these concepts and ideas to make it into the mainstream. 

Agenda Item #3:  Harm Reduction & Medicaid with Alan Clear & Elizabeth Schady

Where did harm reduction billing come from? 2021 MRT (Medicaid Redesign Team) Health Disparities Initiative to address public health crises in drug use. Currently open to tier 1&2 Syringe Exchange Programs (SEPs). Has been difficult for SEPs to get on board with billing for Medicaid. A SEP has a built-in anonymity which does not align with Medicaid. The billing infrastructure is largely foreign to SEPs.

Originally proposed as 14 services, now scaled back to 5 – difficult to fit all the work into those categories. Reimbursement rates are extremely low across the state. SEPs often operate outside of. The general practices of an agency.

Original idea of tiers was to make syringes more available, even when org doesn’t service a lot of clients for that service. Currently attempting to make it more provider friendly. Did a revamp removing stringent educational barriers, especially for peers. Scaled those back, most were removed. Asked for rate increases – based on a statewide cost analysis using HARP rates for health homes – services for severe and persistent mental health diagnoses. NYC has an acceptable on-site rate – only rate not asked to be higher. 

Asked for more categories, such as linkage – lots of work done in SEPs fits into that category. Currently at CMS awaiting approval. If those changes happen, will have to do additional marketing to support implementation. It is important for SEPs to be able to operate with some anonymity for clients.

Can have someone enrolled in both health homes (HH) and harm reduction model. HH requires 2 diagnoses of a chronic illness, or an overarching issue like HIV. Rates are higher. Harm reduction can co-exist with health homes, but may be problematic since both, pending changes, will have linkage and navigation. Providers fear Medicaid audits. HH must have a touch with a patient once a month.

Billing for harm reduction is fairly simple. Very basic service plan with a brief assessment. Billing is in 15-minute increments, with an 8-hour cap, and people must be in the service for at least 8 minutes. Thinking a lot about supporting the implementation of this.

Harm reduction is a very flexible sort of program. Can be difficult to explain due to this flexibility. Having a treatment plan at the beginning does not make sense. Center for Medicaid Services (CMS) want this to fit into a medical model. Office of Natal Drug Policy is recommending that Medicaid reimburse for harm reduction.

Q&A

1. Like that you’re looking at the lower threshold for delivering services. HH are a high threshold. Glad you’re aware of that. OMH peer specialists have been around a long time and CMS reimburses it – strange that AI has a peer training but has no equivalent in being recognized as a provider even though the training for AI and OMH are comparable. 
   1. CMS is very rigid – some don’t recognize the AI’s training institute. Currently there is a 500-hour training requirement – seeking to remove this. 
2. Do you offer syringes for hormone therapy?
   1. Syringe exchange is outside the scope of billing in Medicaid.
3. Can people get a substance use diagnosis when you come in for harm reduction?
   1. Yes, but may be a linkage
4. Can a SERPA from OASAS bill for SEP?
   1. They bill through OASAS
5. Have you spoken to HH clients – often have many patients to case manager – do not have time for more intensive interactions – cannot provide adequate support
   1. For people who are in an HH and not able to get the services they need – want them to come into harm reduction. Hospital based HH are not familiar with home/community visits. Difficult for them to develop that rapport.
6. Not all Ryan White programs are SEPs – how many are?
   1. Perhaps five. Have supportive counseling programs that are co-located with SEPs
   1. May need to require all behavioral health sites to be second tier SEPs
7. Often looks at what peers do, but it doesn’t translate to what they bring – knowledge of the community, etc. How do we get people to understand how to incorporate this work?
   1. Expertise that peers have at the SEPs should go as a credit to training. And people should be getting paid to undergo these trainings.
8. How are outreach activities reimbursed now and in the revamp?
   1. Not included in either – too muddy. Removed from HH because the billing for outreach was funky. Have put in for an increase for offsite services – offsite encounters can be billed. 
9. Do you need a Medicaid number to bill for offsite encounters?
   1. Yes. 
   1. RW needs to pay for outreach.

Agenda Item #4: Public Comment