Interview with Terri Stratton
Terri Stratton is the Executive Director of the El Dorado Community Health Centers. This interview took place on October 10th, 2019.
First off, I guess it would be helpful if you briefly just introduced yourself and described your role and the work you’ve done pertaining to the opioid crisis.
I’m Terri Stratton, I’m the Executive Director of the El Dorado Community Health Centers. In 2015, we received some grant money to start developing a medically-assisted treatment (MAT) program. Our medical director and myself decided that we already see many of these patients, so having an additional tool to be able to provide some treatment for them would be a positive direction for us to go in. We started that effort in 2015 with some grant planning from the California Healthcare Foundation. Since then, we have grown to be a multi-dimensional medically-assisted treatment team, which we call our Complex Care Clinic. We have several physicians - I believe there’s four - working part-time in this medically-assisted treatment program. We have two case managers, LCSWs, RN case managers, and specially trained medical assistants who are all part of this team. We have an active patient base right now of about 270 patients.
How long have you been in your role of the Executive Director?
I started in my role as the Executive Director here in January of 2014, so almost 5 years.
During your time as an Executive Director, what was the most memorable experience you had, whether it was something you observed or something you heard someone say, that just stuck with you?
I think the things that really resonate with me are when I hear patients’ stories of how we were really able to impact their lives. They are incredibly grateful for us being available to provide medical, behavioral health, medically-assisted treatment, all kinds of diversity of services to them that would otherwise not be available. I would say that that’s my biggest impact.
You mentioned that you have been able to administer MAT with the help of a grant from the California Healthcare Foundation. What was that process like in determining the need, or being able to offer MAT, and then applying for the grant. What was that process like?
So, we already had in place within our center one physician who was X-wavered and had been prescribing suboxone to a small group of his patients for a number of years. His medical assistant worked with him to move those patients through, but what we were lacking in that regard was really having that best practice approach with more of a team-based care. That gave us some initial experience in working with medication-assisted treatment. However, we wanted to take on more of a best path practice approach. So, when the funding became available from the California Healthcare Foundation, it was a planning grant, which gave us an opportunity to really look at how we could expand our current activities - which were limited in prescribing suboxone - to having more of a team-based care. So, we utilized that grant to do that. We subsequently got an extension of that grant to start the implementation process and have since also received some funding from HRSA and AGIS as a hub and spoke grant.
Those last two acronyms you mentioned, what do those stand for?
HRSA is the Feds - the Health Resources Services Administration - and that’s where community health centers and federally-qualified health centers get their funding. AGIS is actually not an acronym, it is an entity located in California who primarily runs methadone treatment. They received some funding from the California Department of Healthcare Services to implement some hub and spoke-focused funding in California.
You mentioned looking at the best practices working for a team-based approach, and that grant that you issued that you have been planning. With the focus on having it so that more physicians on your team would have the X-waiver, what exactly did that entail?
The team-based approach as a best practice really looks at the entire patient: Where they are medically now, what the other areas in their life are that either brought them to their current situation, and how to treat them and help them move on to a stable, balanced life. So, looking at not only the physical aspects, which is the physician, the RN case manager, but also having the psychosocial elements looked at with the licensed clinical social worker, and a substance abuse counselor. All of them together look at different parts of that patient as a whole. And they collaborate with each other on a daily basis to make sure that they are giving whole person care to that patient.
Based on what you’ve observed, what do you think is the single biggest barrier or bottleneck that prevents individuals with opioid use disorders, or just a substance abuse disorder in general, from receiving professional help?
I’m going to address that question in a slightly different way. I think it’s important to look at, particularly from my vantage, why we would even want to take on that issue. Is that a reasonable approach?
I think that for us, we came to the realization that from a primary care standpoint, we were seeing these patients anyway. Many of them were on high dosages of opioids, frequently with benzos, some of them had behavioral health issues, and we were trying from a clinical standpoint to address those pieces without really providing an alternative treatment based on best practices, which is the medically-assisted treatment. So as opposed to saying, “No, we don’t want to do that here, not in my backyard,” we came to the realization that we were already seeing many of these patients with these issues anyway. So, to have an additional tool in our toolbox to help treat that was a very reasonable and wise decision to take that on.
There have been some offices that make it easy to access naloxone or other, sort of, high-reduction approaches. Is that something that your office is involved with, or is that something that’s left to other entities?
Well, we actually have a pharmacy where our medically-assisted treatment - or our Complex Care Clinic, as we commonly call it - program is, and every patient that is participating in our program, as well as others that we have concerns about, are given a prescription for naloxone, which they can pick up on their way out. So, we do actively participate with that and make sure that all of our patients do have that. We also are collaborating with the county public health department- who has received some naloxone, too - to make sure that it is given out to those who need it in the community, as well as provide education on how to use that.
The patients who receive medication-assisted treatment, who receive buprenorphine, what other kinds of treatment do they receive? Is there any kind of counseling or anything else that’s part of that sort of treatment package?
Here’s where our medical director who oversees programs could probably be more specific on some of these things, but all patients in our medically-assisted treatment program do receive an assessment at the beginning to recognize where they are in stages of change, is there a scenario that they’re ready to take on and address, as well as their psychosocial behavioral elements. So, all patients go through an assessment process. After an induction is conducted on them, they then participate in ongoing refill groups depending on their stability. It could be once a week or twice a month as they stabilize their involvement in coming in. All of those patients do receive some drug counseling, behavioral health counseling, and RN case management from the RNs to help them stabilize and resume a more normal life.
I could imagine there may be some patients who have a substance use disorder, and probably some other issues that they’re going through as well. I can imagine some of them, due to stigma and for other reasons, may not be as forthcoming about their opioid use disorder, etc. What kind of approach does your Complex Clinic take to help them or make it easier for them to acknowledge what they’re going through?
Well, firstly, the stigma is a reality. I’ve heard it over and over again from our providers, staff, and patients. It is a reality and it certainly is a reality in a more rural environment. We find the diversity of participants and patients in our program does not fit any one niche. They are far and wide and have experiences from multi-substance abuse, to becoming dependent on opioids as a result of an injury or a severe illness, or things like that, so there is a diversity there. One of the ways that we address the stigma is we actually have our program - our medically-assisted treatment program - at one of our larger sites. It is co-located with primary care and our dental office, as well as our pharmacy. So, if you were to enter our lobby area, you would have no idea if that patient is there for pharmacy, dental, primary care, or medically-assisted treatment. So that in and of itself has really helped reduce the stigma. They are not called out or shuttled anywhere in any regard, they are just one of our many patients.
Some of the other things that we’ve done in our community to address stigma is we’ve had ongoing discussions with the more law enforcement side, probation, etc., so that we have a clarity of understanding about this medication, this program, what it means for our common clients’ patients to participate in the program. That is a positive way of getting them onto a route of wholeness, employment, and family reunification, etc. We’ve also met with judges in our county to do an educational session with the same goal in mind so that they understand when they do see clients, and those before the judicial system, that they understand what the value of participants participating in this program means. We’ve had a patient who, prior to coming to us, had her children removed by CPS (Child Protective Services). She went to try to get her children back after she had started the program and had some push back from that, and comments of “Well, you’ve just substituted one drug for another,” which really led us to go and have that educational session with our judicials and our judges locally. When that patient when in and requested to get her children back again, she was allowed to have her children back. So, it was nice to have that restoration and the mom and kids are doing well.
It seems like what you do, the activities that your Clinic can give, go beyond what would be traditionally thought of as healthcare services and encompasses more of a broader, more holistic approach.
Looking at where you are in Placerville, California, does it look like things are starting to turn around? Or does it seem like the area still has some significant challenges ahead with regards to the opioid crisis?
The impact on our community is still a little early to tell. However, there has been some indications in working with some of our healthcare plans that patients are not utilizing the emergency department as much as they were, as well as being hospitalized. So, there are some early indications that patients are getting redirected to and plugged into primary care and the services that we offer within our center, including the medically-assisted treatment program, so those are some early indications. It kind of remains to be seen on some of the long-term successes that may arise out of it. Clearly on an anecdotal level, we have many success stories from patients who were able to get their lives back, became employed, reunification of families, secured housing - many things from a social wellness kind of aspect. Depending on what the measure is, it’s still been relatively new.
I imagine some patients are on government programs like Medicare or Medi-Cal, the California version of Medicaid, or others may be on private insurance. How has it been with medication-assisted treatment in terms of having things covered or having it set up? Any co-pays that are small enough that they could still afford it without too much financial strain? How has that been on the insurance side?
One of the co-tenants of being a federally-qualified health center is that we take patients regardless of their ability to pay. We do accept, in California, Medi-Cal or Medicaid, Medicare, private insurance, and we also have a sliding fee scale for those who do not qualify or have any of the other insurance coverage. Those individuals who either have no insurance, or they have insurance but have high deductibles, are able to take advantage of one of the grants that we currently have, which is the hub and spoke. So, finances should not be a deterrent for any patient’s participation in the program. Medi-Cal, which is Medicaid, does cover medically-assisted treatment; there’s variability depending on what insurance you have, but we do see certainly all walks of life and all kinds of different insurance and all ages.
If somebody gave you a magic wand that allowed you to change any policy or any rule in order to help alleviate the opioid crisis, which policy would you think about changing?
That’s a very proactive question and one which I hope someday to be able to weigh in on. In the meantime, my wish list would probably tell me that from our perspective - this is our community health center perspective - right now, a provider must go through quite a bit of extensive training to get an X-waiver to be able to prescribe buprenorphine, which has been around for quite some time and very well-established. No X-waiver is needed if you are using it for pain management, but as a treatment for substance abuse, the X-waiver is required. So, from my little domain, what I would like to see in a change in policy is for all providers to be able to prescribe it, just like all providers are able to prescribe opioids. So, I think having that ability to really widen the treatment in a primary care setting would be a great thing, as well as a potential deterrent even for those providers who still may prescribe high dosages of opioids.
What rule or responsibility do you think that pharmaceutical companies, such as Purdue, should have in the efforts to alleviate the opioid crisis?
Well, I think to really resolve this issue, which has become quite epidemic in our country, this should be an “all hands-on deck” approach. So, we all have a part in trying to resolve this issue from whatever perspective that we’re coming from, both from a prescribing perspective as well as from a medical - from our vantage - which is the treatment side. So, it is something surely to really impact this epidemic. We all need to weigh in from our vantage points. We all have a portion of that.