MAT Chat with Kheir Clinic: “Building Relationships Is Key”

Eric Schluederberg, DO, is a family physician at the Kheir Clinic in Los Angeles, whose mission is to provide culturally sensitive primary care to underserved and uninsured residents of Southern California. We spoke with him to learn about the key changes that Kheir Clinic has made to create space for its Medication for Addiction Treatment program (MAT) — including how the clinic was able to grow the program even though it didn’t have its own behavioral health specialists.

CCI: How did you decide what changes to make to expand your Medication for Addiction Treatment program?

Schluederberg: The team came together and discussed what was needed to grow our program. Our prescriber is a highly requested provider at our clinic. We knew we had to make time in his schedule a few days a week to meet the needs of prospective and established MAT patients. We wanted more patients to know about our MAT services so we conducted outreach/in-reach and came up with ways to keep patients informed. We also recognized that MAT patients would highly benefit from receiving behavioral health services from licensed clinical social workers who have experience with individuals who suffer from substance use disorders (SUDs). We met with the Korean Youth Counseling Center (KYCC), an organization in our building that provides behavioral health services, to discuss collaboration. They have the licensed clinical social workers we need to offer SUD behavioral health services. In addition to them caring for our patients, we can prescribe medications to their patients.

CCI: Who on your team helped to design and implement these changes?

Schluederberg: It was a team effort. Everyone’s ideas helped design this new program. Our Practice Development Specialist was present at all the MAT meetings, as she reports back to management to get approval before implementing anything new. This ensures we don’t disrupt established department workflow.

CCI: What was involved in designing warm hand-offs to the Korean Youth Counseling Center for behavioral health, and why were these steps important for your fledgling MAT program?

Schluederberg: Our case manager, practice development specialist and prescriber met with the Korean Youth Counseling Center behavioral health counselors on separate occasions. The case manager and practice development specialist discussed workflows with the KYCC team, while our prescriber offered a clinical understanding of treatment. This helped us get acquainted with each other and with our respective services. This is important because we want to provide a brief introduction to and description of patients we refer to KYCC and vice versa. Warm hand-offs are made by the case manager who also manages behavioral health referrals made from our prescriber to KYCC. Patients are introduced to KYCC, and KYCC proceeds with counseling services. We also started having monthly case reviews with KYCC to discuss shared patient cases — it’s helpful to get updates on patient progress. Designing the warm handoff process took about three months.

CCI: Describe one barrier you faced and the strategies you used to overcome it.

Schluederberg: One of our biggest barriers was not being able to provide patients with behavioral health services. We overcame this obstacle through our collaboration with the Korean Youth Counseling Center. Staffing is also a barrier. We had a licensed vocational nurse who would have been an important addition to the program, but that person left around the time the program started. We are still looking for a replacement.

CCI. We’d like to learn more about case management, including the role of your case manager on your MAT team.  Could you talk about the role of your case manager in general, and as part of your MAT care team? In what ways does he support your patients?

Schluederberg: Our case manager is essential. He is the main point of contact and the first point of contact for all patients (and outside entities) interested in MAT. He assists patients who wish to schedule a MAT consultation with our prescriber and also assists the prescriber with MAT referrals to KYCC. He coordinates with their therapists to ensure patients are offered these services. This collaboration helps us provide a “whole person” approach to treatment. Our case manager also follows up with MAT patients who have missed appointments.

CCI: What strategies does he use to contact hard-to-reach patient populations (e.g., patients experiencing homelessness or those who lack access to phones)?

Schluederberg: If a patient’s phone isn’t working, we send postcards to their home. Patients without a phone often leave a friend’s contact number. We will also contact patients via email if that’s the only way they can be reached.

CCI: In your January progress report, you noted that your MAT prescribers received limited substance use disorder support from medical assistants (MAs), which placed a lot of responsibility on the clinician. To address this, you trained MAs who were assigned to X-waivered prescribers.* (See editors’ note below). Could you describe this training?

Schluederberg: The training involved a company-wide presentation on MAT and addressing stigma. MAs were asked to attend appointments with MAT patients when they could and providers could answer questions. Many of the more experienced MAs who had been trained were let go during COVID-19, so we restarted the training process.

CCI: In looking at your baseline and midpoint capability assessment (e.g., IMAT) scores, we see you increased capabilities in every one of the IMAT’s seven dimensions. Could you describe your secret sauce?

Schluederberg: Taking notes on things we were lacking, writing down action items, and setting deadlines for ourselves.

CCI: What do you know now that you wish you had known at the beginning of this process?

Schluederberg: It will take time. Be patient. You will often feel like you’re at a standstill but a new program like this takes time to perfect. Don’t feel discouraged.

CCI: In terms of COVID-19, what are some of the immediate impacts on MAT services?

Schluederberg: Conversion to telephone/telehealth visits.

CCI: What recommendations would you make to others who want to refine their program?

Schluederberg: Building relationships is key. Whether it’s with an organization that can provide services your clinic lacks or health centers that have already have MAT programs. It’s important to build relationships to share information, best practices etc.

CCI: In terms of COVID-19, what are some of the immediate impacts on MAT services?

Schluederberg: Conversion to telephone/telehealth visits.

CCI: I remember hearing that the progress of your MAT program development sometimes seemed frustratingly slow to your team. Yet your team stayed with it, participating in CCI learning events and monthly coaching. What helped keep program and staff development on course?

Schluederberg: We knew from the beginning that implementing a MAT program in a primary care setting wouldn’t be easy. Having a coach guide and reassure us that we were on the right path really motivated us to keep pushing through and helped us get to where we are now. We are not where we want to be, but we’ve made major progress since the start of the program.

CCI: What’s next for your MAT program? What improvements are you contemplating?

Schluederberg: We hope to bring on board a registered nurse (RN) or LVN to help our prescriber with our MAT patients. A lot of the clinical work falls on our prescriber and he is already very busy. Onboarding an LVN or RN would provide some relief.

(Editors’ note: An X waiver permits physicians to prescribe Suboxone (buprenorphine/naloxone) for opioid use disorder.)