How PA’s virtual-first center of excellence is bolstering OUD care

The intensifying opioid epidemic has left in its wake significant loss, prompting public health stakeholders to redouble efforts to curb the crisis. A central aspect of these efforts is expanding access to medication-assisted treatment. In Pennsylvania, strategies to expand this access include offering virtual care access to lifesaving medications.

In April, the Pennsylvania Department of Human Services designated virtual addiction treatment provider Ophelia as an Opioid Use Disorder (OUD) Center of Excellence (COE), making it the inaugural virtual-first statewide COE.

The nationwide OUD crisis has been ongoing for years, with the Department of Health and Human Services (HHS) declaring the epidemic a public health emergency in 2017. The COVID-19 pandemic considerably worsened the problem, with opioid-involved overdose deaths rising from 49,860 in 2019 to 81,806 in 2022.

In Pennsylvania, 5,092 residents died from overdoses in 2022, according to data from the PA attorney general’s office. The office has declared opioids Pennsylvania’s No. 1 public health and public safety crisis.

Using virtual care approaches to improve patient access, Ophelia aims to mitigate the crisis and change how OUD care is delivered.  

“Our mission, first and foremost, is to redesign addiction treatment with a focus on evidence-based principles to expand access and improve outcomes,” said Zack Gray, founder and CEO of Ophelia, in an interview with mHealthIntelligence. “And we're focused on opioid use disorder and co-occurring psychiatric conditions.”

Now, with the COE designation, Ophelia has the opportunity to achieve its lofty goals. However, it must first contend with challenges related to social determinants of health (SDOH) and pharmacy-related hurdles.

UNDERSTANDING OPHELIA’S VIRTUAL MAT FOR OUD APPROACH

For Gray, the importance of timely access to OUD treatment came into sharp focus after losing a loved one to an overdose in 2019.

“[OUD, the] leading cause of death for Americans under 50, is also highly treatable,” he said. “And the treatment protocol looks a little bit like the treatment you might get for depression or anxiety — long-term medication and counseling. It's highly effective, and it is in high demand by the patient population.”

However, access to medication-assisted treatment (MAT) is severely limited for the OUD population. A 2022 NYU Grossman School of Medicine study estimates that 86.6 percent of people with OUD are not receiving necessary medications like methadone, buprenorphine, and extended-release naltrexone.

Ophelia provides MAT access virtually, allowing OUD patients to receive care conveniently and remain in treatment.

OUD patients using the online Ophelia platform can connect with an enrollment coordinator within minutes and with a clinician within 24 to 48 hours. Following a clinical assessment, the clinician e-prescribes needed medications to the patient’s pharmacy. The Ophelia clinical team includes triage registered nurses, nurse practitioners, physician assistants, MDs, and DOs.

“Some come with experience, some come without experience, but are passionate about this patient population…We have a pretty extensive training process to be able to have them mentored, have them grow,” said Allison Berneking, MS, PA-C, Ophelia's regional clinical director in Pennsylvania, in an interview with mHealthIntelligence.

Ophelia also employs a care management team with clinical and non-clinical staff available seven days a week to connect with patients and address emerging clinical issues. This is critical to keeping patients engaged in their treatment.

“It could be issues with their pharmacy; it could be medical complications,” Gray said. “Getting inducted onto suboxone could be a stigma. And every time that we respond to a patient's concern and help them overcome it is an opportunity to keep them in care.”

While providing access to OUD medications and keeping patients engaged in care is at the core of Ophelia’s mission, there is also a concerted effort to help people regain their lives. Berneking emphasized that whole-person care is essential for OUD patients, so the company’s clinical and non-clinical teams also assess patients’ sleep habits and drug use outside of opioids, helping them develop goals around lifestyle changes.

HOW VIRTUAL MAT IMPROVES EFFORTS TO ADDRESS OUD

According to Gray and Berneking, there are numerous benefits to providing virtual MAT for OUD.

Being virtual-only allows MAT providers like Ophelia to offer on-demand and round-the-clock engagement that a brick-and-mortar program is just not set up to support, Gray said. This means patients no longer face long wait times, reducing the risk of them sliding back into drug use.

“You may be on the fence about whether or not you want to get treatment, but if you are without drugs or without medication, and you're going to go into withdrawal the next 24 hours — what do you do? Well, you want to get into care, but if you can't wait a week, you can always text your drug dealer to hold you over until you're able to get into care,” Gray said.

Additionally, virtual MAT allows for multiple touchpoints, keeping patients engaged and reducing the need to travel long distances to see a provider in person. The latter is significant as it mitigates other barriers, like organizing childcare while traveling to a clinic or bringing their child to an unsafe or triggering environment, Berneking said.

Further, telehealth allows patients to receive care where they feel the safest, boosting patient experience and engagement.  

“A lot of these patients have trauma with the clinical and the medical system for lots of different reasons,” Berneking said. “And so, telehealth provides them a space where they can feel that vulnerability and safety and connect with us, and we can meet them there, and we can know their families, and we can see the work that they're doing, and we can have this visibility into their homes. And I think it improves the bond and the rapport.”

Ophelia’s retention metrics bear out the positive relationship between virtual care and patient retention in MAT. Gray noted that patient retention in traditional brick-and-mortar MAT is approximately 30 percent at six months; in contrast, Opehlia’s retention rate is 60 percent to 70 percent at six months and almost 60 percent at one year.

TACKLING SDOH AND OTHER CHALLENGES

Healthcare provider organizations must break down SDOH to ensure the benefits of virtual MAT reach the intended population. A significant SDOH barrier for Ophelia is the lack of technology access among patients. This includes limited access to computers, smartphones, and reliable internet connectivity.

To combat these challenges, Berneking said the company works with the patients to identify workarounds.

“We've had patients where we say, ‘There's free Wi-Fi at the library, go sit in the parking lot of the library, and we can get you connected to Wi-Fi so we can see you for 15 minutes,’” she said.

However, patient-facing SDOH barriers aren’t the only challenge Ophelia faces when deploying its virtual services. Before the COVID-19 pandemic, clinicians needed to have conducted at least one in-person examination before being allowed to prescribe buprenorphine virtually. This requirement was lifted during the pandemic, but many pharmacies are not used to managing these e-prescriptions.

“Forty percent of counties in the country did not have [an in-person] setting, which meant that a lot of pharmacies in the areas of patients we treat had never seen a patient before filling a prescription,” Gray said. “For the most part, the friction that we faced in getting pharmacists to fill prescriptions for our patients took a lot of work [to overcome].”

He added that they spend a great deal of time on the phone now with pharmacies across Pennsylvania, providing education to help them understand why they should dispense medications to Ophelia’s patients. The company also filters out the uncooperative ones.

“We built an internal database and a map of all of the friendly and unfriendly pharmacies in Pennsylvania, and we've got a friendly pharmacy within reach of most patients that we serve,” he said.

THE ADVANTAGES OF BECOMING A STATEWIDE COE

Ophelia has been seeing patients in Pennsylvania since 2020. However, initially, the company had no health insurance contracts, so it had to charge patients cash prices, Gray said. While the company worked to get in-network with health plans in the state as quickly as possible, getting Medicaid contracts proved challenging.

This posed a significant problem to Ophelia’s Pennsylvania operations, as 70 percent of the patients that Ophelia serves are insured under Medicaid. Thus, becoming a COE was critical for the company.

Launched in 2016, Pennsylvania's COE program was established as a response to the opioid epidemic. The state’s DHS initially selected various entities, including primary care practices, hospitals, federally qualified health centers, and substance use disorder (SUD) treatment providers, to identify people with OUD and improve access to treatment. Ophelia is the first virtual MAT provider to receive the designation.

"The Centers of Excellence were designed as a patient-centered model of care that sought to make treatment and recovery an accessible, approachable, and sustainable part of a person's life," said Secretary of Human Services Valerie A. Arkoosh, MD, in a press release. "A virtual-first approach to this treatment gives us more opportunities to meet people where they are and get them the life-saving care they deserve."

Gray stated that Ophelia underwent an extensive evaluation process for the COE program, where the state reviewed its protocols, compliance measures, and outcomes data.

Receiving the designation means that the company will be able to get more Medicaid contracts as Medicaid managed care organizations (MCOs) in Pennsylvania are expected to offer patients a broad network of COE providers.

“And as a result, it's much more likely that we'll be able to expand access to care to the most vulnerable patients in the state,” he said.

The COE designation has also helped Ophelia establish trust with the state's OUD patient population.

“I think as a telehealth-first medical practice, we face scrutiny…I think having the stamp of a Center of Excellence is huge for us in that realm,” Berneking said.

Looking ahead, Ophelia plans to continue its growth trajectory. Gray highlighted the company’s plans, which include expanding within Pennsylvania and New York and moving into new states.

The company also aims to become more integrated with the broader healthcare ecosystem, enabling continuity of care. For instance, Ophelia patients who do not have primary care physicians could get connected to one in a more integrated ecosystem. Conversely, OUD patients coming into hospital emergency departments could be referred to Ophelia.

Gray also hopes that other states will use the COE model in Pennsylvania as an example and begin their own virtual MAT efforts.

“All they have to do is look to Pennsylvania and more or less copy what they've done because it's really a very innovative model, which I don't think is well appreciated about the state of Pennsylvania and its healthcare environment, that can serve as a replicable example for all of the other states out there,” he said.