Report touts needle exchange programs as model for integrated care

A report released this week by The New York Academy of Medicine—a health policy and advocacy organization focused on advancing the health of residents of cities—details the strides made by harm reduction (specifically, needle exchange) programs in New York and their care delivery models. With the programs emphasizing an integration of community-based services and primary care to increase access and reduce emergency-room admissions, the report argues that they provide an unexpected outcomes-based model for health reform.

“A major focus of healthcare reform is the development of value-based payment systems that incentivize improved health outcomes over medical procedures,” Jo Ivey Boufford, MD, president of The New York Academy of Medicine, said in a June 4 media briefing. “To complete this shift there’s a need for models that successfully integrate clinical healthcare with social, public health and community-based services.”

By providing holistic, person-centered care, the report states, harm reduction programs are achieving the triple aim of increased quality, reduced costs and improved health outcomes. A program based in the Bronx called BOOM!Health, Inc., was recognized because of its coordinated and co-located integration of health and behavioral health services as well as basic care such as meals, showers and social support for program participants. In addition to offering syringe exchange, HIV and hepatitis C testing, and care management, BOOM!Health offers on-site primary healthcare, mental health services, Suboxone treatment and pharmacy services.

“For marginalized populations living in precarious circumstances, such services are essential to establishing stability that allows them to take care of their health,” said Paul Schaffer, senior policy associate at the academy and lead author of the report. “[These] delivery models allow a unique level of engagement and trust to develop between them and program participants—a population that the traditional healthcare system has been unsuccessful at effectively serving.”

Need for integrated care

Shaffer says that in a survey conducted by the Injection Drug User Health Alliance of more than 1,300 harm reduction program participants in New York City, three-quarters of respondents had at least one of the following chronic health conditions: asthma, diabetes, hypertension, heart disease, liver disease, cancer or HIV/AIDS, and nearly half had two or more of these conditions. The prevalence of each condition was found to be much higher than the prevalence of HIV among harm reduction participants. This was the impetus behind harm reduction programs in the 1980s, and suggests a shift in the healthcare needs of substance-using populations and a need for improved integration of care.

BOOM!Health president and CEO Robert Cordero explained that, originally, the program was not doing enough coordination of care or paying enough attention to people’s holistic needs. “We were giving them needles but their toes were falling off from diabetes-related issues,” he said. “The entire motivation to get co-located healthcare and pharmacy wrapped around all the basic needs came from this realization.”

While not generally thought of as a point of reference for healthcare reform, those using harm reduction programs are similar in characteristics to the broader Medicaid population, the report states, explaining that both groups have socioeconomic disadvantages, multiple chronic health conditions and a history of costly, crisis-oriented episodic care—making one a good model for the other.

An overarching theme of the study, Schaffer said, is the need for healthcare reform strategies to move beyond the array of clinical care needs of the patient and to address directly the social determinants of health. “This is especially important for high-need, high-cost patients often struggling with both physical and behavioral health issues and often marginalized because of these issues,” he said.

Three takeaways from the report:

1) Partnerships. Healthcare and harm reduction providers are forming partnerships to coordinate complementary services and to increase access to people with the greatest need for comprehensive care. “The complementary value each party brings to the partnership is evident not only in the enhanced array of easily accessible services for patients, but also in the strengthening of the market position of the participating healthcare providers, which provides an important incentive for the healthcare providers in such partnerships,” said Shaffer.

2) The growing acceptance of harm reduction principles. Opioid use demographics are changing and contributing to reduction of hostility toward harm reduction efforts. Similarly, the benefits of expanded access to naloxone to reverse overdoses have gained recognition and support in the industry. “The traditional antagonism between harm reduction and abstinence-based drug treatment programs appears to be decreasing in part because harm reduction providers are a resource in training drug treatment programs to administer naloxone for people in treatment who relapse and overdose,” Shaffer said.

3) Fundamental differences between providers remain. Medical providers are just as susceptible to negative societal attitudes as anyone when it comes to injection drug users, but negative attitudes can potentially undermine their ability to provide effective healthcare. “This attitude must be addressed because it poses a potential barrier for integration,” Shaffer said. Also, medical providers are often poorly trained to distinguish health issues related to drug use from other behavioral and physical conditions affecting drug users, while harm reduction providers often need to gain a better appreciation of the parameters in which medical providers operate, especially in regard to opioids.

This report was funded through a grant from the MAC AIDS Fund.