Literature Collection

IMPORTANCE: The United States is experiencing a crisis of opioid overdose. In response, the US Department of Health and Human Services has defined a goal to reduce overdose mortality by 40% by 2022. OBJECTIVE: To identify specific combinations of 3 interventions (initiating more people to medications for opioid use disorder [MOUD], increasing 6-month retention with MOUD, and increasing naloxone distribution) associated with at least a 40% reduction in opioid overdose in simulated populations. DESIGN, SETTING, AND PARTICIPANTS: This decision analytical model used a dynamic population-level state-transition model to project outcomes over a 2-year horizon. Each intervention scenario was compared with the counterfactual of no intervention in simulated urban and rural communities in Massachusetts. Simulation modeling was used to determine the associations of community-level interventions with opioid overdose rates. The 3 examined interventions were initiation of more people to MOUD, increasing individuals' retention with MOUD, and increasing distribution of naloxone. Data were analyzed from July to November 2020. MAIN OUTCOMES AND MEASURES: Reduction in overdose mortality, medication treatment capacity needs, and naloxone needs. RESULTS: No single intervention was associated with a 40% reduction in overdose mortality in the simulated communities. Reaching this goal required use of MOUD and naloxone. Achieving a 40% reduction required that 10% to 15% of the estimated OUD population not already receiving MOUD initiate MOUD every month, with 45% to 60%% retention for at least 6 months, and increased naloxone distribution. In all feasible settings and scenarios, attaining a 40% reduction in overdose mortality required that in every month, at least 10% of the population with OUD who were not currently receiving treatment initiate an MOUD. CONCLUSIONS AND RELEVANCE: In this modeling study, only communities with increased capacity for treating with MOUD and increased MOUD retention experienced a 40% decrease in overdose mortality. These findings could provide a framework for developing community-level interventions to reduce opioid overdose death.

OBJECTIVES: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DESIGN: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains. SETTING AND PARTICIPANTS: The 155 PACE organizations operating in 32 states and the District of Columbia. METHODS: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. RESULTS: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. CONCLUSIONS AND IMPLICATIONS: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.