Integrating addiction services across settings of care remains a significant priority for states. Advancing a “no wrong door” approach depends on coordination across state agencies, providers, payers, and community partners, and on aligning policies and resources to provide access to treatment and supports wherever individuals enter the system.
This blog highlighting Kentucky’s efforts is the first in a series that will provide examples of innovative and promising strategies that states and their partners are using to integrate high-quality, evidence-based addiction interventions into health and behavioral health care settings.
Why Primary Care Providers Play a Critical Role in SUD Prevention and Treatment
Integrating addiction services into primary care settings offers providers the opportunity to meet people in need of support where they may already be engaging with the health care system. Primary care providers (PCPs) are often rooted in communities and provide a range of services to maintain health and prevent illnesses, including screening and disease management. For people with addiction, PCPs can be a critical intervention point for screening, brief intervention, and referral to treatment, initiating office-based opioid treatment (OBOT), and/or linking patients to more intensive treatment and recovery support. Within primary care settings, integrated, team‐based models of care can help manage patients’ physical, behavioral, and social needs.
State officials seeking models for integrating addiction support services and primary care can look to Kentucky’s partnership between the Kentucky Overdose Response Effort (KORE) and the Kentucky Primary Care Association (KPCA). This partnership supports integrated addiction services in primary care that amplifies the critical roles of primary care providers and peer support specialists in providing services that give people a holistic approach to both their physical and behavioral health needs.
How Kentucky Leverages Peers to Strengthen Delivery of Addiction Support Services in Primary Care Settings
Primary care providers in Kentucky often serve as the principal healthcare entry point in many of Kentucky’s rural and underserved communities and are sometimes the only health care setting for people with addiction. As a result, KORE and KPCA developed a partnership that advances integrated care statewide, with a shared mission of providing mental health and addiction services at the primary care level. KPCA represents a network of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), each governed by unique regulatory structures and funding streams.
Early integration efforts in Kentucky primary care clinics focused on Screening, Brief Intervention, and Referral to Treatment (SBIRT). SBIRT is a key frontline tool for early intervention that can deescalate addiction and connect individuals suffering from addiction to medications for opioid addiction and other treatment services and supports. Kentucky is focused on strengthening the state’s capacity to deliver medications for addiction and other behavioral health and recovery services in primary care settings through these programs.
Peer support specialists, or people who have experienced addiction and provide non-clinical support to others experiencing similar challenges, can play a vital role in helping people manage addiction in primary care settings. In Kentucky, peers supported by KORE and KPCA provide recovery coaching to primary care patients with addiction and conduct outreach to people seeking services. Peers are valued as full team members, frequently bringing lived experience in recovery to their support of individuals, group facilitation, and crisis support roles. Today, 11 clinics across the state have integrated 23 peer support specialists into their teams. To strengthen this workforce, Kentucky prioritizes professional development, including weekly supervision, ongoing education, and events such as an annual peer academy. This includes activities such as:
- Peer-led outreach and follow-up calls to people seeking services.
- Peer integration during exam room encounters.
- Statewide peer networking and mentorship opportunities.
- A focus on both personal and professional development for peers.
Addressing Stigma through Education and Training
Prescriber stigma and hesitation regarding medication for addiction continues to be a barrier for many to access the full array of evidence-based addiction care. KPCA has made significant investments in provider education to expand integrated care capacity, reduce provider concerns, and combat stigma. Initiatives include:
- Monthly behavioral health roundtables.
- On-site technical assistance.
- Education and technical assistance for clinical directors overseeing change management.
These efforts have helped to create cultural change in many clinics, increase the adoption of integrated addiction services, and foster provider champions whose support sustains the momentum for change.
Financing and Sustainability for Peer Supports in Primary Care Settings
Sustainable financing of peer support services in primary care settings remains a challenge in many states, especially for FQHCs and RHCs that face restrictions on same-day billing for multiple services. Kentucky is leveraging State Opioid Response dollars to support salaries and activities that are not covered by the FQHC/RHC rate, and KORE acts as the payer of last resort when insurers do not cover the services necessary for integrated behavioral health care.
Lessons Learned and Future Opportunities
The partnership between KORE and KPCA demonstrates a promising model for improving integrated addiction care in primary care settings. Through peer support integration and targeted education, integrated approaches can support providers in delivering more effective whole person approaches. Kentucky’s integrated care model offers valuable insights for state health officials seeking to implement effective behavioral health solutions in primary care settings.
KPCA and KORE’s experiences highlight several key lessons for state health officials:
- Customization and relationship-building are critical. No universal solution exists, so strategies must be tailored to each clinic’s culture, leadership, and resources.
- Regulations on buprenorphine that exceed federal requirements may contribute to confusion or reluctance of providers to offer medication for addiction.
- Within Community Health Center (CHC) and RHC settings, the prospective payment system (PPS) rate may be insufficient for services such as peer support. Leveraging funding mechanisms that serve as the payer of last resort may help address these financing challenges.
- Clear communication and continuing education opportunities can support long-term culture change.
Acknowledgments
National Academy for State Health Policy (NASHP) would like to thank Jill Martin, Director of Behavioral Health at KCPA and Dr. Caitlyn Hood, Project Director of KORE, for their contributions to this piece. NASHP would also like to thank the Foundation for Opioid Response Efforts for its continued support of NASHP’s ongoing addiction work.
