Many Questions Remain as Officials Hustle to Launch New Addiction Care System

Dec 12, 2018

New Hampshire continues to rank among the hardest-hit states in the opioid crisis. Gov. Chris Sununu and state health officials are now investing heavily in a new system they say will significantly improve care for those struggling with addiction. This so-called "hub and spoke" plan kicks off at the start of the new year. Now, with that launch date just weeks away, NHPR’s Britta Greene and Sarah Gibson having been reporting on how the effort is taking shape. 

They spoke with Morning Edition Host Rick Ganley.

Listen to the full audio report here.

Rick: Sarah, you’ve been focusing on the Southern Tier, around Manchester and Nashua. Britta, you’ve been looking at the rest of the state, is that right?

Britta: Right. And here’s how this hub and spoke plan works. The idea is there’s one central agency, one “hub” in each of nine regions across the state. It’s a first place to go for help. From there, you’ll get evaluated and guided to the treatment and services you need. There will also be one phone number to call statewide, 2-1-1, and one website to get routed to help nearby.

The stakes of getting this to work are high. The overdose rate in New Hampshire is one of the highest in the country, and state officials have been lobbying for years for more money from the federal government to help with the crisis. A big increase in funds finally came through this year, and this is the state’s plan to use it.

Governor Chris Sununu and Health Commissioner Jeffrey Meyers announced the hub and spoke plan in August. Regional hubs are now set to open at the beginning of January.
Credit Britta Greene / New Hampshire Public Radio

Rick: So I guess the big question is: Will it work?

Britta: It has the potential to be a big improvement. As it stands, it’s actually really difficult in a lot of places to figure out where to go for medical treatment, counseling, peer support -- all the things you might need. And, of course, it’s even more challenging to navigate the system if you’re actively struggling with addiction.  

Here's how Corey Gately explained it -- she's leading Lakes Region General Hospital's effort to set up a hub in Laconia. 

New Hampshire health officials divided the state into nine regions such that no resident is more than an hour's drive from the closest 'hub.'
Credit Sara Plourde / New Hampshire Public Radio

Sarah: It's important to note we’re still at the very beginning of figuring out the logistics of how this plan will work.

For one, a lot of the organizations we spoke to this month that will be hosting their regional hub still don’t know where exactly they’ll put it. Again, this is just weeks before the launch -- and that’s just the physical office location.

There are lots of other basics to figure out, too. Some hubs need to hire staff in what continues to be a tight labor market. Everyone is still trying to understand the logistics of data entry and data sharing, and how exactly they will coordinate with 2-1-1, the statewide crisis line that’s reachable at all hours.

Rick: Ok, so lots still to come together. Do you think they’ll be ready in time?

Britta: What we’re hearing is the basic services will be ready, yes, even if it’s in a temporary space.

People involved in getting the system up to speed say there are two key things they’re focused on at the onset. One is marketing, just getting the word out that this is a resource for people in the community and that it’s easy to access.

The other thing is what they call “care coordination,” which is a significant piece of the of the broader plan. Staff at the hubs will track patients over time, helping to coordinate their care across a number of different providers in the community, working not just on medical care but also issues with transportation, housing costs, childcare and food stamps.

Listen to state Health Commissioner Jeffrey Meyers discuss this:  

Rick: Ok, so Health Commissioner Jeffrey Meyers there sounding a tone of optimism, but are there some details here that we just don’t know yet?

Sarah: Right, a fair amount of details to be worked out as I was saying, and there’s also just some skepticism about this plan as a whole.

Rick: In what way?

Sarah: Well, some of it is simply: Will this really make a difference? Will this add to services we already have, or disrupt them?

Take Manchester. Over the past several years, the city has become a destination for people from all over the state to get care and services. That’s because Manchester, and nearby Nashua, were hit early and hard by the opioid crisis. In response, city leaders built their own response network of services from the ground up.

So when news of the hub and spoke model arrived this year, they said: 'Hold on, we don’t want to lose this system we’ve worked so hard to build.'

Granite Pathways, at 303 Belmont St., is adding 5 staff as it expands to become Manchester’s hub.
Credit Sarah Gibson / New Hampshire Public Radio

Rick: How are they going to do that?

Sarah: Well, for one, both cities want to keep their Safe Station programs open. Safe Station is what many people in New Hampshire know as the place to go if you’re in a drug crisis.

Here’s how it works in Manchester: If you want help with addiction, you walk in any time of day or night to a fire station and ask for help. There, you get an immediate assessment. If it’s a medical emergency, you go straight to the hospital. But most of the time, you go to Granite Pathways, which has a contract with the state to serve as a "Regional Access Point Services," - basically, a central agency where you get hooked up with housing, as well as medical and social services. 

You might be thinking this sounds kind of like a hub and spoke system already. And yes, Granite Pathways will be the official hub in Manchester. So, not much is going to change there - just a ramping up of services.

Rick: I know Manchester’s Fire Chief Dan Goonan has been outspoken about Safe Station; he’s obviously a big believer in it. What does he say?

Sarah: I spoke to Goonan last week about what he’s learned from Safe Station, and what could be important for hubs and spokes developing elsewhere. He said timing and coordination are everything. Withdrawal from opioids is so intense - people get so "dopesick," as he puts it - that if they aren’t shepherded through every step of the process, from one spoke to the other, they often fall through the cracks.

Listen to Chief Goonan explain:

And that’s the hope in Manchester: to keep services as they are, with the addition of more funding and more staff, to make those pivots quicker.

Rick: How does this compare to what you’re hearing elsewhere in the state, Britta?

Britta: It’s interesting, just like in Manchester, every community has developed its own network between organizations to deal with this crisis. In some places it’s really strong. In others, it’s less so.

Lakes Region General Hospital will be operating the hub for the Laconia region. Staff there are planning to locate the hub at the hospital, near the emergency department.
Credit Britta Greene / New Hampshire Public Radio

I took a trip to Laconia, where Lakes Region General Hospital will be running the local hub. They’re still trying to figure out where it will be – they want it in the hospital, near the emergency room. But they’re just about to start construction in that area that will last more than a year.

There’s an organization called Navigating Recovery in Laconia that’s really taken the lead locally, working closely with the hospital and others to provide many of the services now detailed in the hub and spoke plan. 

Daisy Pierce, executive director of Navigating Recovery of the Lakes Region
Credit Britta Greene / New Hampshire Public Radio

Daisy Pierce, who leads Navigating Recovery, said the most notable change will be directing people to the hospital, where the hub will be. Traditionally, they've tried to steer people away from the hospital unless there's a medical emergency. 

She said her biggest concern is something not immediately addressed by this new plan: a lack of respite beds and safe, affordable housing.

At the recovery center, I spoke with a participant named Julie Moulton. Here’s how she put it:

New Hampshire's new "hub and spoke" model for dealing with addiction relies on a central agency (the "hub") which will assess individuals dealing with substance abuse, and then refer them to one or more organizations (the "spokes") that will assist with various needs.
Credit Sara Plourde/NHPR

She volunteers with the local homeless population, and she said, even though they have a strong recovery community in Laconia, they’re still not reaching a lot of people – people who often don’t have cell phones to call 2-1-1 or research where to get help. And realistically, these people won’t be able to stay sober if they don’t have a safe, drug-free place to sleep at night.

This is something we’ve been hearing from all over the state. Commissioner Meyers said the department is putting money toward housing, but here in Laconia, it’s not going to come together in the short-term.  

Rick: So what will you be watching for?

Sarah: We’ll be looking at the nitty-gritty stuff like data entry. That maybe sounds minor and technical, but it’s actually really important. Gathering and tracking data on how people use the hub and spokes, what services work well for them, what barriers exist -- that’s going to be essential if we want to understand how to build a system that works.

Kim Haney, the director of Manchester and Nashua hubs, says Granite Pathways will “ramp up” – not replicate – the opioid response in both cities.
Credit Sarah Gibson / New Hampshire Public Radio

I also think Nashua is an interesting place to watch because the organization running the hub there is the same as in Manchester: Granite Pathways. The thing is, in Manchester, Granite Pathways is known and trusted - by the Mayor, by the Safe Stations and by service providers. As Chief Goonan told me, "they play well in the sandbox."

But in Nashua, Granite Pathways is totally new. I’ve been spending some time with Kim Haney, who works for Granite Pathways and is directing both their hubs. Last week, she presented the plan in Nashua to about 50 service providers that may serve as spokes. These people have been working on addiction issues for years on the ground.

Bobbie Bagley, the director for public health and community services in Nashua, is optimistic about working with Granite Pathways, but she says it's a tricky transition:

Here's what Hub director Kim Haney has to say about working in Nashua:

And we’ll have to watch and see how things play out, what relationships are made or challenged, how patient data is shared – all of those things.

Rick: What about you Britta, what are you watching for?

Britta: I think it’ll be really interesting to watch the numbers -- how many people are actually using these hubs. Several people I spoke with said that’s the million dollar question. They have no idea how many people to expect to walk in the door.

Another question is long-term sustainability. The federal funds supporting this program are only guaranteed for two years. Commissioner Meyers says he doesn’t see the money going away, but for that to happen, at the very least, the state is going to have to show that this plan is really working.