Over the past several months, health care organizations have been propping up telehealth programs left and right in response to the coronavirus. Substance use disorder (SUD) treatment providers are no exception.

According to a new survey by the digital behavioral health solutions provider Tridiuum, more than 80% of behavioral health providers started using telehealth for the first time amid the coronavirus.

But Intermountain Healthcare was different. The not-for-profit health care system based in Salt Lake City was ahead of the tele-behavioral health adoption curve.

While Intermountain has been working on tele-behavioral health programs for years, coronavirus-related flexibilities recently helped the organization improve upon some of those projects — especially when it comes to medication-assisted treatment (MAT).

“I’ve been working with my counterpart to develop the SUD program through telehealth [for about a year],” Kerry Palakanis, Executive Director of Connect Care Operations at Intermountain, told Behavioral Health Business. “The pandemic has been a little bit of a shining light for us because it finally solved the Ryan Haight Act issue. And we’re hoping — fingers crossed — that there’ll be some long-term resolution for that, as well as to help us solve the problem of the patient needing to be in a clinical environment to receive care.”

In the past, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 has made it hard for MAT programs to leverage telehealth. The rule prohibits providers from prescribing drugs to patients who they haven’t first seen in-person, except under special circumstances.

Meanwhile, prescriptions are a vital part of the MAT process, which combines behavioral health counseling with medication to help patients kick SUD. Commonly used medications include buprenorphine, methadone and naltrexone, all of which help patients manage cravings and withdrawal symptoms in various ways.

Because of the Ryan Haight Act, new patients must receive an in-person evaluation in order to receive MAT medication. But the coronavirus has changed that, at least for some people.

The Substance Abuse and Mental Health Services Administration (SAMHSA) gave opioid treatment programs (OTPs) the OK to remotely prescribe buprenorphine to new patients they haven’t seen in person, as long as those patients can adequately be evaluated using telehealth.

Plus, the coronavirus has pushed insurers to cover home as a treatment site for patients with SUD, rather than forcing them to be in a clinical environment to get care.

While the flexibilities are set to stay in effect as long as the COVID-19 public health emergency lasts, Palakanis is hoping the new rules remain in place well past the October 25 emergency declaration expiration date.

“If we can maintain the waivers and keep the lifted restrictions away, then we’re looking at that telehealth being … at least 50%, if not more, of substance use disorder treatment going forward,” she said. “The biggest problem we have is this issue of a limited number of prescribers, and a large pool of populations spread across the country. What we can do now is have providers cover a larger net … and meet patients in a variety of areas.”

Building the program

Intermountain is a health system with 24 hospitals, a medical group with about 160 clinics and its own health insurance plan, among other services.

On the behavioral health front, Intermountain has an outpatient SUD treatment program called Dayspring; three behavioral health access centers which operate similar to emergency rooms but for mental conditions; and a growing number of tele-behavioral programs, among other offerings.

Those tele-behavioral offerings include Intermountain’s Crisis Care program, which serves 40 outreach facilities, in addition to Intermountain facilities, to provide tele-crisis services in the emergency department.

Plus, in response to COVID-19, the health system stood up a behavioral health access line for people seeking help with COVID-19-related concerns.

“More importantly, what we’ve been working on for the past year and are really at the point of it taking off is the virtual behavioral health program we’ve created,” Palakanis said. “And as part of that virtual behavioral health program, we have virtual SUD treatment.”

Palakanis is no stranger to tele-SUD programs. In fact, when Intermountain recruited her back in 2018, the health system took special interest in her background building such programs. 

Palakanis became a waivered MAT provider about 10 years ago. She made the decision to do so after several waived providers in the rural Maryland area where she was practicing lost their licenses, leaving SUD patients in desperate need of care and without many options.

“I started immersing myself in education about SUD, and from that developed several network points through telehealth for SUD treatment, in particular MAT, for rural counties in Maryland,” Palakanis said.

Because the area was so rural, telehealth saved patients and clinicians from having to travel long distances to connect for care. Instead, patients only had to go to their nearest health department or behavioral health provider, with those locations serving as clinical sites of care where in-person visit requirements could be met.

While patients were in those clinical settings — usually also receiving daily or weekly counseling — Palakanis and her team would deliver medication therapy using telehealth. 

Pre-pandemic, Intermountain’s remote MAT programming was set up similarly. It targeted rural remote communities, such as western Montana and central Utah.

“We were doing a workaround using the FDA approval, and we were all waiting for the DEA special registration to come through so that we could look at being more proactive and more creative with substance treatments,” Palakanis said, noting that the DEA special registration process would create opportunities for some providers to tele-prescribe MAT drugs. “And then along came COVID.”

These days, COVID-19-related flexibilities have allowed Intermountain to deliver MAT services to new patients outside of clinical facilities and without first seeing them in person. SUD patients can get telehealth SUD treatment by going to an Intermountain facility, a health department or a community behavioral health services provider that works with Intermountain for SUD treatment. They can also make an appointment through the ER.

Intermountain then emails patients a link, which they can click through and receive telehealth on their smartphone, computer or tablet. 

The new COVID-19 rules have allowed Intermountain to drastically expand telehealth services, Palakanis said, because patients can receive care from home without having to be seen in person first. The problem, however, is that those flexibilities might not be permanent. 

“That program is tenuous right now in how it’s going to roll out long-term because we have the benefit of working under the waivers of COVID,” Palakanis said. “Once we get either final confirmation that the waivers are going to stay in place or that the DEA has their special registration done, then we’ll really be able to expand that into a broader aspect.”

Regardless of what happens, Intermountain has a plan: It can always go back to its original model of working with clinical facilities to tele-prescribe MAT drugs, which still serves as a solution for the lack of waivered MAT clinicians in the areas it serves. 

“You first have to know what problem you’re trying to solve,” Palakanis said. “Then from there, start working backwards on what you would need to do for staffing and what you would need to do for equipment and platforms for interactivity.”

She recommends other behavioral health providers — many of whom are new to the telehealth game — do the same.

“Something to be cautious of right now is the fact that the waivers do allow us to use alternate platforms — Google, FaceTime and Skype — but those aren’t necessarily long-term solutions,”  Palakanis said. “While that’s a good band-aid right now, you need to look at a long-term solution if you’re going to provide telehealth and it’s not just a short term solution.”