Please, a few people still joining, but I'm excited to get us started. Thank you for being here. My name is Dr. Amy Ewell, and on behalf of the American Psychiatric Association, I'd like to welcome you to today's webinar, Practitioner and Stakeholder Perspectives on Opiate Use and Treatment Across Rural Northern New England. Next slide. These activities presented on behalf of the SAMHSA Funding Providers Clinical Support System, which is a program operated collaboratively by 19 medical specialty organizations, including the American Psychiatric Association. Please note that following today's presentation, you'll receive a follow-up email within one hour of the webinar. This email will contain instructions to claim your one credit hour for attending, and this activity offers continuing education credit for physicians, nurses, nurse practitioners, pharmacists, physician assistants, and social workers. As we go through the presentation, please feel free to submit your questions by typing them into the question area found in the attendee control panel. We'll reserve 10 to 15 minutes at the end of the presentation for question and answer. So with that, I'm very excited to introduce the faculty for today's webinar, Julia Shaw and Dr. Valerie Harder. Dr. Harder is an associate professor in the Department of Pediatrics and Psychiatry at the University of Vermont Larner College of Medicine. Dr. Harder is the director of the Health Services Research Team at the Vermont Child Health Improvement Program in Pediatrics, and co-lead of the Surveillance and Education Corps in the University of Vermont Center on Rural Addiction. Dr. Harder's research focuses on measuring the impact of public health interventions to improve physical and mental health outcomes of youth and young adults statewide. Her research team leverages large administrative health data sources to assess the impact of quality improvement efforts, targeted interventions, and statewide policies. In addition, she leads evaluations assessing improvement projects around health systems in primary and specialty care. Dr. Harder received her doctorate in mental health epidemiology and her master's in biostatistics from both from Johns Hopkins University School of Public Health. Julia Shaw is the manager of their Surveillance and Education and Evaluation Corps at the University of Vermont Center on Rural Addiction. She came to the University of Vermont Center of Rural Addiction with 10 years of experience in HIV, hepatitis C, and healthcare systems research and policy advocacy. She's passionate about healthcare access and health equity. Prior to joining the Center of Rural Addiction at University of Vermont, she was a policy analyst at Vermont Health, Vermont's Office of the Healthcare Advocate, where she advocated on behalf of Vermonters for healthcare system improvement. Previously, she managed a number of HIV prevention and reproductive health research studies at the Centers for Behavior and Preventive Medicine at the Merriam Hospital and Brown University, where she gained experience in quantitative and qualitative data collection and analysis. Julia holds a master's degree in public health from Brown University. I welcome you both to today's session and thank you so much for leading today's webinar and we're excited to hear from you. Thank you so much. So Julia and I are gonna go back and forth in this presentation and I'll share our results and talk about the services that the University of Vermont Center on Rural Addiction provide in rural Northern New England. So for our objectives of the talk today, we'll describe substances of highest concern to practitioners and stakeholders across rural Northern New England. And when we say Northern New England, we're talking primarily of four states, Northern New York, Vermont, New Hampshire, and Maine. We'll identify top barriers to opioid use disorder treatment in Northern New England. We'll discuss differences between the rural practitioners and the stakeholders' belief about medications for opioid use disorder. I'm gonna be using the acronym MOUD throughout this whole presentation. And finally, we'll describe the rural first responders' beliefs, which is a subgroup of our community stakeholders around MOUD. So UVM core is one of three centers of excellence on substance use disorders funded by the health services and resources administration. The other two centers are at the University of Rochester and the Fletcher Group. UVM core's mission is to expand substance use treatment capacity in rural communities by providing consultation, resources, training, and evidence-based technical assistance to providers and community partners. Core's objective is to leverage evidence-based practices for treating opioid use disorder and other substance use disorders by identifying the substance use treatment needs of rural communities, delivering evidence-based technical assistance and training and disseminating education and resources to rural providers and community partners. Our priority region includes the rural areas in Vermont, New Hampshire, Maine, and Northern New York. These rural areas of Northern New England and New York are of particular interest due to high prevalence of substance use disorders. However, treatment needs and barriers are substantial throughout rural areas of the United States. And while our data collection focuses on these geographic areas, many of our findings are relevant to other rural areas. And we do provide resources and services to providers and community partners throughout the country. Our center includes four cores. Dr. Harder and I are part of the Surveillance and Evaluation Core, which is responsible for CORA's data collection, analysis, and reporting. We also have a Best Practices Core, which provides technical assistance and education and outreach core, and a Clinical and Translational Core, which includes our Clinician Advisory Board. Our process in each of our priority states is to first conduct a baseline needs assessment and then proactively outreach to our baseline needs assessment respondents to offer support, resources, and technical assistance. This often leads to ongoing engagement and continuing technical assistance. We also use our data to inform our education and outreach, as well as the resources that we develop and disseminate. As I mentioned, our Surveillance and Evaluation Core is responsible for the data collection, analysis, and reporting for UBM CORA. We use epidemiological methods to identify substance use treatment needs and barriers in rural communities. We gather direct input from providers, patients, and community partners. We monitor substance use patterns in rural communities, synthesize and disseminate data, and use our findings to inform our technical assistance and outreach activities. Dr. Harder is going to talk about our baseline needs assessment methods and findings across Vermont, New Hampshire, and Maine. Thanks, Valerie. Thanks, Julia. So I'll jump right into some of the methods behind our baseline needs assessment. So we've conducted these baseline needs assessments in three of our four states. We started with Vermont, and then we moved into New Hampshire, and then finally Maine. And right now we're about to launch our Northern New York baseline needs assessment. In these assessments, we ask practitioners and community stakeholders about their perceptions on many topics, including their concerns around substances, barriers to treatment, their comfort treating all substance use disorders, including opioid use disorder, beliefs about different treatment modalities, impact of the COVID-19 on substance use. And finally, we do ask them about what resources UVM Center on Rural Addiction could provide for them to improve their care. We have all of this information on our UVM CORE website, which you can see here, including the full reports from these baseline needs assessments and briefs, along with this presentation that we gave earlier. I'm only going to talk about three of these topics today, or else we would be here for several hours instead of one hour. So today's presentation will focus on substance use concerns, barriers to treatment, and beliefs about treatment. So, as I mentioned, we surveyed both practitioners and community stakeholders in these surveys. And some of the examples that are under the practitioners are listed here. The majority of respondents were physicians, NPs, PAs. And actually in New Hampshire, we had a large contingent of counselors and much fewer physicians. So it's not equal distribution across the three states. For stakeholders, we had first responders, which would be the emergency medical technicians and firefighters, as an example. Then we also had other community stakeholders. So school nurses, state agencies, healthcare organization, mental health organization, legislators. These are all non-clinicians who would be interacting with people with substance use disorders, or maybe working in a field in which they would influence policy around substance use treatment. So our three states, we enacted the baseline needs assessment at different times. As I mentioned, Vermont was first. It was, we were launching it and ready to launch. And right when the COVID pandemic started, we still launched the survey. So we have some interesting perspectives on the influence of COVID-19 on substance use disorders in Vermont, right at the beginning. And then as the other states progressed, we assessed rural and non-rural separately in Vermont, but then in the combined survey for New Hampshire and Maine, New Hampshire was the second state we went to in the fall of 2020, moving into the spring of 2021. And finally, Maine was done in the summer, leading into the summer of 2021. We had relatively good response rates from the three states for Vermont and Maine. They're around 25 to 30%. New Hampshire, you'll notice the response rate is much higher, but this was because we had a different approach due to our inability to obtain contact information from practitioners in New Hampshire initially. So we did a contact survey first in which we went through different societies and solicited for those practitioners and stakeholders to share their contact information with us. So once we had already made contact and they had shared their information, they were much more likely to respond. So that's why you see this higher response rate there. Here are our first table of results showing the breakdown of who responded in each state and the rows of the total numbers that we had. So for practitioners across the three states, we had 457 respondents. We have very different breakdowns of who those people were in the different states. For Vermont, we had a pretty good distribution across those who were wavered to prescribe buprenorphine and those who were not wavered. That was different in Maine, where it's almost every one of the practitioners responding were wavered to prescribe buprenorphine. And one note I'd like to make is that all three of these states completed the baseline needs assessment prior to the lifting of the X waiver requirements. So New York will have a different perspective and well now people don't have to get wavered to prescribe. As I mentioned, New Hampshire had a high number of counselors responding, which we didn't see in the other states. For the stakeholders, we had pretty equal distribution of first responders to other stakeholders in Vermont and Maine, but not that same distribution in New Hampshire. So this just gives you a general view of those 304 rural community stakeholders in our survey. Jumping right into the first question around substances of concern. So we asked practitioners and stakeholders how concerned they were about the use of the following substances among their patients or in their practice or in the community where they were. And at the lower part of the slide here, you can see all of the different substances we asked about, including combinations. So opioids with alcohol, opioid sedatives, opioids and stimulants. So we were interested in all of these different substances of concern and practitioners rated on a scale of zero, which was not at all concerned about this substance to extremely concerned, which they would rate at 10. Here are our first results. The first column you see are the rural practitioners who are out of 457 respondents. These are the top five substances of concern. Again, it was rated from zero to 10. So in the, around a score of seven in their level of concern, you can see for practitioners, there was this higher concern around a combination of opioids with either alcohol or benzodiazepine, which also really interesting is their inclusion of two more common drugs, tobacco and alcohol up there in their top five. So over on the right, you see some similarities with rural stakeholders. So rural stakeholders also were interested, were rating opioids and alcohol combination higher, but then their highest was fentanyl, whereas that was similar to the practitioners, which was in their top five, but not rated up there, fentanyl and heroin. And then another difference is that the more common substances of alcohol and tobacco were not in the stakeholders list of drugs of concern. So here's the figure of all of the substances that we asked them to rate. And it's ordered from highest to lowest based on the practitioner, which is in dark green. And you can see some similarities and some differences across the rating from community stakeholders and practitioners. Some points of interest that I'd like to make is that you can see that marijuana or cannabis is rated amongst the lowest for both practitioners and stakeholders, prescription opioids being more in the middle, and these combined substances, opioid and alcohol being up towards the top. Another thing that we did in our baseline needs assessment was more of a mixed methods approach where at the end of each section, we included some open-ended questions where we allowed the respondents to tell us more about what they had just answered in more quantitative questions. So in this, we asked them, would you like to share anything else with us about your concerns related to substances? So on the right are a couple of examples from practitioners. So a main practitioner is saying that we're seeing a lot more crystal meth use in the last year. On the left, you can see some of the quotes from our community stakeholders. So a New Hampshire stakeholder said there's been an increase in polysubstance use during COVID-19. But then also the statement that alcohol is still the most abused substance from a Vermont stakeholder. So these were really helpful qualitative responses that informed some of our work at UVM CORE in addition to the quantitative analysis that I showed. So moving on to the next topic around barriers and challenges. So we asked the practitioners a question and then varied whether or not it was from the perspective of the patient or from the perspective of a provider. So we asked them to rank the top three responses you view as patient-related barriers to receiving treatment for their opioid use disorder at your practice. And then they repeated that and we asked them to rank the top three provider-related barriers. So similarly amongst stakeholders, we asked the question, please select the three areas you see as the greatest challenges to treating opioid use disorder in the community where you work. So these were their combined thoughts about maybe patient or practitioner-related barriers. So here there's a lot of numbers and percents but I can walk through this with you. So looking at the rural practitioners first and their responses around patient-related barriers, this is the ordering of the top five from highest to lowest in terms of the barriers to opioid use disorder treatment. So for patient-related, they talked about access. So time, transportation of housing followed by stigma. Next slide, Julia. You can see some of the similarities. So if you look across these are shown in different colors. So for time, transportation of housing is really similar to what rural stakeholders also noted as a primary challenge. So time, transportation and childcare. Parenting or family demands was also up there for a patient-related barrier. Stigma was noted by practitioners as being a patient-related barrier and it was also noted by community stakeholders. From practitioner-related barriers, we saw that in their practice, they noted time or staffing constraints. And this was really similar to what the stakeholders said around the not enough treatment capacity related most likely to time and staffing constraints. And then finally across all three, there was some notion of patient management concerns or difficulty with treatment or concerns around treatment. That was a theme across all three groups. So I just wanna take a step back and just talk briefly about how our findings are in relation to what's in the literature. So we found this systematic review that was published in 2020 of rural specific barriers to medication treatment for opioid use disorder in the United States by Lister et al. And in this review, they broke down the barriers to MOUD treatment based on the availability, the accessibility or the acceptability. So there's a lot of information here and this is one of the tables from the published paper. And from what we found in our study in comparison to this study was that the patient barriers that they highlighted were around transportation issues in rural areas. And then the provider related barriers that they highlighted was around lack of staffing and infrastructure. And these are some of the same themes that came out in the survey and the responses we got from our respondents. So we're finding a lot of synergy between what we found and what was presented in this review article. Again, at the end of this section, we asked open-ended question, tell us more of your thoughts around barriers for treatment. So a main practitioner said that transportation is a huge issue. We have no reliable public transport. Another practitioner in New Hampshire talked about needing consistent, accessible community resources for counseling and social work, especially for the underinsured patients. Whereas a stakeholder in New Hampshire said we need more MAT providers in primary care settings as well as we have no treatment centers within our communities. So having even one would be an improvement. Just the perspective here is that these are very, some of these are very rural areas in Northern New England and access to treatment continues to be a major issue. We're gonna take a fun break right now for a little participation. So I believe Violet is going to launch the Zoom poll. And here we'd like you to think about to what extent do you agree with the following statement? And this is on a scale of one, strongly disagree to five, strongly agree. And the statement is medications given to treat people with opioid use disorder, specifically methadone and buprenorphine, replace addiction to one kind of drug with another. I'm noticing that this poll question is not the same question that I have on this Zoom slide. So I apologize for that, but it is the second poll question. This is the second one that I'll show, so. All right, so I'm seeing, I'll share the results, that around 60% of you are strongly disagreeing strongly disagreeing with the statement that medications given to treat people with opioid use disorder replace addiction to one kind of drug with another. And I'm sorry if some of the first people who responded might've thought you were looking at this question. And we have very few disagreeing or strongly disagreeing. So I would say 69% of us are agreeing or strongly agreeing. Oh no, sorry, 69% are strongly disagreeing or disagreeing with this statement. Julia, it might be good advance to slide and the next slide, and I can come back to this one. So one more. So here's what we found from our respondents. On this same question. So here for practitioners where our group had 69%, here in our survey across the four states, it was 59%. So it's relatively similar to what you all are responding. So I'm assuming a majority of you are practitioners, but maybe some of you are community stakeholders as well. So amongst our community stakeholders, 43% strongly disagreed or disagreed with this statement. And the difference between these two groups was statistically significantly different. So if you wanna go, oh yeah, we'll go forward. So here's a thought question for everyone around addiction. And let's think about how would you define addiction? So just take a moment. We're not gonna have an interaction on this one, but think about it and we can advance the next slide, Julia. So the National Institutes on Drug Abuse at the NIH defines addiction as a chronic relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. And you can see here that there's some similarities and there are some differences. Medications for opioid use disorder is not an addiction. There are differences except for the last bullet here. So there is physiologic dependence amongst those who were prescribed MOUD. So let's think about this a little bit further. So if you go to the next slide, Julia, MOUD does have physiologic dependence, but because people with opioid use disorder already have physiologic dependence on opioids, the dependence from MOUD or medications for opioid use disorder is not considered an adverse consequence as conveyed in the definition of addiction. Also, there are clear positive benefits of medications for opioid use disorder. Research shows that MOUD improves physical, psychological and social quality of life. So at the end of this section around beliefs about MOUD, we also asked them to, again, share some of their thoughts. So a New Hampshire practitioner shared that the most important improvements are in policy and legislation. Buprenorphine should be free of cost and access not restricted by the X waiver requirements and as we know now, those have been lifted. There was some differing opinions. So there was a Vermont practitioner who had very strong views around use of methadone and suboxone. So you can see that quote here. The other hand is stakeholders. And I think I saw a chat come up of who we consider stakeholders. We have both first responders as school nurses, legislators, mental health treatment staff, people who are generally not clinicians but are working in the field is who we consider stakeholders. So here's a main stakeholder saying methadone needs to be taken away. A Vermont stakeholder said, we need to think of treatment in combination with prevention, intervention, harm, reduction and recovery. Just focusing on one of these will never solve the issues at hand. Okay, so we're just backing up a little bit. So we don't have to do this Zoom poll again. We'll just move on to the results. So we did ask another beliefs question and that was medications like methadone and buprenorphine are the most effective way to treat people with opioid use disorder. And what we found is that 72% of our practitioners agreed with this statement. Whereas, agreed or strongly agreed. Whereas 36, only 36% of our community stakeholders agreed or strongly agreed with this statement. And again, that difference was statistically significant. So just wanna take a moment here to talk about medications for opioid use disorder or MOED. MOED are safe and FDA approved. MOED are more effective than other forms of treatment. Many studies have shown that MOED can be used alone or in combination with other treatment services. And at UVM Center on Rural Addiction, we have some hopefully helpful MOED resources. There's a resource guide on our website. So please go to that website, access our guide. We have other cores who are happy to interact with you and help get you more resources that you would like. Thank you, Julia, for going back. So one of the things we did with this question that we all answered, medications, or this statement we reflected on. Medications given to treat people with opioid use disorder replace addiction to one kind of a drug with another. So what we're looking at here is a breakdown or a subgroup analysis of our community stakeholders. We wanted to say, why are these numbers so different amongst our community stakeholders related to our practitioners? It might be that there's a real difference in the groups of respondents in this group. So first thing we looked at was the group of first responders. We separated those folks out. And again, those were emergency EMTs and firefighters and some very small number of police. And so here we see that there was a real difference here 50% of our first responders actually agreed or strongly agreed with this statement. Whereas all of the other community stakeholders that I had listed out there, those were just some examples but anyone else is grouped into this other group and they're down at 24%. Whereas 53% are disagreeing or strongly disagreeing which is more in line with the practitioner numbers. And again, this is a statistically significant difference. So looking and separating out our community stakeholder qualitative responses, there were some Vermont first responders who felt that Vermont needs to support EMS with Narcan more. And then we had a main first responder, my awareness is by crisis situations when responding with an ambulance. And finally a main first responder said, I'm not sure I'm going to be able to do this and finally a main first responder said, inadequate access to treatment and the continuation of inappropriate prescribing of opiates is destroying our community. The other stakeholders grouped together, there's one in Maine that said, first responders need more education about opioid substance abuse and its treatment. And finally another stakeholder said, we have a collaborative approach involving tribal and regional or we need a collaborative approach involving tribal and regional health systems, EMS and law enforcement. All right, I believe this is our last thought question and we would love if you could respond in the chat so others can see, what would you recommend as the single most important improvement to increase access to opioid use disorder treatment in your community? If you would like to note your profession and whether you work in rural or non-rural areas that could be helpful. Well, if you have thoughts, oh, thank you. If you have additional thoughts, you can also go to the UVM CORA website. You can email us. We're happy to interact with you. We have our best practices core. We have our education and outreach core. Oh, these are really interesting. Yeah, this is what I like, getting the feedback from those who are in the field. All right. I believe I'm handing back to you now, Julia. Yep. Thank you. Please keep putting it in. Others will like to see your responses. Yeah. So this question that we just asked of all of you was part of our needs assessment. We asked an open-ended question asking both practitioners and stakeholders for the most important improvement needed to increase access to opioid use disorder treatment in their communities. And we did receive a broad range of responses. From those responses, we identified some common themes, which were also reflected in our quantitative survey findings. So a primary theme was the need for more rural treatment sites, including both inpatient and outpatient treatment, mental health services, mobile clinics, and other low barrier services, and rapid treatment induction. Respondents also highlighted the need for community collaboration, care coordination, including effective case management and involvement of counselors in care coordination. Many respondents highlighted the need for more waivered providers or more prescribers in general, as well as increased provider knowledge and comfort around OUD treatment, as well as the need for additional support staff. Many respondents also highlighted the need for additional social supports for patients, as well as additional resources and outreach about available services to increase awareness. And finally, a number of respondents described reducing stigma as the most important improvement needed to increase OUD treatment access. So I'm going to highlight some of the key themes from both the quantitative and qualitative responses to our baseline needs assessment surveys. These themes include stigma, polysubstance use, social determinants of health, system capacity, and knowledge. I'll review each of these themes in a bit more detail, and we'll also talk about some of the resources that are available to help address these needs. So as you may recall, stigma was reported as a top barrier to treatment by both practitioners and stakeholders. We also saw stigma reflected in the beliefs about OUD and MLUD reported by some practitioners and stakeholders. For example, as Valerie had described, one fifth of practitioners and one third of community stakeholders believe that MLUD replaces one addiction with another. This was even more pronounced, as we just talked about, among first responders, with half believing that MLUD replaces one addiction with another. So UVM CORA has a number of existing resources related to stigma. We have two recorded webinars available on our website, one by Dr. Peter Jackson on stigma in the clinical setting, and another by Dr. Marjorie Myers on stigma in the context of pregnancy, parenting, and substance use. We were also part of the University of Rochester's Taking Action Summit. So you may remember that the University of Rochester is one of the other Rural Centers of Excellence on Substance Use Disorders funded by HRSA, similar to UVM CORA. And there are many great presentations from that summit that are all available online. There's also a resource available from PCSS, Changing Language to Change Care, Stigma and Substance Use Disorder by Dr. Sarah Wakeman. We also are about to launch a nationwide survey similar to our baseline needs assessment with some additional questions added specifically related to stigma. So we're looking forward to hopefully engaging with some of you on that survey and to sharing the results in the future. As Valerie highlighted previously, use of multiple substances was an area of concern for both practitioners and stakeholders and was highlighted in many open-ended responses as well as in our quantitative data. Areas of concern included opioids in combination with alcohol, sedatives and stimulants. And respondents also noted ongoing concern about fentanyl contamination of other substances and about the use of alcohol and tobacco products both alone and in combination with other substances. So we have a number of relevant webinar recordings related to polysubstance use. These are all available on our website again, including two on alcohol use disorder and one on stimulant use disorder. We also have an in-depth provider training video on the use of contingency management for substance use disorders. That's available on our website and it does have continuing education credit available. Also through our technical assistance activities, we offer a number of resources to support practitioners and community partners in working with individuals who use multiple substances. So we have harm reduction resources like fentanyl test strips and naloxone, which as we all know are essential harm reduction tools for people who use opioids and other substances that might be contaminated with opioids. We also offer tobacco toolkits that include nicotine replacement therapy and other tools for people who receive medication treatment for opioid use disorder. There's also a polysubstance use resource available from PCSS, actually two, one on alcohol use and one on management of other substance use co-occurring with opioid use disorder available through PCSS. Actually, before I move on from this, I also wanna just highlight, we also have a program at UVM CORA where we offer clinician office hours. And this is a topic, polysubstance use that has come up for practitioners who have utilized those office hours. So that's an opportunity where a clinician, if you're working in a rural area, you can sign up for an office hour session and we have expert clinicians from UVM CORA who provide an hour of their time each week to speak directly with other practitioners on treatment issues, difficult cases, those kinds of things. And polysubstance use is one of their areas of expertise. So a common theme throughout our baseline needs assessments was the importance of addressing treatment barriers related to social determinants of health. So for people in rural areas experiencing barriers like lack of stable housing, lack of transportation and lack of access to technology, engaging in treatment can be extremely challenging. We do offer some resources that can help address some of these barriers. We offer medication lock boxes that can help people who don't have stable housing protect their medication. We offer telehealth supplies for people who can't easily travel to treatment appointments or who don't have access to the technology they need for their treatment plan. We also do have a recorded webinar on our website on social determinants of mental health and substance use, which is a great resource for those interested in learning more about social determinants of health. And there's a PCSS resource specifically on opioid use disorder and social determinants of health as well. The capacity of the treatment system was another common theme in our baseline needs assessment data. As I mentioned previously, this includes the number of available treatment providers and sites, the availability of effective care coordination and the treatment of co-occurring conditions. So many of our technical assistance, education and outreach activities are geared toward improving the capacity of the treatment system. I've described a few of those under previous themes and I'll talk about a few more when I speak about our final theme, which is knowledge. There are a few webinar recordings available on our website specifically related to expanding capacity and treatment access, including one on telehealth for substance use disorders specifically in rural areas and another on the use of sustained release buprenorphine in the outpatient setting. We also have a recorded webinar available on co-occurring PTSD and SUDs. And from PCSS, there is a resource managing common psychiatric conditions in primary care as well. So the final theme from our needs assessments that I'll touch on today is knowledge. Many respondents highlighted the lack of adequate training and support as a barrier to treatment access. And when asked about high priority resources, requested training, mentorship, resources and support. So I'll highlight a couple of programs related to increasing practitioner knowledge. The first is the clinician office hours program, which I spoke a little bit about already, and that is ongoing. And again, it's one hour per week and you can sign up for that through our website. This gives practitioners the opportunity to directly access support and mentorship from our core clinicians. We also offer a scholarship program. It's generally twice a year and that allows practices to apply, to participate in a two day intensive training with our CORA clinicians, faculty and staff. So we recently completed our spring session of that scholarship program and we'll likely have another session next fall. And finally, I just wanna highlight the many resources that are available on our CORA website. If you go to uvmcora.org slash resources, we have all of our webinar recordings as well as many resource guides, research spotlights highlighting important findings and all of our baseline needs assessment data reports. We hope you'll find those useful. So before we move on to questions, I just wanna thank all of you for attending today. And I also wanna thank all of our baseline needs assessment respondents who gave us their time and provided such valuable and actionable input on the treatment systems in rural Northern New England. So I'll pass it back over to PCSS now to facilitate some question and answers. Thank you. Dr. Yo, we can't hear you. Thank you, sorry. I need to double unmute myself. But thank you, Julia and thank you, Dr. Herter for a very informative presentation. We'd love to take some questions from the audience and I'd love it. Yeah, there's more to kind of put in there. I guess one question I had for the two of you is it sounds like one need identified was training and that you, you know, have worked to provide training opportunities for clinicians and practitioners. And I was wondering how organizations are supporting clinicians to access training or kind of is it is this something that people are doing on their own time or is there either kind of more systemic interventions being done to support practitioners to get this training and have the time to do the training? Yeah, I know for the scholarship program, so that's the more intensive training that we offer. It's two full days in person. For those we, the practices really commit as a practice to participating in that. They send a chunk of their staff. We provide a financial incentive for that training. So we're able to cover some of the lost revenue for the smaller practices who may not be able to see as many patients on those days. And then, so for those, the practices do kind of commit as a practice to participating. For our other offerings, for example, our clinician office hours, we do those over, if you're in the Eastern time zone, we do them over the lunch hour. So they're currently 12 to one on Thursdays. So that allows for clinicians to participate in those hopefully during time when they're not seeing patients. And then in terms of some of the other resources I know, so for our webinars, we offer continuing education credit for those. So that's something that's often supported by provider organizations. So people who participate live can receive continuing education credit for those. And then if you view the webinar within a month of our website, you can also claim continuing education credit for those. So those are some of the ways that CORA is able to support practitioners and organizations. I'm not sure about organizations, about larger organizations, maybe Valerie, I don't know if you have any more insight on that, other ways that they support their providers. And I think many providers do reach out, they hear about CORA. Some of the respondents to our survey are actually provided an opportunity to connect with CORA. We reach out to them. And so that is like an individual connection. I don't think I have other examples of how larger organizations are supporting it though, but that we could bring back to our education and outreach But that we could bring back to our education and outreach team to follow up on that one. Yeah, so it's great to have these opportunities kind of during, depending on your time zone, during kind of lunchtimes or whatnot, and providing those continuing education credit. But definitely know that clinicians are kind of stretched thin in many different ways. And was just curious if you guys had heard of any systemic kind of ways to address that, although the scholarship opportunity that you offer sounds like one very clear way to, you know, provide financial support to the practice to cover some of the losses of lost clinical time and whatnot, which is great. And along those lines, one of the attendees asked a question about just whether or not you know of kind of what efforts are being made to educate and increase understanding and acceptance of medications for obese youth disorders as a gold standard treatment among the stakeholder groups that had a different perspective or kind of responded in a different way. Yeah, so that's something that CORA is working really hard on. I mean, our mission is essentially to get this evidence base into the field. So we, like I said earlier in the presentation, we do direct outreach to the respondents from our baseline news assessments. That has focused more on practitioners to this point. We've done more direct outreach to practitioners, but we do offer, like we have lots of written information, and then we have opportunities for organizations or practices to bring in one of our clinicians as a speaker and that kind of thing. So we do a lot with sort of getting the information from the literature out into the field. And then for stakeholders, we've been, we actually have been speaking with a few different EMS folks in our region, and we're sort of in the process of conceptualizing what that might look like in terms of reaching first responders specifically, because I know, as we've seen in our data, there is a lot of misinformation within that group. And I think some of it can be addressed fairly easily. One of the challenges I know with that group is we've heard, you know, directly from those folks that they sort of see, they see the worst part of the situation. So they see the overdose, they see the person go, you know, either go off in the ambulance or not go off in the ambulance. And then they may see the same person multiple times, that kind of thing. And what they don't see is the people who are successful. So when somebody goes into the hospital, and then is connected with treatment and succeeds, they probably won't see that person again. So they don't have that loop closed on seeing sort of the people who are successful, they tend to see the people who are still really struggling and accessing those emergency services, sometimes on a regular basis. So that's something we've been thinking a lot about and are trying to connect with people who've there are some interesting programs within our service area where local departments of health have worked with law enforcement and other first responders and kind of trying to close those information loops and make sure that all the different entities are communicating with one another. So that's something that we're, we've been looking into, and hopefully we'll be able to do some more work on in the future. Great. Another question that came up in the Q&A, which I'm not sure, if you guys will be able to answer, but an attendee was curious about how clinicians or practitioners or practices are managing people who don't have insurance. And I didn't know if that's something you kind of heard of as a barrier among some of the respondents or kind of what you guys hear out in the field. Yeah, I mean, I think we definitely did hear that in our data, not having the financial means to access treatment, whether it's lack of insurance, under insurance, or the providers don't accept insurance or they don't accept to the, or the, whatever treatments available doesn't match with the insurance that you have. Those kind of challenges are definitely huge. I think it varies a lot state by state on sort of Medicaid eligibility, what Medicaid covers, and then also how many providers accept Medicaid. So I think in Vermont, we're pretty lucky that we have expanded Medicaid and we have a lot of infrastructure in place to get people insured. And then a lot of our practitioners here do accept Medicaid. So we are lucky in Vermont, but I do think that's a huge challenge in other places. Valerie may have more information about that as well. Not specifically how the clinicians are managing the uninsured, but just remembering that those are great questions for clinician office hours. If you're a rural practitioner, there's definitely resources to ask other clinicians, specifically those types of questions. Lisa, one of the slides, I think when I responded to the survey, talked about mobile units and was just wondering if those have, you know, if any of the states are using mobile units. I'm in the city and so we often, especially thinking about trying to reach adolescents or young adults who are experiencing homelessness will have these mobile VMs that have been functioning within Boston and didn't know if you guys, if any of the states are using mobile VMs in these rural areas. Yeah, I know there's at least one project in Vermont. It's a grant funded project where one of our, it's actually through one of our syringe services programs. So they're doing both harm reduction and then also MLUD. I think it's largely, at least from what I've heard, largely in that kind of piloting phase where there's kind of specific funding for individual projects. But I'm hopeful that that will, as those projects are hopefully successful and the evidence-based builds, that there'll be more systemic funding for those going forward. Because definitely, you know, we saw so many people just talking about transportation as a barrier and not only transportation, but then the time they lose, you know, getting to their appointments if they don't have transportation and then they have to take public transportation. And in these rural areas, it may either be not available at all or it can take like the entire day to get to an appointment and back if the site is far further away. So I think those kinds of programs, meeting people where they are and, you know, using the limited resources that are available in rural settings and getting them out to more people will be really, really valuable. And we'd love to learn about your experiences and if others have experiences with these mobile units too, please share. So thank you again for being here and sharing all of your knowledge and expertise. And it's great to learn about what's been happening in these rural areas. If we could transition to that a couple more slides, I'll mention a few more things about PCSS. So this is a kind of more details on that piece. We've been talking about different mentorship programs and more details on the PCSS mentoring program. And so you can go to pcssnow.org mentoring to find a variety of helpful resources that are offered. And the mentorship program offers general information to clinicians about evidence-based clinical practices and prescribing medications for obese disorders. Next slide. Another resource is the PCSS discussion forum. And this is a forum staffed by PCSS mentors who have expertise in medication for substance use treatment and clinical education. And this is a simple and direct way to receive an answer related to medication for substance use treatment if you have one. Next slide. PCSS is very thankful for all the collaborators that are part of this collaboration. And so, again, to remind you that today's presentation was on behalf of the SAMHSA-funded provider clinical support system, which is operated collaboratively by 19 medical specialty organizations, including the American Psychiatric Association. And next slide. And so thank you again for joining us today. As I mentioned at the beginning of the talk, there will be an email sent within the next hour or so that will provide you with a link to access the continuing education credits. And, again, just want to give one final thanks to Dr. Harder and to Julia for joining us today and sharing all this information. So, and thank you for attending, everyone. Thank you. Thanks for having us.

opiate use

treatment

rural northern New England

SAMHSA-funded Provider Clinical Support System

baseline needs assessment

substances

barriers to treatment

beliefs about medication for opioid use disorder

University of Vermont Center on Rural Addiction