Friday, January 3, 2025
1/3/2025
The BHSE initiative will include establishing a new, innovative El Centro SUD CARES model dedicated to providing in-the-field MOUD treatment, counseling, and patient navigation services through a multi-disciplinary team that works closely together to provide intensive MOUD treatment, recovery, care coordination, peer support, linkages with supportive social services, and health navigation meeting patients in non-traditional environments such as their homes, in the jail, at the homeless shelter, or other public locations. The target population who will receive in-the-field MOUD treatment services includes those with SUD/OUD who are the hardest-to-reach patients often involved in the justice system, homeless, and have complex care needs that likely include a mental illness. These patients have needs that can simply cannot be addressed in a traditional clinic setting in a 15-minute encounter and/or through a series of time-limited office visits. These patients require a SUD care team that can employ a more hands-on, intensive approach designed to best develop a personal connection with the patient that leads to a trusting relationship and one where the patient is able to reach out and access supportive services as they are ready. This home-visiting model that brings MOUD treatment to the patient – meeting them where they are – provides a much more supportive environment in managing such challenging mental health and medical conditions in addition to an ongoing addiction and substance use. It is our hope that this model can be replicated in rural communities throughout New Mexico and across the nation as a successful solution to addressing the hardest-to-reach, most complex cases for SUD/OUD. This initiative further enhances the delivery of MOUD treatment by strengthening a relationship with the San Miguel Detention Center to provide MOUD treatment in a private room at the jails for inmates beginning 4 weeks prior to their release. This in-the-field MOUD treatment and recovery model currently is the missing link to serving the highest need SUD/OUD patients that often enter the safety-net system with a health care crisis (overdose, psychiatric crisis, etc.), have complex health care and social needs to have any stability in their lives and begin a path towards recovery, and simply cannot be served in a 15-minute visit within a clinic setting. The El Centro SUD CARES home visiting team will spend as much time as is allowed with the patient – providing MOUD treatment, counseling, and intensive wrap-around services all designed to build a personal connection and trusting relationship with the patient. El Centro will hire 1.5 FTE MAT Providers, 1.0 FTE SUD Counselor, 2.0 FTE Community Health Workers, 1.0 FTE Peer Recovery Specialist, 1.0 FTE Health Navigator, and 1.0 FTE Front Desk Staff/Clinic Manager that will comprise the El Centro SUD CARES home visiting team to provide in-the-field MOUD treatment, counseling, and recovery services to the hardest-to-reach, homeless, and justice-involved SUD/OUD individuals with complex care needs. MOUD treatment will include prescribing buprenorphine and/or injectable naltrexone at a minimum. The MAT Providers, SUD Counselor, and CHWs will comprise the core care team that will attend in-the-field visits together as one unit. In addition, the Health Navigator or Peer Support Specialist may attend the visit, as needed, but also support the patient’s needs in the office filling out paperwork, conducting phone calls, scheduling referrals, documenting referrals and follow-up, conducting recovery groups, and following up with patients on a regular basis. The Front Office Staff/Clinic Manager will be stationed in the office to field phone calls, schedule intakes and in-the-field visits, as well as support the coordination with the jails, Drug Court, law enforcement, Recovery Café, and numerous other social services.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).