Staten Island, New York, or Richmond County is home to 480,000 individuals and is significantly representative of the United States demographically and socio-economically. Demographics aside, Staten Island also presents a unique venue as a social policy laboratory because its population is isolated on,
yes, an island. Everything from social determinants of health, to hospital visits, to treatment itself are all conceivably concentrated in one geographic location, providing an opportunity to limit outside variables which could impact a
policy experiment.
Staten Island has disproportionately suffered from the overdose crisis. The number of overdose deaths per 100,000 on the island is much higher than the national rate and it maintains the second highest borough rate of death due to overdoses in NYC. Staten Island has emerged as a center of overdose treatment innovation.
Several SI-based outreach programs already identify individuals for addiction treatment based upon their SUD experience or prior overdose. These include the HOPE Opioid Diversion Program, a partnership between behavioral health providers, local government units, the Office of the Richmond County
District Attorney and the NYPD, as well as the Relay Program, which utilizes ER departments to connect overdose survivors with supportive services.
The Hotspotting Program is centrally administered by the Staten Island Performing Provider System (SI PPS). The SI PPS was created out of the New York State (NYS) Medicaid Redesign program (1115 Waiver), a multi-billion-dollar effort to transform NYS’s Medicaid program. The SI PPS stands as an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations with 12,000 employees, 19 community based organization partners and 75 network partner organizations.
To enhance its health objectives, the SI PPS developed an advanced population health management (PHM) data platform and warehouse which integrates health data from multiple disparate sources, including medical and pharmacy claims, clinical data, emergency management systems (911), law enforcement data, payor data and clinical event notifications (CEN) from the local health information exchange (HIE). As early as 2015 the PPS prioritized expanding the number of waivered providers on Staten Island and supported expansion of MAT induction in ERs. This resulted in an increase of nearly 350% of individuals successfully receiving MAT for 6 months or more without interruptions in service. A warm hand-off program was instituted to engage individuals at the time of discharge from in-patient settings and provide immediate follow-up after ER encounters for an overdose. While the rate of overdoses on Staten Island declined precipitously from 2015-2018 because of these efforts, the subsequent fentanyl crisis and associated poisoning of the drug supply then caused overdoses to surge once again.
In the years since its establishment, SI PPS had an immense impact on the Staten Island care system and Staten Island’s residents. The PPS reduced avoidable hospital readmissions by 25% via an intensive care coordination model. The opioid crisis was tackled head on with development of programs that increased the availability of evidence based opioid medication assisted treatment (MAT) in both ERs’ and community based providers resulting in a 500% increase (300 to over 1500) in individuals receiving this life saving service.
The PPS initiated a first of its kind Certified Peer Recovery Advocate (CRPA) training program which allows individuals with lived experience to work alongside clinical professionals to engage opioid addicted individuals. PPS also provided funding for innovative programs like the “Next Step Walk-in Program”, which provides 24/7 access to treatment and CRPAs for individuals seeking opioid services. Perhaps amongst the most impactful achievements sponsored and supported by the PPS was the “HOPE” heroin overdose prevention program created by the Richmond County DA. Their safe prescriber program educated prescribers about opioid alternatives and evidence-based prescribing algorithms, reducing unnecessary prescriptions for opioids by 31%. These innovative programs have all been strengthened by the PPS’s reliance on data and business intelligence with regards to their program designs.
In February 2019, the MIT Sloan School of Management’s Initiative for Health System’s Innovation (HSI) announced a formal collaboration with the Staten Island Performing Provider System to explore and evaluate how the SI-PPS community centered data platform and innovative approach to community-based care could be used to address systemic healthcare challenges, including the opioid overdose crisis. This partnership subsequently led to the development of the predictive algorithm and analytics system which the Hotspotting Program centers around.
In May 2021, Northwell Health officially partnered with SI-PPS to ensure the continuation of their work and now Northwell is the corporate parent and the sole member of the SI PPS LLC. Later that year, the SI PPS secured $5 million in funding to operationalize this algorithm into a comprehensive program for opioid misuse prevention, establishing an unprecedented value- based care coordination program standard for overdose and OUD treatment and prevention.
The Staten Island Hotspotting Program is a two year, $5 million dollar pilot which has engaged 1,500 Staten Island residents.
The Hotspotting Program’s two-year Staten Island pilot program, launched in January 2022, builds upon the SI PPS strong data platform system as well as its alliance of treatment partners to employ and prove the Hotspotting Program’s effectiveness as a value-based care management program for substance use disorder.
The Hotspotting Program demonstrated greater initial results in overdose reduction and an increase in services provided to participants in the first year of the program. There was an 81% reduction in non-fatal overdoses for those clients engaged in the program. More importantly, there were two overdose-related deaths compared to 11 in the non-engaged group. This data strongly suggests that the Hotspotting Program has had a powerful effect on overdose prevention and a significant impact on lives saved.
Although any program needs years of results to evaluate the full impact, these initial results suggest a strong impact of participation in the multiple levels of service that the program provides. Outcomes for these services include 100% of clients had a CRPA assigned to them at the initial point of engagement; from the prevention aspect, 84% of clients received harm reduction services (e.g., Narcan, an overdose reversal agent, screening for hepatitis, fentanyl test strips, and clean syringes); and from the social aspect, 91% completed screening for social care needs, with 78% of those needs met by community-based partners. The overall reduction of emergency room and inpatient care demonstrated that coordinated care could improve outcomes and ultimately impact the cost of care. A thorough analysis of visits that were specifically related to overdose and substance misuse showed that the engaged group had a reduction of 56.2% and 42.6% for ER and inpatient utilization, respectively.
The second phase of the program was launched in July 2023.
The Care Coordination Plan incorporates four major treatment partners: Richmond University Medical hospital Center, Staten Island University Hospital (a Northwell Health Member), Community Health Action of Staten Island (a community grants based member of the FQHC Sun River Health), and the Staten Island District Attorney’s Office (See pilot partner description on the next page). The program intends to comprehensively treat 1500 Medicaid recipients on Staten Island over two years who are each at risk of a future opioid misuse event (see pilot program timeline). Staten Island has traditionally been amongst the hardest hit New York State Counties for the Opioid Overdose Epidemic and is also significantly representative of the United States in terms of socioeconomics and demographics, establishing it as a particularly useful social policy laboratory location for scalability considerations.
The Staten Island Hotspotting pilot will be broken down into two one year care coordination cohorts, each with the goal of treating roughly 750 individuals. Over the course of the pilot, continued refinement efforts will focus on the number of treatment partner tracks included, the structure of the alternative reimbursement paradigm, as well as the predictive analytics system’s underlying algorithm and composition. Lastly, the SI pilot program will seek to develop a business case for insurance companies to see the value of establishing a more equitable and effective reimbursement program for providers. As the initiative achieves greater scale and produces positive dual results on both the patient outcome and healthcare utilization reduction front, managed care organizations will be positively influenced to step in and assume the program’s direct reimbursements to treatment providers under this effort.
