t pennsylvania

DEPARTMENTOF DRUG AND

ALCOHOL PROGRAMS

House Human Services Committee

Informational Meeting
Augustzs,2020

Testimony of
Jennifer Smith, Secretary
Department of Drug and Alcohol Programs

One Penn Center, 2601 NorthThird Street, 5tn FL I Harris burg, PA 17110 | 7t7-783-82@ | www.ddap.pa.gov
Thank you, Chairman Murt, Chairman Cruz, and distinguished members of the House Human
Services Committee, for the opportunity to provide testimony on the Department of Drug and
Alcohol Programs (DDAP) efforts in response to COVID-I9.

For those new to the committee, my name is Jennifer Smith, and I have the pleasure of serving as

Pennsylvania's Secretary for DDAP. Acting as the Single State Authority (SSA) for substance use
disorder services, DDAP is responsible for the administration of control, prevention, intervention,

treatment, rehabilitation, research, education, and training activities in Pennsylvania. We serve a

critical role in coordinating efforts with our partners at the federal and local levels, as well as across

state agencies.

As we enter month-six of COVID-I9 mitigation efforts, the drug and alcohol field continues to
amze me with its tenacity, resourcefulness, and willingness to support some of Pennsylvania's
most vulnerable citizens. Navigating the COVID-I9 pandemic while battling the opioid epidemic
and the rise of stimulant usage across the commonwealth is a monumental task. Nothing about the

circumstances or decisions sutrounding COVID-19 has been easy, but our provider network and
the recovering community have navigated the initial shock and subsequent implementation of
revised guidance andpolicies well. I've outlined some ofthose changes below.

Guidance and Policy Updates

As I stated, DDAP is responsible for overseeing the treatment, rehabilitation, and recovery of
individuals with substance use disorder. While we regulate drug and alcohol treatment facilities,
it is important to note that DDAP does not directly fund these facilities. All of DDAP's funding
for licensed facilities is contracted through local entities called Single County Authorities (SCAs).
We have made the following regulatory changes in response to COVID-I9 to better serve
Pennsylvanians: l) updated guidance to opioid treatment programs (OTPs), and2) expanded use
of telehealth.

Opioid Treatment Proerams

On March 16,2020,the Substance Abuse and Mental Health Services Administration (SAMHSA)

issued guidance to OTPs in recognition of the evolving issues sunounding COVID-I9 and

2
emerging needs facing OTPs. These issues include but are not limited to patients congregating in
provider waiting areas to access medication, increased exposure to staff, and increased travel
restrictions throughout the commonwealth due to mitigation efforts.

This flexibility allowed DDAP to request blanket exceptions from SAMHSA regarding OTP
prescribing practices for take-home medications within the commonwealth. SAMHSA approved
DDAP'sblanket exceptions and DDAP suspended regulatory requirements to allow the following:

1. For patients who are stable, OTPs may prescribe take-home doses of up to 28 days.

@reviously the maximum allowable take-home dosage was 14 days.)

2. For patients who are less than stable but the physician believes can safely handle take-
home medication, OTPs may prescribe take-home doses of up to 14 days.

Providers implementing these waivers must notify DDAP and provide policies that have been
updated to reflect these changes. To date, 81 out of approximately 100 providers commonwealth-
wide have submitted policies to use these blanket exceptions. These waivers make it easier for
patients to adhere to the treatment regimen recommended by their medical provider, even under

the difficult circumstances presented by the COVID-19 global pandemic.

Telehealth
Pennsylvania's drug and alcohol treatment facilities are not unique in facing challenges in

providing access to quality care while enforcing COVID-I9 mitigation efforts. A key component
in an individual's ability to maintain sobriety is accessing appropriate services. Therefore, as

authorized by GovemorWolf's Proclamation of DisasterEmergency, DDAPsuspendedregulatory

requirements that to now allow SCAs to use DDAP funding for outpatient substance use disorder
treatment facilities when providing counseling and other clinical services using telehealth
technology. Counselors meeting qualifications specified in 28 Pa. Code $ 704.76) and employed
by a licensed drug and alcohol outpatient clinic may provide telehealth using real-time, two-way
interactive audio-video transmission services . While the two-way interactive transmission is the
preferred method, services provided by telephone and in the home are also acceptable.

J
For some Pennsylvanians, like the medically compromised and those experiencing transportation
or child care issues, the use of telehealth has allowed them to remain engaged in treatment while
taking necessary precautions to remain healthy during the pandemic. For otherso telehealth can
pose a risk of limited accountability. However, just like the decision to increase take-home
medication, the use of telehealth is ultimately a clinical decision in the best interest of the patient,

balancing their treatment needs against the risks of in-person interactions. A similar embrace of
telehealth has taken place across all sectors of health care during the pandemic.

Challenges
Just as any state agency or business throughout Pennsylvania, the drug and alcohol field has
experienced challenges associated with COVID-19. Examples of challenges include the need for

adequate personal protective equipment (PPE), reduced census in treatment programs, barriers to

warrn hand-off protocols, and the isolating nature of the mitigation efforts.

PPE

Drug and alcohol treatment facilities are considered health care facilities, which are eligible to
receive PPE from the commonwealth. However, PPE shortages in the early stages of COVID-I9
made it difficult for some facilities across the commonwealth to obtain the PPE that met their

needs. To help mitigate the impact of the shortages, the department continued to share resources

for accessing PPE from third-party entities and the proper protocols for facilities to access PPE
supplied by the commonwealth. Additionally, many treatmentproviders adapted by taking the

opportunity to form direct relationships with medical equipment suppliers to reduce the risk of a
future shortage within their facilities. At this time, we believe treatment facilities have access to
the appropriate amount of PPE.

Reduced Census

Much like Pennsylvania businesses, treatment providers have lost revenue as a result of the
pandemic. Contributing factors include a reluctance of people to leave their homes and expose

themselves to COVID-19, as well as the need to reduce capacity to comply with mitigation
requirements, including social distancing, imposed by the Govemor and Secretary Levine and

the guidance from the Centers for Disease Control and Prevention. Being able to accommodate

4
fewerpeople ultimately means reduced revenue at a time when costs are climbing due to added
equipment, sanitizing, and overtime for employees who need to step in for fellow coworkers
facing unforeseen circumstances as a result of the pandemic.

And still, providers continue to adapt their operations and facilities to safely meet the needs of
patients by staggering mealtimes, reducing group sizes, conductingtelehealth sessions, and

working to adhere to the mask-wearing mandated throughout their facilities. To directly meet the
needs of patients who have tested positive for COVID-19, residential facilities have created
quarantine wings forpatients showing symptoms and have partnered with otherproviders to

transfer patients, if needed.

Barriers to Warm Hand-off Protoco ls

A key component to Pennsylvania's success in decreasing overdose deaths has been the

development and implementation of warm hand-off protocols between local hospitals and
treatment providers. With the support of DDAP and the Department of Health (DOH), every

SCA throughout the commonwsalth has partnered with hospitals to directly and personally

connect individuals who have entered their emergency rooms after an overdose to treatment
providers who can get them on the road to recovery. Successful programs involve Certified
Recovery Specialists (CRS), who visit overdose patients in the hospital, counseling them, and
developing a trusted relationship that can make them feel comfortable seeking treatment.
Unfortunately, due to hospital visitor restrictions implemented to protect people from COVID-19
early during the pandemic, CRSs were unable to meet with patients directly in most hospitals.
While some hospitals are resuming normal protocols, others have transitioned to using devices
(like Ipads equipped with Facetime) to connect CRSs to patients, and there are still hospitals
unable to meet established protocols for warm hand-offs. Unfortunately, this has meant fewer

referrals into treatment from emergency rooms, but increased overdose cases in some regions of
the commonwealthmean thatthere are certainly still patients in need.

Although some hospitals have adopted technologies to connect patients with the CRS, the
transition has been difficult with the current strain health systems are facing.

5
Isolation
Anxiety. Boredom. Loneliness. These are all emotions that Pennsylvanians may be experiencing
while we continue to face this pandemic. Those emotions paired with hardships like job loss,
food insecurity, and housing instability have created the perfect storm for a potential increase in
overdoses and the need for substance use disorder education, prevention, and treatment. We are

finding that the recovery community, those living in recovery from the disease of addiction, are
most susceptible to experiencing a recurrence of use and therefore overdoses. Anecdotally
we've heard this is true for those who are early in recovery as well as some in long-term
recovery.

For individuals battling substance use disorder, a sense of community and support is critical. It is
important for individuals to know that recovery groups are meeting both virtually and in-person
while following Govemor Wolf's and Secretary Levine's directives and practicing social
distancing: allowing gatherings of no more than250 participants outdoors and 25 indoors,
remaining six feet apart, wearing a mask, and asking participants to say home if sick.

There has never been a more important time than now to check on your loved ones and
neighbors, offer support when necessary, and lend a helping hand when needed.

It is critical that Pennsylvanians know that the drug and alcohol treatment system is essential
health care and will continue to accept patients. Providers are operational and can be accessed by

calling Pennsylvania's Get Help Now hotline at 1-800-662-HELP (4357). The hotline is
available 24/7 - even during the pandemic - and is staffed by trained professionals, many of
whom are individuals in recovery. These professionals directly connect callers to local treatment
and resources forthemselves or loved ones. Help is available regardless of a person's insurance

coverage or financial situation.

Conclusion
On behalf of the department and the Wolf Administration, thank you for your continued focus on
and response to thepublic health crises we face in both COVID-l9and substance use disorder.
We regularly meet with our stakeholders to troubleshoot issues related to the pandemic and

emerging overdose trends and issues, and we remain committed to working with members of

6
Pennsylvania's General Assembly and the federal govemment to better support the drug and
alcohol field. As a board member and Secretary for the National Association of State Alcohol and
Drug Abuse Directors, Inc. (NASADAD),I meet regularly with my counterparts nationwide to
discuss challenges and share what's working well in Pennsylvania, like sharing data outcomes
from providers using telehealth, a recently developed survey for OTPs to better understand what
policies and practices have worked well during the pandemic, and working with DHS' Office of
Mental Health and Substance Abuse Services to require behavioral health managed care

organizations to allow altemative payment affangements to provide stability to mental health and

drug and alcohol treatment providers.

As we approach the month of September, which has been long recognized and celebrated in the
drug and alcohol field as Recovery Month, I'd like to leave you with the following: Pennsylvania
will recover from this. I know thatbecause the drugand alcohol community is a group thatbelieves

in recovery and resilience and lives those principles every day. This community has weathered
many storms, epidemics, and crises together. Treatment works, and recovery is possible - even

(and especially) now.

7
 Written Comments for Jonathan Woll Chief Executive Officer
Pyramid Healthcare, lnc.

Before the Pennsylvania House Human Services Committee

Harrisburg, PA
Tuesday August 25,2020

Rep. Tom Murt

Majority Chairman, House Human Services Committee
110 Ryan Office Building
Harrisburg, PAtTtz9

Rep. Angel Cruz

Minority Chairman, House Human Services Committee
528E Main Capitol Building
PO Box 202780
Harrisburg, PALT!20

Good morning Chairman Murt, Cruz and members of the House Human Services Committee. My name is
Jonathan Wolf and I am the President and CEO of Pyramid Healthcare. I would like to speak to you today
about the effects Covid-19 has had on the behavioral healthcare treatment industry in Pennsylvania.

As the CEO of Pyramid Healthcare, I have been afforded a broad view of the effects of Covid-19 on our
behavioral health system. Pyramid has 46 treatment facilities in Pennsylvania, with over 1,000
detoxification and residentialtreatment beds, 17 medication assisted treatment (MAT) programs, and
employs 1,513 Pennsylvanians. Our programs are located throughout the commonwealth, from Erie,
Butler and Allegheny Counties in the West, to Blair, Centre, Mifflin, York, Lancaster and Dauphin
counties in central Pennsylvania, and in Monroe, Luzerne, Bucks, Lehigh, Chester, Montgomery and
Delaware County as well as Philadelphia. Last year we treated 32,647 Pennsylvanians.

At the outset of the pandemic, through quick action we were able to convert all of our 31 outpatient
treatment facilities to a telehealth model of service delivery. Both private and governmental payers
relaxed their rules, allowing providers to treat clients virtually. Since March 16 Pyramid has delivered
over 435,000 hours of group therapy, conducted over 51,000 individual and family treatment sessions
and successfully completed over 4,000 evaluations by psychiatrists through telehealth. Based on surveys
of over 900 telehealth clients, 97o/o said they were satisfied with their experiences and 98% said they
were developing the skills necessary to successfully manage their symptoms.

Clearly, prior to Covid-19, telehealth was over-regulated and too often discouraged by commercial and
governmental payers and regulators. We have proven that the virtual delivery of behavioral healthcare
is a viable way to augment in-person outpatient treatment. I urge you to take the necessary steps to
ensure that we do not regress to the constraining regulation of the past. Rather, we should require that
payers and regulators embrace the efficacy of telehealth treatment and the need for virtual creativity in
the delivery of care.
As with most every behavioral healthcare provider in Pennsylvania, we have seen significant cost
increases and revenue reductions. Even though we are treating clients in inpatient medical settings face-
to-face, we were neither prioritized for PPE nor funding. The cost to my company to acquire PPE and
increased cleaning and sanitation costs is now over 5500,000 and rising daily. The equipment and
connection costs to convert an entire system to telehealth was almost 5200,000. We have provided over
5700,000 in hazard pay to nurses and other clinical staff bravely treating clients face to face every day.
The cost to test clients and staff to date is over 5150,000 and the cost to treat staff who have become
positive nears 5500,000, and again, is growing rapidly.

While the cost of providing care has risen dramatically, patient volumes have decreased. Due to the fear
that people have in leaving their homes to seek treatment, and our need to reduce beds for patients'
safety, we estimate revenue losses of over S13 Million since mid-March. The cost to create isolation
pods has cost over 5500,000 dollars. Unfortunately, there is no end in sight to these cost increases and
revenue losses.

Commercial payers did nothing to help offset these increased costs and reduced revenue. Only in rare
cases did Pennsylvania counties step in with financial assistance. We work with every county in
Pennsylvania, and are yet to be given any portion of the significant Cares Act funds distributed to the
Counties. The Medicaid managed care organizations (MCO's) have provided early, equalizing payments
and/or temporary rate increases which has helped but it is not enough. Treatment facilities are closing.
ln the last year, our company alone has closed 7 programs, including one of the last residential drug and
alcohol treatment facilities in the Commonwealth for adolescents.

It would seem appropriate that a special fund be established to help residential mental health and
chemical dependency facilities survive this pandemic.

However, there is an even bigger, long term issue.

The cost increases and revenue losses are the tipping point for behavioral health providers who are
treating the uninsured and have not been adequately funded prior to Covid-l-9. The costs for an acute
care hospital bed, nursing care, and 3 meals per day varies from 51,600 to 58,000 per day in
Pennsylvania. Behavioral health inpatient providers are paid only about $2SO per day by Medicaid for
the provision of those same basic nursing and support services, but also must include the cost of doctors
and counselors. ln many cases, the Pennsylvania Medicaid MCO's refuse to pay for the basic cost of care
as established by each County. So, I will sadly tell you that the network of chemical dependency
treatment providers is disintegrating, and at the worst possible time when we are attempting to deal
with the ongoing opioid epidemic.

We cannot attract and retain the necessary staff to treat clients due to the low Medicaid payer rates.
Our staffturnover rate exceeds 4OTo, and that is the norm in Pennsylvania. New providers do not want
to enter the PA market to help meet the overflowing demand for treatment because delivering services
to public clients is increasingly impossible from a business perspective.

The answer is that we must hold the Medicaid managed care organizations accountable to provide
adequate payments to behavioral healthcare treatment providers that ensures a robust, effective
network of care to and win the war inst the ioid e

Thank you very much for your concern and support and for the opportunity to testify
 Written Comments for Mark Schor, Division President
Acadia Healthcare

Before the Pennsylvania House Human Services Gommittee

Harrisburg, PA
Tuesday, August 25, 2020

Rep. Tom Murt

Majority Chairman - House Human Services Committee
110 Ryan Office Bldg.
PO Box 202152
Harrisburg, P A 17 120-2152

Rep. Angel Cruz

Minority Chairman - House Human Services Committee
528E Main Capitol Bldg.
PO Box 202180
Harrisburg, P A 17 120-2180

Good morning, Chairmen Murt, Cruz and the members of the House Human Services Committee.
My name is Mark Schor and I am the Division President of Acadia Healthcare. Acadia Healthcare
is one of the largest providers of behavioral healthcare in the country with over 500 facilities in
the United States and Great Britain. My Division includes approx. 25 Behavioral Health and Drug
& Alcohol treatment facilities across Pennsylvania, offering acute psychiatric and residential
addiction treatmenttotaling to 30,000 individuals a yearand consisting of 1500 beds, MAT and
outpatient services while employing over 3,500 Pennsylvanians. Our facilities operate and are
based in15 Pennsylvania counties. ln some of those areas we are the largest employer and
provide critical support to the local economies through the purchasing goods and services and
paying taxes.

I want to express my appreciation to Chairmen Murt and Cruz and the members of the House
Human Services Committee for holding this hearing. My comments today deal with the impacts
of COVID-19 on treatment providers caring forthose addicted to drugs during the most deadly
opioid epidemic of our time with deaths from overdoses continuing to grow during the crisis.

Historically, our programs have been underfunded well before the pandemic. ln 1988 the average
Medical Assistance and County reimbursement rates were between $125 and $150 dollars per
day. 32years later our rates range from $175 to the low $200s or about $50/day more. l'm sure
you can imagine that an average yearly increase of $1.50 does noit cover all of the cost of living
and other related cost increases, let alone additional costs incurred during the pandemic. During
those 32 years we have had to provide salary increases, raise staffing levels to meet state
mandated requirements and add resources and personnelto respond to the many requests from
the state and Medicaid managed care organizations (MCOs)to add things like peer support, offer
MAT, and provide to a growing number of regulatory bodies an inordinate amount of reporting.
This has been exacerbated by the fact that there is no consistency or communication between
MCOs and the state and myriad of county contracts. . The administrative burdens have become
overwhelming and are mandated without collateral funding to support it all. Not only do we not
receive additional funding to comply with all of these requests and mandates, in many cases the
Medicaid MCO's pay us rates below the cost based rates established by the counties and far
below our cost base.
When the COVID crisis hit back in March, we were incredibly challenged to continue to fight the
opioid epidemic by continuing to provide this life saving treatment. The human cost of our staff
getting sick, hospitalized and even die in order to maintain this mission of delivering life-saving
behavioral healthcare was and is nothing less than devastating. What has made it more difficult
is that to date, we have received no additional funding from the state and some modest help from
some of the MCOs while we have endured over $6lVt in added costs and lost revenues during the
crisis and compounded by these human costs and exclusive of the testing costs which we now
estimate at between $100k and $200k per month.

What is most disturbing is that we have observed federal dollars come to the state, down to the
counties and even the MCOs, but none of it gets to the providers of care it was intended for.
Additionally, we have been told by the holders of the county block grant funds, that as a for profit
provider we are not entitled to those funds, even though we may well be the major provider of
D&A services in those counties. What is more concerning is that there is no mention of that
restriction in how the funds are to be used as well as the fact that unlike not for profits that were
eligible, we pay taxes that contribute to those funds. Over the past 6 months we have closed 8
programs due to severe underfundinq.

lncreased costs due to COVID have included and are related to the purchasing of PPE, Hazard
Pay and overtime, additional staff to monitor and care for sick patients and recruitment costs to
continue to staff the facilities when staff are out sick. To ensure safety and meet regulatory
guidlines we are paying for outside cleaning and disinfecting services, testing and have lost
revenue due to reduced bed capacity in order keep everyone safe by creating isolation units and
quarantine units during this pandemic.

We are respectfully requesting additional support to sustain the provision of these critical
services to some of the most vulnerable and at risk individuals among us during this
unprecedented healthcare crisis. By reducing the administrative burdens, increasing the
provider rates permanently and providing specialfunds to offset COVID costs, we would be able
to continue to provide these critical services and stop the increasing number of closures.

Again, I want to thank the Chairmen and the Committee for allowing me to speak on this
important issue. I will be happy to answer your questions.

Respectfully submitted by

Mark Schor
Division President
Acadia Healthcare
 PRO.
Pennsylvania Recovery
r.
Orga n izations Al I ia nce
9OO S Arlingaon Ave, Suite 254A
HarrisLrurg, PA 171O9 10l-4

PA House of Representatives House Human Services Committee

lnformational meeting on SUD and OUD issues during the COVID-19 pandemic.
August 25th,2O2O Testimony William Stauffer LSW CCS, CADC

o pRO-A wishes to thank the House Human Services Committee for including us here today in this
informational meeting.
o We are also deeply grateful to the treatment and recovery support service system workforce who
are tirelessly serving people in need across Pennsylvania in these very difficult times.
o The most underutilized resource we have to support addiction recovery are the thousands of
pennsylvanians in recovery who understand how to effectively recover from addiction. Recovery is
contagious - lets spread it!
o People recover in community. Strong, effective policy and interventional strategies are best
developed collaboratively with recovering people and recovery community organizations who are
central to the effectiveness of those strategies.

What is a Recovery Community Organization - A recoverv communitv orqonization (RCO) is an

authentic, independent, non-profit orgonization led and governed by representatives of communities of
recovery. These organizations orgonize recovery-focused policy advocacy activities, carry out recovery-
focused community education ond outreach programs, and/or provide recovery support services.
Who we are - the Pennsylvania Recovery Community Organizations - Alliance (PRO-A): We are the
statewide RCO, a 501C3 that started in 1998 with a mission to 'To mobilize, educate and advocate to
eliminate the stigma and discrimination toward those affected by alcohol and other substance use
conditions; to ensure hope, health and justice for individuals, families and those in recovery" has we
have worked collaborativelv to develop recoverv initiatives within the substance use care svstem
across five PA administrations. We have over 5000 members and membership has alwavs been free.
We provide education, training and technical assistance across the state of Pennsylvania.
o 24 states have statewide recovery community organizations similar to PRO-A, many of which have
also supported financially through state resources'
r We were born out of what is called the national New Recoverv Advocacv Movement predicated on
the belief that no policy or service should be developed without the full participation of the
authentic recovery community. These concepts were embraced across our care systems and were
heavily influential in the development of Recoverv Oriented Svstems of Care (ROSC)that here in PA
established collaborative efforts across several departments of government and recovery
community stakeholders over the last 1-5 years.
o peer recovery support services provided by authentic recovery community organization's remain a
fundamental element of a recovery-oriented system of care vision in Pennsylvania and beyond.

PRO-A collaborative work with our Department of Drug and Alcohol Programs (DDAP) has historicallv
been central its state olan (page 11)
 "Recovery is the foundation of DDAP's work on behalf of individuats and fomities experiencing
drug ond alcohol problems. With recovery as o cornerstone of DDAP's work, it is essentialthat
we support and promote the statewide recovery orgonization to ensure that we continually
have representation of the faces ond needs of the individuals and famities that we exist to serve
distinct from stakeholders in the direct service orena. tt also provides a mechonism to engage
ond support individuals and groups across the Commonwealth concerned obout the issues of
oddiction and recovery.

Noted work conducted by PRO-A for the state of Pennsylvania include:

r Development of the Recovery Oriented Svstems of Care - White Paper in 2008 through the
Pennsylvania Drug and Alcohol Coalition established in collaboration with Pennsylvania Governor's
Policy Office, Department of Public Welfare, Office of Mental Health & Substance Abuse Services
and the Department of Health, Bureau of Drug and Alcohol programs.
r Development of the Certified Recovery Specialists (CRS) with other RCOs, one of the first peer
credentials in the nation, designed by the recovery community to serve our needs.
o Oversight of the Certified Drug and Alcohol Recoverv Housins (CDARH) Task Force for DDAp. This
report assisted the hard work of this body in the passage of Act 59 of 2017.
o Authored a paper at the request of DDAP to examine national trends to improve best practices for
our recovery community Thriving Communities in Recoverv: policv Report on National Trends, Best
ract an nt Environmen
o Facilitated a series of focus groups in 2019 for our Department of Drug and Alcohol Programs on
Peer Familv Support Services (PFSS) to inform the development of family peer services.
o Completed a2O2O, preliminary report to our Department of Drug and Alcohol Programs titled
Strategic Peer Workforce Development focused on strengthening the SUD peer professional
workforce that came out of our organizations grassroots efforts over the last two decades.

Supporting Recovery During the COVID-19 Pandemic

1. Stabilize our fragile treatment and recovery support service system. Dramatic increases in
substance use across the country and evidence of increased resumption of use within the recovery
community highlight the dire need we have to preserve our care infrastructure.
2. Focus resources on strengthening our public substance use service system infrastructure, including
our treatment and recovery support service system which has been underfunded for decades.
3. Strengthen and support our SUD service system workforce who are on the front lines and face
overwhelming odds to provide care day in and day out.
4. lnclude the recovery community at all levels of our care system design and implementation as
ultimately recovery occurs in community to ensure a long-term care infrastructure that works for
generations to come. This will help us spread the "social contasion of recoverv and hooe."

COVID-l9, Deaths of and Serving Diverse Communities

The opioid epidemic is part of a larger trend in America related to deaths of despair which have hit
rural communities particularly hard. Deaths related to despair over the last two decades include opioid
and other overdoses, increasing mortalitv rates associated with alcohol dependence and, as noted bv
the CDC a steadily increasing rate of suicide in America across the last several decades.

2
The underlying elements of deaths of despair seem to link to a general loss of hope, loss of purpose
and loss of connection across our society. These are deeply troubling trends that suggest a need to
strengthen community, strengthen family and social institution connectivity and strengthen
employment and civic engagement across our society. Deaths of despair seem to have has a greater
impact in rural communities, which perhaps has led to an increased focus on deaths from these causes

These deaths of despair have been largely experienced by white, non-Hispanic males. We also know
that the African American have been experiencing reduced life expectancy for decades. On average
still les s than that of non-Hisoanic White men born in 1-990. Accordi ng to a paper published in 2012 in
the Frontiers of Psvchiatrv. African Americans have higher abstinence rates than the general
population, but experience a disproportionate health consequences related to addiction and significant
disparities in drug related incarcerations. When in treatment, studies have found that African
Americans are less likely to complete, largelv because of socioeconomic factors. All of these dynamics
may very well be exacerbated by the COVID-19 Pandemic. A recent study published in the Lancet on
the COVID-19 pandemic found that Black, Asian and Minority Ethnic individuals had an increased risk of
infection COVI D-19 and worse clinical out es. includins ITU admissi and mortalitv We must move
towards care that addresses the needs of all our diverse communities, including black, indigenous and
people of color.

The COVID-l-9 Pandemic has been exceptionally difficult for the entire recovery community' COVID-19
related social isolation and stress can i ncrease susceptibilitv to su bstance misuse, ad diction. and
relapse. Recovery occurs in community, and the pandemic has disrupted that community. We have
seen a spike in overdose deaths with early data estimating that overdoses are up bv roughlv 18%, with
later reports suggesting that the increases could be as high as 42%. lt is being reported that as many as
7( f)OO non nla miaht dia frn m ct tct .la nrrarrlnca nr rlrn hol misu triggered by the uncertainty and
unemployment caused by the COVID-L9 pandemic. We are also seeing a dramatic increase in alcohol
sales nationally. March 2020 alcohol sales were up 55%, fueling concerns about increased substance
misuse to cope with the stressors of COVID-19. Methamphetamine, which is on the increase in PA, has
been found in some studies to reduce resistan ce to COVID-19 throueh lowe immunitv and
increased rates of infection.

The Pandemic is also resulting in disruption of treatment and recovery support services. Programs
across the state have closed, like this one a few weeks ago in Berks county. We have a care system
workforce working tirelessly to keep services open and safe. And they are doing it with the lowest
substance u orofessional oav rate other than West Vireinia in our SHA resion. Care disruption is
largely due to fear of people with addictions seeking help is a result of COVID-19. Programs are also
experiencing financial difficulties created by census levels well below the break-even point due to the
Pandemic and experiencing increased costs to safeguard patients and staff from COVID-19 through
testing and protective measures.

There are alarming stories of relapses within our community, even among people who would under
more normal circumstances be considered stable. Recently, at the World Economic Forum COVID
Action Platform. Dr Judith Grisel of Bucknell University stated in respect to addiction recovery that
"repairing the holes in the bucket requires connecting with other people. Our addictions thrive in
alienation and so it's absolutely a challenge to figure out ways to cope and connect that are

3
sustaining." Loss of connection due to physical distancing, shelter in place requirements and job losses
may well underpin increased resumption of use in our communities.

Efforts to decrease deaths of despair, including those from addiction must include addressing the
disparate social determinants of health in stark relief as a result of the COVID-19 pandemic. We must
begin to examine service access and utilization data so we can more fully understand care disparities
and move towards care without disparate outcomes. This will mean moving away from an acute crisis
orientation and addressing broad care sytstem infrastructure needs. To do this effectively, we must
include people in recovery in the design, development, facilitation and evaluation of care. This is vital
in order to develop these care models in consideration of the diverse communities who use them and
the communities in which they will sustain recovery over the long term.

Moving Beyond a crisis orientation to Sustain our care lnfrastructure

Crisis mentality narrows focus - We have been on a crisis footing in respect to addiction for many
years, well before the opioid epidemic. While a great deal of progress had been made reducing
overdose deaths, those deaths must be viewed in terms of our larger SUD service structure
infrastructure needs specifically and healthcare disparity in general. Overdose deaths are tragic and
sudden, but are also only part of the picture in respect to how addiction kills our family members and
friends. whole person recovery is key to long term efficacy for our care system.

Opioid Addiction is only part of the dynamic - We have somewhat incorrectly focused federal
resources flowing to the states on opioid as overdoses highlight these tragic losses, yet missed the
larger trend of deaths of despair and disparate social determinates of health occurring in our society.
ln this 20L5 report by the CDC, OAo/^ nf nc st rh ornin r rcorc rannrfar.l use of at c+ nha nthor drr rc
I

durine the past vear, and 61% reported using at least three different drues. ln addition, a significant
percentage of heroin users met diagnostic criteria for past-year misuse of, or dependence on, other
substances. We must treat and support the whole person. including recoverv support needs.

Moving services into the virtual environment - One of the untold success stories of the COVID-j.g
pandemic is the work that the recovery community did to move recovery support services and
recovery fellowships into the digital realm during the early weeks of the COVID-L9 pandemic. pRO-A
has played a very active role in supporting efforts to address these needs since the early days of the
Pandemic. Most notably coauthoring a paper with internationally esteemed author Bill White on who
is left behind in on line services and facilitating training nationallv and roundtables across the countrv
to support the effective development of on line treatment and recovery support services. Some people
find digital services less intimidating and more convenient to access, while others have difficulty using
them or prefer face to face interaction. We have the opportunitv in the earlv stages of the use of
telehealth services to determine with whom and how thev can be used most effectivelv.

lnclusion of grassroots recovery community organizations - People recover in community and

nurturins the environment in which recoverv is fostered is criticallv important for persons with
addictions, our families and our communities. Recovery fosters resiliency and the development of
recoverv capital. Evidence suggests that recovery is contagious - it has been characterized as the
contagion of hope. Recovery benefits everyone in the communities it occurs in, this has been a central
focus through the mission of PRO-A since our inception and we are prepared to assist in these efforts.

4
Addressing the Trauma Load on the Recovery Community from COVID-19 - We are learning that the
trauma load created by the COVID-19 pandemic is particularly hard on our recovery communities. PRO-
A is working to provide support and educational material like our Post Traumatic lnformation Sheet
while getting information out across state on virtual and in person recoverv events and COVID-19
resources and srrooort platforms in order that people can sustain their recovery. Focusing support and
inclusion strategies on recovery communities is important for a myriad of reasons. We are learning
1[s1 strengthening recoverv in communities has protective properties against addiction, and make
communities healthier. There is evidence that recoverV can spread in wavs that improve overall
communitv wellness. and helping others can actuallv help people sustain their own recoverv.

Strengthen our care system infrastructure for the next generation - As programs are shuttering their
doors across Pennsylvania in recent weeks, it has become increasingly apparent that many programs,
particularly the public sector programs teeter on the edge of solvency even in the best of times. This is
in no small part because resources for strengthening our substance use care system have always been
limited. As all service systems, we need more resources in order to improve that care system. We also
uld cons we are tn that
care service svstem over the long term to ensure it is available for the next gen€rdtion.

Long Term Recovery Care Service and Support Model

Beyond the COVID-1-9 pandemic, addiction is arguably our most profound national public health crisis
We should be shouting from the rooftops whot science is showing us - that maximum effectiveness of
recoverv is achieved with a five-vear sustained recoverv model - 85% of people with a substance use
disorder (SUD ) will remain in recoverv for ife if thev achieve five vea rs of recove rV
I

Achieving this standard of care across our service system requires expanding peer and community
focused services and reorienting care to a long-term service model. lt should link clients to peer
professionals to make conti n tinence more appealing d bevond interventions fo cused on the
individual or fa milv to include the lo lcommu nitv to incentivize longer-term recovery. Such a model
includes treatment assisted by medication, peer support services, family supports and case
management to help people get back into care quickly in the event of resumption of use. People
should be able to obtain multiple services based on individual need, generally reducing in intensity
over time. ln the event of resumption of active use, people must be able access more intense care in
real time with no arbitrary limits, delays, or barriers, much like what happens with a heart attack'

When a person gets a diagnosis of cancer, our medical system orients care to initiate multiple
interventions, procedures, supports and checkups over the long term. lf one approach does not work,
we move to another. We do not refuse care or limit care if one procedure does not work. lt is a chronic
care model Such a svstem is flexible . orooerlv resourced, and offers multiple pathwa vs to health. The
svstem coordinates ca re in a suooortive manner through the disease pro cess to then celebrate five
vears in remission. This model, the five years recovery model, makes sense to the recovery community.
Qrrcfamc rnr{ no nnot da+ n r r+ nf cricic rrri
la aliba aa srs mt n r.l caf While we have made significant
strides here in addressing the opioid element of the addiction crisis, the COVID-19 pandemic is showing
that our overall care system infrastructure is frail and now is an opportune time to consider how to
reshaoe our care svstem for maximum efficacv to ddress our addiction eoidemic in a svstematic and
manner inclusive of our recoverv communitv stakeholders at the state and local levels.

5
 P TCDAA
ftr$rytTltkr Alroa15tor: *l C***tl S{* In**lr*h$l rld{m,tlrils"r
Ar tltls o{d* {**g i.ffi &ras {ii*d*E

TESTIMONY BEFORE THE HOUSE HUMAN SERVICES COMMITTEE

Presented by

Judy Rosser, Director, Blair County Drug and Alcohol Program, lnc, PACDAA Chair

Diane Rosati, Director, Bucks County Drug and Alcohol Commission

August 25,2020

7
Good morning. Thank you for the opportunity to present comments today. My name is Judy

Rosser, and I am the Director of the Blair County Drug and Alcohol Program lnc., and Chair of
the Pennsylvania Association of County Drug and Alcohol Administrators (PACDAA). We are an
affiliate of the County Commissioners Association of Pennsylvania (CCAP) representing the 47

Single County Authorities of the Commonwealth. ln 1972, the Commonwealth of Pennsylvania

established a single state agency and a system of Single County Authorities to implement

substance abuse prevention, intervention, treatment and recovery services through county-

based planning and management. Act 63, The Pennsylvania Drug and Alcohol Abuse Control

Act, requires the Department of Drug and Alcohol Programs to develop a State Plan for the

control, prevention, intervention, treatment, rehabilitation, research and training. Single County

Authorities are responsible for local implementation of that plan.

Single County Authorities, under the direction of the Pennsylvania Department of Drug and
Alcohol Programs (DDAP), are the backbone of each county's drug and alcohol service delivery
system for residents. Among other essential roles, we ensure seamless access and quality drug
and alcohol services for Pennsylvania residents. lt is worth noting that there are over 22 million
people in the US who are in long term recovery from substance use disorders. Our services are
critical to Pennsylvania residents, to move them, too, toward recovery.

SCA's receive state and federal block grant funding and federal opioid grant funds from the

Department of Drug and Alcohol Programs, Behavioral Health Services lnitiative (BHSI) and Act
152 funding from the Department of Human Services. SCA's work diligently with local partners

to manage Behavioral HealthChoices networks and services.

Today, I am here with Diane Rosati, Director of the Bucks County Drug and Alcohol Commission,

to discuss the SCA response during the COVID-19 Pandemic. We continue to address an
epidemic of substance abuse within the global pandemic. As COVID-19 rates fluctuate across

the state, local response from the SCA's and their provider networks also vary. We will share our

local experiences and response during these challenging times.

Across the Commonwealth, there are also shared impact and the need for some statewide

solutions:

2
 a We must find creative ways to keep individuals who are in recovery connected to

recovery support and treatment services. lsolation, particularly during early recovery,

increases the risk and likelihood of relapse.

a We need to support the provider network as they struggle to keep clients and staff safe

from the virus

a Funding must be sustainable and flexible. We have become reliant on federal opioid

funding to expand services;we need continued funding to maintain these services and

expand them to serve individuals who abuse other substances.

Diane will share her SCA's perspective and experiences from Bucks County

We are singularly focused on ensuring the community is aware that help is available; prevention
and treatment are effective; and recovery is not only possible, it is likely, with living examples
woven within the fabric of our neighborhoods, workplaces, families and houses of worship.

SCAs have met the challenges of COVID-19. Our own SCA is located in Southeastern
Pennsylvania, a suburban county which borders both rural and urban communities. ln Bucks
County, we were as prepared as possible;we responded most effectively as it is what the
community deserves. Additionally, we are continuing planning on an ongoing basis for what
our needs and challenges may be going fonvard. I appreciate the opportunity to share a
summary of our preparation, highlights of accomplishments and challenges.

Preparation:

Bucks County leads the state of Pennsylvania in the volume of unused medication collection. We
are "number one" in the state, we have 44 permanent medication boxes and a community that
has leaned in and drops off their medications on a regular basis. lt is just part of our culture. The
quarantine brought a special challenge, as families were remaining in the home, potentially with
children having access to medications.

We prepared social media posts and a video by our District Attorney, on using Medication Lock
Boxes and the lJp and Away and Out of Sight campaign. We provided Medication Lock Boxes to
treatment providers who were permitted to allow Medication Assisted Treatment (such as
Methadone) take home doses, to ensure the medication was securely stored. We also offered
Lock Boxes and Deterra Disposal Bags to community members.

As you all know the topic of Recovery houses can be challenging. Today I am here to share
some good news regarding Bucks County Recovery Houses. We have hired, with HealthChoices
Reinvestment funding, a Recovery House Coordinator. He works directly with each house owner

3
on policy, complaints, and program outcomes. I am pleased to report that there have been no
COVID-19 positive residents, at least thus far, which is quite an accomplishment for a shared
living arrangement. All recovery houses have been proactive in preventing the spread of the
virus by diligently pre-screening potential residents, regularly stocking houses with
cleaning/sanitizing supplies, and implementing additional chore requirements including daily
sanitization of high-contact surfaces throughout the house. Recovery house staff have closely
monitored residents coming and going to and from the home to ensure any out-of-house
activity is safe and for essential purposes. Visitors coming to the recovery houses are forbidden
at this time, unless first approved by management. BCDAC, lnc. has assisted in supplying
recovery houses with masks for residents upon request.

lmagine being new to drug and alcohol recovery, and at the same time, having a COVID -19
diagnosis. You have burned every bridge with your family and cannot return home, or you are
homeless, or you do not qualify for a hospitalization because you are not that medically
compromised. Our SCA partnered with local Department of Health, as well as Mental
Health/Developmental Programs, Housing and providers, and contracted with a local hotel
where we house such "guests" while providing telehealth and on-line recovery supports for
about a 14 day stay while they convalesce. They take their own temperature each day, receive
daily delivered meals, participate virtually in recovery supports such as AA meetings, have a case
manager for any challenge they encounter, and have a safe, secure place where they can
convalesce.

Accomplishments:

Narcan is the life- saving medication, to counteract an opiate overdose. At the onset of the
pandemic, County jails were focused on reducing jail population and maintaining a COVID-19
free environment, to the best of their ability. As our county jail was releasing inmates according
to their identified criterial, we recognized that some inmates with Opiate Use Disorders were
being discharged to the community. Ourjail leadership agreed to provide education on Narcan,
as well as doses of Narcan, upon release. For the general public, also at the onset of the
pandemic, we had unfortunately cancelled in person Narcan trainings which we frequently offer.
To pivot and still meet community need, we notified county residents that we had partnered
with an organization to fund mail-order Narcan.

Virtual or on-line strategies have become the norm. We know that people respond in many
different ways to in person versus on- line communication. We deeply appreciate the flexibility
of Virtual, or Telehealth, which has kept our system afloat. We have heard from families who
benefit from the convenience of on-line therapeutic family sessions, as well as no wait for intake
or assessment services. Our treatment as well as prevention services have utilized virtual

4
communications and adjusted to meet community needs. We now conduct virtual on-site
monitoring of our recovery houses, with visual tours as well as resident interviews.

Challenges:

We know that when someone is ready for treatment - we must be ready to assist. During
COVID-10, treatment providers have risen to the occasion. They have obtained necessary PPE,
established social distancing, and often had to reduce their capacity. For example, one provider
had to reduce their capacity from 65 clients to 33, to allow for social distancing. Less people
were seeking treatment, especially at the onset of the pandemic. lncredible costs of cleaning
and sanitizing, staff hazard/overtime pay and purchase of HVAC or furniture, are all challenges.
Some have had to completely shut down for a period of time, or stop taking referrals, due to
staff or client COVID-19 diagnosis. We are concerned with how our highly regarding
drug/alcohol treatment providers will weather this storm, as we have already seen some closing
their doors. CARES funding has been a lifesaver for many providers. Our county had allocated
funding based on provider and community need. The concern is the unknown, and how
providers canlshould prepare knowing that CARES funding may be time limited. lf the provider
learns they need a new HVAC system, or needs to add on to their building due to social
distancing, will additional CARES funding be available into 2021?

People who are new, or even not so new, to recovery, can have "triggers" on beginning to use
their drug again. Our job is to build their resiliencies and help develop new skills and coping
mechanisms while they participate in treatment. We have notices that the rate of "AMA" or
Against Medical Advice, has increased. One key factor is that these folks have received some
form of government funding (example: unemployment compensation) and they are leaving
treatment and using the funds to support their drug use. Of course, we are not advocating to
not provide these funds to individuals, but simply making the case that this is another challenge
that is being addressed in treatment centers and recovery houses.

I wanted to end on a hopeful note, as that is our role, to offer hope for change, to demonstrate

that together we can make a difference, and to show each of you just how hard we are all

working on behalf of PA residents.

A few county leadership-directed items that we are proud of are:

On Day One of the quarantine we were led by a county Commissioner to establish a

Behavioral Health Helpline for Bucks County residents. The Helpline is staffed by MH/DP
and D/A staff and offers support for individuals who are oven;'vhelmed by all that this
healthcare crisis has brought.

5
 a We have a highly regarded website, bcdac.org. We expanded our Facebook and Social
media, also adding lnstagram posts and our staff planned postings and campaigns a
month in advance. We added a COVID-19 link which provides local resources. Our
agency tagline, "We Are Here to Help" is one that we demonstrate daily.

Thank you so much for the opportunity to share our Bucks County COVID-19 response. Judy's
perspective from a smaller, more rural county has been different, but common threads connect
the SUD system across the Commonwealth.

I would first like to thank the members of the committee for their interest and concern
regarding the impact of COVID-I9 on the disease of addiction. As I have described in the

opening, the SCA is on the front line in planning to address this issue in our community. We
provide a firsthand perspective on not just the negative impact but also what we see is

working in this current environment. From my experience, not just as a SCA but also a
provider of care coordination of services, recovery support services and prevention, we have

learned some valuable lessons, some good and some that need improvement.

First, I need to stress the isolation produced by the shutdown has had a negative impact

on our recovering community. lsolation for someone in recovery is a risk factor for relapse.
We saw this in the last five months. The recovery support system that is not just the

treatment system but those grass root supports, such as 12 step recovery supports, SMART

Recovery, Celebrate Recovery, faith communities are still being impacted. Most of our

support groups are hosted by churches. Some of the churches have still not opened to

allow these groups to return. Online support services are still available but cannot replace

the fellowship that is inherent and needed to sustain a healthy recovery. I myself have 32
years of recovery through a faith pathway and I can tell you the isolation produced by the

shutdown was real and I am still impacted today as my church has not reopened.

From an SCA perspective, the response by the state and federal government was impressive.

Regulatory barriers that could have completely left individuals without care in those first few

weeks were removed. Examples include permitting Medicaid and SCA funding of telehealth

services (telephone/video conferencing). This allowed our treatment system to continue to

6
maintain community -based services and not leave individuals without connections and

support. The SCA and provider system quickly adapted and were able to keep individuals in
care during those first 3 months and still today.

The PA Department of Human Services, Office of Mental Health and Substance Abuse

Administration (OMHSAS) and the Department of Drug and Alcohol Programs (DDAP) were

also quick to look at regulatory barriers and allow for the exceptions to the requirement of

face to face services. They worked with the Behavioral Health Managed Care Organization to

ensure alternate funding payments to sustain providers during the crisis.

One of the barriers which are very real, especially in the rural and disadvantaged

communities is the lack of internet connections. lndividuals who would have gone to

different locations in their community to use free wi-fi to make calls and text, during the
shutdown did not have this available to them. This left some without services and feeling
very isolated.

Our capacity in residential facilities was impacted due to the need to organize the
population into smaller pods in orderto minimizethe riskof a COVID-19 outbreak. PPEand
testing were not made available to these residential facilities. Facilities were left scrambling

to find resources. These shortages continue to exist today. We did not see admissions
impacted by this during the shutdown timeframe due to the drop of person seeking help.

Currently, we are beginning to see outbreaks of the virus in our facilities. Anecdotally it is

being reported that most are asymptomatic but due to the out breaks and instructions to set

up redlyellow/green pods, we are starting to see some impact on capacity to admit. The

one frustration of the facilities is the lack of testing resources. Labs are oven,vhelmed and it

can be days until results are received. This ties up the beds in the red pod, impacting

admissions. This is an emerging concern.

Most of our community-based providers have returned to face to face seruices. We initially

seen the engagement in telehealth services but after approximately 10 weeks we saw a drop

in engagement. ln Blair we saw most of our providers returning to face to face services as

7
 soon as we went green but still offering telehealth as needed. The concern for the

recovering community drove these decisions.

The current environment continues to impact our recovery resources. The challenges to
maintain the services while trying to keep staff and clients safe and healthy is weighing

heavy on the system. Additional state and federal funding will inevitably be required to

sustain facilities and cover Covid costs (PPE/Cleaning/ lost income from Shutdowns). Some

of our providers residential and community based especially in our rural communities will
not be able to survive without support.

We will continue to work diligently with the legislature, state and federal agencies to share

our progress and concerns and appreciate the opportunity for ongoing dialogue. Our

contact information is listed below.

Thank you again for this opportunity

Judy Rosser, Executive Director

ihffisno.-
/ \ pemrqensnrps
*q/&er{+r*
1i3ti !j"$3i i*,!r :',at+:i .41?r,ti-;. prl !t*{1.'
a r€ illr litli
ati 18!,!"..t.,,
bl.lrdt* or9

Diane W. Rosati, Executive Director

Bucks County Drug & Alcohol Commission, lnc.

55 East Court Street

Doylestown, PA 18901

2ts-622-50s0 (cell)

www.bcdac.org