ARTS: Service Request Authorization Submission and OTP ......Dimension 5-Relapse, continued use, continued problem potential Dimension 6-Recovery/living environment The ASAM Criteria,

ARTS: Service Request Authorization Submission and OTP/OBOT Overview

Magellan Of Virginia

July 2017

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July 19 2017ARTS: SRA Submission and OTP/OBOT Overview

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http://www.magellanofvirginia.com/

Objectives of Today’s Training

• Outline the elements of a multidimensional assessment.

• Discuss the 6 dimensions of ASAM criteria and how they relate to the submission of a SRA.

• Give an overview of opioid treatment programs

• Give an overview of office based opioid treatment (OBOT)


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ASAM Criteria

July 19 2017

ARTS: SRA Submission and OTP/OBOT Overview

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Guiding Principles of the ASAM Criteria

Multidimensional assessment

Clinically driven-outcomes-driven treatment

Individualized length of service

Broad and flexible continuum of care

Adolescent-specific needs

Clarifying treatment goals

Move away from “treatment failure” as a criterion

Interdisciplinary team approach to care

Role of the physician

Focus on treatment outcomes

“Informed consent”

Medical necessity clarification

ASAM definition of addiction


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Multidimensional Assessment Elements

• History of present episode

• Family history

• Developmental history

• Alcohol, tobacco, other drug use. Addictive behavior history

• Personal/Social history

• Legal history

• Psychiatric and Medical history

• Spiritual history

• Review of systems

• Mental Status Examination

• Physical Examination (as appropriate for individual needs)

• Formulation, diagnoses

• Survey of assets, vulnerabilities, supports

• Treatment recommendations

The ASAM Criteria, American Society of Addiction Medicine, 3d Edition, 2013


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The Six Dimensions of Multidimensional Assessment

Dimension 1-Acute intoxication &/or withdrawal potential

Dimension 2-Biomedical conditions, complications

Dimension 3-Emotional, behavioral, cognitive conditions, complications

Dimension 4-Readiness to change

Dimension 5-Relapse, continued use, continued problem potential

Dimension 6-Recovery/living environment

The ASAM Criteria, American Society of Addiction Medicine, 3d Edition, 2013


Submitting a Service Authorization Request (SRA) for ASAM Level of Care 2.1 to 4.0

July 19 2017


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Key Ideas to Keep in Mind

• Want to give the complete picture of an individual and their need for treatment at this time

• Some history is necessary, but focus generally on current symptoms, strengths and needs

• All 6 dimensions of ASAM need to be addressed and documented at both initial SRA and at extension requests

• The Service Authorization Request should articulate the “Why Now” (Why the individual is seeking treatment or assessment)


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Dimension 1 - Acute Intoxication &/or withdrawal potential

• What is current risk associated with individual’s level of intoxication?

• What intoxication management services needed to address acute intoxication?

• Risk of withdrawal symptoms, seizures, complications based on withdrawal history (observed or reported)?

• Current signs of withdrawal? Or intoxication (UDS results)?

• Any thoughts, urges, cravings, dreams of using, euphoric recall

• Scores from standardized rating scales? (e.g. CIWA, COWS)

• Vital signs?

• Sufficient supports to assist in ambulatory withdrawal management?


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Dimension 1 - Acute Intoxication &/or withdrawal potential


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As with every dimension Magellan needs enough supporting information to be able to determine where

on the continuum the member falls.

Examples:

Ryan has no current signs or reported symptoms of withdrawal.

Dimension 2 - Biomedical Conditions, Complications

• Current physical illnesses that need to be addressed due to risk for treatment complications?

• Chronic conditions that need stabilization or ongoing disease management? (e.g. chronic pain)

• Does individual have any communicable diseases that could impact the well-being of staff or others?

• Physical health indicators? (Appetite, hours and quality of sleep)

• Current medications (prescription or OTC, including PRN)

• Any lab results

• Is the individual pregnant? What is her pregnancy history especially with an opioid use disorder?


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Dimension 2 - Biomedical Conditions, Complications


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Examples:

Ryan has been diagnosed with COPD and diabetes, she has been taking medications appropriately for

both of these conditions and reports being medically stable.

This information is from the initial SRA, but can also be captured in box 1 “Justify ASAM Level of Care” in

the extension request to support the continued stay at the specific ASAM Level of Care

Dimension 3 - Emotional, Behavioral, Cognitive Conditions, Complications


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• Current psychiatric illnesses that need to be addressed? (current mood/affect, psychosis)

• Chronic conditions that need stabilization or ongoing treatment?

• Are emotional, behavioral or cognitive signs appear to be an expected part of the addictive disorder-or are they autonomous?

• Are behavioral symptoms severe enough to warrant specific mental health treatment?

• Any self-harm, or suicidal or homicidal ideations? (safety planning in place?)

• Is the individual able to manage the activities of daily living?

• Can the individual cope with any emotional, behavioral or cognitive conditions?

Dimension 3 - Emotional, Behavioral, Cognitive Conditions, Complications


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Example:

Ryan has been diagnosed with Major Depressive Disorder. He has been taking Citalopram 20mg as

prescribed by his PCP for this diagnosis. Ryan currently reports feelings of depression and this has led

to him using alcohol with greater frequency (5 times per week) in order to cope with these symptoms. He

has not been able to identify healthy coping skills to more effectively deal with these symptoms.

Dimension 4 - Readiness to change

• How aware is the individual of the relationship between his/her substance use behaviors involved in the pathological pursuit of reward or relief and his/her negative life consequences?

• How ready, willing or able does the individual feel to make changes to his or her substance use/addictive behaviors?

• How much does the individual feel in control of his/her treatment service?

• Where is the individual in the stages of change?

• Does the individual believe there is a need for change?

• Is the individual engaged with any other supports (AA/NA)

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Dimension 4 - Readiness to change

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Example:

Ryan was in IOP in November of last year, but ceased attending services. She reports this was due to

her depression worsening and feeling that there was no point. She struggles with recognizing the

connection between her mood and her alcohol use. Ryan reports currently being willing to engage in

treatment because her daughter has been upset by Ryan’s behaviors when drinking. Ryan is currently in

the preparation stage of change, and with support could move toward the action stage.

Dimension 5 - Relapse, Continued Use, Continued problem potential

• Is the individual in immediate dangers of continued severe mental health distress and/or substance use?

• Does the individual have any recognition or understanding of or skills in coping with her substance use and/or co-occurring mental health disorder to prevent relapse, continued use or continued problems?

• Have addiction and/or psychotropic medications assisted in recovery before?

• What are the individual’s skills in coping with protracted withdrawal, cravings or impulses?

• How well can individual cope with negative affects, peer pressure, and stress?

• How severe are the problems that may continue if individual not engaged in treatment?

• How aware is the individual of relapse triggers and skills?

• What is individual’s daily structure?


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Dimension 5 - Relapse, Continued Use, Continued problem potential


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Example:

Ryan has been drinking alcohol since the age of 14, and has been getting drunk with regularity since he

was 19. He has had 2 periods of sustained abstinence, the longest of which lasted about 2 years.

Ryan is unwilling to completely cease drinking at this time. He reports that he is willing to reduce his

usage and avoid “overdrinking” but reports that he does not feel his behaviors are bad enough right now

for him to need to cease using all together.

Dimension 6 - Recovery/living environment

• Do family members, significant others, living situations or school/work situations pose a threat to safety or engagement in treatment?

• Does the individual have supportive friendships, financial resources or educational or vocational resources to increase the likelihood of successful recovery?

• Are there legal, vocational, regulatory, social service, criminal justice mandates that may enhance motivation?

• Are there transportation, child care, housing or employment issues that need to be clarified, addressed?

• What is the individual’s discharge plan? (including housing)

• What is the plan for familial or supportive network engagement? (information about family sessions)


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Dimension 6 - Recovery/living environment


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Examples:

Ryan has recently moved in with her daughter after being evicted from her apartment. Her daughter is

currently supportive of Ryan and has been helping her meet financial needs and with working to avoid

using alcohol. Ryan spends a great deal of time with her boyfriend during the day while her daughter is

at work. She will often drink with her boyfriend, and he has been encouraging her to move in with him

rather than continuing to stay with her daughter.

Opioid Treatment Program Overview

July 19 2017


Opioid Treatment Programs (OTP) – Setting and License Type

• Can be offered in any licensed program with the necessary and appropriate licenses or accreditations.

• They are usually provided in private outpatient clinics, Community Services Boards, or hospital medication units

• Require a Department of Behavioral Health and Developmental Services (DBHDS) Opioid Treatment Service License.


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OTP – Requirements Overview

• Linkage with or access to psychological, medical, and psychiatric consultation.

• Access to emergency medical and psychiatric care through affiliations with more intensive levels of care.

• Access to evaluation and ongoing primary care.

• Ability to conduct or arrange for appropriate laboratory and toxicology tests including urine drug screenings.

• Availability of physicians to evaluate and monitor use of methadone or buprenorphine and of pharmacists and nurses to dispense and administer methadone or buprenorphine.

• Cognitive, behavioral, and other substance use disorder-focused therapies, reflecting a variety of treatment approaches, provided to the patient on an individual, group, or family basis.


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OTP Requirements Overview Continued

• Assessing, ordering, administering, reassessing, and regulating medication and dose levels appropriate to the individual; supervising withdrawal management from opioid analgesics, including methadone or buprenorphine; overseeing and facilitating access to appropriate treatment for opioid use disorder.

• Ensuring methadone or buprenorphine monoproduct is prescribed only to pregnant women (or for 7 days while transitioning members from methadone or buprenorphine/naloxone). All other patients receive buprenorphine/naloxone, methadone, or naltrexone products.

• Monitoring the maximum daily buprenorphine/naloxone dose of 16 mg unless there is documentation of an ongoing compelling clinical rationale for a higher maintenance dose up to maximum of 24 mg.

• Ability to ensure medication for other physical and mental health conditions are provided as needed either on-site or through collaboration with other providers.

• Ensuring take home doses have a maximum 28 days limit (one month supply) dispensing at a time.


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OTP – Requirements for Risk Management

• Random urine drug screening, conducted a minimum of 8 times per year for all patients.

• Virginia Prescription Monitoring Program checked at least quarterly for all patients.

• Opioid overdose prevention education including the prescribing of naloxone.

• Referral for screening for HIV, Hepatitis B and C, and Tuberculosis at treatment initiation and then annually or more often based on risk factors.

• OTP’s have the option of providing care coordination which includes integrating behavioral health into primary care and specialty medical settings through interdisciplinary care planning, monitoring and linkage to appropriate community resources.

***Refer to Chapter IV Covered Services and Limitations for the ARTS manual for additional information and requirements.


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Office Based Opioid Treatment (OBOT) Overview

July 19 2017


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Office Based Opioid Treatment (OBOT)

• Must be provided by a buprenorphine-waivered practioner

• May be provided in a variety of practice settings including primary care clinics, outpatient health system clinics, psychiatry clinics, Federally-Qualified Health Centers, Community Services Boards, Local Health Departments and physician’s offices.

• Must be contracted and credentialed by the MCO’s, MMP’s or BHSA (Magellan) to perform OBOT services.


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OBOT Requirements Overview

• Access to emergency medical and psychiatric care.

• Ensure providing individualized, patient centered-multidimensional assessment and treatment.

• Affiliations with more intensive levels of care such as Intensive Outpatient Programs and Partial Hospitalization Programs that unstable patients can be referred to when clinically indicated.

• Assessing, ordering, administering, reassessing, and regulating medication and dose levels appropriate to the individual; supervising withdrawal management from opioid analgesics; overseeing and facilitating access to appropriate treatment for opioid use disorder and alcohol use disorder.


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• Ensure buprenorphine monoproducts are only prescribed in the following scenarios: when a patient is pregnant, when converting a patient from methadone or buprenorphine monoproduct to buprenorphine containing naloxone for a period not to exceed 7 days, or in formulations other than tablet form for indications approved by the FDA (pursuant to Board of Medicine regulations). All other members should be prescribed buprenorphine/naloxone or naltrexone products.

• The maximum daily buprenorphine or buprenorphine/naloxone dose should be 16 mg unless there is documentation of an ongoing compelling clinical rationale for a higher maintenance dose up to maximum of 24 mg.


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• Due to a higher risk of fatal overdose when opioids are prescribed with benzodiazepines, sedative hypnotics, carisoprodol, and tramadol, the prescriber can only co-prescribe these substances when there are extenuating circumstances and must document in the medical record a tapering plan to achieve the lowest possible effective doses if these medications are prescribed (pursuant to Board of Medicine regulations).

• Ability to ensure medication for other physical and mental health conditions are provided as needed either on-site or through collaboration with other providers.

• Ability to ensure buprenorphine products are only dispensed on-site during the induction phase. After induction, buprenorphine products should be prescribed to the member.


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• Cognitive, behavioral, and other substance use disorder-focused therapies, reflecting a variety of treatment approaches, provided to the patient on an individual, group, or family basis.

• Routine and/or random urine drug screens, conducted a minimum of 8 times per year for all members with at least some tests unannounced or random.

• Virginia Prescription Monitoring Program checked at least quarterly for all members.

• Opioid overdose prevention education including the prescribing of naloxone for all members.

• Members must be seen at least weekly by the buprenorphine-waivered practitioner or credentialed addiction treatment professional during the first three months when initiating treatment. Member must have been seen for at least 3 months with documented clinical stability before spacing out to a minimum of monthly visits with a buprenorphine-waivered practitioner or credentialed addiction treatment professional.


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• Periodic monitoring of unused medication and opened medication wrapper counts when clinically indicated.

• For members who have not been screened for infectious diseases within previous 12 months, screening provided on-site or referral for screening for infectious diseases such as HIV, Hepatitis B and C, and tuberculosis at treatment initiation and then at least annually or more often based on risk factors.

***Refer to Chapter IV Covered Services and Limitations for the ARTS manual for additional information and requirements.


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OTP and OBOT Care Coordination

Substance Use Care Coordination: Service Definition

• Integrates behavioral health into primary care and specialty medical settings

• Care Planning

• Monitoring member progress

• Tracking member outcomes

• Participating in Interdisciplinary team meetings (medical and behavioral) to develop and monitor individualized treatment plans

• Helps to link members to community resources

• Tracks and supports members when they obtain medical, behavioral health, or social services outside the practice

• CPT Code G9012 must be billed with moderate to severe opioid use disorder as the primary diagnosis for non-pregnant members and any opioid use diagnosis for pregnant members

**If the OTP or OBOT provider is not providing the Substance Use Care Coordination, then a licensed Substance Use Case Management provider may work with the member receiving OTP or OBOT services.

***Please note that Medicaid can only reimburse for Substance Use Care Coordination or Substance Use Case Management


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Substance Use Care Coordination: Provider Requirements

• At least a bachelor's degree in one of the following fields (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and has at least one year of substance abuse related clinical experience providing direct services to persons with a diagnosis of mental illness or substance abuse; or

• Licensure by the Commonwealth as a registered nurse with at least one year of clinical experience; or

• An individual with certification as a substance abuse counselor (CSAC) or CSAC-Assistant under supervision .

• An OTP or OBOT


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Substance Use Case Management in the OTP/OBOT setting

Substance Use Case Management: Service Definition

• Enhancing the member’s access to community, promoting living skills, the use of local community resources, and overall adjustment to the community

• Initiating and maintaining contact with member’s significant other in order to promote the member’s ISP and community adjustment

• Ensuring that member has authorized release of information for significant others and that these releases are up to date

• Linking the member to community supports that support the member’s path to recovery and life goals as outlined in their ISP

• Assuring the coordination of services and service planning within the provider agency, with other providers, and with other human services agencies and systems

• Monitoring service delivery through contacts with the members to ensure satisfaction of the member and to assess the quality of care


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Substance Use Case Management: Service Definition

• Advocating for members based on the current ISP or if their needs change

• Supporting the member with transitions that may occur within the member’s life

• Knowing and monitoring the member’s health status

• Understanding the member’s identified needs, and preferences in order to ensure the member is receiving the most appropriate services

• CPT service Code H0006

**If the OTP or OBOT provider is not providing the Substance Use Care Coordination, then a licensed Substance Use Case Management provider may work with the member receiving OTP or OBOT services.

***Please note that Medicaid can only reimburse for Substance Use Care Coordination or Substance Use Case Management


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Substance Use Case Management: Provider Requirements

• At least a bachelor's degree in one of the following fields (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and has at least one year of substance abuse related clinical experience providing direct services to persons with a diagnosis of mental illness or substance abuse; or

• Licensure by the Commonwealth as a registered nurse with at least one year of clinical experience; or

• An individual with certification as a substance abuse counselor (CSAC) or CSAC-Assistant under supervision.

• A licensed DBHDS Case Management provider (license number 16-003 or 16-001 with SA listed)


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Resources

ASAM Materials

http://www.asamcriteria.org/

ASAM Training

https://www.trainforchange.net/training

Magellan of Virginia ARTS Webpage

http://www.magellanofvirginia.com/for-providers-va/arts-information-training-communication.aspx

Magellan of VA Medicaid/DMAS Rates

http://www.magellanofvirginia.com/media/1612857/07-01-17_va_medicaid_dmas_rates.pdf

Magellan Provider Portal

https://www.magellanprovider.com


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http://www.asamcriteria.org/

https://www.trainforchange.net/training

http://www.magellanofvirginia.com/for-providers-va/arts-information-training-communication.aspx

http://www.magellanofvirginia.com/media/1612857/07-01-17_va_medicaid_dmas_rates.pdf

https://www.magellanprovider.com/

Confidentiality Statement for Educational Presentations


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By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

Questions?

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Thanks

Documents

ARTS: Service Request Authorization Submission and OTP ......Dimension 5-Relapse, continued use, continued problem potential Dimension 6-Recovery/living environment The ASAM Criteria,