Planning and Implementing Comprehensive Medication Assisted Treatment Service Delivery Models

Marlies Perez, Division Chief, Substance Use Disorder Compliance Division, California Department of Health Care ServicesRebecca Boss, Director, Rhode Island Department of Behavioral Healthcare, Developmental Disabilities & HospitalsModerator: Colette Croze, Medicaid IAP Truven/Watson Health Team – Croze Consulting

California’s Medication Assisted Treatment Service Delivery Model

Marlies Perez, MADivision Chief, Substance Use Disorder Compliance Division, California Department of Health Care Services

1115 SUD Waiver & Medication Assisted Treatment (MAT) Services

• Narcotic Treatment Programs Required Services• Required Medications: Methadone, Buprenorphine, Oral Naltrexone, Disulfiram,

and Naloxone• Optional Medications: All other FDA approved MAT• Counseling mandatory• American Society of Addiction Medicine (ASAM) assessment for other services

needed• Additional MAT services through SUD providers, coordination with emergency

departments, mandated in contracts, telehealth and upon release from jail • Other Fee-For-Service MAT Benefits

• Regional assessment centers• Brief ASAM screen then full assessment at the provider• CONTINUUM software

Medi-Cal Coverage of MAT

DMC-ODS Pilot Program Standard Drug Medi-Cal Program Other

Opioid (Narcotic) Treatment Program (methadone, buprenorphine, naloxone, disulfiram)

Narcotic Treatment Program (NTP) (methadone)

Medi-Cal Fee-For-Service Medical Benefit (physician administered) (buprenorphine, injectable naltrexone – with TAR)

Additional MAT (all medications for SUD)

Naltrexone Treatment (oral for opioid dependence)

Medi-Cal Pharmacy Benefit (buprenorphine, naloxone, injectable naltrexone – with TAR, disulfiram, acamprosate – with TAR)

Medication services as a component of Withdrawal Management n/a

Narcotic and non-narcotic drugs (other than methadone) used for outpatient heroin or other opioid detoxification services.

CA’s State Targeted Response (STR) to the Opioid Crisis Grant

• California’s Focus• Rural areas without a Narcotic Treatment Program in their geographic area • Increasing the availability and utilization of buprenorphine statewide• Improving MAT access for CA’s American Indian and Native Alaskan tribal

communities

• California’s MAT Expansion Projects • Implementation of the CA Hub and Spoke System (CA H&SS)• Developing the Indian Health Program MAT Project• Offering training and mentoring from the California Society of Addiction Medicine

Opioid STR and Medicaid

• Leveraging Medicaid• Complements 1115 DMC-ODS waiver MAT expansion efforts• Mandating providers in CA Hub and Spoke System MediCal certified

• Vermont Hub and Spoke Model • Vermont SME’s assisting with CA project• Utilizing Treatment Needs Questionnaire and OBOT Stability Index

• CA Hub and Spoke System• Awarded 19 statewide CA H&SS• Learning Collaborative and Clinical Trainings by UCLA• Systems operational in late August 2017

CA Hub and Spoke System

• CA H&SS: a model comprised of NTPs or Medication Units that serve as the Hubs and Data 2000 waivered prescribers who prescribe buprenorphine in office-based settings who serve as the Spokes.

• Hub: a Department licensed NTP or Medication Unit.• Spoke: either (1) a federally waivered prescriber who prescribes and/or

administers buprenorphine, or (2) one or more federally waivered prescribers and a MAT team. A Spoke may consist of individually waivered professionals, FQHCs, or SUD treatment providers.

• MAT Team: consists of a licensed health practitioner and/or licensed behavioral health professional to perform duties that do not require a prescribing license.

CA Hub and Spoke System Requirements

All CA H&SS must submit an Outreach Plan which includes how the system will participate and collaborate with the 36 local county opioid safety coalition networks.

CA Hub and Spoke System Requirements

Required Treatment Services• Prescribe and dispense all FDA approved MAT for an OUD• Counseling• Provide naloxone and training• HIV and HCV testing and referral to services• Case management• Professional medical, social work, and mental health services, offered to patients

onsite or by referral • Recovery and/or peer support services• Local access to maternal addiction treatment• Serve as the subject matter expert on opioid dependence and treatment to the Spokes• Utilize the OBOT Stability Index and the Treatment Need Questionnaire tool

CA Hub and Spoke System Requirements

Optional Treatment Services• Re-entry services for clients leaving correctional facilities• Neonatal abstinence syndrome treatment programs• Patient transportation• Telehealth infrastructure and services• Implementation Infrastructure

Other Requirements• Participation in one of five regional learning collaboratives• Clinical trainings conducted by the University of California, Los

Angeles• Data collection, performance measures and UCLA evaluation

Lessons Learned

• Stakeholder Buy-In• Extensive provider outreach• Intensive stakeholder meetings for 1115 process

• Conduct a Gap Analysis• Analyzed MAT data with CMS (Medicaid Innovation Accelerator Program)• Statewide Mapping Project with Foundations/University of California, Los Angeles• CA Opioid Overdose Surveillance Dashboard

• Utilize Other Resources• California Health Care and Blue Shield Foundations as instrumental partners• Statewide Prescription Opioid Misuse and Overdose Prevention Workgroup

comprised of over 20 California state departments impacted by opioids

Lessons Learned

• Leadership Champions• Early adopters at the state, county, provider and local levels

• Utilize the Media Interest• Reduce stigma and educate on MAT services

• Statewide Opioid Taskforce• Inter-departmental effort• Importance of education and information dissemination

• Dream Big• Collaborate with new partners• Utilize proven strategies and create/test new ones

Contact Information

Marlies Perez, MASubstance Use Disorder Compliance Division Chief,

California Department of Health Care Servicesmarlies.perez@dhcs.ca.gov

Rhode Island’s Medication Assisted Treatment Service Delivery Model

Rebecca Boss, MADirector, Rhode Island Department of Behavioral Healthcare, Developmental Disabilities & Hospitals

Improving MAT Care with Health Homes

Providing whole health care to opioid dependent individuals receiving medication assisted treatment can be quite complex and challenging due to several issues including:

• Multiple co-morbidities • Inconsistent care coordination• Poor connections for primary care, do not attend wellness appointments,

are not connected to specialists • Stigma associated with MAT and substance use histories • Unstable living environments• Historically enabled use of acute care settings for non-emergencies

Opioid Treatment Provider Health Homes

• The OTP Health Home provides clients with resources to navigate an often fragmented service delivery system.

• Working with Opioid Treatment Providers (OTPs) as health home providers allows:

• Heightened contact between medical & clinical professionals who have on-going therapeutic relationships with patients allowing use of existing & enhanced resources to improve patient health, decrease inadequate, ineffective medical care through:

• A focus on relationships with primary and specialty care versus emergency care• Provision of wellness promotion activities• Routine health monitoring• Care management to assist development of recovery supports that promote self-care

Collaborative Efforts to Create Health Homes

• Devised a clear plan to create the OTP Health Home1. Define the services2. Define the population to be served3. Define the provider configuration4. Create reimbursement rates/payment methodology5. Determine health information technology (HIT) requirements6. Define the outcome measures

• Created three new positions in the State Plan Amendment • Administrative Coordinator: 1.0 Full time equivalent (FTE)• Training Coordinator: 0.5 FTE• HIT Coordinator/Consultant: 0.5 FTE

Reaching the OTP Health Home Population

• Enrollment began October 2013

• What your Health Home can do for you:• Help you find a family doctor if you don’t already have one and provide you with direct access to

medical staff to respond to your needs and answer your questions• Assist you in obtaining mental health treatment or any special medical care that you might need• Help you manage your medications and other medical treatments• Provide access to health education opportunities addressing smoking, nutrition and physical

activity• Provide you with a case manager who can help you access other services and supports (such as

housing and employment) needed for your recovery

Creating Health Home Teams and Functions

• OTP Health Home program proposes to create Health Home teams composed of medical directors, master’s level clinicians, registered nurses, case managers and/or peer specialists, pharmacists

• Each client would have an assigned nurse and case manager to: • Monitor healthcare needs• Assist with referral, scheduling, and transportation to medical and other

appointments • Develop a health plan• Provide health promotion and wellness activities • Facilitate transitions between levels of care • Support recovery needs • Identify and provide resources that support wellness and recovery

Level LEVEL 1 LEVEL 2 LEVEL 3

Risk

Typ

e

Low Risk: Practice healthy behaviors; involved in primary careModerate Risk: Borderline results from blood analysis; inconsistentpractice of healthy behaviors

High Risk: Blood analysis indicates development of disease process;high risk behaviors; frequent ED visits, missed appointments

Chronic Conditions: Involvement with primary/specialty care;disease process requires community supportive programming/assistance

Focu

s Prevention, maintenance Refer to appropriate provider(s),prevent further progression of disease process, reduce high risk behaviors

Maintain or improve level of functioning

Activ

ities

Individual coaching or counseling, group participation, etc.

Case management activities including referrals, transition toother levels of care, monitor medication adherence, engage family, community supports

Monitoring, re-evaluating patient needs, medication adherence, coordination of care w/ providers

Developing Patient Acuity Levels to Improve Care

Implementation Highlights

Successful Implementation of Health Home Model in 13 Clinics• 22 Health Home Teams provide services to more than 2,600 patients• Overlay of patient acuity model for patient risk stratification allows Health Home

Teams to better address patient needs• Creation of OTP Health Home Database• First Commission on the Accreditation of Rehabilitation Facilities (CARF)

accredited OTP Health Home in the U.S.

Promoting Education & Collaboration• Development or enhancement of collaborative relationships with MCOs,

community health centers, recovery services, private practitioners • Development of statewide educational & consultative network

Lessons Learned from OTP Health Home Implementation

Collaborate• Pre-arrange memorandums of understanding, qualified service agreements with community

agencies, hospitals, MCOs, etc. • Understand how Health Home clinical features align with current practices

Standardize• Develop standardized forms, policies, guidance documents

Monitor • Identify and/or develop reporting systems needed for outcomes, payment & payment

tracking Educate

• Provide education to existing & new staff that clarifies their roles, expectations, responsibilities

• Include team-building activities• Establish communication guidelines to facilitate implementation

Developing Centers of Excellence (COE)

• Developed out of Governor’s Overdose Prevention Action Plan’s goal to increase access to MAT

• COE Goals• Expand role of OTPs to include buprenorphine & Vivitrol• Admit patients through OTPs & transfer to waivered physicians within 6 months• Expand the role of the Health Home Team• Establish new procedures, protocols & guidelines

• Ensuring care quality with COE Certification Standards • Admit within 24-72 hours of referral in Level 2, within 24 hours for Level 1

How COEs Work• Service delivery & continued supports:

• Not required for all MAT clients – just one treatment option • Time-limited treatment is meant to stabilize patients• Success stems from coordination with primary care & ability to build on the

capacity of community providers • Clinical & recovery support services at COEs can continue after patient is

referred to a primary care provider• Recovery coaches plan an important role in delivering services, especially during

care transitions • COEs are able to rapidly re-admit patients who again require more intensive

services & interventions • COE Services: Comprehensive evaluation, treatment referral, medication

induction & stabilization, enhanced treatment services, support to community providers for transferred patients

Supporting Providers Working with COE

• DATA 2000 Waiver Trainings• Assist physicians in obtaining DEA waiver • Provide training to support staff to better prepare practices for OUD• Two 8-hour trainings• Over 300 trained

• Continue DATA 2000 waiver trainings using Half & Half format as requested

• Collaboration with RI Board of Medical Licensure & Discipline, RI Department of Health to determine where trainings are wanted

• Provide at least 4 trainings annually

• Collaboration with Warren Alpert Medical School at Brown University to incorporate DATA 2000 waiver training into medical school curriculum

Current Status and Next Steps

• State certified the first COE in October 2016 • Eight COE sites across the state

• OTP with five sites• Hospital based with two sites• Community Mental Health Organization with one site

• Next Steps• Use of STR funding to provide psychiatric services to OTPS and COES through

State Hospital • Increased testing of fentanyl• Provision of Nurse Care Manager to large physician based buprenorphine

providers

Contact Information

Rebecca Boss, MADirector, Rhode Island Department of Behavioral Healthcare,

Developmental Disabilities & Hospitalsrebecca.boss@bhddh.ri.gov

Questions for the Speakers?

Marlies Perez, Division Chief, Substance Use Disorder Compliance Division, California Department of Health Care ServicesRebecca Boss, Director, Rhode Island Department of Behavioral Healthcare, Developmental Disabilities & HospitalsModerator: Colette Croze, Medicaid IAP Truven/Watson Health Team – Croze Consulting