Enhanced Substance Abuse Management in Higher Risk Populations Pano Yeracaris, MD, MPH Vice President & Chief Medical Officer, Network Health Annual Community Health Institute May 9-11, 2012 Resort & Conference Center of Hyannis Hyannis, MA
Enhanced Substance Abuse Management in Higher-Risk Populations Pano Yeracaris, MD, MPH Vice President and Chief Medical Officer May 10, 2012
Case study I 52-year-old male member Diagnosed with schizophrenia, diabetes, and dyslipidemia Has significant back pain, bouts with nausea and vomiting, and prior history of addiction Lives with long-term girlfriend Receives SSI disability benefits Been in recurrent car accidents (not the driver) Prescribed methadone, oxycodone, insulin, metformin, and multiple psychiatric medications Gets off medication and decompensates 3
Agenda About Network Health Effects of substance abuse (SA) on cost SA care strategies Case and intervention studies Potential for enhanced SA management Challenges 4
About Network Health We are a comprehensive, nonprofit health plan serving Massachusetts residents with low and moderate incomes We aim to improve the health and well-being of our members and their diverse communities We have more than 20,000 primary care providers (PCPs) and specialists We serve more than 200,000 members in more than 300 Massachusetts cities and towns We have a diverse workforce of more than 400 employees 5
Network Health strategy Excellence in clinical quality and cost structure Segment, target, and engage highest-risk members Focus on the top 10% of high-cost members Work to improve health outcomes Use integrated care approach Engage through clinical community outreach Offer innovative care management programs Continue to enhance programs 6
Effects of substance abuse (SA) on cost Members with SA diagnosis significantly impact total medical expense (TME) In FY11, MassHealth members with SA diagnosis had 2.6x higher PMPM costs than members without SA diagnosis Members with likely SA and no evidence of treatment had TME 25% higher than those with some form of treatment National data shows very similar results 7
SA care strategies Require notification only for detox admissions Use an integrated care approach for discharge planning and aftercare Prioritize members with potentially untreated SA for clinical community outreach 8
Network Health s integrated care approach Fully integrated, in-house approach addresses member needs across the care continuum Multidisciplinary team Co-manages cases and collaborates on care management rounds Shares integrated clinical software Has dedicated outreach office staff and geographically based clinical community outreach team Internal referral system for case consultations Classify cases according to primary member needs Consult to support all member needs Cultural competence Leverage data to address social and cultural barriers to care 9
Integrated care program and initiatives Medical needs After-hours access to medical clinician Asthma education program Early intervention pregnancy program High emergency department utilization program High-risk maternity program Neonatal intensive care unit program Newborn, childhood, and adult wellness screening program Partnership with Neighborhood Diabetes Provider partnerships for special programs Utilization management (UM) aftercare program Behavioral health (BH) needs After-hours access to BH clinician Attention deficit hyperactivity disorder program Children s Behavioral Health Initiative program Community service provider program Emergency service provider program Substance abuse early intervention program Social needs Assessment for enrollment in other programs Assistance with applications for special programs Assistance with food, clothing, and other essentials Assistance with transportation Cellphone lending program Coordination and connection with local resources Wellness needs Age-specific obesity management services Health coaching for certain diagnoses/conditions Infant, toddler, and child car seats Member outreach calls to coordinate care and reduce gaps Progressive wellness reminders and appointment scheduling Provider partnerships to close identified gaps in care UM aftercare program Safe living environment Smoking cessation programs Support and coordination for basic needs Toddler and child bike helmets 10
Clinical community outreach Engage members for 2 6 weeks of outreach intervention using motivational interviewing Connect/Reconnect with PCP and other services Increase member participation in available benefits and resources Preventive health care services Community resources Transition to longer-term care management as needed 11
Case study II 46-year-old male member Has history of alcohol and cannabis dependence Expressed interest in SA treatment during assessment 12
Interventions Case study II (cont d.) Assisted with detox admission and post-detox treatment Outcomes Participates in sober transitional living program 13
Case study III 43-year-old male member Has history of opioid dependence, asthma, and diabetes Refused to enter SA treatment initially 14
Interventions Case study III (cont d.) Coordinated medical care and community resources Provided education on SA treatment Outcomes Entered detoxification program 15
Intervention study in Washington Five-year study of SA treated population vs. untreated population $252 PMPM reduction in TME if attended program $363 PMPM reduction if completed program $899 PMPM reduction after one year of methadone treatment 16
Kaiser intervention studies in California Group-based outpatient and day treatment with integrated primary care $220 PMPM reduction in TME versus control group (independent primary care) 18 months pre-treatment vs. 18 months post-treatment TME in SA treatment group reduced by 26% Psychiatry services (2.1 hrs/year) improved abstinence rates and reduced yearly TME during five years of study 17
Screening, Brief Intervention, and Referral to Treatment (SBIRT) studies Multiple studies show improved results at societal level Reduction in trauma, ED use, and hospitalization suggest positive effect on TME Access and availability of services an issue, as are disconnected SA and primary care services 18
MASBIRT training/ technical assistance opportunities The MASBIRT team continues to consult with and train health care workers and teams in a variety of settings If you are would like to incorporate SBIRT into routine clinical practice at your site, the MASBIRT team is available to: Meet with you and your staff Provide an implementation strategy assessment Conduct trainings Provide technical assistance Topics can include SBIRT implementation strategies, motivational interviewing, and ways to integrate brief treatment Call Lee Ellenberg at 617-414-6922 to learn more or to plan a training Source: Massachusetts SBIRT News, Spring 2012, Issue 2 19
Observations from intervention studies Improving care outcomes: Usually requires more comprehensive system of care Requires integration of SA services and primary care Needs strong partnerships to address access and quality 20
Potential for enhanced SA management Ideally within accountable care organization Combined medication and psychosocial treatment most effective Stepped care approach based on level of severity Adequate support and training for primary care Consultation and support for moderate addiction Co-management of care for more complex cases Psychiatrist or addiction specialist as primary treater for most complex cases 21
Deming s 14 points (modified from Charles Kenny s The Best Practice) Communicate clearly about goals Ensure quality at every step Build partnership/collaboration Incorporate continuous quality improvement Institute on-the-job training Drive out fear, create trust Strive to reduce intradepartmental conflicts Remove barriers that rob people of pride of workmanship Include everyone in the company to accomplish transformation 22
Challenges Creating an organized system of care to treat co-existing SA and mental illness Funding Education/Training Community health Personnel 23
Three critical questions for performance improvement What do we want to achieve? What will we do to achieve it? How will we know if we are successful? 24
Back to case study I What can we do? 52-year-old male member Diagnosed with schizophrenia, diabetes, and dyslipidemia Has significant back pain, bouts with nausea and vomiting, and prior history of addiction Lives with long-term girlfriend Receives SSI disability benefits Been in recurrent car accidents (not the driver) Prescribed methadone, oxycodone, insulin, metformin, and multiple psychiatric medications Gets off medication and decompensates 25
Discussion 26