Project RAMP Care Management Strategies Jack Warwick, MPH, Project Coordinator Program Evaluation and Research Unit (PERU) Project RAMP Implementation Team
Objectives: 1. Review substance use disorder (SUD) case management; 2. Present Rural Access to Medication Assisted Treatment in Pennsylvania (RAMP) Project care management team roles and responsibilities; 3. Discuss strategies to improve patient compliance; and 4. Review best care coordination practices.
Substance Use Disorder Case Management
SUD case management offers a patient a single point of contact with health and social service systems. 1 D&A 1. Substance Abuse and Mental Health Services Administration. Comprehensive Case Management for Substance Abuse Treatment (TIP 27). Rockville, MD 20857: Substance Abuse and Mental Health Services Administration, 2000.
Case management is centered on the client and the specific needs of each client. 1 1. Substance Abuse and Mental Health Services Administration. Comprehensive Case Management for Substance Abuse Treatment (TIP 27). Rockville, MD 20857: Substance Abuse and Mental Health Services Administration, 2000.
Examples of typical case management responsibilities 1 : Create and implement a treatment plan with realistic expectations and goals; Educate and consult patient on SUD; Assist patients with financial management, such as obtaining financing; Help patients utilize resources and meet non-treatment needs; Regularly communicate with patients and providers; Perform level of care assessments; and Manage referrals to SUD and other treatment providers. 1. Substance Abuse and Mental Health Services Administration. Comprehensive Case Management for Substance Abuse Treatment (TIP 27). Rockville, MD 20857: Substance Abuse and Mental Health Services Administration, 2000.
In Project RAMP, Care Management is the glue that holds the treatment process together. D&A Care Manager
Care Manager Roles and Responsibilities
Referral Process for Patients Referred from Primary Care Provider to Substance Use Disorder Treatment Provider
Referral Process for Patients Referred from Community to an MAT Provider
Care Management Ongoing Care Coordination and Follow-up
Project RAMP Real-Time Data Collection Process
Care Management Team Data Collection: Two Formats
Project RAMP Outcomes and Metrics Outcomes Data Metrics Screening # Patients screened per week Patient Enrolled in MAT Date of MAT enrollment Type of MAT Treatment # Patients receiving naltrexone # Patients receiving buprenorphine Referral to Care Management Date of primary care provider (PCP) referral to CMT (CMT) Number of Physician (PCP) Date of all PCP encounters Contacts Involving Injections, Scripts, Monitoring # Encounters for medication administration, prescription, and other services Access to Substance Use Date of First face-to-face SUD encounter for intake Disorder (SUD) Treatment Engagement with SUD Date of all SUD encounters Treatment # Encounters patient is continuing initial level of care (LOC) Date of Encounter and new LOC, if patient changes LOC during treatment Date of Patient discharge from SUD treatment # Patients discharged for successful completion of SUD treatment/loc, client choice, and other Access to MH Treatment Date of First face-to-face MH encounter for intake Engagement with MH Date of all MH encounters Treatment # Encounters patient is continuing initial level of care (LOC) Date of Encounter and new LOC, if patient changes LOC during treatment Date of Patient discharge from MH treatment # Patients discharged for successful completion of MH treatment/loc, client choice, and other Discharge from MAT Date of Patient Discharge from MAT Treatment # Patients discharged for evidence of medication diversion, non-compliance, client choice, incarceration, and successful titrate
Real-Time Data Reporting
Individualized Data Reports for Quality Improvement
Importance of Data Collection and Quality Improvement Improve referral processes and treatment protocols; Monitor patient progress in the SUD treatment continuum; Improve retention to treatment; and Identify barriers and facilitators to providing MAT and related care.
Summary of Care Manager Responsibilities: Manage referrals and warm-handoffs closely with PCPs and other treatment providers; Coordinate psychosocial services; Manage and/or develop comprehensive service and treatment plans individualized for each patient with the clinical and treatment team; Refer patient to the necessary treatment provider based on the LOC as soon as possible; Work with providers to identify the best medication for the patient based on his/her medical profile and history by conducting an MAT assessment;
Summary of Care Manager Responsibilities (cont.): Coordinate ambulatory detox with the hospital and SUD providers, if necessary. Provide peer support via a certified recovery specialist (if available); Assist the clinical team with medication management to improve patient compliance; and Participate in data collection and quality improvement efforts to actively work to improve retention and treatment success.
Strategies to Improve Patient Compliance
Overview of Strategies: 1. Educate patients on opioid use disorder (OUD), SUD, and addiction; 2. Work with the MAT provider to understand what services and resources would benefit the patient most; 3. Review the treatment plan with the patient and build a mutual understanding; 4. Help to mitigate the risk of diversion; 5. Assist with managing laboratory testing; 6. Assist with patient follow-up and engagement in both psychosocial and medication treatments; 7. Coordinate the medication arrangements with the pharmacy of choice; and 8. Use evidence-based practices when communicating and providing ongoing feedback to patients, such as motivational interviewing and motivational enhancement.
Strategy 1: Educate patients on OUD, addiction, and the risks/benefits of MAT.
Strategy 2: Work with the MAT provider to identify the services and resources that would help the patient reach their treatment goals.
Strategy 3: Review treatment plan with patient and build a mutual understanding of the goals of the treatment.
Strategy 4: Work to mitigate the risk of diversion by meeting regularly with patients to provide ongoing assessments.
Strategy 5: Assist with managing laboratory testing, such as conducting random urine drug tests.
Strategy 6: Assist with patient follow-up and engagement in both psychosocial and medication treatment. D&A Care Manager
Strategy 7: Coordinate the medication arrangements with the pharmacy of choice. Rx Care Manager
Strategy 8: Use evidence-based practices when communicating and providing ongoing feedback to patients, such as motivational interviewing and motivational enhancement.
Best Care Coordination Practices
Overview of Best Care Coordination Practices: 1. Develop Referral Protocols with the entire treatment team; 2. Conduct level of care assessment with patient in a timely fashion and at a location that is convenient for the patient; 3. Obtain a release of information form for the drug and alcohol treatment provider; 4. Conduct a warm handoff or a direct linkage to care; 5. Follow-up with patient and clinical team if the patient declines treatment; and 6. Facilitate ongoing and routine communication between the entire clinical team.
Key Practice 1: Develop referral protocols between clinical team, treatment providers, and care management team.
Key Practice 2: Conduct Initial Assessment with Patient ASAP at a Location that is Convenient for the Patient. D&A Care Manager
Key Practice 3: Obtain a release of health information form from the medical provider or SUD treatment provider.
Key Practice 4: Facilitate direct linkages in the form of warm handoffs to improve care coordination and patient treatment engagement.
Key Practice 5: If a patient declines treatment, follow-up with the patient and notify the entire clinical team.
Key Practice 6: Facilitate clear and ongoing communication between the entire clinical team.
RAMP Care Management Summary
Project RAMP Care Management Summary SUD case management offers a single point of contact for a patient during the treatment process. Care managers in Project RAMP play a central role to the patients MAT by: 1. Managing referrals and warm handoffs in a timely and efficient manner; 2. Designing and/or managing service and treatment plans for each patient; 3. Coordinating and ensuring participation in psychosocial services; 4. Providing peer support and assisting with access to non-treatment needs and resources; 5. Assisting the clinical team with medication management; and 6. Participating in data collection and quality improvement to improve treatment outcomes.
Project RAMP Care Management Summary (cont.) Coordination of care is imperative to treatment success. Care coordination can be optimized by: 1. Developing referral protocols with each provider involved in the patients treatment; 2. Obtaining a release of health information from the patient to ensure open communication; 3. Always conducting a warm handoff or direct linkage to care; 4. Following-up with the patient and clinical team if the patient declines a recommended treatment; and 5. Facilitating ongoing and routine communication between all members of the treatment team.