Treatment of Opiate Dependence: Clinical Needs and Care Coordination Opportunities to Enhance Patient Safety James Schuster, MD, MBA Chief Medical Officer Community Care
Community Care Mission and Vision The mission of Community Care is to improve the health and well-being of the community through the delivery of effective and accessible behavioral health services Community Care believes that the highest quality services are best provided through a not-for-profit partnership with public agencies, experienced local providers and involved members and families Community Care s vision is to improve the quality of services for members through a stakeholder partnership focused on outcomes 2
Governance and Ownership Community Care is owned by the University of Pittsburgh Medical Center (UPMC) The Board of Directors is comprised of 17 members (7 from UPMC and 10 representing community stakeholders) Board seats are assigned to Consumer, Family, and Provider representatives 3
Membership Trend Membership Growth Revenue Growth Revenue Growth 1999 2000 2001 2002 2003 2004 2005 2006 2007 208,963 292,842 402,369 476,000 520,152 587,162 597,011 712,847 917,604 4
Dkkdd Pennsylvania HealthChoices Erie Crawford Mercer Lawrence Beaver Washington Greene Butler Allegheny Venango Armstrong Westmoreland Fayette Clarion Warren Forest Jefferson Indiana Somerset McKean Elk Cambria Clearfield Bedford Cameron Blair Potter Clinton Centre Huntingdon Fulton Franklin Mifflin Tioga Lycoming Juniata Perry Cumberland Adams Union Snyder Bradford Northumberland Dauphin York Sullivan Montour Columbia Lebanon Schuylkill Lancaster Susquehanna Wyoming Luzerne Berks Lackawanna Carbon Chester Lehigh Wayne Monroe Pike Northampton Bucks Montgomery Delaware Philadelphia Community Care Office Current Contracts January 1, 2007 Implementation July 1, 2007 Implementation 5
Care Management Function Customer Service First line telephonic response to members, families, providers, and other stakeholders through the Customer Service Representatives Care Management Collection and assessment of clinical information and authorization of member care through medical necessity criteria 6
Role of the Care Manager Care Management includes: Assessment of clinical data Adherence to Medical Necessity Criteria Provider adherence to Performance Standards Ensure coordination and continuity of care 7
Role of the Care Manager (continued) Additional areas include: Full participation of the member and family in the development of a strengths-based treatment plan inclusive of the transition plan Use of Recovery Principles in the treatment process 8
Quality Program Details the structures and processes needed to enable the organization to achieve its desired outcomes The program: Outlines the blueprint for quality. Incorporates the tenets of continuous quality improvement. Provides rationale for the program. Uses data to monitor and manage processes and outcomes. Completes annual updates. Involves everyone in the organization. 9
Why Does a Managed Care Company Want to Expand and Improve Addiction Treatment Services? Key part of our mission Part of our mandate from Department of Public Welfare Addictions significantly increase the morbidity of our enrollees, e.g. inpatient mental health admissions and readmissions 10
Prevalence of Opiate Abuse and Addiction National surveys vary widely, up to 3% Probably higher in Medicaid enrollees Probably higher in rural areas 11
Treatment Concerns Coordination of Care Low Rates of Members in Treatment Low Rate of Persistent Treatment 12
Prevalence of Methadone Treatment County A 0.6% County B 0.6% County C 0.4% County D 0.14% 13
Rates of Buprenorphine Treatment County A 0.2% County B 0.03% County C 0.1% County D 0.07% 14
Treatment Opportunities In the 48 rural counties in PA, several have no treatment programs easily accessible Most facilities are in urban areas Other health care providers also limited in rural settings, including primary care providers Necessary goals include rehabilitation and harm reduction 15
Treatment Limitations Often short lengths of time in treatment 90 day in treatment rate for members in rehabilitation usually under 30% Coordination of treatment between substance abuse and mental health providers often limited Relatively few providers licensed for both mental health and addiction services 16
Interventions to Improve Coordination Community Care policy of paying for methadone and other outpatient providers to see members while in rehabilitation Encouraging providers to pursue dual licensure or at least dual competency, or Co-location of providers Funding of care managers to facilitate entry into and coordination of care (Lewistown model, Capital region services) 17
Future Challenges Inadequate number of providers (methadone and buprenorphine) Inadequate access to mental health services for members with co-morbid conditions Inadequate time spent in treatment Aging of the population 18
Potential Strategies Recruit additional providers Psychiatric consultation when needed Community Care PCP/HealthCare provider consultation line Continued efforts to increase funding of treatment services in the community Development of services to increase care collaboration Outreach to MCO to assist when members identified with significant concurrent MH or PH needs 19