Transcript ED Care Coordination - Virginia Association of Health Plans

ACHIEVING TRANSFORMATION:
CMO PRIORITIES AND
OPPORTUNITIES FOR
COLLABORATION
Dr. Katherine Neuhausen
Chief Medical Officer
Department of Medical Assistance Services
Agenda
1.
ARTS Updates and Next Steps
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Network Development & CMS Requirements
Office-Based Opioid Treatment Providers
ARTS Care Coordinators
Upcoming Training Opportunities
PUMS 2.0
Chronic Pain Treatment
Integrated Behavioral Health & Primary Care
LARC Updates
ED Care Coordination
The Scope of the Opioid Crisis
Agenda
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Prescription Opioid Fatal Overdoses (2015-16)
4
Heroin/Fentanyl Fatal Overdoses (2015-16)
5
ARTS Network Development
ASAM Level of Care:
Region:
Central Region
Charlottesville Region
Far Southwest Region
Halifax/Winchester Region
Roanoke/Alleghany
Tidewater Region
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2.1 2.5
3.1
25 24
6
5
13 14
8
8
32 25
21 20
23 22
128 118
0
2
1
1
7
3
4
18
3.3
&3.5 3.7
4
2
6
6
10
5
11
44
Total
Total
4 Providers Members
10 27
4
7
6 36
4
6
13 19
10 16
15 24
62 135
90
26
76
33
106
75
99
505
5958
1801
4765
1865
2674
3566
4497
25,126
Provider Recruitment Activities
Presentations to Provider Associations
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Provider Association Stakeholder Group – Sept. 2016
VHHA Behavioral Health Workgroup – Sept. 2016
Virginia Association of Treatment and Recovery Providers – Sept. 2016
VACBS Conference – Oct. 2016
Psychiatric Association of Virginia Annual Conference – Oct. 2016
Medical Society of Virginia Annual Conference – Oct. 2016
Virginia Health Care Association Annual Conference – Oct. 2016
Virginia Network of Private Providers – Oct. 2016
Virginia Academy of Family Physicians Annual Winter Meeting – Feb. 2016
ARTS 101 Provider Information Sessions
• 2 webinars attended by over 140 providers
• 12 in-person informational sessions completed in September and October
• Over 800 providers attended the sessions
Health System Outreach and Engagement
Health Systems and Medical Groups Already Engaged by DMAS
• Mountain States Health System
• Carillion Clinic
• Lewis Gale Medical Center
• VCU Health System
• UVA Health System
• Bon Secours Medical Group
• Sentara Medical Group
• Winchester Medical Center
Future Meetings with Health System Senior Leadership
• Sentara Health System
• Virginia Beach Psychiatric Hospital
• Virginia Hospital Center
• Novant Health
• Bon Secours Health System Leadership
• HCA Capitol Division
Network Development Timeline
 Thursday, November 10 from 3-4:30 PM: ARTS Workgroup Meeting
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DMAS will present credentialing pathways including external
contractor for residential (ASAM Level 3) certification
Tuesday, November 15 from 1-3:30 PM: Opioid Treatment Program
(OTP) Recruitment Event at DMAS
Friday, November 18, 2016 from 2-4 PM: ARTS Network Meeting to
discuss ARTS networks by region (conference line available)
December 1, 2016: MCOs will submit ARTS Network Development
Plan to DMAS describing current ARTS networks and plans to develop
a more comprehensive network by ASAM level of care in each region
March 1, 2016: MCOs will submit an ARTS Network Readiness Plan
to DMAS describing ARTS services networks by region and specifying
which ASAM levels of care will have adequate numbers of providers
and which levels of care will require further provider development
CMS Requirements for Network Adequacy
in 1115 Waiver
 For residential (ASAM 3.1, 3.3, 3.5, or 3.7) and withdrawal
management levels of care (ASAM 1 WM, 2 WM, 3.2 WM and
3.7 WM), at least one sublevel level of care is required to be
available to beneficiaries upon implementation within each
MCO network
 Within three years, all ASAM levels and sublevels of care
delivering ARTS benefits will be required to be available to
recipients within each MCO network
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Office-Based Opioid Treatment (OBOT)
Providers will be credentialed by MCOs
Care Team Requirements
• Buprenorphine-waivered physician may practice in a variety of practice
settings including primary care clinics, outpatient health system clinics,
psychiatry clinics, FQHCs, CSBs, and physician’s offices
• On site licensed behavioral health provider providing counseling to
patients receiving buprenorphine
MAT Requirements
• Buprenorphine monoproduct only for pregnant women. All other
patients receive buprenorphine/naloxone or naltrexone products
• Maximum daily buprenorphine/naloxone dose 16 mg unless
documentation of compelling clinical rationale for higher dose up to
maximum of 24 mg
• No tolerance to other opioids, soma, stimulants, or benzos except for
patients already on benzos for 3 month relapse or tapering plan
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Office-Based Opioid Treatment (OBOT)
Providers will be credentialed by MCOs
Risk Management and Adherence Monitoring Requirements
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Random urine drug screens, a minimum of 8 times per year.
Virginia Prescription Monitoring Program checked at least quarterly.
Opioid overdose prevention education including prescribing of naloxone.
Patients seen at least weekly when initiating treatment.
Patient must have been seen for at least 3 months with documented
clinical stability before spacing out to a minimum of monthly visits.
Benefits
• No PAs required for buprenorphine or buprenorphine/naloxone
• Buprenorphine-waivered physician in the OBOT can bill all Medicaid health
plans for substance use care coordination PMPM for members with
moderate to severe opioid use disorder receiving MAT.
• Can bill for peer supports.
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Role of the ARTS Care Coordinator
 Qualifications = Licensed Clinical Psychologists, LCSWs,
LPCs, NPs, or RNs with experience treating substance use
disorder
 Perform an independent assessment of requests for all
ARTS residential treatment services using member
information transmitted by providers via a uniform service
review request form with attached clinical documentation
 Use ASAM Criteria to perform multidimensional
assessment of members, place members at appropriate
levels of care, and make recommendations for length of
stay in residential treatment
 Medical directors, physicians employed by MCO, or ARTS
care coordinator can perform the independent assessment
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DBHDS ASAM Training Opportunities
 Two day trainings for ARTS Care Coordinators
 January 3-4, 2017 - Southwest Virginia. Location
TBA. Click here to register.
 January 5-6, 2017 - Southwest Virginia. Location
TBA. Click here to register.
 March 1-2, 2017 – Tidewater Area. Portsmouth Behavioral
Health Services, 1811 King Street, Portsmouth, VA
23704. Click here to register.
 Requested mid-March training in Richmond
 One day trainings for MCO and provider
administrators and CMOs – Dates TBA
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PUMS 2.0 and ARTS
PUMS - Current Triggers
PUMS 2.0 – Proposed Triggers
1 = Buprenorphine Containing Product: Therapy in 1 = Buprenorphine Containing Product*: Therapy in the past
the past 30 days – AUTOMATIC LOCK-IN
30 days – AUTOMATIC LOCK-IN**
2 = High Average Daily Dose: > 120 morphine
2 = High Average Daily Dose: > 120 cumulative morphine
milligram equivalents per day over the past 90 days milligram equivalents (MME) per day over the past 90 days
3 = Overutilization: Filling of > 7 claims for all
controlled substances in the past 60 days
4 = Doctor Shopping: > 3 prescribers OR > 3
pharmacies writing/filling claims for any
controlled substance in the past 60 days
5 = Use with a History of Dependence: Any use of a
controlled substance in the past 60 days with at
least 2 occurrences of a medical claim for
controlled Substance Abuse or Dependence in the
past 365 days
3 = Opioids and Benzodiazepines concurrent use – at least 1
Opioid claim and 14 day supply of Benzo (in any order)
4 = Doctor and/or Pharmacy Shopping: > 3 prescribers OR > 3
pharmacies writing/filling claims for any controlled substance
in the past 60 days
5 = Use of a Controlled Substance with a History of
Dependence, Abuse or Poisoning/Overdose : Any use of a
controlled substance in the past 60 days with at least 2
occurrences of a medical claim for controlled Substance Abuse
or Dependence in the past 365 days
6 = Use with a History of Poisoning/Overdose: Any
use of a controlled substance in the past 60 days
with at least 1 occurrence of a medication for
controlled substance overdose in the past 365 days
6 = History of Substance Use, Abuse or Dependence or
Poisoning/Overdose: Any member with a diagnosis of
substance use, substance abuse or substance dependence on
any claim in any setting (e.g., ED, pharmacy, inpatient,
outpatient, etc) within the past 60 days
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Chronic Pain Treatment
 Experience in other states that decreasing opioid rx
can lead to increased use of heroin
 ARTS only addresses opioid use disorder treatment
NOT chronic pain
 Models that CMO workgroup will explore:
 Expanding pain specialist network and
interdisciplinary pain teams
 Increasing coverage for non-pharmacological
therapies : aquatic therapy, cognitive behavioral
therapy, aerobic and physical therapy,
acupuncture and chiropractic
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Upcoming CMO & Pharmacy Director
Meetings and Optional Trainings
 Thursday, November 17 from 11 AM-1 PM:
Combined CMO & Pharmacy Director Workgroup to
Discuss OBOT and Substance Use Care Coordination
Quality Measures
 Thursday, November 17 from 1-2:30 PM: Optional
PMP Training with Ralph Orr, PMP Director
 Thursday, December 15 from 11 AM-1 PM: CMO
Workgroup Meeting to Discuss Chronic Pain
Treatment Care System & Payment Models
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Integrated Behavioral Health & Primary Care
 Ben Miller, national expert on VBP who presented at
VAHP event in Summer 2015 will be visiting DMAS
in early January
 Will share data on cost savings to Medicaid and
commercial health plans from global payments for
primary care including integrated behavioral health
(due to decreased ED visits and hospitalizations)
 Creating survey of FQHCs, CSBs, health systems,
and primary care providers to identify “true” health
homes with integrated behavioral health and
primary care for CCC Plus
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LARC Updates
 November 15 from 9-11 AM: VDH LARC Workgroup Meeting
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(conference line available)
December 1, 2017: DMAS will release Medicaid provider
memo on LARC in FFS and Managed Care
January 1, 2017: DMAS will follow lead of 17 other states and
change payment methodology to allow hospitals to bill for
post-partum LARC device separately from delivery DRG
January 1, 2017: MCOs will voluntarily allow separate
payment for post-partum LARC device and insertion
April 1, 2017: Medallion contract addendum will require
separate payment for post-partum LARC device and
insertion by MCOs
ED Care Coordination: What does an MCO
Care Coordinator Need to Be Successful?
 ED Visits
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Demographic data including current address and phone,
emergency contact and phone, caregiver (if applicable)
Diagnosis (such as overdose) and Discharge instructions
Past Medical History and Medications
Pregnant
Providers – PCP and behavioral health providers, followup appointments needed
 Admissions
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All of the above, plus Discharge summary
ED Care Coordination: What are the
Advantages of Real-Time Data to the MCO?
 Outreach while members are in the middle of an event.
 Enables relevant assessment of the situation, including the
need for MCO to assist with:
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Follow-up appointments
Transportation issues
Prescription fills and medication reconciliation
Next steps understanding and follow-through
• Addressing a member’s immediate needs in real time
establishes trust and fosters ongoing collaboration that
impacts health status and behavior
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DMAS Expectations for CCC Plus
 HOSPITAL AND EMERGENCY DEPARTMENT (ED) ALERT
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SYSTEM FOR CARE TRANSITIONS
Timely data alerts in a usable format to the MCO and
treating providers regarding ED visits and hospital
admissions, discharges, and transfers.
System shares alerts with in-network PCPs
Information delivered as real-time as possible and not
longer than 24 hours after the ED discharge.
Having this data enables care coordinators and PCPs to
provide timely outreach to offer interventions that could
prevent potential future unnecessary ED or hospital
readmissions, and improve health outcomes.
DMAS Expectations for CCC Plus
 Member follow-up post ED discharge is required to ensure
community services remain intact and uninterrupted.
 The Contractor’s system must receive admission discharge
transfer (ADT) feeds from in-network health systems and
free-standing EDs.
 ED data shall be available to DMAS upon request.
 Hospital and ED alert system to be operational no later
than December 31, 2017.
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