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Treatment of Opiate Dependence: Clinical Needs and Care Coordination Opportunities to Enhance Patient Safety James Schuster, MD, MBA Chief Medical Officer.

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Presentation on theme: "Treatment of Opiate Dependence: Clinical Needs and Care Coordination Opportunities to Enhance Patient Safety James Schuster, MD, MBA Chief Medical Officer."— Presentation transcript:

1 Treatment of Opiate Dependence: Clinical Needs and Care Coordination Opportunities to Enhance Patient Safety James Schuster, MD, MBA Chief Medical Officer Community Care

2 2 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

3 3 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

4 4 Membership Growth Revenue Growth ,963292,842402,369476,000520,152587,162597,011712,847917,604 Membership Trend

5 5 Erie Crawford Mercer Lawrence Beaver Washington Greene Fayette Allegheny Westmoreland Butler Armstrong Clarion Venango Forest Warren McKean Potter Cameron Elk Jefferson Clearfield Indiana Cambria Somerset Bedford Blair Centre Clinton Huntingdon Fulton Franklin Adams Cumberland Perry Mifflin Lycoming TiogaBradford Columbia Northum- berland Dauphin York Lancaster Chester Berks Lebanon Schuylkill Luzerne Wyoming Susquehanna Lackawanna Wayne Pike Monroe Carbon Lehigh Northampton Bucks Montgomery Delaware Philadelphia Juniata Sullivan Community Care Office Current ContractsJanuary 1, 2007 ImplementationJuly 1, 2007 Implementation Elk Huntingdon Mifflin Montou r Union Snyder Dkkdd Pennsylvania HealthChoices

6 6 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

7 7 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

8 8 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

9 9 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.

10 10 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

11 11 Prevalence of Opiate Abuse and Addiction National surveys vary widely, up to 3% Probably higher in Medicaid enrollees Probably higher in rural areas

12 12 Treatment Concerns Coordination of Care Low Rates of Members in Treatment Low Rate of Persistent Treatment

13 13 Prevalence of Methadone Treatment County A0.6% County B0.6% County C0.4% County D0.14%

14 14 Rates of Buprenorphine Treatment County A0.2% County B 0.03% County C0.1% County D 0.07%

15 15 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

16 16 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

17 17 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)

18 18 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

19 19 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


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