0. SYSTEM TRANSFORMATION TO ADVANCE RECOVERY AND TREATMENT
Los Angeles County Department of Public Health Substance Abuse Prevention and Control
SYSTEM TRANSFORMATION TO ADVANCE RECOVERY AND TREATMENT
START-ODS
Los Angeles County’s Substance Use Disorder Organized Delivery System

1. Expansion of Substance SUD Services under ACA
3/21/2016
Expansion of Substance SUD Services under ACA
March 23, 2010: President Obama Signs the Affordable Care Act (ACA) to Achieve the “Triple Aim”
Improving the Individual Experience of Care
Improving the Health of Populations
Reducing the Per Capita Costs of Care for Populations
January 1, 2014: Medi-Cal Eligibility Expansion
New beneficiaries now include single adults without children,
with income up to 138% Federal Poverty Level (FLP)
November 21, 2014: DHCS Submits DMC-ODS Waiver Amendment to CMS
Expands available levels of care, adopts ASAM criteria, supports
quality assurance/utilization management
August 13, 2015: Stakeholder Process Launched
SAPC Launches DMC-ODS Stakeholder Process to Officially Launch
Efforts to Expand and Improve SUD Services in LAC
February 11, 2016: Implementation Plan Submitted
LAC Submits plan to DHCS and CMS for review
and approval, pending response
May 1, 2016: Medi-Cal Eligibility Expansion
Children under 19 are eligible for full-scope Medi-Cal regardless of immigration status, if other eligibility requirements are met
July 1, 2016: My Health LA SUD Expansion
Substance use disorder (SUD) treatment services available to
individuals eligible for My Health LA
The healthcare system has been in transition since adoption of the Affordable Care Act (ACA) in With expansion of the Medi-Cal eligible population in January 2014 and the State’s submission of the Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver to the Centers for Medicare and Medicaid (CMS) in November 2014, the substance use disorder (SUD) system is on the pathway to parity with the physical and mental health systems. This will be a long, and at times challenging transition for our field, but necessary to improve the quality and availability of services that will lead to better health and social outcomes for our clients.

2. SYSTEM TRANSFORMATION TO ADVANCE RECOVERY AND TREATMENT OF SUBSTANCE USE DISORDERS
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This is the greatest opportunity in recent history to design and implement a substance use disorder (SUD) system of care that has the financial and clinical resources to more fully address the complex needs of all our patients.
The SUD Organized Delivery System Waiver comes with significant opportunities to improve our system of care, but also comes with significant expectations of our providers.
New opportunities to provide better care for our clients include: The provision of case management, care coordination both within the SUD system and with other systems such as health and mental health, recovery support services, physician consultation services for DMC physicians, and enhanced access to medication-assisted treatment.
The higher expectations of our providers include: Required use of evidence-based practices (EBP) such as Motivational Interviewing and Cognitive Behavioral Therapy, required use of the ASAM Criteria and DSM-5 diagnoses to determine medical necessity and the appropriate level of care, and enhanced documentation that is more detailed and frequent than previously provided.
The SUD Organized Delivery System Waiver is an unprecedented opportunity to truly transform and upgrade our system of care, and its success will depend heavily on SAPC and its providers to effectively work together to serve our patients.
SAPC is fully committed to do what it can to ensure providers have the tools in terms of training, finances, and support to accomplish the goals of the SUD Organized Delivery System Waiver, and will rely on its providers for their active participation in this process. SAPC will be holding various workgroups focused on several key aspects of the waiver in the coming months, and will rely on providers to attend and participate so they can help to shape and build our redesigned system of SUD care.

3. Note: Not all key elements in the diagram will be expanded upon in this presentation.

4. KEY CHANGES: SYSTEM OF CARE DEVELOPMENT
SINGLE BENEFIT PACKAGE BASED ON DMC:
All beneficiaries/patients have the same access to services regardless of health coverage or funding/referral source. Other funding sources (e.g., CalWORKs, GR, AB109) will be use for uncovered services or to extend services if capped and medically necessary.
My Health LA SUD benefit package for low income uninsured individuals will be the same and commence July 1, 2016.

5. …A SINGLE BENEFITS PACKAGE FOR ALL PATIENTS, INCLUDING MY HEALTH LA
NEW DMC BENEFITS…
Beneficiary Access Line
Medically Necessary Services:
Individually Counseling
Family Counseling
Group Counseling
Case-Management and Care Coordination
Recovery Support Services
Short-Term Residential
Youth: up to two 30-day episodes
Adults: up to two 90-day episodes
Withdrawal Management
Ambulatory
Residential
DMC covered services are significantly expanded, and most are not capped if medically necessary (except residential) and available for all Medi-Cal beneficiaries.
…A SINGLE BENEFITS PACKAGE FOR ALL PATIENTS, INCLUDING MY HEALTH LA

6. KEY CHANGES: BUSINESS DEVELOPMENT
DMC 1st Payer for Most clients and Services:
Medi-Cal eligible individuals must receive DMC reimbursable treatment services by DMC providers.
This includes outpatient, intensive outpatient, residential, and withdrawal management (formerly detox), case management, and recovery support.
This will be required once the new State-County contract is signed and the SAPC SUD benefit package is launched.
DMC will be the primary funding source for our entire system of care moving forward. As a result, the Organized Delivery System Waiver pertains to changes that will impact every single SUD provider within our network.

7. NOW: Multiple primary payers and funding sources
LATER (by July 1, 2017): DMC will fund most services for most patients
NOW: Multiple primary payers and funding sources

8. INCREASED DMC ELIGIBLES MORE PATIENTS SERVED
3/21/2016
INCREASED DMC ELIGIBLES MORE PATIENTS SERVED
YOUTH: IN THREE YEARS, PROJECTED CHANGE IN ADMISSIONS
10, ,696 (+55%)
ADULTS: IN THREE YEARS, PROJECTED CHANGE ADMISSIONS
60, ,698 (+47%)

9. KEY CHANGES: INFRASTRUCTURE DEVELOPMENT
DMC RATES: New fee-for-service DMC rates will be negotiated with DHCS with an opportunity to transition to an alternate reimbursement structure (e.g., performance-based, capitation) in later years of the waiver.
SAGE: SAPC’s MANAGED CARE INFORMATION SYSTEM: Efforts to support use of MCIS, and other technology based systems.
A key SAPC priority is to determine and secure rates that will support the enhanced expectations of the SUD Organized Delivery System Waiver. SAPC is able to negotiate with the State on the DMC rates that will be the primary funding source of SUD services in LA County. These higher DMC rates would help to enhance our workforce and services, and also help to encourage new providers to become DMC certified so that we can grow our provider capacity and improve access to SUD services, particularly in medical detox and residential settings. See presentation by Patrick Gautier for more information on the methodology.

10. Los Angeles County DMC Rates for Fiscal Year 2017-2018
ASAM LOC/Service
Unit of
Service (UOS)
Interim Rate
per UOS
Projected Persons Served
1.0 Outpatient
15-minute
(except group* session)
$29.63
25,667
2.1 Intensive Outpatient
$32.01
10,591
3.1 Residential
Day Rate
$145.71
(includes $36.43 for R&B, non-DMC funds)
1,648
3.3 Residential
$187.85
(includes $46.96 for R&B, non-DMC funds)
3,244
3.5 Residential
$166.70
(includes $41.47 for R&B, non-DMC funds)
10,026
1-WM Withdrawal Management
$210.46
1,047
3.2-WM Withdrawal Management
$381.37
(includes $95.34 for R&B, non-DMC funds)
4,186
Case Management
$33.83
24,511
Recovery Support Services
$20.89
10,748
Group Sessions calculated by # minutes for the group / # of beneficiaries / # of counselors = Total Minutes per Beneficiary.

11. NOW: Not all SAPC providers and provider sites are DMC certified.
LATER (by July 1, 2017):
All SAPC Treatment Contractors will be DMC Certified and AOD Certified/Licensed for all Contracted Levels of Care
NOW: Not all SAPC providers and provider sites are DMC certified.

12. KEY CHANGES: CLINICAL DEVELOPMENT
ASAM CRITERIA AND MEDICAL NECESSITY
The American Society of Addiction Medicine (ASAM) Criteria and medical necessity will determine initial and ongoing patient eligibility for level of care placement.
EVIDENCE-BASED PRACTICES
At minimum, all clinical/counselors staff must be capable of effectively implementing and consistently using Motivational Interviewing and Cognitive Behavioral Therapy
QUALITY IMPROVEMENT and UTILIZATION MANAGEMENT
SAPC QI and UM will be a central component to ensuring effective care, including appropriate placements and transitions in levels of care.
CLINICAL DEVELOPMENT: To ensure positive health outcomes for patients the waiver requires implementation of new clinical standards and management practices. This includes requires use of the ASAM Criteria to determine placement at the appropriate level of care based on medical necessity, use of two DHCS selected EBPs (in Los Angeles County this is Motivational Interviewing and Cognitive Behavioral Therapy), and implementation of Quality Assurance and Utilization Management programs. See presentation by Gary Tsai for more information on the methodology.

13. KEY CHANGES: BUSINESS DEVELOPMENT
SERVICE CHANGES TO MEET PATIENT NEEDS:
Services need to be patient-centered versus program-centered (e.g., individualized treatment plan determines type and frequency of services).
Patients will have more opportunities to decide which provider best meets their needs, and choose accordingly.
Agencies can expand field-based services, business hours, days of operation, and otherwise tailor the program to better match patient preferences.

14. KEY CHANGES: SYSTEM OF CARE DEVELOPMENT
MEDICATION-ASSISTED TREATMENT (MAT):
Adult patients will be informed of MAT as one of the treatment services available for alcohol and/or opioid dependence.
COORDINATE HEALTH AND MENTAL HEALTH SERVICES:
Care coordination and case-management will include ensuring necessary collaboration and connections (e.g., attended appointments) with physical and mental health services.

15. TRAINING & TECHNICAL ASSISTANCE
STAKEHOLDER
WORKGROUPS
TRAINING & TECHNICAL ASSISTANCE
Contribute to
the new service design and clinical expectations
Staff development, train-the-trainer, and agency-specific assistance
Essential to the success of this system transformation will be the stakeholder workgroups, and on-going clinical and business capacity building to support providers in this significant transformation.

16. 3/21/2016
START
…..enhancing substance use disorder services to achieve improved individual and community health outcomes ….you play an essential role in the success of this transition!