Treatment of Opiate Dependence:Clinical Needs and Care

Coordination Opportunities toEnhance Patient Safety

James Schuster, MD, MBA

Chief Medical Officer

Community Care

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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

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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

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Membership Growth

Revenue GrowthRevenue 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

Membership Trend

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Erie

Crawford

Mercer

Lawrence

Beaver

Washington

GreeneFayette

Allegheny

Westmoreland

Butler

Armstrong

Clarion

VenangoForest

Warren McKean Potter

CameronElk

Jefferson

Clearfield

Indiana

Cambria

SomersetBedford

Blair

Centre

Clinton

Huntingdon

Fulton FranklinAdams

Cumberland

Perry

Mifflin

Lycoming

Tioga Bradford

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 Contracts January 1, 2007 Implementation July 1, 2007 Implementation

Elk

Huntingdon

Mifflin

Montour Union

Snyder

Dkkdd

Pennsylvania HealthChoices

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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

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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

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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

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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.

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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

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Prevalence of Opiate Abuse and Addiction

• National surveys vary widely, up to 3%• Probably higher in Medicaid enrollees• Probably higher in rural areas

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Treatment Concerns

• Coordination of Care• Low Rates of Members in Treatment• Low Rate of Persistent Treatment

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Prevalence of Methadone Treatment

• County A 0.6%• County B 0.6%• County C 0.4%• County D 0.14%

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Rates of Buprenorphine Treatment

• County A 0.2%• County B 0.03%• County C 0.1%• County D 0.07%

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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

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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

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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)

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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

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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