H.O.P.E. Clinic - SUD Treatment Integration Pilot Project

Clayton Chau, MD, PhDMedical Director, Care Management, Behavioral Health Services & Provider Continuing EducationAssistant Clinical Professor of Psychiatry, UCI Medical Schoolcchau@lacare.org

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L.A. Care Health Plan

The nation’s largest publicly operated health plan The public plan of the Medi-Cal Two-Plan model developed

in 1992 An independent local public agency created by the State of

California to serve low-income Los Angeles County residents Designed to provide health coverage to vulnerable

populations and to support the safety net in Los Angeles County

Active membership of over 1.7 million members in six product lines

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Our Project

Project Description: Prevention and early intervention in opioid misuse in non-cancer patients at two pilot sites

Project Rationale: L.A. Care Health Plan proposed an Early Intervention Initiative focusing on patients at risk for opiate utilization as part of pain management for non-cancer related conditions

Project Goals: Implement Opioid Risk Assessment at PCP setting Use of SBIRT, SOAPP, COMM and ORT screening tools Referral to Substance Abuse Treatment

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L.A. Care’s Approach

A multi-pronged approach which included: Provider education Identification of at-risk patients Referring patients to HOPE clinic (explained later in this

presentation)

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Initial Target Population

Inclusion Criteria: Patients on one or more Opioids utilizing 3 or more

pharmacies Patients on one or more Opioids utilizing 3 or more

providers Patients on 3 or more Opioids Also analyzed ER visits for select procedure codes

and their associated diagnoses to identify potential misusers of Opioids

Data Sources: L.A. Care Pharmacy Benefits Manager (PBM) data,

Hospital, ER, and Physician claims and encounter data

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Interventions

The Screener and Opioid Assessment for Patients with Pain (SOAPP) is administered prior to writing the initial Rx

Current Opioid Misuse Measure (COMM) is used to help clinicians identify whether a patient, currently on long-term opioid therapy, may be exhibiting misuse behaviors

Use of Screening, Brief Intervention and Referral to Treatment (SBIRT) tool

L.A. Care Behavioral Health staff provided Motivational Interviewing training (MI) and SBIRT training

Medical residents met with identified patients to conduct MI Pharmacy Lock-In policy has been drafted and is awaiting State

final approval

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Progress Made

At Harbor UCLA Family Medical Center All Family Medicine residents have completed

initial training in MI Family Medicine faculty have also completed MI

training in the past 3 years In October 2014, established HOPE (Helping

Overcome Pain Effectively) clinic to focus on alternative therapies for chronic nonmalignant pain management

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HOPE Clinic

A clinic focused on non-pharmaceutical pain management Goal is to establish an interdisciplinary team approach and

to increase alternative pain therapies for patients HOPE clinic serves more thorough patient history and

MI/SBIRT follow up Limitations – No guarantee that patients identified with

potential misuse and/or dependence will be seen given the patient has to agree to attend the clinic

HOPE Clinic takes place the 1st and 4th Wednesday afternoons of the month

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Outcomes

Identified 80 unique patients, across both participating clinics, who met inclusion criteria (Patients on one or more Opioids utilizing 3 or more pharmacies; Patients on one or more Opioids utilizing 3 or more providers; Patients on 3 or more Opioids)

After review of patient charts, Harbor UCLA clinic identified 20‡ patients for intervention

‡ As this is a teaching facility, multiple residents pass through this site over time resulting in prescriptions written by multiple residents for the same patient. Thus, manual review of each patient chart was necessary to rule out false positives (doctor shoppers)

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Outcomes cont.

Harbor UCLA Clinic has implemented SBIRT Harbor UCLA clinic has recently transitioned into an EHR which

has greatly enhanced its ability to screen potential Opioid misusers

Harbor UCLA has built SOAPP and COMM into its EHR HOPE Clinic is now in operation MI is now initiated at the first clinic visit and continued at

HOPE clinic L.A. Care’s Pharmacy Home (Pharmacy Lock-In) Policy was

approved by DMHC and is pending DHCS approval

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Challenges

Substance Use Disorder (SUD) medications and services are carved out; L.A. Care’s ability to track patients’ use of SUD services is limited at best, and the health plan is unable to conduct an opioid replacement program

Time constraints and limited resources for clinical staff Stringent regulatory requirements for the Pharmacy Lock-In

Process

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Challenges cont.

Limited Access to Substance Abuse Treatment Providers Multi-System data retrieval Software connection issues to multiple databases caused

tedious workaround PBM transition effective 1/1/2015

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Successes

MI is now implemented at patient’s first clinic visit Residents have been introduced to best-practice models Residents have been encouraged by patients’ response to the

program, even at its initial stages Implementation of the HOPE Clinic Developing a protocol for prevention and early identification of

opioid misuse Identifying a Physician Champion at the pilot site to lead the

initiative on opioid misuse prevention and early identification

Q & A