The State of Rhode Island and Providence Plantations

Opioid Treatment ProgramHealth Home Initiative

Susan A. Storti, PhD, RN, NEA-BC, CARN-APOTP Health Home Administrative Coordinator

401.521-5759 x115sstorti@dataofri.org

CSAT/SOTA Pre-Conference SessionAATOD ConferenceMarch 29, 2015

Atlanta, GA

OTP Health Home Patient Enrollment

Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec Jan2013 2014 2015

0

500

1000

1500

2000

2500

3000

3500

1523 1511

2218

20562208

22912356

2638 2673 26472777

2924

2699

2917

2620

An Overview of The Process…..• Development of standardized policies, procedures and general

guidelines• Creation of standardized forms, Releases of Information, MOUs,

Community Resource Guide, etc.• Revision of organizational EMRs• Outreach to partners (i.e., FQHCs, CMHO Health Homes, hospitals,

private practices, etc.)• Develop state-wide training network

o Hire training coordinatoro Conduct training needs assessmento Identification of available training opportunities

• Engage IT company • Collaborate with BHDDH to

o Revise Health Home Audit Standards and Self-Assessment toolo Develop a Plan of Careo Conduct Mock Auditso Design OTP Health Home Database

OTP Health Home Implementation Plan Goal 1: Develop an understanding of the behavioral health home’s key clinical features and system-level infrastructure needs. Objective 1: Conduct an assessment of the opioid treatment program (OTP) environment.

Implementation Steps

Activity Who is responsible Due Date Visit OTPs and meet with Program Administrators HH Coordinator 11/13 Validate involvement with Prescription Drug Monitoring Program (PDMP) HH Administrative Coordinator 12/13 Assess involvement with Current Care HH Administrative Coordinator 12/13 Assess technology capabilities HH Administrative Coordinator 12/13 Assess general training needs

HH Administrative Coordinator Revision (05/14): HH Training Coordinator

12/13 05/14 - ongoing

Goal 2: Create strategic integrated plan, including establishment of Health Home teams and the development of policies, procedures, and general guidelines. Objective 1: Establish Health Home Care Coordination Teams.

Implementation Steps

Activity Who is responsible Due Date Identify number of patients eligible for health homes at each clinic OTP Leadership, BHDDH 10/13 Reassess number of patients eligible for health homes at each clinic following Medicaid expansion OTP Leadership,

Revision (05/14) BHDDH

01/14, 02/14 03/14, 04/14

Assist OTPs in identification of potential HH Care Coordination Team members based upon SPA position descriptions

HH Administrative Coordinator 12/13 - ongoing

Assist OTPs in requesting waivers to fill open HH Care Coordination Team positions ( master’s level team leader, physician, registered nurse, case manager-hospital liaison, case manager, pharmacist), as appropriate

HH Administrative Coordinator 12/13 - ongoing

OTP Health Home Care Coordination teams meet 90% required staffing model HH Administrative Coordinator 12/13 Maintain staff competencies, professional qualification and experience as described throughout the RI Rules and Regulations for the Licensing of Behavioral Health Organizations

OTP Leadership 11/13 - ongoing

OTP Health Home Implementation Plan

System Change Document

ChallengeBuilding A Foundation

For ChangeDefining & Measuring

OutcomesDocumenting The Current

SystemDefining A

New SystemImplementing

ChangeRe-evaluate & Revise

Promoting Team Based Care

Refocus clinic culture and environment to adhere to the new comprehensive level of care connecting patients with resources in the health care system and community.

- Reliable and timely feedback on successes and failures in both function of the team and achievement of the team’s goals.- Measures include: patient outcomes, patient care processes that lead to improved patient outcomes, and values outcomes- Patient satisfaction survey and/or focus groups

- Reallocation of clinical time between medication assisted treatment and Health Home services- Lack of clear understanding of roles and responsibilities of Health Home team members- Broad variation in provider capacities and organizations

- Understand and define new roles within the context of the health home service delivery model - Design workflow processes and protocols, clarify roles and responsibilities of team members, and develop a communication mechanism to assess patient’s needs and deliver team-based services.

- Meet with existing clinic staff to discuss: how changing positions within clinic practice can potentially affect capability of delivering care; principles of team-based health care (shared goals, clear roles, mutual trust, effective communication); and new rules and systems- Develop new workflow processes in the clinic - Update program policies and procedures to reflect delivery of OTP Health Home services- Design processes to integrate responsibilities to patients, team members, and clinic staff.- Meet with patients to discuss new OTP Health Home program and ensure understanding the goal of improving their quality of life and overall health and have patient sign consent form- Match internal and external resources to team-based care

10.01.13 -12.31.13 10.01.13 -ongoing 10.01.13 -ongoing 10.01.13 - ongoing 10.01.13-ongoing 10.01.13-ongoing

Data Collection – OTP Health Home Database

Health Home Outcomes

Goal 1: Reduce Hospital Admissions and Readmissions Goal 2: Reduce Preventable Emergency Room Visits Goal 3: Reduce Skilled Nursing Facility Admissions

CMS Core Measures- BMI- Ambulatory Care – Sensitive Admission- Care Transition – Transition Record Transmitted to Health Care Professional- Follow-up After Hospitalization for Mental Illness- Plan – All Cause Readmissions- Screening for Clinical Depression and Follow-up Plan- Initiation and Engagement of Alcohol and Other Drug Dependence Treatment- Controlling High Blood Pressure

Data Collection - OTP Health Home Database

OTP Health Home Specific Goals- The # of OTP HH Patients Reporting Housing Stability- Improved Employment/Wages Earned- Reduce Rate of Arrest and Incarceration- Reduction of Illicit Drug Use- Reduction of Smoking Rates- Chronic Disease Management- Coordination of Care for Individuals with Chronic Conditions

Medicaid Expenditure Data- Individual- Aggregate

OTP Health Home Database

Reporting

Reports

Care and information was provided to me in a language or way I could easily understand.

I am comfortable receving health home services at this clinic.

I feel respected and listened to by the Health Home staff.

I feel I am invovled in my care and included in the decision making regarding my care.

The Health Home staff has an understanding of my health care needs and successfully coordinates care with my other healthcare

providers.

The Health Home staff encourages and welcomes the input and support of my family.

The Health Home staff sees me as a whole person and addresses multiple needs when necessary.

I feel the Health Home staff helped me obtain information I needed so that I could take charge of managing my health and/or illness.

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

64.0%

62.3%

64.1%

59.1%

54.5%

53.2%

59.9%

56.5%

Strongly Agree

[n=626]

[n=613]

[n=609]

[n=613]

[n=631]

[n=593]

[n=608]

[n=632]

Data Collection – Patient Satisfaction Survey*Patient Experience….

*Preliminary Results

I am satisfied with the amount of time the Health Home staff spent with me during my appointment.

My beliefs about health and well-being were considered as part of the services I received.

I am treated the same as other patients who receive care at this clinic.

The Health Home staff encourages me to develop my specific goals to improve my health when needed.

I am satisfied that my health information is kept confidential and shared only as necessary with other healthcare providers involved in my care.

I am satisfied with the assistance provided by the Health Home staff in identifying and/or contacting mental health, primary care, or specialty health services.

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

62.7%

55.7%

61.0%

56.4%

60.2%

61.2%

Strongly Agree

[n=611]

[n=634]

[n=626]

[n=629]

[n=629]

[n=629]

Data Collection – Patient Satisfaction Survey*Patient Satisfaction….

*Preliminary Results

I would follow through if I were referred outside of the clinic for mental health, primary care, or specialty health services.

I am learning the skills I need to deal more effectively with daily problems.

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

46.3%

53.7%

Strongly Agree

[n=590]

[n=612]

Data Collection – Patient Satisfaction Survey* Patient Engagement….

*Preliminary Results

Data Collection – Staff Experience

• Provision of individual care• Patient engagement in healthcare; for many it is the first time• Sense of empowerment and self-efficacy experienced by patients• Increase in activity beyond receiving medication• Increase in access to a wide range of services• Positive changes within their roles• Increase in family involvement• Enhanced care coordination with hospitals and extended care

facilities• Enhanced communication between clinical, medical and Health

Home staff• Development of collaborative and cohesive teams• Excitement about potential innovative programming as a result of

Health Homes

Data Collection – Patient Experience

• Focus Groups - recently completed• Held at each clinic; 20-30 minutes with an average of 5 participants • Asked to sign a Consent to Participate• Audiotaped and transcribed • Patients asked to briefly describe and/or respond to the following:

- their experience with the Health Home program- how they learned about the Health Home program- ways they are more aware of the importance of wellness and

recovery as a result of the Health Home program- how could the program be improved

• Preliminary results demonstrating positive impact on patient’s lives….

Highlights• Successful implementation of Health Homes in 12 clinics across the state• 22 Health Home Teams providing services to more than 2,600 patients • Employed 59 full-time and 3 part-time staff• Overlay of patient acuity model allowing Health Home teams to better

address patients needs• Development of collaborative relationships with United Behavioral Health,

Neighborhood Health Plan of RI, CMHOs, CHCs, CTC, private practitioners, etc.

• Creation of an OTP Health Home Database• Development of a state-wide educational and consultative network• Professional development activities• Clinic-based pilot programs (i.e., acupuncture, home visits, NHP teams

monthly meetings with HH teams, etc.)

Lessons Learned….

• Pre-arrange Memorandums of Understanding, Qualified Service Agreements, etc. with community agencies , hospitals, managed care organizations, etc.

• Develop standardized forms, policies, guidance, etc.• Identify and/or develop reporting systems needed for outcomes, payment

and patient tracking • Provide education to existing and new staff including clarification of roles,

team building activities, expectations, responsibilities, etc.• Address EMR and re-disclosure issues – HIPPA and Confidentiality

Regulations• Introduce Health Homes widely to the community at large• Consider a phase-in implementation strategy• Prepare existing patients for upcoming changes

Opportunities for Continued Growth

Continue to work toward …..• Establishing bi-directional communication and referral processes with

community based primary care physicians

• Partnering to extend case management services offered in primary care practices

• Enhancing collaboration between managed care organizations, primary care physicians, and OTP Health Homes to eliminate duplication of effort

• Expanding screening, assessment and referral activities through strategic partnerships

• Developing unified strategies to drive positive patient outcomes