Division of Alcohol and Drug Abuse Programs Vermont

Division of Alcohol and Drug Abuse Programs Vermont Hub and Spoke model for OTP’s as Health Homes March 29, 2015 Tony Folland Vermont SOTA Vermont Department of Health

Vermont Population 626, 562 1. Northwestern Hub Howard. Center Chittenden Clinic Chittenden, Franklin, Addison & Grand Isle 2. Northeastern Hub BAART Behavioral Health Services Essex, Orleans & Caledonia 3. Central Vermont Hub Central Vermont Addiction Medicine Washington, Lamoille & Orange 4. Southwestern Hub Rutland Regional Medical Center Rutland & Bennington 5. Southeastern Hub Southeast Regional Comprehensive Addictions Treatment Center (Habit OPCO & Brattleboro Retreat) Windsor and Windham

Brief Evolution of MAT Services Late entering MAT services, 1 st OTP opened in October 2002 Opened Buprenorphine Induction Hub in 2004 Quickly became #1 nationally in per capita DATA 2000 waivered physicians OTP expansion to 5 in state clinics and 1 out of state clinic with significant Vermont utilization In 2012 650 individuals treated in OTP’s and roughly 1500 -1800 in OBOT programs. 2011 Development of MAT treatment rules to regulate DATA 2000 waivered physicians with 30+ patients Vermont Department of Health

Integrated Health System for Addictions Treatment Vermont Department of Health

Care for Complex Addictions – the “Hub” “HUB” A Hub is a specialty treatment center responsible for coordinating the care of individuals with complex addictions and co-occurring substance abuse and mental health conditions across the health and substance abuse treatment systems of care. A Hub is designed to do the following: Provide comprehensive assessments and treatment protocols. Provide methadone treatment and supports. For clinically complex clients, initiate buprenorphine or antagonist treatment and provide care for initial stabilization period. Coordinate referral to ongoing care. Provide specialty addictions consultation and support to ongoing care. Vermont Department of Provide. Health ongoing coordination of care for clinically complex

Developing The “Hub” Engaged stakeholders regionally, statewide and within the state system Introduced concept to community providers and sought participation in committees Pregnant women, Children and Families Workgroup Physician Workgroup Identify resources, services and connections for women and family supports Clinically driven algorithm development for matching patients with pharmacotherapy agents and clinical treatment settings Guidelines for medical screening and comprehensive assessment Guideline development for patient structure, if medication other than Methadone (eg. Daily dosing vs. multitude of OBOT structure options) Clinical Workgroup Behavioral health screening, admission, assessment, and treatment planning procedures for the hubs Operationalizing “Health Home” language/definitions with behavioral health supports (eg. Health Promotion=Treatment and Patient selfmanagement)

Care for Complex Addictions – the “Spoke” “SPOKE” A Spoke is the ongoing care system comprised of a prescribing physician and collaborating health and addictions professionals who monitor adherence to treatment, coordinate access to recovery supports, and provide counseling, contingency management, and case management services. Spokes can be: Blueprint Advanced Practice Medical Homes Outpatient substance abuse treatment providers Primary care providers Federally Qualified Health Centers Independent psychiatrists Vermont Department of Health

Spoke (OBOT physicians with support) Polled OBOT physicians regarding most significant concerns/barriers to expansion or perceptions of optimal care Consistent feedback: patients may require more time/coordination of care than physicians had in their schedules Using existing VT Health Home infrastructure (Blueprint for Health) Community Health Team model physicians were offered in-office supports

Spokes continued Any willing provider any structure of OBOT provider New or existing providers Vermont Department of Health

Health Home Services Defined Comprehensive care management Care coordination Health promotion Transitions of care Individual and family support Referral to community services Vermont Department of Health

Comprehensive Care Management Comprehensive care management includes activities undertaken to identify patients for MAT, conduct initial assessments, formulate individual plans of care, and manage patient care across the health, substance abuse and mental health, social services and long term systems of care. Vermont Department of Health

Care Coordination and Referral to Community Supports Once an individualized plan of care is developed, the Health Home RNs and licensed clinician case managers are primarily responsible for monitoring its implementation (with patient engagement) through appropriate coordination, referrals, and follow up of services and supports across treatment and human services providers. Vermont Department of Health

Health Promotion Health promotion activities are part of every plan of care and include activities that promote patient activation and empowerment for shared decision-making in treatment, healthy behaviors, and self-management of health, mental health, and substance abuse conditions. Depending on the needs of the individual, the patient may elect to engage in one-on-one activities or group educational health promotion programs. Vermont Department of Health

Care Transitions Care transitions focus on streamlining the movement of patients from one treatment setting to another, between levels of care, and between health, specialty mental health and substance abuse, and long term care providers. Vermont Department of Health

Individual and Family Supports The RNs and licensed clinician case managers are primarily responsible for supporting the resilience of patients and their families through various activities, including but not limited to: advocacy, assessments of individual family strengths and needs, education about the Agency of Human Services resource systems, and facilitating participation in the ongoing development and revision of care plans. Vermont Department of Health

Payment Methodologies In Hubs Under ACA 90/10 split for up to 8 quarters (2 years) for health home related services Overall estimated that 30% of Hub services met criteria for 90/10 funding Monthly bundled rate payment to providers $ 493. 37 PMPM with 1 documented health home service 345. 36 with TAU Note: If Buprenorphine or Naltrexone products are the pharma, meds are paid outside of this PMPM rate Vermont Department of Health

OBOT Health Home Supports ACA funding for 2 FTE, non-billing responsible staff per 100 patients 90/10 funding split in Spokes (ACA section 2703 VT SPA) 1 FTE licensed behavioral health provider 1 FTE nurse provider Any configuration of service providers/service areas to provide Health Home Services Vermont Department of Health

Data Considerations • • Physician visit planners/panel management guidelines developed consistent with other chronic illnesses Standard OTP documentation requirements and physician chart notes Standardized releases across hubs Standardized waitlist reporting

Accreditation Requirements NCQA PCMH requirements (specialty care) mirror the primary care standards: over 86% of all Vermonters in PCMH practices Blueprint for Health support: project manager and embedded staff supports First Hub (Chittenden Center) has completed its baseline assessment of data Vermont Child Health Improvement Program (VCHIP) doing evaluation assessing program adherence and cost impacts Vermont Department of Health