1. Rachel Gonzales-Castaneda, PhD, MPH
Adopting Medical Necessity Guidelines under EPSDT in the Youth SUD System of Care: An Illustration using LA County
CIBHS Webinar
May 15, 2018
10-11:50am
Rachel Gonzales-Castaneda, PhD, MPH

2. Learning Objectives
Review the SUD Youth System of Care: Past and Current
Review Medical Necessity Guidelines under the Drug Medi-Cal Organized Delivery System (DMC-ODS) Youth benefit - Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Use LA County’s System Transformation to Advance Recovery and Treatment-Organized Delivery System (START-ODS) Initiative as an Illustration

3. What opportunities does DMC-ODS bring?
Traditional System Limited:
Over the past decade, there has been continued attempts at bringing about systemic reform to the SUD Service Delivery System
Mental Health Parity and Addiction Equity Act (2010) focused on ensuring equitable (the same) benefit packages for SUDs - financial terms, conditions, requirements, and treatment limitations as they do for mental and medical conditions.
The Patient Protection and Affordable Care Act of major emphasis on integrating SUD prevention and treatment in Health Plans (SBIRT) covered by Medicaid (CA adopted in Jan 2014)
The Medicaid 1115 waiver option: Drug Medi-Cal Organized Delivery System Pilot Program – DMC-ODS is part of reform attempts at improving the SUD system of care
*Group Counseling
No routine screening practices
No standardized assessments used to identify SUDs or treatment need (level of care)
Limited service coverage (benefits):*
No early interventions
No case management
No family therapies
No recovery support
No MAT
What opportunities does DMC-ODS bring?

4. The DMC-ODS Waiver expands DMC reimbursable services and creates a fuller continuum of care
Current DMC-SUD System
New DMC-SUD System
 Outpatient
 Intensive Outpatient
 Residential (Perinatal Patients Only)
 Opioid Treatment Program
 Individual Sessions (Crisis Only)
 Group Sessions
 Residential (All Populations – 3 LOCs)
 Additional Medication Assisted Treatment
 Withdrawal Management (Detox)
 Individual Sessions (No Limits)
 Family Therapy
 Case Management/Care Coordination
 Recovery Support Services

5. What is EPSDT? S S T D A R A D N
In order to receive DMC-ODS Services, youth must meet “medical necessity.” Met when:
One SUD diagnosis* is identified from the Diagnostic and Statistical Manual-DSM OR are assessed to be “at-risk” for developing a SUD
Youth must meet the ASAM criteria definition of medical necessity for services based on the ASAM criteria
What is EPSDT? S S T D A R A D N

6. DMC-ODS EPSDT What screeners are used in the SUD field?
Program
Definition
Diagnostic and Statistical Manual of Mental Disorders-DSM
No minimum age limitation for SUD diagnoses. Prevalence estimates for youth generally include ages
The American Society of Addiction Medicine –ASAM Criteria
Defines adolescence in its glossary as ages
The American Academy of Pediatrics
Defines adolescence as ages 11 to 21.
Early and Periodic Screening, Diagnostic and Treatment
Benefit covers individuals under age 21.
EPSDT is the federal youth Medi-Cal benefit. What is meant by youth?
Stands for: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services to address physical and mental health conditions, as well as substance use disorders.
Early: Identifying problems early.
Periodic: Checking health during periodic, age-appropriate intervals.
Screening: Providing physical, mental, developmental, dental, hearing, vision and other screening tests to detect potential problems.
Diagnostic: Performing diagnostic tests to follow up when a risk is identified.
Treatment: Control, correct or reduce health problems found.
What screeners are used in the SUD field?
What Diagnostic Tests are used in SUD field?

7. Screening is an Essential and Routine Practice Conducted in Public Health Settings
Screening is an evaluation process used for early identification of “risk of having or developing” unrecognized illness or disease.
Screening is NOT Assessment. Assessment is used after risk is detected to further evaluate for disorder (severity level) and for making a clinical diagnosis
Screening is an evidence-based practice component of S-BIRT
Recommended to identify “at risk” individuals (young & old) for developing a substance use disorder and triaging risk

8. Clinical SUD Diagnosis
Routine screening among Youth Populations aligns with National Best Practice standards endorsed by professional bodies:
National Institute of Drug Abuse
National Institute of Alcohol Abuse and Alcoholism
American Academy of Pediatrics
Substance Abuse Mental Health Service Administration
California Society of Addiction Medicine
The EPSDT Medicaid Pediatric Assurance
At-Risk for SUD
Clinical SUD Diagnosis
Why is it important to screen someone for alcohol or drug use before jumping to an assessment?

9. Screening allows for the identification of Initial RISK before assessment… What do rates look like?

10. Why Screening in the SUD Field is a National Priority
Substance Use Disorder-Severe 5%
Substance Use Disorder-Moderate
Substance Use Disorder-Mild
Severity
70%
Problematic Use
Substance Use (Misuse)
25%
No Past Year Substance Use
Routine Screening addresses diverse risk patterns among youth

11. Screening allows for the identification of Initial RISK before assessment… And Addresses Youth Engagement Issues common in Youth Settings

12. Youth Self-Evaluations of SUD Risk are Biased
Developmental Considerations:
Experimentation: “curiosity” “exploring new experiences”
Sensation Seeking: “looking for positive experiences”
Social Acceptance: “fitting in”
Emotional interest: “coping” “comfort” “relieving pain”
“Will my friends still like me, if I stop?”
MJ is not a drug: It’s not harmful or addictive…
Everyone over-reacts about how much me and my friends drink…
It helps me cope, so why are you telling me to stop?
I got into trouble, but I don’t have a drug problem.
I can’t be the only one not using at parties or when with friends…

13. The Practice of Screening
Efficient - Quick, easy to administer, and compatible with electronic medical records
Comprehensive - screens for tobacco, alcohol, other drugs commonly used by youth
Age Appropriate – validated among youth populations
What are the validated Screeners for Youth Populations?

14. Validated Screening Tools for Youth that Identify Risk
CRAFFT (Car, Relax, Alone, Forget, Friends/Family, Trouble)
6 items
Screens for substance use broadly with integration of risky behaviors/issues
Screening to Brief Intervention (S2BI)
7 items - Expands “substances” screened for
Questions consumption patterns
Distinguishes Risk levels
CRAFFT
S2BI

15. The CRAFFT Identifies (flags) Risk that warrants further assessment
Risk Flag 2+
No = 0 points; Yes = 1 point

16. LA County Youth Engagement Screener (Youth 12-17)

17. The goal of the SAPC YES Screening Tool
Risk Indicators: Peers, Use for mental health,
Family and School Trouble, Consumption Patterns
The goal of the SAPC YES Screening Tool
Engage while Detecting Risk for further assessment of potential SUD
S2BI Algorithm

18. Further Assessment LA County Developed Youth* ASAM Assessment
Version is Paper-Based
Includes DSM 5 Diagnostic Criteria
6 Dimensions Adapted for developmental appropriateness – language and items
Includes At-Risk Determination Criteria
Encourages use of MI opportunities for engagement
*In LAC, medical necessity is determined using a full ASAM assessment for each Medi-Cal-eligible youth

19. LA County ASAM Assessment
DSM 5 Clinical Indicators of SUD vs. Indicators of SUD Risk

20. Example of Integration of Questions
DSM 5 Clinical Indicator

21. DSM 5 Built into Clinical Assessment

22. LA County At-Risk Protocol

23. Definition of “At-Risk” – Los Angeles County
To meet medical necessity for specialty SUD services, youth and young adults under the age of 21 must meet at least one of the following criteria:
Have at least one diagnosis from the current Diagnostic and Statistical Manual (DSM) of Mental Disorders for Substance-Related Disorders, with the exception of Tobacco-Related Disorders and Non-Substance-related disorders, and meet the ASAM Criteria for necessary services; OR
Be assessed to be “at-risk” for developing a substance use disorder.
Youth or young adults under the age of 21 may be determined to be “at-risk” if they meet the following criteria:
If the substance use does NOT meet the minimum criteria for a SUD from the DSM-5 (with the exception of Tobacco-Related Disorders and Non-Substance-Related Disorders);
AND
Determined to be at-risk of developing a SUD using the At-Risk Determination Tool based on reports of experimental or early-phase substance use, associated biopsychosocial risk factors, and information gathered from the full ASAM assessment.

24. The At-Risk Determination Tool consists of Clinical Factors Considered to be important SUD Risk Indicators (collected in the ASAM Assessment)
Hawkins, J.D., Catalano, R.F., and Miller, J.Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention, 112(1),

25. At-Risk Determination Tool – Los Angeles County25

26. LA County Transformed System of Care for Youth
Substance Use falls along a Continuum of Risk & Severity
No Use
SUD
At Risk for SUD
Recovery
SUD
Aftercare
At-Risk
No Use
Treatment ?
Prevention
Outpatient Treatment
Drug Education
IOP Treatment
Residential Treatment
WM and MAT *Authorized by SAPC

27. Treatment Agencies that Provide “Services”
Medical Necessity:
SUD or At Risk for SUD
Treatment Agencies that Provide “Services”
“IOP”
Level 2.1
MAT*
“OP” Level 1.0
“OP” Level 1.0-AR
Residential
(Levels 3.1/3.5)
Moderate Intensity
Clinical Services
Low Intensity
Clinical Services
At-Risk Services
High Intensity
Clinical Services
Withdrawal Mgmt*

28. “At-Risk” Service Benefits – Los Angeles County
These services are low-intensity, limited to 16 units of service (in 15 minute increments; totaling 4 hours), and must be provided in outpatient SUD settings.

29. “At-Risk” Youth Services in LA County
Short-term (Brief) Services
Level of Care: 1.0-AR
Outpatient Setting
Intake and Assessment Services
120 minutes
Brief Services (120 minutes) between provider & youth…
What are Therapeutic Components?
Session 1
30 Minutes
Session 1
30 Minutes
Session 3
30 Minutes
Session 4
30 Minutes
Individual Counseling
Psychoeducation
Case Management

30. Treatment Rates: Outpatient for At-Risk Youth & Young Adults 12-20 Only

31. Additional Resources for Addressing Youth SUDs
SAPC Provider Manual & Forms:
Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health:
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefit:
S2BI: questionnaire-quickly-rates-teens-substance-use
Adolescent SBIRT Learner’s Guide: content/uploads/2016/11/Adolescent-SBIRT-Learners-Guide-V2.pdf U R C E S E S O R

32. Group Discussion How is Screening and Assessment implementation going?
Questions

33. Rachel Gonzales-Castaneda
Follow-Up
Rachel Gonzales-Castaneda