1. Integrated Health Home Services in an Opioid Treatment Program: A Model Yngvild Olsen, MD, MPH Institutes for Behavior Resources, Inc./REACH Health Services Baltimore, MD November 5, 2014

2. Background on IBR/REACH  1960 – Founded as nonprofit (501c3) organization to develop & implement behavioral solutions to community problems  IBR conducts applied research programs under contract  1991 -- REACH (Recovery Enhanced by Access to Comprehensive Healthcare) established as mobile methadone treatment  2000 -- IBR purchased 2104 Maryland Avenue  2010 – REACH moved to fixed site for all OTP services

3. Population Characteristics  Primarily opioid use disorder  Over 60% have other SUDs including alcohol, nicotine, cocaine and benzodiazepines

4. Population Characteristics (N=622) CharacteristicsNo. (%) Gender Female284 (45.8) Male337 (54) Transgender1 (0.2) Age 18-3990 (14) 40-59458 (74) 60-7974 (12) Race/Ethnicity African-American460 (74) Caucasian159 (25.5) Other3 (0.5) Employment/Income Status Employed, part or fulltime140 (23) Unemployed298 (48) Disabled146 (23) Other38 (6) Health Insurance Medicaid360 (57.9) Medicare97 (15.6) Grant funded163 (26.2) Other2 (0.3)

5. Cause for Integration The National Council for Behavioral Healthcare – Substance Use Disorders and Health-Care Home  SUD interventions can reduce healthcare costs and utilization  Many individuals served in specialty treatment centers have no PCP  Continuing care should link the continuum of SUD services together and support individual’s change process  Health evaluation and linkage to healthcare can improve SUD status  On-site services are stronger than referral services

6. Why Integration of Care at IBR/REACH?  Substance-use treatment services at REACH not integrated with primary care  Effects include:  Failure to prevent and treat acute & chronic conditions  Waste of healthcare resources  Reduced recovery rate  SU conditions add to Medicaid health care costs*  SU conditions can cause or exacerbate chronic health conditions* *SAMHSA-HRSA and Maryland Medicaid

7. Opportunities  Affordable Care Act and Medicaid expansion  Up to one-third of newly insured will require care for behavioral health services  Concerted push by Federal agencies and Maryland to integrate services for people with behavioral health needs

8. Integrated Care Model  Recovery Oriented Systems of Care and the Patient-Centered Medical Home  Whole-person orientation  Strengths-based  Collaborative process  Safe and high-quality care  Enhanced access to care  Payment that recognizes the added value  New measures for what constitutes recovery with the incorporation of good personal health and good citizenship in addition to abstinence (McLellan)

9. Chronic Health Home Objectives  Further integration of behavioral and somatic care through improved care coordination;  Improve patient outcomes, experience of care, and health care costs among individuals with chronic conditions; and  Enable Health Homes to act as locus of coordination for OMT populations through provision of additional care coordination services.

10. Participant Eligibility Criteria  Medicaid enrollee  Opioid use disorder that is being treated with methadone, AND one other qualifying chronic condition

11. Health Home Services  Comprehensive Care Management  Care Coordination  Health Promotion  Comprehensive Transitional Care  Individual and Family Support  Referral to Community and Social Support

12. Integrated Care Model  Use classic counseling techniques to engage and motivate patients  Make use of incentives  Sharing of feedback between patient and the team  Recovery support in the community  Take advantage of technology

13. Experience To Date (N=187*) DiagnosisFrequency, No. (%) Obesity/overweight131 (70) Mental Health98 (52) Diabetes Mellitus25 (13) Hypertension86 (46) Heart Disease10 (5) COPD18 (10) Asthma39 (21) HIV23 (12) Hepatitis C57 (30) Other11 (6) More than one co-morbid condition 155 (83) *52% of those eligible

14. Qualitative Changes  Patient is an active participant in the process  Focus on recovery, health, and wellness via language, approaches to care, and strategies of engagement  Increased trust and service seeking  Communication -- secure emails, phone calls, web-based IT system, weekly team meetings, and joint patient visits  Nurses understanding methadone and buprenorphine  Multi-disciplinary team approach and meetings

15. Other Changes  Decrease in administrative/quit/leaving AMA discharges  2013 – discharges as % of average monthly census was 13%  2014 – discharges as % of average monthly census on track to be 6%  Patients asking for on-site comprehensive services including primary care and psychiatry

16. Challenges  A lot of time documenting  Coordination of care with other providers is critical and often time consuming and frustrating  Variable comfort level with medically complex patients among counselors  Culture change where each team member owns responsibility for patient care and participates actively in broad behavior change service delivery  Information exchange and data tracking and reporting

17. Expected Benefits  Positive patient outcomes, reduced drug use and more stable, productive lives  Lower rates of emergency room use  Reduced hospital admissions/re-admissions  Reduced health care costs  Less reliance on long term care centers  Improved patient care experience – less stigma  Improved access to social services and community supports

18. Questions?