1. CSAT/SOTA Pre-Conference Session
AATOD Conference
March 29, 2015
Atlanta, GA
The State of Rhode Island and Providence Plantations Opioid Treatment Program Health Home Initiative
Susan A. Storti, PhD, RN, NEA-BC, CARN-AP
OTP Health Home Administrative Coordinator
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2. OTP Health Home Patient Enrollment
Opt out rate: 11.2% (291patients have opted-out) 12/31/14
Common Reasons for Opting-Out
Lack of engagement
Duplication of services
Feeling stable and having no needs
Other insurance
Take-home status
Resistance to change 2

3. 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
Hire training coordinator
Conduct training needs assessment
Identification of available training opportunities
Engage IT company
Collaborate with BHDDH to
Revise Health Home Audit Standards and Self-Assessment tool
Develop a Plan of Care
Conduct Mock Audits
Design OTP Health Home Database

4. OTP Health Home Implementation Plan

5. System Change Document
Challenge
Building A Foundation For Change
Defining & Measuring Outcomes
Documenting The Current System
Defining A
New System
Implementing
Change
Re-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
ongoing
ongoing
ongoing

6. 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

7. 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

8. OTP Health Home Database

9. Reporting

10. Reports

11. Data Collection – Patient Satisfaction Survey* Patient Experience….
*Preliminary Results

12. Data Collection – Patient Satisfaction Survey* Patient Satisfaction….
*Preliminary Results

13. Data Collection – Patient Satisfaction Survey* Patient Engagement….
*Preliminary Results

14. 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

15. Data Collection – Patient Experience
Focus Groups - recently completed
Held at each clinic; 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….

16. 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.)

17. 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

18. 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 18