People with opioid use disorders are a small percentage of Medicaid enrollees, but they represent a significant percentage of costs in terms of emergency department utilization and repeat hospital admissions. By using opioid treatment programs (OTPs) as these patients’ “health homes,” the Centers for Medicare & Medicaid Services (CMS) is hoping that these costs can be cut—and at the same time, health care can be vastly improved for these patients. Health homes in OTPs are strongest in Rhode Island, where Rebecca Boss, the state’s lead in the project, completely buys into the OTP model.
The payment approach is key: Rhode Island uses a weekly bundled payment. The Rhode Island Opioid Treatment Program Health Home State Plan Amendment involves offering OTP patients the chance to have daily contact with clinical professionals.
Linda Hurley, MA, President/CEO of CODAC Behavioral Healthcare, based in Providence, has been involved with the health homes project from the beginning. Ms. Hurley describes OTPs as a “culture of healing,” not just for opioid use disorders, but in general. “It’s beyond the relationship between the patient and the therapist,” says Ms. Hurley. Whether it’s the nurse at the dosing window or the front desk person helping patients figure out insurance, the entire program is aimed at helping the patient get healthy. That’s why OTPs are an ideal setting for being a health home—a location where a patient can receive or be connected to all the health care he or she needs.
About five years ago, Rebecca Boss asked several OTPs, including Ms. Hurley’s, to talk about how to apply the health home concept. Ever since then, the group has met every Tuesday, every week. The group included OTPs, primary care, third party payers—all of the stakeholders—and they looked at barriers to access. The most important part of the health home paradigm is getting the other providers to treat the OTP patients. So the OTPs did help educate primary care physicians about the importance of working with these patients. At the same time, the OTPs learned a lot from primary care people, said Ms. Hurley.
“I’ve been doing this for almost 30 years, and decade after decade I have to go out and provide information to a new group of doctors,” said Ms. Hurley. Listening to them at these Tuesday meetings, she learned a lot about the barriers patients face. “Historically, our patients have the least amount of resources to follow treatment recommendations,” she said. “They have a high no-show rate.”
Talking with the physicians “opened my brain and my heart.” She learned to reach out to them, and, importantly, to have a case manager from the OTP go with struggling patients to the primary care physician appointment. For example, one patient, in early treatment, went to the physician for an appointment, and was very intoxicated. There were families in the waiting room, but because the OTP’s case manager was there to meet the patient, disaster was averted. As it turned out, the patient didn’t actually have an appointment that day, and the practice was willing to give the OTP—and the patient—another chance. “He was exhibiting a symptom of his disease of addiction,” said Ms. Hurley.
The health home team at the OTP consists of a pharmacist, a physician and RN, a master’s level clinician, and two case managers. That team sees 150 patients in the OTP. In addition, each patient continues to have his or her regular treatment team.
One CODAC patient had been depressed, and had low self-esteem. But it wasn’t until the health home initiative that a case manager tried to find out more, and learned that the patient had a lot of dental pain. In fact, from a cosmetic perspective, the dental pain was compounded by the fact that she felt her teeth were unattractive. Through the health home, she got dental care. “All the Wellbutrin in the world wouldn’t have fixed this,” said Ms. Hurley, referring to the antidepressant, bupropion.
CODAC had to add to its facility to make room for the new program. Across the state, health homes in OTPs created 68 new jobs. “Rhode Island says health homes are here to stay—they like the outcomes,” said Ms. Hurley. Emergency department visits have gone down. And this is clearly related to the OTP patients’ understanding that they now have primary care physicians, that their personal physician is not the emergency department doctor.
Finally, the health home initiative ended up with the OTP community in Rhode Island banding together to create a health home leadership group, to make sure services offered from one OTP to another were comparable. “We went a step further,” said Ms. Hurley. “We pooled health home funds, based on the number of patients each entity had, and purchased three positions.” These positions were a health home coordinator, who set up metrics and an auditing tool; a software consultant; and a training coordinator.
The health home program in Rhode Island has been fully operational for two years.