Health home model allows OTPs to cast a wider net

Patients with opioid use disorders are at risk for a wide range of health problems stemming from the addiction itself—without even considering other chronic conditions that might be related to genetics or lifestyle choices. Managing such comorbid conditions can be confusing and costly for anyone, but particularly for individuals with ongoing, active addiction.

For complex patients in Baltimore City, Md., however, there is a promising new modality—not just for sobriety, but for better health.

Yngvild Olsen, MD, MPH, medical director for the Institutes for Behavior Resources Inc. REACH Health Services, presented data at the annual conference of the American Association for the Treatment of Opioid Dependence (AATOD) Oct. 31 on a new health-home model offered at REACH.

Typically, health homes aim to deliver comprehensive care. The specific goal of the REACH program, according to Olsen, is to provide a whole-person approach to substance use disorders (SUDs) while also addressing behavioral, somatic, and social needs. By expanding existing opioid treatment program (OTP) services—traditionally limited to medication therapy with methadone, buprenorphine or naltrexone—to include primary care services and care coordination, there is the hope that substance use treatment will be more successful, with chronic and acute conditions better managed and healthcare utilization decreased.

One of the reasons the health-home model was put into place was to combat the tremendous cost of opioid use disorders and poor health outcomes that the state’s Medicaid program was facing, Olson says.

“It’s about being more proactive in identifying health goals and chronic conditions, and about connecting patients with resources to manage those conditions,” she says. “That’s not something that’s been in the wheelhouse of the OTP program.”

New way of thinking

Not only does the health-home model require a lot of work in terms of care coordination, Olson says it also requires a change in the way clinicians are thinking, too. Instead of siloes of care delivery, the teams need to think in terms of total health.

“I’m a primary care provider by training, so for me this was kind of a no-brainer,” Olson says. “If the goal is to help people manage their opiate and other SUDs, you can’t really do that by separating people into little bits and pieces.”

The focus in many opiate treatment programs is not just medication, but behavior change, Olson says, and those lessons can also be applied across the health spectrum.

“With a lot of chronic illnesses, a lot of what we are trying to help people with is behavior change, and that’s not unique to substance abuse disorders,” she says. “We want to integrate behavioral health and the medical care, and apply the techniques and approaches we know work to other chronic illnesses.”

Mark Parrino, MPA, president of AATOD says using the health home model in an OTP also requires strong support from state leaders as well good program management.

“In any state where any one of those elements isn’t present, it doesn’t work there,” Parrino says. “From a national perspective, this isn’t catching on in any big way because you don’t have those essential elements in place.”

Basic health services

Often, patients with SUDs face barriers in receiving basic health services because community providers are not receptive to the population, and patients have low levels of health literacy and poor support systems, according to the presentation.

Payment is also a problem. Maryland’s home health model requires OTP sites to also be enrolled as Medicaid providers, accredited as a health home by Commission on Accreditation of Rehabilitation Facilities (CARF), and have a provisional designation as a health home for providers in-process of accreditation. Patients must be Medicaid enrollees with an opioid use disorder that is being treated with a medication plus one other qualifying chronic condition.

Under the health home model, two services must be provided to each patient monthly in order to reimbursed. Two different services can be performed on the same date—which is often not allowed in other state Medicaid programs—and services can be provided by counselors, nurses, physicians, nurse practitioners, and administrative staff.

Services that are billable under the model include the creation of treatment plans, medical appointment scheduling assistance, health education about chronic conditions, sexual education and family planning, smoking prevention or cessation programs, nutritional and exercise counseling, according to the presentation. Counselors at the OTP health home help patients make appointments, provide counseling on behavior changes, and help them with housing, transportation, or legal needs.

New challenges

Some challenges of using the health home model are the time-consuming nature of care coordination and documentation for this population, a wide range of comfort levels among counselor in handling patients with medically complex issues, conflicts between the payment model and patient needs, and integrating the health home model into the daily function of the OTP program, according to the presentation.

According to a white paper drafted by the Hilltop Institute and the University of Maryland for the Maryland Department of Health and Mental Hygiene, participating health homes receive an initial intake and assessment fee of $98.87 when they enroll a new individual into the health home. Health homes receive no payment for any months that enrollees receive fewer than two services, according to the report.

The program is funded by Maryland’s Medicaid program, and more than 5,000 participants across the state have received services though from than 30 health homes state-wide, with most of the programs (80%) focusing on psychiatric rehab.

Long view on health homes

There are currently three states with mature health home models in place—Vermont, Rhode Island, and Maryland—Parrino says. In a recent survey of 51 CEOs across 30 states, Parrino says AATOD found that most states aren’t even close to developing similar OTP/health home programs.

Although preliminary results in the white paper show only “incremental progress” toward program goals, the analysis also notes that only a short period of time has passed since the program’s inception, and more time might be needed to adequately assess the long-term effect.

Initial results indicate that ambulatory care and emergency department visits, as well as readmission rates were higher in the health home study group than in a comparison group, but that the length of hospital stays was shorter in the health home study group.

Olson says her agency is in the midst of a more in-depth look into the success of the health home model, but she says she has seen some pretty dramatic changes in individual patients, both in terms of their success in managing substance abuse, and their other health issues.

“From a patient perspective, we have found that people started paying more attention to their other health problems,” Olson says. “We’ve seen some pretty amazing turnarounds of patients’ overall health.

Olson says the model also does a lot in the way of improving employee engagement and morale, as well as building trust with patients.

“Now, after having worked in an OTP that has a health home, I can’t imagine working without it because it’s really made such an unbelievable difference in the morale of our staff, the demeanor of our patients, the outcomes we’re seeing,” Olson says. “It’s really kind of seeing the small steps and the positive stories that come back from patients and staff. It is just so unbelievably rewarding. To me, it’s really a measure of quality of care.”

Rachael Zimlich, RN, is a freelance writer based in Ohio.