One nonprofit and four for-profit opioid treatment programs (OTPs) in Rhode Island are demonstrating how a health home approach to treating their population can decrease Medicaid costs and improve health and quality-of-life outcomes. The next challenge for the programs likely will involve withstanding the real possibility of state Medicaid cuts at a time when the state is scheduled to meet more of the initiative's funding responsibility.
Three leaders involved with the OTP health home initiative in Rhode Island addressed a workshop audience March 29 at the national conference of the American Association for the Treatment of Opioid Dependence (AATOD). Rhode Island is one of a tiny minority of states that has sought and secured a state plan amendment from the federal government to establish health homes within OTPs; a two-year period in which the federal government is footing 90% of the bill for the health home portion of the OTPs' services ends June 30.
Under the health home model employed at each of the state's methadone treatment programs, a full-time team leader, registered nurse and two case managers work in tandem with a part-time physician and a part-time pharmacist to coordinate patients' comprehensive service needs. Improvement of employment conditions and housing stability stand alongside reductions in illicit drug use and smoking as central goals of the health home approach.
“This is more than just a medical program,” said Michael Rizzi, president and CEO of CODAC Behavioral Healthcare.
At the time the state of Rhode Island approached the state's OTPs and urged them to develop a health home model, these programs never had conducted a joint project. But the opportunity to improve patient care while establishing a new revenue source was attractive. “Our Medicaid bundled rate hasn't been changed since … we can't remember,” said Rizzi.
OTP leaders met weekly for 18 months to design a plan, guided in part by a previous state plan amendment process undergone by the state's community mental health organizations. Peter Morris, chief operating officer of the OTP Discovery House, credited the state for suggesting the approach and the federal government for showing its financial commitment. “This is an initiative the feds are really promoting,” Morris told the conference audience.
The 12 clinics represented in the participating treatment organizations have a combined total of 22 health home teams. Rizzi said that while the OTPs expected around 1,500 of their patients to enroll in the voluntary health home program, around 2,600 have elected to participate. “They began to see the value to this in negotiating a complicated, complex and sometimes intimidating healthcare system,” Rizzi said.
The core measures used to evaluate health home services include variables such as body mass index along with more common behavioral health measures such as follow-up care after hospitalization. The health home teams work in close communication with the clinical professionals who oversee medication-assisted treatment (MAT) at the OTPs; Rizzi said they do not operate in silos.
A Rhode Island official in the workshop audience said the initial data emerging from the project is pointing to significant decreases in hospitalization and pharmacy costs, which are offsetting the expenses associated with implementing health homes. Per-member Medicaid costs appeared to decline by about $1,500 for the typical health home participant in 2014.
While those cost offsets can help make the case for continuing this initiative when the state begins to assume half of the responsibility for the health home costs in July, that will be a challenging pitch at a time when the new state administration has proposed around a 10% cut in state Medicaid spending as part of a deficit-closing effort. No specific cuts have been delineated. “We feel confident that the initiative will be in the budget,” Morris said.
Susan Storti, PhD, administrative coordinator for the OTP health home initiative, said the experience of the past two years has brought many lessons, including the wisdom of conducting site visits to identify strong points and shortcomings of the OTPs' efforts, as well as the importance of stratifying support based on varied levels of support needed by patients. She cited the case of a 29-year-old opioid addict and ex-inmate to illustrate how the person-centered care of a health home approach can pay dividends.
“He felt embraced in the OTP,” Storti said. “He had tried treatment before, but he said this time he decided to acquiesce and give recovery a true try.”