Implementation of Long Acting Naltrexone:

Pitfalls & Progress

12th Annual Statewide Conference:

Integrating Substance Use, Mental Health, and Primary Care Services

Mary Taylor Fullerton, MFT Matt Boyle , CADC II

Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose.

Mary Taylor Fullerton; San Mateo County Behavioral Health & Recovery Services

I have no financial relationships to disclose

I will not discuss off label use and/or investigational use in my presentation

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DisclosuresImplementation of Long Acting Naltrexone: Pitfalls &

ProgressMary Taylor Fullerton & Matt Boyle

DisclosuresImplementation of Long Acting Naltrexone: Pitfalls &

ProgressMary Taylor Fullerton & Matt Boyle

Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose.

Matt Boyle; San Mateo County Behavioral Health & Recovery Services

I have no financial relationships to disclose

I will not discuss off label use and/or investigational use in my presentation

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Outline• Pilot background• Program Implementation

• Successes & Challenges• Lessons Learned• Data / Outcomes• Policies & Procedures• Next Steps

18 months; 17 clients Criteria

18+ Chronic alcohol misuse 2 Emergency Dept (ED) visits last 2 months Not currently using opiates

The Pilot

Outcomes

Alcohol cravings & Urge to Drink

Emergency Dept. visits – 6 mo pre Pilot - average 5.8 ED visits 6 mo post Pilot - average 0.2 ED visits

Drinking Days per month 6 days - At start of Pilot 0.4 days – After 2 months of Pilot

The Pilot

Outcomes

Increased stable housing Increased behavioral health service

utilization Some participants employed

Client story: Pete

The Pilot

Collaboration between: Health Plan of San Mateo Behavioral Health & Recovery Services Horizon Services – Palm Avenue Detox HealthRight 360; MAT / PC Clinic Voices of Recovery of San Mateo

Pilot to Program

System wide Goal: any door…

Medication Assisted

Treatment

IMAT Team

Primary Care

Interface MAT

BHRS Clinics

MAT / PC Clinic

NRT Clinic

New

New

New

System wide Goal: any door…

Medication Assisted

Treatment

IMAT Team

Primary Care

Interface MAT

BHRS Clinics

MAT / PC Clinic

NRT Clinic

New

New

New

Behavioral Health - Alcohol & Other Drug Services BHRS Supervisor BHRS Analyst BHRS Case Manager / Assessor Specialist (5) BHRS Benefits Analyst

Behavioral Health – Primary Care Interface Team MAT MD BHRS Case Manager / Assessor Specialist (4)

BHRS Implementation

New MAT Services

SMMC

3 CM

7 days / wk

12-19 hrs / day

Embedded in ED &

PES

Criminal Justice

2 CM

5 days/ wk

Field based

New MAT PC Clinic

2 CM

MD / Nurse

Basic PC

MAT services

Expanded Detox

2 Care Coordinato

rs

3 dedicated

beds

Extended stay

Primary Care

4 CM / 1 MD

Embedded in PC

6 sessionsCOD CM

IMAT

Identifying population Hiring passionate staff Comprehensive Training

Motivational Interviewing Trauma Informed Care Strength Based Case Management SBIRT; ASAM Dimensions

Implementation Successes

Promoting MAT amongst providers IMAT Vehicles Emergency Dept. integration

Shift huddles Referral process Data sharing Ct success stories

Implementation Successes

Clinic timing Learning Hospital system Promoting MAT amongst providers Establishing procedures & policies

Building from ground up (+ / -) Probation partnering Beds, beds, beds …. And housing

Implementation Challenges

Primary Care Clinic Integration Client Care ownership Continuity in referrals

Staffing busy ED Tracking trends

Removing Barriers Integration Hands OFF vs. Warm Hand Off

General [outdated] attitudes towards SUD - stigma

Implementation Challenges

Importance of being a great partner The critical non-crisis hours

Collaborative care & Communication The warm handoff

Everyone is motivated for something Clients & partners

Early Lessons Learned

Data & Outcomes

Basic demographic info Insurance (for HPSM) Referral Source Housing status Frequency to ED, “High Utilizer List” Cost Utilization (to come w/ LEAN) # Connected to services or referred to treatment # Receiving injection MD: Vitals, Urge to Drink, Drinking Days

Data collected

Outreach and engagement Referral to care providers SUD Assessment for inclusion in MAT Improvement in physical and psychiatric health Reduction in urge to drink (Urge to Drink Scale) Reduction in alcohol consumption (Drinking Days) Reduction in utilization of emergency services Increased utilization of primary care services Housing status

Outcomes Measured

New program codes in Electronic Medical Record AD BHRS MAT Episode, designated Service & Discharge

Codes Excel Spreadsheet “Client Tracker” End of Shift Reports at ED/PES HPSM “High Utilizer” / cost utilization list Multiple EMR research Monthly Quality Improvement Committee (QIC)

Review High Utilizer lists of the ED, PES, and other systems, create engagement plans.

Case presentations highlight barriers, gaps and service needs.

Collection Methods

Weekly Data Reporting: San Mateo Medical Center LEAN Reports

IMAT Referrals

SMMC ED SMMC PES CJ/LE/Prob. Call Center AOD TxInnovative Care Clinic

Other Community Refl.

TOTAL

Week of: * 10/02/15 - 10/10/15 13 2 0 0 0 1 2 18

6/01/15 -10/10/15 124 31 8 5 3 3 11 185

IMAT Outcomes

Total Referred

Active Cases Outreach / Engagement

Not Interested in Services

Engaged & Referred to Provider

Waiting on Dr. appt.

Have Received Vivitrol IM Number of Injections

6/01/15 - 10/10/15 185 94 75 53 22 14 33

344 Referrals 140 Active Clients

In Outreach / Engagement or Case Management phase

16 unique clients total of 40 Vivitrol injections

32 clients waiting on a doctor's appointment While we wait for MAT clinic to open

Outcomes: 6/01/15 – 10/23/15(pre-HR360 clinic)

In nearly 5 months, only 1 of 16 Vivitrol clients has had subsequent alcohol-related ED/PES visit

Five of our initial IMAT clients have completed 90 days of residential AOD treatment! 3 of the 5 were high utilizers of emergency services

ED & PES Shift Huddle Report Outs

Data / Outcomes as of 10.23.15

Client stories: Erik

Ranked #3 on HPSM priority population “High Utilizer" list; over $103,000 in health care costs in 2014 alone Not including several visits to other ED’s and jail

Since July 2015, has not visited the ED, PES or jail using PC and MH clinics to meet health care needs

Will receive 5th Vivitrol injection next week

Scheduled to graduate from 90 day treatment program 11/09

Outcomes

Policies & Procedures

IMAT Electronic

Health Record Procedures

BEHAVIORAL HEALTH AND RECOVERY SERVICES INTEGRATED MEDICATION ASSISTED TREATMENT TEAM

IMAT Avatar Documentation & Service Code Descriptions The client chart should document facts, staff interventions, and client progress. PROGRESS NOTES: There must be a brief written description in the client record each time services are provided. Progress notes provide a clear, ongoing record of the client’s condition, interventions attempted, client’s response to care provided, and progress the client is making toward realizing his/her goals and objectives. Notes can facilitate the coordination of care and communication between team members. Funding sources look to see that progress notes record a service for every billing, show evidence of collaboration with community resources, demonstrate on-going necessity for intervention, and show that the time billed seems appropriate for the service provided. Progress notes describe BEHAVIOR and GOAL addressed. Include: your direct observations, what ct self-reported, and any reports from others; state who reported what. Remember that if it is not written it did not happen. Document your INTERVENTIONS, show that you addressed the client’s need with the standard of care. Include the PURPOSE of the intervention. For example, “a safety plan was developed to stabilize the crisis.” Describe client’s RESPONSE to your intervention, or the outcome / result of service. Also, include a PLAN if needed - address any immediate needs and next steps needed. IMAT SERVICE CODES

AD60 -Outreach and Engagement includes but not limited to:

Initial contact Psycho-education

General background / information gathering Exploring treatment, resource options

AD61 - Case management These service activities may include (not limited to): communication, coordination, and referral; monitoring service delivery to ensure client access to services; monitoring ct progress once he/she receives access to services; and development of the plan for accessing services. Identification and pursuit of resources necessary for the client to access service and treatment. Inter- and Intra- agency communication regarding appointments/forms. Discharge planning and Placement services.

Electronic Community referral form

San Mateo Medical Center Referral

Procedures

IMAT Job Duties at San Mateo Medical

Center

“Hi, my name is ____ I am from IMAT, Integrated Medication Assistance Treatment team with BHRS, and I am here to meet with any patients who have alcohol problems and offer them services; you can reach me at x2735 or my cell #.”

BEHAVIORAL HEALTH AND RECOVERY SERVICES IMAT CASE MANAGER PROCEDURES AT SMMC

o Check email and read END OF SHIFT REPORT from staff o Check in with all three stations and provide your name, role, phone: x2735 and cell #

1. Triage & Registration window 2. Charge Nurse at Emergency Department

check yellow IMAT binder for referrals 3. PES Nursing Station

o Attend shift huddle: ED at 7 AM & 3PM, PES at 8:40 AM

When patients are referred:

o Carefully collect demographic info for accurate reporting: First/Last Name, Date of Birth, SSN, Medical Record #

o Check Avatar & Sorian to determine if patient has open episodes or past history of services. Carefully check by first/last name, birthdate, SSN, MR #

o If in ED: Obtain yellow sticker and check PulseCheck to help track accurate client info o Meet with patient:

IMAT approach: Welcoming, Non-judgmental, Trauma-informed, & Strengths based Check in with patient’s assigned Nurse (when available) before & after your outreach Provide info and education about IMAT services

o Determine if patient meets criteria for IMAT: Alcohol related problems that appear chronic (use PulseCheck in ED) High utilizer to ED and/or PES for alcohol related issues Health Plan of San Mateo member (San Mateo MediCal) Verbalizes interest in IMAT (specifically MAT medications & reducing alcohol use)

Document: ** Regardless of patient interest / appropriateness**

o Excel: Enter all info in excel tracker S: drive / HPSM / Ct Tracking – Restricted Folder o Avatar: Open AD995100 AD BHRS MAT episode, write progress note of your interaction(s) o If patient is currently open to county service (with patient’s verbal permission) email the appropriate

team regarding the ED or PES episode and IMAT service attempt o Continue to document in Avatar any subsequent patient contact

IMAT Candidates: When patient meets criteria AND is interested in IMAT

o Complete Release of Info as necessary – upon follow (this includes county connected patients) o If patient needs detox make referral to Palm Ave Detox or First Chance Sobering Station o Make follow up plans / warm handoff to Case Manager at PAD, HR360, ARM, or client’s “home team” o If patient is connected to county services, email their team about your intervention, relay info that their

patient is candidate for MAT, can they provide? or referral to HR360

End of Shift o Call Palm Ave Detox and First Chance Sobering Station for available bed count & potential IMAT referrals o Erase name from ED / PES white boards o Create and email IMAT team your End of Shift Report (SEE ATTACHED format for documentation):

Include: Every referral, follow up needed on next shift, available bed counts, potential referrals Email to: All IMAT Case Managers, IMAT Supervisor & IMAT Program Analyst

IMAT Transportation

Challenges: Proposal

IMAT Updates & Challenges I N T E G R A T E D ME D I C A T I O N A S S I S T E D T R E A T M E N T

July 24, 2015

In the last four weeks, IMAT Case Managers have:

Screened and/or outreached to 32 individuals in the SMMC Emergency Department & Psychiatric Emergency Services and Palm Ave Detox

Responded in the field to 6 referrals from: SSF Police Dept., BHRS Service Connect, BHRS Psychiatric Emergency Response Team (PERT), and the IVSN Homeless Outreach Team (HOT)

Successfully placed 7 individuals in Short Term Residential Stabilization Coordinated the process for 3 of these individuals to receive their first Vivitrol injection

All this before the HealthRight 360 MAT clinic is even open! Even with this promising work, we are seeing some major obstacles in our team’s ability to be successful. We are finding that for most of these individuals, timing is of the essence and we have a justifiable need for three dedicated IMAT vehicles to be permanently assigned, given that three Case Managers are on shift at one time.

Timeliness is linked to better outcomes o When clients move from contemplation to action, the window of opportunity to engage

is limited Many HPSM High Utilizers are regularly presenting at SMMC, discharge can happen rapidly;

o Our ability to connect them with services frequently hinges on our ability to transport Language, cultural, and legal barriers inhibit clients from accessing services;

o These individuals do better with 1:1 supported transportation by a Case Manager and direct linkage to services (vs. a taxi voucher)

Many of the IMAT clients have co-morbid, ambulatory issues that often make reliable transport by taxi cab challenging

Costs of procuring vehicles to be offset by: o Making efficient use of staff time o Reducing emissions and fuel costs of driving to/from motor pool o Reimbursement costs of staff driving own vehicles

Examples of Transportation activities: o Get clients door-to-door: SMMC > Palm Ave Detox, to MAT clinic, etc. o Help clients secure medications prescribed at SMMC discharge and get safely to Detox o Enroll in benefits, attend interviews, court dates, doctor appointments, etc.

On-boarding new clinic Streamlining referral & communication

process with contracted partners Opioid Use Disorders ASAM Criteria, dimension ratings

Prepping for Drug Medical Waiver Adding billable components (Case

Management, Withdrawal Management)

Next Steps

Thank you!Q & A