Clemans-Cope L, Wishner JB, Allen EH, Lallemand N, Epstein M, Spillman BC
Abstract
PURPOSE:
The United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states-Maryland, Rhode Island, and Vermont – adopted the ACA’s optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral healthcare and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program’s implementation from the perspectives of multiple stakeholders.
METHODS:
We conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation.
RESULTS:
Overall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state’s existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care.
CONCLUSIONS:
The OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states
Insights Results
Overview of article/model
Retrospectively examined Medicaid opioid health homes’ (OHH) development and implementation in Maryland, Rhode Island, and Vermont
The ACA’s optional Medicaid health home model allows states to coordinate care and integrate services for high need, high cost Medicaid beneficiaries with complex chronic health needs. States that adopt the health home State Plan Amendment (SPA) are eligible for an enhanced federal match of 90% for up to eight quarters for health home programs to cover the cost of providing enrollees with six core services: 1) Comprehensive care management; 2) Care coordination; 3) Health promotion; 4) Comprehensive transitional care and follow-up; 5) Individual and family support; and 6) Referral to community and social services
Under the Medicaid health home model is the OHH model, which coordinates opioid agonist therapy provided by opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) providers, with medical and behavioral health care and other services, including those addressing social determinants of health. The OHH model structure, payment, and design is dependent on the state
Methods of article
Authors interviewed key informants at each study site (Maryland, Rhode Island, Vermont); conducted a literature review on home health program (as defined by the ACA and CMS guidelines); and reviewed available information on home health opioid programs. Materials reviewed included federal Medicaid health home state plan option standards, Substance Abuse and Mental Health Services Administration (SAMHSA) opioid treatment program requirements and guidelines, opioid agonist therapy basics, health home state plan amendments and related documents (e.g., state requests for proposals), state Medicaid policies related to opioid use disorder, opioid prevalence data, treatments and services offered by health homes, and any other relevant materials, including state progress and evaluation report
The evaluation was conducted in 4 phases
Results
Phase 1 of the evaluation focused on exploration and adoption decisions of the opioid-focused health homes. Rhode Island and Vermont were primarily seeking to address the growing opioid epidemic. Vermont was specifically interested in increasing access to opioid agonist therapy through OBOT providers. All three state OHH programs shared the goals of addressing comorbidities through increased access to and coordination of primary and specialty care for people with opioid use disorder, overcoming stigma associated with opioid use disorder patients among medical providers, and empowering these patients to navigate the medical system and social services independently. Key factors associated with states’ decision to adopt OHH model included: 1) Good working relationships between state agencies overseeing substance abuse services; and 2) The availability of enhanced matching funds to support the required services
Phase 2 focused on evaluating the preparation phase. In all 3 states, the Preparation phase involved developing a SPA application to submit to CMS, which outlined all elements of the program design. Discussants reported a high degree of collaboration among various state agencies responsible for Medicaid and SUD services in developing the new OHH program, often stemming from other state reform initiative. Many discussants said that stakeholder engagement in program design was critical. The 3 states differed in health home provider selection and recruitment, but implementation at the provider level in all 3 states was mostly led by a few OTPs eager to adopt the new model that paved the way for other providers to follow. Overall, the degree to which providers were involved in program design and received guidance and support to prepare them for the new program launch, and the level of goal and culture alignment between OTPs and the health home model were facilitators to implementation
Phase 3 focused on evaluating active implementation. Key factors that were associated with effective implementation of the health home models across all three states include: 1) High level of cross-agency collaboration to design state OHH programs; 2) Interactions with CMS/contractors to guide program development and help state identity and address issues before implementation; 3) Highly motivated early adopter(s) among providers leading the way; 4) Study providers reported flexibility/workplace culture change during implementation (e.g., adjusting roles, expectations); 5) Study providers reported care coordination limitations because of confidentiality issues and technological barriers/difficulty exchanging patient information with other providers; and 6) Study providers reported OHH reimbursement rates sufficient to cover the provision of required health home services (excluding start-up costs)
Phase 4 focused on program sustainment and lessons learned. All 3 states have continued to fund their OHH programs past the enhanced federal matching period, but uncertainty about future Medicaid financing and possibility of the ACA repeal have caused some concern about the future of the programs. Provider concerns about OHH sustainability primarily centered on financial viability of the model. Discussants identified state flexibility on program requirements (e.g., ability of providers to adjust staffing ratios in response to patient needs); adequacy of health home reimbursement to hire, train, and retain competent staff; and more implementation support as key factors in their continued participation in the program
Key takeaways/implications
Lessons learned from discussions with providers: 1) Timing of OHH implementation should be considered against other health system changes to ensure providers are not distracted and/or overwhelmed by simultaneous initiatives; 2) A wide range of stakeholders, particularly primary care physicians, hospitals, and specialist, should be included in program development to gain their buy-in and foster collaboration across providers; 3) Requiring provider participation, coupled with extensive implementation support, and autoenrollment policy seem to encourage robust participation in the program among both providers and eligible Medicaid beneficiaries; and 4) Program evaluation is essential for providing evidence to support continued investment in OHH models
Barriers to effective implementation of the OHH model existed at every stage of the process (planning, implementation, enrollment). The most commonly cited barriers to achieving program goals: 1) Shortages of primary care providers, dentists, and other providers willing to accept referrals of patients on opioid agonist therapy; and 2) Limitations related to data confidentiality issues and/or technical barriers preventing the effective exchange of patient information to other providers
Areas for future research: 1) Buy-in from other payers for the OHH model in order to support the financial viability of providers to sustain necessary staffing and services; 2) Whether OHH programs are effective (e.g., health outcomes, utilization, costs) and cost-effective; 3) Mixed methods and qualitative research in exploring workforce issues, how provider characteristics and staff engagement impact rapport with patients and their outcomes; 4) Facilitators and barriers to replication of the OHH model in other states
Study limitations include: 1) Retrospective analysis of opioid health home models may intraduct recall bias; and 2) Interviews with limited subset of participants in program
