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Experiences of three states implementing the Medicaid health home model to address opioid use disorder—Case studies in Maryland, Rhode Island, and Vermont

Open AccessPublished:October 06, 2017DOI:https://doi.org/10.1016/j.jsat.2017.10.001

      Highlights

      • 3 states use the Medicaid Health Home model to address opioid use disorder.
      • The model integrates opioid agonist treatment with health care and social services.
      • Stakeholders reported successful implementation despite challenges.
      • The model has the potential to meet complex needs of disadvantaged patients.
      • Experiences of these 3 states can inform development of similar treatment initiatives.

      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 health care 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.

      Keywords

      1. Introduction

      The United States is facing an epidemic of opioid-related drug overdoses and substance use disorder (SUD). The Affordable Care Act (ACA) included several provisions designed to improve care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including SUD. This study focuses on one of those initiatives—the ACA's optional Medicaid health home model—which provides states with enhanced federal matching funds for up to eight quarters for health home programs that provide enrollees with a set of required services designed to improve care coordination, integrate primary and mental/behavioral health care, and address social determinants of health. Three states—Maryland, Rhode Island, and Vermont—have chosen to implement the health home model for individuals with opioid use disorder. This study examines the approaches of the three states in planning and implementing the opioid health home (OHH) programs. The OHH model 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. Despite the potential applicability of this model to other states and payers, no study has yet provided information about factors affecting successful implementation of the OHH model. This study aims to fill this gap by identifying facilitators and barriers to implementation of the OHH program from the perspectives of multiple stakeholders, comparing and contrasting the programs, examining factors important to program success and issues concerning long-term sustainability, and identifying directions for future research on the OHH model.

      1.1 Background

      The growing rates of opioid use disorder and opioid-related overdose deaths in the United States have become an urgent public health issue. The number of people who died from drug overdoses involving opioids quadrupled between 1999 and 2015 (
      • Centers for Disease Control and Prevention (CDC)
      ). More people died from drug overdoses in 2015 than in any previous year for which data is available, and 63.1% (33,091) of those deaths were related to opioids, including illicit opioids (e.g., heroin) and prescription opioids (e.g., pain relief medication;
      • Rudd R.A.
      • Seth P.
      • David F.
      • Scholl L.
      Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
      ). In 2016, deaths from drug overdoses continued to grow at considerably higher rates than in 2015 (). Underlying the death rates are high levels of opioid use disorder (
      • Substance Abuse and Mental Health Services Administration (SAMHSA)
      Federal guidelines for opioid treatment programs.
      ). While progress has been made since approximately 2012 in reducing inappropriate opioid prescribing (
      • Drug Enforcement Administration (DEA), U.S. Department of Justice
      Special report: Opiates and related drugs reported in NFLIS, 2009–2014.
      ), overdose deaths have continued to increase during that period. Under these circumstances, a renewed emphasis on new treatment options is an urgent public health need.
      Treatment of people with opioid use disorder is complex and has been compared to treatment of other chronic relapsing conditions such as diabetes and hypertension; medically-supervised withdrawal from opioids is usually not sufficient to produce long-term recovery. A central component of opioid use disorder treatment is the use of opioid agonist therapy and behavioral counseling, with education, peer and group support, and motivation encouragement often incorporated into treatment (
      • Schuckit M.A.
      Treatment of opioid-use disorders.
      ). FDA-approved opioid agonist therapy for opioid use disorder includes methadone (available only at OTPs) and buprenorphine (available at both OTPs and OBOTs) or extended-release injectable naltrexone (available from any provider licensed to prescribe) (
      • Substance Abuse and Mental Health Services Administration (SAMHSA)
      Treatments for substance use disorders: Medication for opioid use disorders.
      ).Though effective treatments for opioid use disorder exist, only about 14.6% of individuals with opioid use disorder received treatment in 2014 (
      • Substance Abuse and Mental Health Services Administration (SAMHSA)
      Federal guidelines for opioid treatment programs.
      ). Numerous research efforts and public health initiatives are underway to address the opioid epidemic, mainly to expand provider capacity and increase rates of treatment, particularly opioid agonist therapy and counseling (
      • Department of Health & Human Services (HHS)
      HHS opioid research portfolio brief - Translating science into action.
      ).
      OTPs, central to the new OHH model, have existed for decades providing primarily methadone to patients with opioid use disorder across the country (
      • Substance Abuse and Mental Health Services Administration (SAMHSA)
      Federal guidelines for opioid treatment programs.
      ). OTPs must be certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), and methadone, an opioid agonist used in long-term opioid use disorder treatment, must be dispensed at an OTP. In addition to opioid agonist therapy, OTPs are required to provide directly, or through referrals to other providers and organizations, medical, counseling, vocational, educational, and other assessment and treatment services (
      • Social Security Act 42 U.S.C. § 1396w-4
      State option to provide coordinated care through a health home for individuals with chronic conditions.
      ).
      Besides expanding Medicaid coverage to millions of formerly uninsured low-income nonelderly adults, the ACA included several provisions designed to improve care coordination in state Medicaid programs and improve outcomes for those with chronic physical and mental health conditions, including SUD. One of those initiatives is the ACA's optional Medicaid health home model, which allows states to coordinate care and integrate services for high need, high cost Medicaid beneficiaries with complex chronic health needs (
      • Social Security Act 42 U.S.C. § 1396w-4
      State option to provide coordinated care through a health home for individuals with chronic conditions.
      ). 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 ().
      As of May 2017, more than one million enrollees were participating in 32 unique health home models in 21 states and the District of Columbia, with several other states planning to develop their own health home programs (). Three of these states—Maryland, Rhode Island, and Vermont—have implemented the health home model specifically for individuals with opioid use disorder, aiming to increase care coordination and case management, integrate opioid use disorder treatment with medical and behavioral health services, and connect enrollees to social services and supports in the community (
      • Moses K.
      • Klebonis J.
      Designing Medicaid health homes for individuals with opioid dependency: Considerations for states. Centers for Medicare & Medicaid Services.
      ).

      2. Methodology

      To examine the use of the health home model by states to address the opioid epidemic, we conducted site visits and discussions with key informants in each study state. We also conducted literature review and background research on the health home program as defined by the ACA and the Centers for Medicare and Medicaid Services guidelines, and studied available information on each opioid health home program to gain a deeper understanding of the context in which these programs developed and operate, identify appropriate informants and case study sites, and inform development of core discussion guides. Materials reviewed included federal Medicaid health home state plan option standards, 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 reports. Table 1 shows key features of opioid health home programs implemented in Maryland, Rhode Island, and Vermont, based on the background research.
      Table 1Opioid health homes at Glance, 2016.
      StateMarylandRhode IslandVermont
      Effective dateOctober 1, 2013July 1, 2013July 1, 2013
      Geographic scopeStatewideStatewideStatewide
      Target populationMedicaid recipients with opioid use disorder and the risk of developing another chronic conditionMedicaid recipients with opioid use disorder currently receiving or who meet criteria for opioid agonist therapy and are at risk for another chronic conditionMedicaid recipients with opioid use disorder and the risk of developing another substance use disorder or co-occurring mental health condition, especially depression and anxiety
      Enrollment1275 as of September 2016
      Department of Health and Mental Hygiene (2016). Maryland Medicaid Chronic Health Homes Quarterly Report July to September 2016. Retrieved from https://mmcp.dhmh.maryland.gov/SiteAssets/SitePages/Health%20Home%20Program%20Updates/Quarterly%20Health%20Home%20Report-%20July%20-%20September%202016.pdf.
      2851 as of May 2016
      Centers for Medicare and Medicaid Services (CMS) (2016). Medicaid Health Homes: An Overview, Fact Sheet September 2016. Retrieved from https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technical-assistance/downloads/hh-overview-fact-sheet-sep-2016.pdf.
      5499 as of May 2016
      Centers for Medicare and Medicaid Services (CMS) (2016). Medicaid Health Homes: An Overview, Fact Sheet September 2016. Retrieved from https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technical-assistance/downloads/hh-overview-fact-sheet-sep-2016.pdf.
      Designated providersOpioid treatment programs (OTP)Opioid treatment programs (OTP)Hub: opioid treatment programs (OTP)

      Spoke: Office-based Opioid Treatment (OBOT) providers supported by the Community Health Team (CHT)
      Number of providers/sites10Five providers with 12 locationsFive Hub providers

      127 spoke providers
      Health home teamHealth home director

      Nurse care manager

      Physician or nurse practitioner consultant

      Administrative support staff
      Supervising physician

      Registered nurse supervisor

      Master's level team leader/program director

      Case manager/hospital liaison

      Case manager

      Pharmacist
      Hub/OTP: program director

      Registered nurse

      Master's level licensed clinician case manager



      Spoke/OBOT: Community Health Team consisting of a registered nurse and

      Master's level licensed clinician case manager
      Payment model$100.85 PMPM
      Maryland Department of Health and Mental Hygiene (2016). Health Home Fee Schedules. Retrieved from https://mmcp.dhmh.maryland.gov/Documents/Health%20Homes%20Fee%20Schedule-%207-1-16.pdf.


      Additional onetime payment of $100.85 for each enrollee's initial intake.
      $214 PMPM (paid as a weekly bundled rate of $53.50)
      State Of Rhode Island Executive Office Of Health And Human Services (2016). 6/29/2016 Public Notice of Proposed Amendment to Rhode Island Medicaid State Plan. Retrieved from http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/SPA/16-003OTPHHPublicNotice.pdf.
      Hubs: $148.01 PMPM
      Department of Vermont Health Access (DVHA) (2014). Hub and Spoke Health Home Rates. http://dvha.vermont.gov/for-providers/1hub-spoke-rates.pdf; Vermont Health Homes for Opioid Addiction Hub and Spoke: Program Overview, (2013). http://www.achp.org/wp-content/uploads/Vermont-Health-Homes-for-Opiate-Addiction-September-2013.pdf.


      Spokes: $163.75 PMPM
      d
      • State Of Rhode Island Executive Office Of Health And Human Services
      6/29/2016 Public Notice of Proposed Amendment to Rhode Island Medicaid State Plan.
      . 6/29/2016 Public Notice of Proposed Amendment to Rhode Island Medicaid State Plan. Retrieved from http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/SPA/16-003OTPHHPublicNotice.pdf.

      2.1 Discussants

      To identify potential discussants, we reviewed available public information about OHH programs and obtained recommendations for key discussants to include in this study from a health home program official in each state. For provider discussants, we selected OHH providers in each state purposefully to yield “information-rich” discussants that were especially knowledgeable and experienced with the program and the system context for reform, i.e., those with relatively large OHH enrollment and/or a history of successful treatment and innovation. We considered a total of 38 organizations, including state agencies, opioid use disorder treatment providers, and others, for inclusion in the study (15 in Maryland, 12 in Rhode Island, and 11 in Vermont) and conducted discussions with representatives from 21 distinct organizations (seven in Maryland, eight in Rhode Island, and six in Vermont). Final selection of organizations was based on knowledge gained through the background document review, recommendations from state health home program officials for stakeholders knowledgeable about the program, and logistical considerations in planning the site visits.

      2.2 Data collection and analysis

      Our proposed study design, including plans for identifying and contacting discussants, site visit procedures, semi-structured discussion guides, and human subject protections, was reviewed and approved by the Urban Institute Institutional Review Board prior to data collection activities. We conducted case studies from October to December 2016, completing 28 semi-structured discussions with 70 unique discussants across the three states, including representatives from state Medicaid and other agencies (n = 13), OHH provider organizations (n = 49), Medicaid managed care (or comparable) organizations (n = 5), and provider associations (n = 3). Discussions with state officials and representatives from Medicaid health plans and provider associations were conducted over the phone (n = 19), and discussions with health home providers and staff were conducted in person at each provider's site (n = 8). In some instances, we held several distinct discussions with individuals from the same organization or agency, and some discussions included multiple discussants per appointment.
      To compare and contrast the approaches of the three study states, providers, and other nongovernmental actors in the planning and implementation of the OHH programs, we adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model (
      • Aarons G.A.
      • Hurlburt M.
      • Horwitz S.M.
      Advancing a conceptual model of evidence-based practice implementation in public service sectors.
      ) as a guiding framework to explore key phases in the OHH evolution in each state (Table 2). This model of Evidence-Based Practice implementation identifies factors in the outer context and inner context that are hypothesized to impact program implementation in four phases of implementation. We adapted the EPIS model to analyze implementation of the OHH program, characterizing the outer context as factors relating to government and non-governmental organizations, and the inner context as factors relating to providers and individual adopters. We prioritized aspects of the model that the research team considered to be most critical to analyze implementation successes and challenges—namely, the inner context of active implementation—thus improving relevance to policymakers and providers considering the OHH program in other states.
      Table 2Conceptual model of the four phases of implementation and factors related to opioid use disorder health home model adoption in the study states, adapted from selected components of the EPIS model.
      Source: Adapted from Aarons, Gregory A., Michael Hurlburt, and Sarah McCue Horwitz. “Advancing a conceptual model of evidence-based practice implementation in public service sectors.” Administration and Policy in Mental Health and Mental Health Services Research 38.1 (2011): 4–23.
      Stakeholder groupPhase 1

      Exploration and adoption decision

      (E)
      Phase 2

      Preparation

      (P)
      Phase 3

      Active implementation

      (I)
      Phase 4

      Program sustainment and lessons learned

      (S)
      Government (federal, state, local)
      • Monitoring and review of issue
      • Funding
      • New legislation, regulation, or policy
      • Goal alignment
      • Program design/SPA development
      • Support for program developers
      • Gathering stakeholder input
      • Leadership and engagement
      • Funding
      • Monitoring
      • Program design adjustments
      • Responsive legislation and regulation
      • Funding
      • Maintaining a critical mass of enrollees
      • Monitoring and evaluation
      Nongovernmental organizations (provider associations, consumer advocates, payers)
      • Information sharing
      • Goal alignment
      • Information sharing
      • Information sharing
      • Information sharing
      • Monitoring and evaluation
      Providers (OTPs and OBOT providers who became OHH providers)
      • Knowledge/skills
      • Perceived need and capacity for change
      • Goals
      • Decision to participate
      • Technical assistance for application
      • Adoption champions
      • Staff engagement
      • Adaptability
      • Infrastructure development
      • Culture change
      • Meeting program requirements
      • Staff and patient demographics
      • Provision of new services
      • Technical assistance received
      • Financial viability
      • Use of program as standard practice
      • Critical mass of staff engagement
      • Monitoring and evaluation
      OTP = opioid treatment program; OBOT = Office-Based Opioid Treatment; OHH = Opioid Health Home; SPA = state plan amendment.
      For Phase 1, Exploration and Adoption Decision, we examined states' motivation and thinking behind development of opioid-focused health homes and goals. For Phase 2, Preparation, we analyzed state strategies and processes in health home SPA development and model design. For Phase 3, Active Implementation, we examined how various elements of the OHH program were implemented across the three states, as well as provider experiences in adapting to the new model of care. Finally, Phase 4, Program Sustainment, focused on state provisions for and key issues in sustaining the programs, as well as lessons learned from the implementation for policymakers and providers considering the health home program for treatment of opioid use disorder. The EPIS model allowed us to identify common themes and key factors that either facilitated or impeded OHH program development and implementation. The EPIS framework informed the creation of the protocols, however, to facilitate the flow of conversation, the discussion protocols were organized topically and not by phase. The EPIS analysis is retrospective, as all discussions were conducted in the same (final) phase of implementation, following the implementation and maturation of the program.
      Discussions were recorded, transcribed, and analyzed with qualitative data analysis software (NVivo). The structure for the coding scheme was based on the EPIS framework, where codes were organized into four categories corresponding to each phase of the opioid health home development and implementation (e.g., Exploration and Adoption of Decision, Preparation, Active Implementation, and Sustainment). In addition, several codes were categorized as “other” to capture information that did not fall under any of the four EPIS categories. In total, we used 28 codes to organize and sort qualitative data collected through discussions. Three members of the research team coded discussion transcripts; one coder each was responsible for analyzing discussions in a study state. Each transcript was reviewed and coded by one researcher only. We began coding by performing a trial analysis where the same discussion transcript was coded by each coder. We then compared the coded transcript across the three coders, discussed the appropriateness of each code selected, and refined definitions and directions for each code to ensure consistent coding among three different coders.

      2.3 Limitations

      There were several limitations of this study. First, the EPIS analysis is based on interviews conducted only with programs following the implementation and maturation of the opioid health home model. Discussants were interviewed once and asked to reflect on each phase of implementation. Ideally respondents would be interviewed at several points during the implementation process. However, during the study period, all three states were in the same phase of the implementation (about three years after the effective date of implementation), and the participating providers with whom we spoke had implemented their programs during the initial opportunity. It is thus a retrospective analysis, and as a result, the perceived barriers and facilitators are perceived by discussants post-hoc and were not articulated during the actual implementation phase, for the first three phases. The early experiences may be misremembered. Second, we obtained information and perceptions from a relatively small number of discussants and our findings are specific to the OHH programs implemented in these three states and are therefore not generalizable. The scope of the study did not include discussions with providers that decided not to implement the program, which limits our findings, particularly related to implementation barriers. In addition, some discussions took place before and some after the 2016 presidential election, the results of which appeared to influence discussants' views on long-term sustainability.

      3. Results

      3.1 Phase 1: exploration and adoption decision

      In the Exploration phase, we examined states' motivation and thinking behind the development of opioid-focused health homes. Maryland saw the OHH model as a way to better integrate medical care and social services with treatment for people with opioid use disorder and mental health conditions; 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 the OHH model included good working relationships between the state agencies overseeing substance abuse services and Medicaid benefits and the availability of enhanced matching funds to support the required services. For opioid treatment providers, the main appeal of the model was the reimbursement for care management and other health home services, which some OTPs had already been performing but with inadequate resources (Table 3).
      Table 3Summary of key factors affecting exploration and adoption of opioid health home programs in the study states, according to discussants.
      Source: Authors' analysis of three case studies summarizing findings from discussions.
      MDRIVT
      Collaborative relationships between the substance abuse agency and Medicaid agency or other similar entity
      Other broader efforts to address behavioral health issues in the state at the time; state leaders focused on goals aligned with OHH model
      Presence of delivery system/provider infrastructure suitable for the OHH model
      Availability of enhanced federal matching funds to support the state's efforts
      Appeal of the model to OTP providers
      Legend: ● = factor is present; ◖ = factor is partially present; ○ = factor is not present in that state.

      3.2 Phase 2: preparation

      In all three states, the Preparation phase involved developing a state plan amendment (SPA) application to submit to Centers for Medicare and Medicaid Services (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 initiatives, which may have helped avoid “reform fatigue,” particularly in Rhode Island and Vermont. Other factors facilitating program development included consultations with CMS, technical assistance contractors, and other health home states (Table 4). Many discussants said that stakeholder engagement in program design was critical.
      Table 4Summary of key factors affecting preparation phase of opioid health home programs in the study states, according to discussants.
      Source: Authors' analysis of three case studies summarizing findings from discussions.
      MDRIVT
      Previous experience with health home program and/or care coordination initiative
      High level of cross-agency collaboration to design state OHH programs
      Study providers reported no or little “reform fatigue” at the system level
      Interactions with CMS/contractors to guide program development (i.e., SPA application) and help state identify and address issues before implementation
      Stakeholder engagement in the planning and design process before program launch (e.g., regular planning meetings, work groups, public hearings)
      Medicaid health plans involved in program design and implementation
      Mandatory participation among OTP providers
      Highly motivated early adopter(s) among providers led the way
      Little resistance to participation among providers in the study
      Study providers received guidance and support in preparation for program implementation
      High degree of goal alignment and workplace culture match between providers and the OHH program
      Legend: ● = factor is present; ◖ = factor is partially present; ○ = factor is not present in that state.
      The three states differed in health home provider selection and recruitment, but implementation at the provider level in all three states was mostly led by a few OTPs eager to adopt the new model that paved the way for other providers to follow. As one provider advocate said: “For the OTPs, several elements made health homes attractive. It enabled us to enhance the delivery system by affording us the opportunity to create health home teams and hire new staff to be the care coordinators. … The intent was to recognize all the areas that affect [our patient's] wellness, such as legal work, probation and parole, homelessness, vocational training, education—things that, in their absence, could have a negative effect on wellness and recovery.”
      Maryland and Vermont opened participation in the program to all OTPs, and OBOT providers in Vermont, who met the state criteria, while Rhode Island made OHH program participation mandatory. At the time of our study in fall 2016, all OTP providers were participating in the model in Vermont because they reportedly felt the state had implicitly expected all OTPs to become hubs. Some Rhode Island providers only reluctantly became health homes and at least one OTP was reported to had closed to avoid mandatory participation. In Maryland, 10 of the 79 OTPs in the state, or 13%, participated. Some attributed low OHH participation in Maryland to provider fatigue related to concurrent initiatives and system changes, as well as to perceived high start-up costs of the program. 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 (Table 4).

      3.3 Phase 3: active implementation

      For the third phase, we examined how various elements of the OHH program were implemented across the three states. The flexibility states have in designing their programs within the core health home requirements resulted in variation in the OHH models implemented by Maryland, Rhode Island, and Vermont. One key difference is that Maryland that did not explicitly or implicitly require that all OTPs participate in the OHH program, which contributed to very low OTP participation and may have significantly hurt the implementation and program impacts. Factors associated with effective implementation of the health home model in the three study states are shown in Table 5.
      Table 5Summary of key factors affecting active implementation of opioid health home programs in the study states, according to discussants.
      Source: Authors' analysis of three case studies summarizing findings from discussions.
      MDRIVT
      Most or all OTPs in the state are participating in the OHH program
      Staffing model is adaptable to provider and patient needs
      Study providers reported flexibility/workplace culture change during implementation (e.g., adjusting roles, expectations, and workflow between nurses and case managers)
      Study providers reported strong state support (e.g., technical assistance, training, guidance) throughout implementation
      Enrollment policies and procedures facilitate enrollment of eligible patients
      OHH program enrollment is on target or exceeds expectations
      Enrollee retention in the OHH and continuity of care are high
      Study providers reported having some experience with health home–like services before implementation
      Study providers reported care coordination limitations because of confidentiality issues and technological barriers; difficulty exchanging patient information with other providers
      Study providers reported adequate supply of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder
      Study providers reported sufficient resources inside and outside OHH to address social determinants of health and provide linkages to needed social services and supports
      Study providers reported delivering services to a high share of OHH enrollees (>75% per month across all study providers)
      Study providers reported OBOT providers were available to treat lower-acuity patients
      Study providers reported using health IT for a range of activities, such as to coordinate care, assure transitional care, and link patients to services as appropriate
      Study providers reported satisfactory capacity or support for meeting data reporting requirements
      Study providers reported OHH reimbursement rates sufficient to cover the provision of required health home services (excluding start-up costs)
      Study providers reported OHH reimbursement rates sufficient to cover start-up and ongoing costs associated with OHH program (e.g., hiring staff, certifications)
      Study providers reported no difficulties with denied payments related to administrative issues
      Legend: ● = factor is present; ◖ = factor is partially present; ○ = factor is not present in that state.

      3.3.1 Provider structure and team composition

      All three states designated OTPs as health home providers, but Vermont developed a unique “hub and spoke” model that includes OTPs, or hubs, that serve more clinically complex patients and OBOT providers, or spokes, that focus on less complex patients. While all three states require that a registered nurse be part of the health home team, they differ in their requirements for other types of health care professionals. In Vermont, staffing mandates differ for OTPs and OBOT providers; OTPs must hire the necessary staff to provide all health home services, whereas Blueprint Community Health Teams provide health home services for most OBOT patients. In addition, the states vary in their minimum staff-to-patient required ratios. Some OTPs in all three states said that the staffing ratios were not sufficient to meet the needs of the more complex OHH enrollees, and others felt that the staffing ratios were too prescriptive and unresponsive to provider circumstances and changing needs of the patients Other provider-related factors associated with effective implementation include adequacy of resources to deliver health home services, organizational adaptability, and availability of training and other resources to support program implementation (Table 5).

      3.3.2 Enrollment

      OHH programs in the study states target Medicaid beneficiaries with opioid use disorder who have or are at risk for developing another chronic condition; according to our discussants, almost all Medicaid beneficiaries who seek opioid use disorder treatment qualify for OHH enrollment. Rhode Island and Vermont automatically enroll all eligible patients in OHH, and providers in these states reported strong enrollment because very few patients decide to opt out. In contrast, Maryland's opt-in policy, coupled with low OTP participation in the program, has contributed to lower-than-targeted program enrollment. Providers in all three states experienced difficulties with keeping some patients continuously enrolled in OHH despite applying various strategies to strengthen continuity of care; often this was because of the instabilities in the lives of this population (Table 5).
      One provider characterized the OHH population as including “some of the best families in [town]” and “homeless transients.” Across all health homes we visited, 70 to 80% of patients were Medicaid beneficiaries, with about a third to a half of OHH eligible Medicaid beneficiaries enrolled in Maryland and up to 95% or more in Vermont and Rhode Island. Providers reported serving roughly equal shares of men and women, and very low pregnancy rates among female health home enrollees (between 1 and 6%). None of the health homes served adolescents. HIV/AIDS rates were also low, under 2% in Rhode Island and Vermont but somewhat higher in Maryland, and hepatitis C was cited as a major comorbidity across all states. OHH providers across the three states estimated that anywhere from 20 to 40% or more of their patients had some involvement with the correctional system.

      3.3.3 Services

      Basing the OHH in programs that provide opioid agonist treatment was a major reason for the reported success of the model, according to discussants. Treatment for opioid use disorder offered in health homes in this study includes opioid agonist therapy, behavioral therapy, toxicology, treatment planning, peer support, and naloxone overdose therapy. This treatment is integrated with six services required by the OHH model: (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.
      The OHH model constituted a new approach to care for almost all OHH providers in the study, but most reported that their state provided the reimbursement, staffing, structure, training, and support necessary to adopt the program. Many OTPs in the study had experience delivering health home–like services before the initiative, which facilitated OHH implementation. Discussants universally agreed that the health home model is a promising mechanism for addressing the complex medical, behavioral, and psychosocial needs of individuals with opioid use disorder, where “health homes can be the glue” in bringing a range of services and resources together to better serve this population. As one OHH provider said: “[Many] people with an opioid disorder have had some bad experiences with the helping profession being not very helpful—so building that trust and rapport takes time…Playing that role in their overall health and helping them navigate through those overall systems is our job [as a health home].”
      The following discussion focuses on challenges and opportunities OHH providers reported with respect to the provision of core services required by the health home model.

      3.3.3.1 Care management

      Even though most OTPs had been providing some care management prior to health homes, providers reported that OHH allowed them to devote more time and resources to assessing patients' needs, developing care plans, monitoring progress toward patient's goals, and reporting outcomes. Many providers felt they could enhance care management because health home payment model covered activities that had not been reimbursable before, such as data entry. Discussants reported that OBOT providers in Vermont's spoke model were more likely to take patients with high needs after OHH adoption because of the additional care management support by the Community Health Teams. However, some providers noted that care management sometimes crowded out the provision of therapy and counseling.

      3.3.3.2 Care coordination

      Providing referrals to needed medical care and social services and coordinating with outside providers, including integrating primary and behavioral health care with opioid use disorder treatment, constituted the bulk of the care coordination service as reported by OHH providers. Some OHH providers waited until after an OHH enrollee was stabilized on opioid agonist therapy to screen for, educate about, and make referrals to address common needs such as controlling blood pressure and cholesterol, nutrition counseling, and dental care. Care coordination provided by OHH staff was reported to reduce unnecessary emergency department (ED) visits.
      One of the most significant challenges to effective care coordination reported by OHH providers was the limited ability of OHHs to share patient data with other providers because of substance abuse records confidentiality laws (i.e., federal regulation 42 CFR Part 2) and technological barriers. Another barrier to care coordination was a combination of the scarcity of available primary care providers, psychiatrists, dentists, and others and the unwillingness of medical providers to accept patients with opioid use disorder (Table 5). Reportedly, opioid agonist therapy patients are perceived to be a high risk for no shows and noncompliance with treatment by the medical community. On the other hand, discussants also reported that fear of judgment and maltreatment often prevented opioid agonist therapy patients from seeking needed medical care. OHH staff reported that as part of the care coordination service, they sought to reduce the stigma that some providers may associate with opioid agonist patients by fostering better relationships between the medical community and health home enrollees, conducting outreach and education to medical providers, and accompanying OHH enrollees to medical appointments.

      3.3.3.3 Transitional care, individual and family support, and health promotion

      Transitional care service requires that OHHs ensure continuity of care and assist enrollees in transitions back to OHH care after hospital stays or ED visits. Many study providers reported that OHH allowed them to improve the rates of ambulatory care follow-up appointments after detox and rates of patients filling their prescriptions. Many OTPs were already providing individual and family supports to patients, but some OBOT spoke providers in Vermont reported that integrating individual and family supports was challenging. Health promotion activities largely centered on educating patients about their chronic health conditions and encouraging positive lifestyle changes such as better nutrition or smoking cessation.

      3.3.3.4 Referral to community and social support services

      The complex psychosocial needs of opioid use disorder patients necessitate that OHHs link patients to social services and supports, including health insurance (e.g., re-enrollment in Medicaid), disability benefits, subsidized or supportive housing, peer support, legal services, employment services, and other services as appropriate. OHH providers reported that staff assessed enrollees' social determinants of health needs by informally discussing patient needs or by using a formal screening tool developed by the health home or another organization. Implementation of the OHH model allowed many OTPs to expand this service by providing a mechanism for care managers to get reimbursed for the time it takes to establish relationships with community-based organizations and social service agencies and help patients access some hard-to-get services. Even with added resources, all providers reported difficulties in obtaining some critical services for their patients, particularly transportation and housing (Table 5).

      3.3.4 Health IT, data, and billing systems

      All but one OHH provider surveyed in this study used electronic medical records (EMR), which reportedly strengthened communication between team members within health homes. However, we found that most OHH providers in the study had inadequate health IT systems in place to fully support coordination of care with outside providers, receive notifications of hospital admissions or ED visits, monitor patients' compliance with care plans, and measure outcomes. Most providers in the study also said that infrastructure to meet data reporting requirements was inadequate or providers lacked organizational capacity to comply with state reporting systems; in some cases, providers manually enter data into multiple databases. Some OHH providers reported challenges related to billing systems and processes that states established for their health home programs, generally owing to lack of technical assistance or funding to make their billing systems align with the state systems (Table 5).

      3.3.5 Payments

      OHH payment levels were developed based on prospective staffing levels, ranging from approximately $100 to $214 per member per month across the three states (Table 1). Maryland and Rhode Island kept payments for health home services and payments for opioid use disorder treatment separate, while Vermont bundled payments for health home services and opioid use disorder treatment together. OHH providers generally thought health home services were adequately reimbursed, although not enough to cover start-up costs and to offer competitive salaries. Some pointed out that the health home payment rates are financially viable only if providers can deliver the required minimum services to, and get reimbursed for, most or all eligible enrollees each month. Though some providers in Maryland reported difficulty in doing so, providers in Rhode Island and Vermont reported that they were able to deliver health home services to and bill for a relatively high share of OHH enrollees (75 to 99%).

      3.4 Phase 4: program sustainment and lessons learned

      For the Sustainment phase, we examined key issues affecting program sustainability and lessons learned. All three 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. Private insurance and Medicare participation in the model were identified as critical to long-term sustainability, but only Vermont's OHH got support from some private insurers (but not Medicare) thus far. Many discussants noted that recognizing opioid addiction as a chronic health condition and decreasing hesitance among many providers toward treating individuals who are on opioid agonist therapy are also needed to support and sustain opioid health homes and other treatment programs (Table 6).
      Table 6Summary of key factors affecting the sustainment phase of opioid health home programs in the study states, according to discussants.
      Source: Authors' analysis of three case studies summarizing findings from discussions.
      MDRIVT
      Support from state government, including the governor's office, legislature, and state agencies
      Participation of other payers (e.g., Medicare, private payers) in the model
      Medical system and community organizations in which OHH operates are cooperative and supportive
      Study providers deemed OHH program and reimbursement structure sufficiently flexible to support provider financial viability
      Study providers reported adequate workforce supply and implementation support
      Study providers reported adequate reimbursement to support competitive salaries, promoting staff retention
      Legend: ● = factor is present; ◖ = factor is partially present; ○ = factor is not present in that state.
      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 lessons that emerged from our discussions include the following:
      • 1.
        The timing of OHH implementation should be considered against other health system changes to ensure that providers are not distracted and/or overwhelmed by simultaneous initiatives.
      • 2.
        A wide range of stakeholders, particularly primary care physicians, hospitals, and specialists, 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.
      • 4.
        Program evaluation is essential for providing evidence to support continued investment in OHH models.

      4. Discussion

      This is the first study to retrospectively examine the Medicaid opioid health homes' development and implementation in Maryland, Rhode Island, and Vermont. The Medicaid health home option allows state Medicaid programs to develop new models of integrated medical care, mental health care, and social services with opioid agonist treatment and thus address the growing opioid epidemic. We found that overall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Coordination of behavioral and physical health care and social support services in the OHH program was facilitated by the trusted relationships between patients and their opioid use disorder treatment providers. The OHH programs capitalized on OTPs' deep experience providing opioid agonist therapy and their ability to build strong relationships with patients to improve patient care and health outcomes. Across nearly all study sites, providers offered examples of enrollees whose lives and care were dramatically changed for better because of health home services. Many providers talked about the significance of the health home model as a way to address the numerous health and psychosocial challenges faced by people with opioid use disorder. Though discussants acknowledged persistent “silos” of medical, mental health, and substance use disorder treatment systems, for many the health home model presented an opportunity to draw on new resources and training to break down these silos in order to provide whole-person, effective care to people with opioid use disorder.
      Our study brings forth several considerations for states and stakeholders who are weighing implementing the OHH model in Medicaid. Based on the experiences of the study states, key facilitators of the exploration and preparation phases of the OHH model include the existence of collaborative relationships between the key state agencies, prior experience implementing a care coordination initiative and/or a health home model, and engagement of providers in the planning and design of the program. In particular, meaningful engagement of providers in the preparation phase appeared to lead to substantial investment in training, support, and technical assistance to OHH providers in the program adoption, greatly facilitating overall implementation.
      These findings are consistent with previous research. A study of the early implementation phase of the Medicaid opioid health homes emphasized the benefits of state multi-agency collaboration and provision of education and training to support practice transformation in facilitating program implementation (
      • Moses K.
      • Klebonis J.
      Designing Medicaid health homes for individuals with opioid dependency: Considerations for states. Centers for Medicare & Medicaid Services.
      ). In addition, our study results are consistent with a national evaluation of 13 Medicaid health home programs in 11 states that first implemented the model to care for Medicaid beneficiaries with chronic physical and mental health conditions, which identified similar factors associated with successful implementation of the model, including all-inclusive pre-implementation planning and design and adequate funding to cover enhanced services and practice transformation (
      • Spillman B.C.
      • Allen E.H.
      • Lallemand N.
      • Hayes E.
      Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Progress and Lessons from the First States Implementing Health Home Programs, Annual Report –Year Four.
      ).
      Barriers to effective implementation of the OHH model in the opioid use disorder treatment settings existed at every stage of the process, and states and stakeholders could consider options to address these. Across all states, the most frequently cited barriers to achieving the key program goals of care coordination related to the broader medical system, especially shortages of primary care providers, dentists, and other providers willing to accept referrals of patients on opioid agonist therapy, and limitations related to data confidentiality issues and/or technological barriers preventing effective exchange of patient information with other providers. To address issues of reluctance to treat this patient population among the broader medical system, state and federal entities may need to do more to educate the broader medical provider community about treating patients with opioid use disorder, including issuing guidelines, engaging providers in learning collaboratives, and ensuring that reimbursement rates are sufficient to provide care for complex patients. Opioid treatment programs can play a significant role in reducing stigma or discrimination from medical providers who may hold negative beliefs about patients on opioid agonist therapy. Indeed, some OHH staff in the study reported that part of their job description was to reach out to and educate other providers in the community about opioid use disorder and the ways these providers can play a part in addressing the opioid epidemic. To address the barriers to care coordination related to federal patient confidentiality regulations, states could provide education and training on what information can be shared without a signed release from the patient, incorporating recent changes to 42 CFR Part 2, which addresses the confidentiality of substance use disorder patient records, provide 42 CFR Part-2 compliant release forms, and disseminate effective strategies to encourage patients to allow data sharing among their care providers.
      Despite reporting having largely achieved program goals related to enrollment and care integration, officials in study states were concerned about long-term program sustainability. Thus, there appears to be a need to explore buy-in among other payers for the OHH model in order to support the financial viability of providers to sustain the necessary staffing and services. This study, however, did not address the question of whether the programs were effective and cost-effective. Thus, one important area for future research is a rigorous evaluation to assess the OHH program impacts on health outcomes, utilization, and costs, including a reliable counterfactual group and detailed examination of patients, providers, and programs. Additional mixed methods and qualitative research would be useful in exploring workforce issues, how provider characteristics and staff engagement impact the rapport with patients and their outcomes, and facilitators and barriers to replication of the OHH model in other states.

      5. Conclusions

      By building on the trusted relationships between patients and experienced opioid use disorder treatment providers, and integrating evidence-based opioid agonist therapy approaches with coordination of physical and behavioral care and social supports, the opioid health home model in these Medicaid programs is an important innovation. There is strong bipartisan support for addressing the opioid epidemic, and for providing effective treatment for people with opioid use disorder. Recent laws, including the Comprehensive Addiction and Recovery Act of 2016 and the Twenty-First Century Cures Act, authorize funding for local treatment efforts. The experiences of Maryland, Rhode Island, and Vermont can provide important insights to other states, providers, and policymakers seeking to address the opioid epidemic with new treatment models based on evidence-based practices.

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