Project RAMP Care Management Strategies...2018/07/13 · Project RAMP Care Management Summary •...

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Project RAMP Care Management Strategies

Jack Warwick, MPH, Project Coordinator

Program Evaluation and Research Unit (PERU)

Project RAMP Implementation Team


Objectives:

1. Review substance use disorder (SUD) case management;

2. Present Rural Access to Medication Assisted Treatment in Pennsylvania (RAMP) Project care management team roles and responsibilities;

3. Discuss strategies to improve patient compliance; and

4. Review best care coordination practices.


Substance Use Disorder Case Management


SUD case management offers a patient a single point of

contact with health and social service systems.1

D&A

1. Substance Abuse and Mental Health Services Administration. Comprehensive Case Management for Substance Abuse Treatment (TIP 27). Rockville, MD 20857: Substance Abuse and Mental Health Services Administration, 2000.


Case management is centered on the client and the specific

needs of each client.1



Examples of typical case management responsibilities1:

• Create and implement a treatment plan with realistic expectations and goals;

• Educate and consult patient on SUD;

• Assist patients with financial management, such as obtaining financing;

• Help patients utilize resources and meet non-treatment needs;

• Regularly communicate with patients and providers;

• Perform level of care assessments; and

• Manage referrals to SUD and other treatment providers.


D&A

Care

Manager


In Project RAMP, “Care Management” is the glue that holds

the treatment process together.

Care Manager Roles and Responsibilities



Referral Process for Patients Referred from Primary Care Provider to

Substance Use Disorder Treatment Provider



Referral Process for Patients Referred from Community to an

MAT Provider


Care Management Ongoing Care Coordination and Follow-up


Project RAMP Real-Time Data Collection Process


Care Management Team Data Collection: Two Formats


Project RAMP Outcomes and Metrics

Outcomes Data Metrics

Screening # Patients screened per week

Patient Enrolled in MAT Date of MAT enrollment

Type of MAT Treatment # Patients receiving naltrexone

# Patients receiving buprenorphine

Referral to Care Management

(CMT)

Date of primary care provider (PCP) referral to CMT

Number of Physician (PCP)

Contacts Involving Injections,

Scripts, Monitoring

Date of all PCP encounters

# Encounters for medication administration, prescription, and other services

Access to Substance Use

Disorder (SUD) Treatment

Date of First face-to-face SUD encounter for intake

Engagement with SUD

Treatment

Date of all SUD encounters

# Encounters patient is continuing initial level of care (LOC)

Date of Encounter and new LOC, if patient changes LOC during treatment

Date of Patient discharge from SUD treatment

# Patients discharged for successful completion of SUD treatment/LOC, client

choice, and other

Access to MH Treatment Date of First face-to-face MH encounter for intake

Engagement with MH

Treatment

Date of all MH encounters

# Encounters patient is continuing initial level of care (LOC)

Date of Encounter and new LOC, if patient changes LOC during treatment

Date of Patient discharge from MH treatment

# Patients discharged for successful completion of MH treatment/LOC, client

choice, and other

Discharge from MAT

Treatment

Date of Patient Discharge from MAT

# Patients discharged for evidence of medication diversion, non-compliance, client

choice, incarceration, and successful titrate


Real-Time Data Reporting


Individualized Data Reports for Quality Improvement


Importance of Data Collection and Quality Improvement

• Improve referral processes and treatment

protocols;

• Monitor patient progress in the SUD

treatment continuum;

• Improve retention to treatment; and

• Identify barriers and facilitators to

providing MAT and related care.


Summary of Care Manager Responsibilities:

• Manage referrals and warm-handoffs closely with

PCPs and other treatment providers;

• Coordinate psychosocial services;

• Manage and/or develop comprehensive service and

treatment plans individualized for each patient with

the clinical and treatment team;

• Refer patient to the necessary treatment provider

based on the LOC as soon as possible;

• Work with providers to identify the best medication

for the patient based on his/her medical profile and

history by conducting an MAT assessment;


Summary of Care Manager Responsibilities (cont.):

• Coordinate ambulatory detox with the hospital and

SUD providers, if necessary.

• Provide peer support via a certified recovery specialist

(if available);

• Assist the clinical team with medication management to

improve patient compliance; and

• Participate in data collection and quality improvement

efforts to actively work to improve retention and

treatment success.

Strategies to Improve Patient Compliance



Overview of Strategies:

1. Educate patients on opioid use disorder (OUD), SUD, and addiction;

2. Work with the MAT provider to understand what services and resources would benefit the

patient most;

3. Review the treatment plan with the patient and build a mutual understanding;

4. Help to mitigate the risk of diversion;

5. Assist with managing laboratory testing;

6. Assist with patient follow-up and engagement in both psychosocial and medication

treatments;

7. Coordinate the medication arrangements with the pharmacy of choice; and

8. Use evidence-based practices when communicating and providing ongoing feedback to

patients, such as motivational interviewing and motivational enhancement.


Strategy 1: Educate patients on OUD, addiction, and the

risks/benefits of MAT.


Strategy 2: Work with the MAT provider to identify the services and

resources that would help the patient reach their treatment goals.


Strategy 3: Review treatment plan with patient and build a mutual

understanding of the goals of the treatment.


Strategy 4: Work to mitigate the risk of diversion by meeting

regularly with patients to provide ongoing assessments.


Strategy 5: Assist with managing laboratory testing, such as

conducting random urine drug tests.


Strategy 6: Assist with patient follow-up and engagement in both

psychosocial and medication treatment.

D&A

Care

Manager


Strategy 7: Coordinate the medication arrangements with the

pharmacy of choice.

Rx

Care

Manager


Strategy 8: Use evidence-based practices when communicating and providing ongoing

feedback to patients, such as motivational interviewing and motivational enhancement.

Best Care Coordination Practices



Overview of Best Care Coordination Practices:

1. Develop Referral Protocols with the entire treatment team;

2. Conduct level of care assessment with patient in a timely fashion and at a

location that is convenient for the patient;

3. Obtain a release of information form for the drug and alcohol treatment

provider;

4. Conduct a warm handoff or a direct linkage to care;

5. Follow-up with patient and clinical team if the patient declines treatment; and

6. Facilitate ongoing and routine communication between the entire clinical

team.


Key Practice 1: Develop referral protocols between clinical team,

treatment providers, and care management team.

D&A

Care

Manager


Key Practice 2: Conduct Initial Assessment with Patient ASAP at a

Location that is Convenient for the Patient.


Key Practice 3: Obtain a release of health information form from the medical provider or SUD treatment provider.


Key Practice 4: Facilitate direct linkages in the form of warm handoffs to improve care coordination and patient treatment engagement.


Key Practice 5: If a patient declines treatment, follow-up with the patient and notify the entire clinical team.


Key Practice 6: Facilitate clear and ongoing communication between the

entire clinical team.

RAMP Care Management Summary



Project RAMP Care Management Summary

• SUD case management offers a single point of contact for a patient during

the treatment process.

• Care managers in Project RAMP play a central role to the patients MAT by:

1. Managing referrals and warm handoffs in a timely and efficient manner;

2. Designing and/or managing service and treatment plans for each patient;

3. Coordinating and ensuring participation in psychosocial services;

4. Providing peer support and assisting with access to non-treatment needs and

resources;

5. Assisting the clinical team with medication management; and

6. Participating in data collection and quality improvement to improve treatment

outcomes.


Project RAMP Care Management Summary (cont.)

• Coordination of care is imperative to treatment success.

• Care coordination can be optimized by:

1. Developing referral protocols with each provider involved in the patients treatment;

2. Obtaining a release of health information from the patient to ensure open

communication;

3. Always conducting a warm handoff or direct linkage to care;

4. Following-up with the patient and clinical team if the patient declines a recommended

treatment; and

5. Facilitating ongoing and routine communication between all members of the treatment

team.

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