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Project RAMP Care Management Strategies
Jack Warwick, MPH, Project Coordinator
Program Evaluation and Research Unit (PERU)
Project RAMP Implementation Team
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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.
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Substance Use Disorder Case Management
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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.
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Case management is centered on the client and the specific
needs of each client.1
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.
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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.
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.
D&A
Care
Manager
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In Project RAMP, “Care Management” is the glue that holds
the treatment process together.
Care Manager Roles and Responsibilities
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Referral Process for Patients Referred from Primary Care Provider to
Substance Use Disorder Treatment Provider
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Referral Process for Patients Referred from Community to an
MAT Provider
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Care Management Ongoing Care Coordination and Follow-up
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Project RAMP Real-Time Data Collection Process
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Care Management Team Data Collection: Two Formats
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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
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Real-Time Data Reporting
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Individualized Data Reports for Quality Improvement
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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.
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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;
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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
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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.
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Strategy 1: Educate patients on OUD, addiction, and the
risks/benefits of MAT.
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Strategy 2: Work with the MAT provider to identify the services and
resources that would help the patient reach their treatment goals.
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Strategy 3: Review treatment plan with patient and build a mutual
understanding of the goals of the treatment.
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Strategy 4: Work to mitigate the risk of diversion by meeting
regularly with patients to provide ongoing assessments.
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Strategy 5: Assist with managing laboratory testing, such as
conducting random urine drug tests.
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Strategy 6: Assist with patient follow-up and engagement in both
psychosocial and medication treatment.
D&A
Care
Manager
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Strategy 7: Coordinate the medication arrangements with the
pharmacy of choice.
Rx
Care
Manager
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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
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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.
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Key Practice 1: Develop referral protocols between clinical team,
treatment providers, and care management team.
D&A
Care
Manager
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Key Practice 2: Conduct Initial Assessment with Patient ASAP at a
Location that is Convenient for the Patient.
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Key Practice 3: Obtain a release of health information form from the medical provider or SUD treatment provider.
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Key Practice 4: Facilitate direct linkages in the form of warm handoffs to improve care coordination and patient treatment engagement.
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Key Practice 5: If a patient declines treatment, follow-up with the patient and notify the entire clinical team.
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Key Practice 6: Facilitate clear and ongoing communication between the
entire clinical team.
RAMP Care Management Summary
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Copyright 2018, University of Pittsburgh. All Rights Reserved.
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.
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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.