Addressing Emerging Health Care Issues from the Governance ... · •The press related to opioid addiction in western NC and the ... Chicago Department of Public Health closed six

Addressing Emerging Health Care Issues from the Governance Level:

A Spotlight on Substance Use DisorderPolicy & Issues Forum 2019

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,375,000 financed with non-governmental sources. The contents are those of the author(s) and do not necessarily

represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Learning Objectives

1. Gain insight into how health centers are addressing the need in their community related to SUD.

2. Gain insight into how health center boards have navigated the strategic, oversight, advocacy, and other governance implications of offering these services.

3. Identify what questions to raise in your own health center's boardroom.

Please share your:

• Name

• Health Center

• Why you decided to attend this session today

Panelists

• Moderator: Dr. Donald Weaver, MD, Senior Advisor, NACHC

• Panelists:• Blue Ridge Health (Hendersonville, NC)

‒ Richard Hudspeth, MD, CEO and CMO

• Henry J. Austin Health Center (Trenton, NJ)‒ Dr. Kemi Alli, MD, CEO

• PCC Community Wellness Center (Chicago, IL)‒ Amanda Brooks, AM, LCSW, CADC, Chief Population Health Officer‒ Robert J Urso, MS, MHA, BSN, President & CEO

Roles of the Board (“Collective”)

Strategic Direction

Adopt Policies

Provide Oversight

Board’s Strategic

CompositionCEO

Oversight &

Partnership

Ensure Resources

Board Functioning

8

Blue Ridge HealthRichard Hudspeth, MD, CEO and CMO

Blue Ridge Health in Western NC

• Overall we have nineteen different sites in seven counties in western North Carolina. 37,000 patients and 140,000 visits.

• We currently have 30 FTE primary care, plus 13 FM residents, 20 FTE BH counselors and 6.75 FTE psychiatric prescribers (includes psychiatry and nurse practitioners).

• Our SBIRT screening policy: all new patients and established patients once a year for SUD, interpersonal violence, and depression over 12 years of age and as needed per clinical judgment.

• We have integrated care, crisis walk-in, ongoing BH therapy. • We have 24 providers with DEA X-Waiver for MAT.

The Need in Our Community


Substance Abuse Treatment Activities

• Counseling and MAT in our BH and primary care clinics.• BH services are offered in individual and group formats.• Different modalities are offered, such as CBT, somatic therapy,

motivational interviewing.• Offered to adults and specific programs for pregnant women.• Provide RN case management services.• Offer suboxone for chronic pain and provide group therapy

facilitated by joint medical and BH providers.• Screen adolescents in our school-based health centers.• Participation in community forums, task forces, etc.



Governance: Board Education and Input

• The Board approved our MAT policy which includes the protocol, SBIRT screening protocol, patient definition for appropriateness for MAT for our clinic, including pregnant patients, payment (slide scale), our required suboxone patient contracts, use of drug screens, and dismissal policy.

• The press related to opioid addiction in western NC and the variety of board members is strong so at the time of the policy there was minimal need for board education.

Governance: Strategic Direction

• Management uses numerous needs assessment tools to present new potential service line information to the board.

• These include information from each of our communities’ innovation groups, our hospital and health department community health assessments, our own internal data, and local, state and nationwide data on any initiative, such as opioid addiction, or Hepatitis C, etc.

• We are undergoing our next strategic planning now. The last was done three years ago. Not surprising there was no mention of this emerging health initiative in our last strategic plan.

Governance: Oversight

• We use the same sliding fee for this service as we use for medical.

• There were many private providers who are providing this service but at a much more expensive rate than us.

• We first started with internal referrals and then expanded to outside referrals carefully so as not to overwhelm our system and providers.

• There may be more concern that the patients seeking this service may refuse to pay more than truly have an inability to pay, although currently is defined as inability to pay. The board refining our policy to reflect this tension remains a challenge.

• We have aggressively sought grant funding to help us serve more.• We provide quality reports and quality dashboards to our board

members every month.

Governance: Advocacy

• Our first level of advocacy was with our own providers. • We have advocated on local, state and national level for

support and for policy changes to help improve our opioid addiction statistics.

• We highlight our work on this problem at community forums, locally and statewide.

• We share patient stories about the impact this program has had on their lives.

PCC Community Wellness Center

Amanda Brooks, AM, LCSW, CADC, Chief Population Health OfficerRobert J Urso, MS, MHA, BSN, President & CEO

PCC Community Wellness CenterBob Urso, MS, MHA, BSN, President and CEO & Amanda Brooks, LCSW, CADC, CPHO

MCH Fellowship

Community Health

Fellowship

PCC Lake Street PCC

Parkside

PCC Austin

PCC at The

Boulevard

PCC West Town

PCC Melrose

ParkPCC SouthBirth

Center

PCC Erie Court

PCC at WS

WSMC

PCC Salud

PCC at Steinmetz

PCC WIWC at WSMC

Integrative Medical Education:

WSMC & NAH Family Medicine Residencies

Integrative Service Delivery Initiative:

CHS (PHO)Norwegian (PHO)Altruista Health

Integrative Referral System:

Inpatient/Outpatient Diagnostics

Major Community Collaborations

• West Suburban Medical Center

• Westlake Hospital• Norwegian American

Hospital• Steinmetz High School

• Northwestern University, Department of Family

Medicine• Walgreens 340B

Program• CEDA-WIC

• Dominican University, UIC, UIUC, UofC,

Loyola: Schools of Social Work

• Riveredge Hospital• Oak Park Health

Department

PCC Community Wellness Center

Governance: Board Education and Input

PCC’s Approach to Governance Strategy:Four Primary Factors

Department of Health and Human Services 2018-

2022 Strategic Plan

Grant Opportunities

Behavioral Health Strategic Plan

(Initiative) Utilizing UCLA Johnson and Johnson

Healthcare Executive Program Community Healthcare Improvement

Program (CHIP)

PCC’s Community

Health Assessment

Report


Department of Health and Human Services 2018-2022 Strategic PlanStrategic Goal 2. Protect the health of Americans where they live, learn, work, and play. Strategic Objective 2.3. Resolve the impact of mental and substance use disorders through prevention, early intervention, treatment, and recovery support.


• Within PCC’s target communities, 196 of the 210 census tracts comprising these communities are designated as Mental Health Professional Shortage Areas by HRSA.1

• And although the need for services is high, many low income Chicago residents lost access to behavioral health care when the Chicago Department of Public Health closed six of its mental health clinics during 2012.

• Substance abuse treatment capacity in Illinois is declining. From 2007-2012 the state of Illinois decreased its treatment capacity for alcohol and substance use disorders by 52%, making the number one treatment capacity decline in the United States (Kane-Willis et al, 2015).

1 Health Resources and Services Administration. HPSA and MUA/MUP by State and County. http://hpsafind.hrsa.gov/index.aspx and http://muafind.hrsa.gov/index.aspx, respectively. Accessed 12/01/2013.


• The Westside of Chicago is the epicenter of Chicago’s opioid epidemic.

• Data shared by Medicaid Managed Care Organizations (MCO) indicated that the Westside of Chicago has the longest wait times for patients seeking residential treatment, inpatient detoxification, and outpatient treatment services.

• Many community treatment partners are at such significant overcapacity that organizations are unable to meet the needs of the community, resulting in minimal two-three week times.

• There are limited numbers of providers available to treat OB patientswith substance use disorders, none of which currently are being provided in an integrated setting.


• As a result, PCC has become the safety net provider for mental health and substance abuse services, thus focusing on the implementation of mental health services for children, adolescents, and adults, with integration of substance abuse treatment for PCC’s adult patients and community members at large. With growing focus on additional social determinants of health, such as housing and employment, PCC intends to offer comprehensive integrated services that address all biopsychosocial factors that contribute to improved whole health outcomes.


Diversification – to broaden a mix of products or servicesA primary objective of diversification is to strengthen one’s primary service line in order to secure, if not increase its market share. Diversification strategies should seek to extend an organizations’ sphere of influence, directly or indirectly, to activities that may lead patients to seek services at a future time.


Diversification opportunities for PCC Behavioral Health are as follows:• Colocation with Behavioral Health Organizations/Agencies• Develop/enhance new services

• Expand MAT clinics• Integrative health medicine

• Pain management program • Yoga, meditation, massage, acupuncture

• Intensive outpatient program • PCC will partner with treatment facilities to accept PCC referrals• PCC will contract to bring IOP services on site at PCC locations


PCC Grant Awards• 2014 HRSA Behavioral Health Expansion:

o Year 1: $250,000o Year 2: $250,000

• 2016 HRSA Substance Abuse Expansion:o Year 1.5: $325,000

• CVS/NACHC:o Year 1: $85,000o Year 2: $85,000

• Office of Women’s Health:o Year 1: $271,000o Year 2: $271,000o Year 3: $271,000

• 2017 HRSA AIMS:o Year 1: $175,700

• 2018 HRSA Substance Use Disorder/Mental Health:

o Year 1: $377,500• Community Mental Health Board of Oak Park

Township:o Year 1: $20,000

• Total Grants: $2,381,200


• Integrated level 1 outpatient substance abuse treatment include medication assisted treatment with Buprenorphine and Naltrexone

• 24 DATA Waived prescribers• 1:1 ratio of medical prescriber to behavioral health provider

providing integrated services at each medical encounter• High Risk Chemical Dependency Program for pre-natal patients

with an opioid use disorder (OUD)• Multigenerational care for families with OUD


• Closed loop service model with partner hospital• PCC Attendings manage adult and maternal child health

inpatient services• Inpatient inductions

• PCC employed care coordination staff round on inpatient service

• PCC employed care coordinator staffed in ED• Patients service between 2015-2018= 763• FY2018= 6299 medical and behavioral health encounters


Chemical Dependency

Clinic

PCC Austin

PCC Salud

PCC Lake

PCC Melrose

Park

PCC South

PCC West Town

PCC Boulevard

PCC at West

Suburban


Medical Director of Chemical

DependencyKathleen McDonough

DATA Waived MD/FNP

Chief Population Health Officer

Amanda Brooks

Behavioral Health Manager

Chemical Dependency Team

LeadBehavioral Health

Consultants

Chemical Dependency Care

Manager

Care Coordination and Peer

Specialists


• 50% continuous engagement and retention since 2014• Focused opportunities

• High risk 90 day drop out• 12+ month drop out

• Integration of Peer Recovery Support Specialists• Expansion of Hub-and-Spoke model• Focused quality initiatives

• Hepatitis immunization and treatment• Narcan distribution• Improved engagement at 90 days• Hospital readmissions ≤16%


• Budget 9 patients per 4 hour session• Lower productivity allows time for collaborative care and

increased counseling to address psychosocial factors that impact use and recovery


0

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400

450

Jul'17

Aug'17

Sep'17

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Nov'17

Dec'17

Jan'18

Feb'18

Mar'18

Apr'18

May'18

Jun'18

PCC FY18 Chemical Dependency Clinic Productivity/Budget

Outpatient Productivity (Medical)Threshold (Medical)Outpatient Productivity (Behavioral Health)Threshold (Behavioral Health)

0

50

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Jul '18 Aug '18 Sep '18 Oct '18 Nov '18 Dec '18

PCC FY19 Chemical Dependency Clinic Productivity/Budget

Outpatient Productivity (Medical)Threshold (Medical)Outpatient Productivity (Behavioral Health)Threshold (Behavioral Health)

Governance: Advocacy

July 13, 2018: PCC Community Wellness Center hosted a press conference for the Chicago Department of Public Health (CDPH) and the Department of Business Affairs & Consumer Protection (BACP) to announce a milestone in their pharmaceutical license requirement taken to prevent

opioid addiction and address the opioid epidemic.

October 6, 2016: PCC Community Wellness Center hosted Chicago Mayor Rahm Emmanuel who announced findings of a heroin task force and

suggested initiatives to take control of the problem and save lives.

Henry J. Austin Health Center

Over 16,000 patients generated over 70,000 visits in 2018

Dr. Kemi Alli, MD, CEO

Reverse Integration at its BEST!

These are 4 Primary Care Offices embedded in these organizations, we call our Integrated Care Satellites (ICS)

Our Patients . . . . .

1 in 9 are homeless

Over half African American and female

1/3 are Latino

2/3 fall 200% or more below the federal poverty level



• Trenton is New Jersey’s capital and is ranked the 15th highest town for heroin abuse in a state of 565 municipalities, putting it in the third percentile.

• Drug overdose deaths continue to rise from 2,221 deaths in 2016 to 2,750 in 2017 to over 3,000 in 2018.

• HJAHC has 14,000 and we have identified over 1,990 individuals (more then 1 in 10 patients) with SUD and currently have 195 in MAT.

• HJAHC is still the only Primary Care Setting in our entire county providing MAT services.

State Commission of Investigation. (2015). Scenes from an epidemic: A report on the SCIs investigation of prescription pill and heroin abuse. Cited in ô30 NJ towns.ö Available at: patch.com/new-jersey/Parsippany/30-nj-towns-most-heroin-abuse-0

Governance and Mission Statement

The mission of Henry J. Austin Health Center is to provide patient-centered,

comprehensive, accessible, efficient, quality primary care, mental health and substance

abuse treatment services to the culturally diverse greater Trenton community. Our

exceptional dedicated, well trained team delivers best practice healthcare, working with

community partners to provide extraordinary customer service and quality outcomes. Our

vision is to improve the quality of life through superior health care outcomes for the Greater

Trenton community as their medical home of choice

Governance and Strategic Plan

Strategic Initiatives Integrated Care (includes SUD) Create efficient and cost effective systems Maximize Revenue Continuous Quality Improvement Programs

Strategic Initiatives Integrated Care (includes SUD) Create efficient and cost effective systems Maximize Revenue Continuous Quality Improvement Programs

Strategic Direction and Medical Home Model

Teams are Everything . . . .

PatientPatient

Provider

Clinical Pharmacist

Nurse

Community Health Worker

Medical Scribe

Unit Receptionist

Unit Receptionist

Peer Recovery Specialist

Medical Assistant

Behavioral Health

Counselor

Just how we deliver care . . . . . . .

At every site in each department there is a Behavioral Health Counselorto provide on the spot intervention on substance misuse/abuse and

behavioral health illnesses.

ALL patients 13 years and older are screened at EVERY visit.

We have created a comprehensive Medication Assisted Treatment (MAT) program. On the road to ALL providers having a MAT Waiver.

Budget Considerations . . . . .

Integrated Healthcare (SUD)

services have become 1 of our 4

COST CENTERS:

1. Medical Services

2. Pharmacy Services

3. Integrated Services

4. Administration

Integrated Healthcare (SUD)

services have become 1 of our 4

COST CENTERS:

1. Medical Services

2. Pharmacy Services

3. Integrated Services

4. Administration

Sustainable program . . . .

HJAHC realized in order to create a sustainable program billable integrated care CPT codes are needed along with regulations that did not create barrier to the program.

• With our NJ Primary Care Association met with Medicaid over two years and 5 additional integrated care codes including group visit codes and Health and Behavioral Codes !

• As part of our State Department of Health’s Integrated Healthcare Advisory Panel, helping to shape the regulations around integrated care and MAT for the state of NJ.


Using Technology to improve access through electronic consults, video conferencing (Project ECHO) and telemedicine . . . . . .

Quality Assurance and Improvement . . . .

(2.00)(1.50)(1.00)(0.50)0.000.501.001.502.002.50

Months Working CapitalGoal

Months Working Capital 0.06 (0.82) (1.06) (1.39) (1.54) (1.00)Goal 2.0 2.0 2.0 2.0 2.0 2.0

3/31/2007 3/31/2008 3/31/2009 3/31/2010 3/31/2011 12/31/2011

Emerging Issues –Governance Questions

• How does the issue factor into the health center’s Needs Assessment?• How does the issue factor into the health center’s Strategic Plan or into an

update to the Strategic Plan?• What type of board education is needed on the issue?• What type of patient and community input is needed on the issue?• What are the budgetary implications of the issue?• What implications does the issue have for financial, quality, or other forms of

board oversight?• Are there any policy issues connected to the issue that require board

involvement?• How does the issue link to the health center’s advocacy plans?

Peer Sharing: Questions for Your Boardroom

Take time to:

• Discuss how your board is navigating substance use disorder from a governance level

• Discuss other governance questions a board may want to consider when addressing an emerging issue

Additional Resources• At P&I March 29, 3:30 pm - PFE3 – The Opioid Epidemic: How Do We Take Care of the Compassionate

Care Team?

• Resources Business Plan for Medication-Assisted Treatment (MAT) http://www.nachc.org/wp-

content/uploads/2019/02/MAT-Business-Plan.pdf Documentation and Charge Capture Process: Medication-Assisted Treatment http://www.nachc.org/wp-

content/uploads/2019/02/MAT-Service-Delivery-Report.pdf Integrating Buprenorphine Therapy for Opioid Use Disorder into Health Centers available at

http://mylearning.nachc.com/ or https://www.healthcenterinfo.org/ Landscape for Community Health Center Integration of Behavioral Health & SUD/OUD Services

http://www.nachc.org/wp-content/uploads/2018/09/NACHC-BHI-SUD-OUD-Env-Scan-Policy-Paper-Aug-2018.pdf

Policy Landscape for Community Health Center Integration of Behavioral Health & SUD/OUD Services http://www.nachc.org/wp-content/uploads/2018/09/NACHC-BHI-SUD-OUD-Policy-Snapshot-Aug-2018.pdf

Rising to the Challenge http://www.nachc.org/wp-content/uploads/2018/03/NACHC_PI_2018_WEB_v1.pdf

Sharing Behavioral Health Information for Treatment Purposes: Mental Health and Substance Use Disorder available at http://mylearning.nachc.com/ or https://www.healthcenterinfo.org/

The Role of Community Health Centers in Addressing the Opiod Epidemic https://www.kff.org/medicaid/issue-brief/the-role-of-community-health-centers-in-addressing-the-opioid-epidemic/

Acronyms• BH – Behavioral Health• CBT – Cognitive Behavioral Therapy• DATA – Drug Addiction Treatment Act• DEA – Diversion Control Division• FTE – Full time employee• IOP – Intensive Outpatient Program• MAT – Medication Assisted Treatment• OB - Obstetrics• OUD – Opioid Use Disorder• SBRIT – Screening, Brief Intervention, and Referral to Treatment • SUD – Substance Use Disorder

Documents

Addressing Emerging Health Care Issues from the Governance ... · •The press related to opioid addiction in western NC and the ... Chicago Department of Public Health closed six