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  1. HFS
  2. Agency Information
  3. Report on the Detoxification Services Planning Process and Recommendations
  4. Recommendations for Policy, Services and Program Improvements

Recommendations for Policy, Services and Program Improvements 

 
  1. Hospital-Based In-Patient Services, Medications, Protocols Standing Orders

The following are presented to identify the problems with current policies, services and programs, as well as to recommend changes which, when implemented, will aid in the recovery of the client first and foremost, increase the quality of services, improve access and reduce costs. The strategic manner in which these potential changes are phased in without disruption and the effectiveness with which they are communicated to all parties will determine the success of all of these efforts.

  1. Problem Identified: Suboxone (Buprenorphine+Naloxone) and Buprenorphine, an approved expensive medication for treatment of opiate addiction, has the potential for misuse, abuse or diversion, and was being used for maintenance purposes without any counseling, sometimes by prescribers who may not have met the DEA qualification to prescribe this medication.

    Recommendation: HFS and DASA staff and our pharmacy consultants worked together to develop Suboxone and Buprenorphine Prior Authorization Criteria, which were put into effect earlier this year. Those criteria limit the dosage, dispensable quantity initially and upon renewal, and specify a 12 month lifetime duration of therapy. Additionally, the prescriber must be qualified and along with the patient would develop a treatment, counseling and tapering plan. Urine drug testing, provider review of the Illinois Prescription Drug Monitoring Program, coordination with inpatient detoxification admissions and drug/alcohol related Emergency Department (ED) visits as well as use of the same pharmacy to fill prescriptions is required. These criteria will also make it safer for patients to use Suboxone and Buprenorphine.

  2. Problem Identified: Significant inconsistency and variability (unexplained) in existing protocols for admission at various detox facilities creates confusion among the unit staff, ED staff and others responsible for referrals and admissions.
    Recommendation: Adopt/support the use of agreed upon standards for admission criteria such as ASAM which serves to place individuals in the appropriate level of care in the most appropriate settings.
  3. Problem Identified: The populations served in a hospital based detox facility are not frequently defined and there is significant variation in who is served. For example, pregnancy is an excluded condition in a facility, yet a pregnant patient is sometimes admitted. In addition, there is no protocol or standing order to require a pregnancy test prior to or even during hospitalization. Other examples are exclusions by age, cocaine use, alcohol use, co-morbid medical conditions, and certain insurance types in some inpatient detox units, again creating confusion among the unit staff, ED staff and others responsible for referrals and admissions. Some inappropriate admissions which the facility is not prepared to serve may be avoided if the problem is resolved.
    Recommendation: Specified pre-defined populations which are served or excluded at an acute detox unit should be a requirement for purposes of consistency and statewide planning purposes. Exceptions and deviations for cause must be justified.
  4. Problem Identified: The capacity of a detox facility, i.e., the number of clients who can be treated simultaneously and efficiently at any given time due to staffing or resource limitations, is not always clear; some facilities already have a maximum number while others do not. A pre-defined capacity can serve as a Quality Assurance (QA) measure.
    Recommendation: Pre-defined Capacity of an acute detox unit should be a requirement for quality assurance (QA) and monitoring purposes.
  5. Problem Identified: Polypharmacy (use of multiple medications in the same patient, sometimes for the same condition) is a problem evident on many of the hospital standing order sets which were made available. Accordingly, the standing/routine orders initiated upon admission and continued until discharge may contain orders for multiple and sometimes conflicting medications without a specified indication, such as: Methadone and Suboxone for withdrawal in the same patient; more than one tranquilizer and multiple anti-depressants dispensed regularly to every patient admitted; multiple as necessary (PRN) medications, 15 in one instance, for sleep, pain (some opioids); constipation and diarrhea for the same patient; cough, congestion, acid reflux, and an eye ointment in the absence of any documented symptoms. These orders are implemented by the unit staff even before an attending physician has evaluated the patient. This practice puts patients at risk due to higher incidence of falls/other injury, drug-drug interaction, drug-disease interaction and a higher than average incidence of side-effects. Additionally, unnecessary medication orders represent avoidable cost and waste of resources.
    Recommendation: The practice of prescribing by way of standing orders should be eliminated and that each medication order should be prescribed individually by an attending physician upon or after patients' admission.
  6. Problem Identified: The problem of unjustified laboratory tests ordered by way of routine or standing orders, promotes waste and avoidable costs. Sometimes, a test may lead to unnecessary or harmful further testing and treatment.
    Recommendation: The practice of routine testing in hospitals by way of standing orders without a specific physician order and without a diagnosis or reason should be eliminated. Those requirements are a norm in the outpatient world.
  7. Problem Identified: There is insufficient evidence that discharge planning is being done in advance of the patient's release at most locations. Arrangements for after-care, patient compliance and incidence of recovery are negatively impacted in the absence of such planning.
    Recommendation: A written post-discharge plan should be required upon or shortly after admission, subject to modifications until hospital discharge.
  8. Problem Identified: Few facilities currently require a psychiatric or psychological evaluation or even counseling during a detox admission. The chance of recovery is increased if co-morbid mental health problems are identified and treated timely.
    Recommendation: At a minimum, a screening psychological or psychiatric evaluation should be required early upon hospital admission; outliers identified on that screening should be seen by a psychiatrist or a psychologist prior to discharge.
  9. Problem Identified: Many patients do not get connected for outpatient follow up; that enhances their risk of readmission and decreases the chances of recovery.
    Recommendation: Completed arrangements/appointment for follow up visit, within an appropriate time frame after discharge, must be documented in patient's discharge orders, and the patient should receive a prescription no longer than 30 days upon discharge. The inpatient detox units may arrange appropriate outpatient follow up by one of their team members or another designated provider if unable to secure a follow up appointment for continued outpatient care after discharge. The processing of detox inpatient payment claims could be approved based on at least one post discharge outpatient visit by way of attestation.
  10. Problem Identified: There is insufficient evidence that the IL Prescription Drug Monitoring Program is accessed by the treating staff team to verify that the patient is getting controlled medications filled via a single provider and a single dispenser. There is an existing state law to that effect.
    Recommendation: The IL Prescription Drug Monitoring Program must be accessed and documented during each detox admission.
  11. Problem Identified: There is inconsistency among hospitals in ordering a urine drug screen test upon detox admission. Few require it. The treating providers do not know if a patient is using other than prescribed medications, complying with or diverting what has been prescribed.
    Recommendation: Urine drug testing should be a requirement upon each detox admission, as well as a provider review and documentation of that result prior to discharge. In appropriate cases, a blood alcohol level or a blood toxicology test to detect abuse of Benzodiazepine class of tranquilizers should also be required, since urine drug testing may miss these medications.
  12. Problem Identified: All team members in a detox unit should be appropriately qualified, credentialed/re-credentialed and subjected to criminal background checks. There is insufficient evidence of this process currently in all detox treatment facilities.
    Recommendation: Timely and pre-determined credentialing of all detox unit staff should be required and posted.
  13. Problem Identified: Systemic barriers surfaced during the many discussions among participating hospital and DASA community provider managers. The need for enhanced collaboration, and integration of targeted mental health, substance abuse, and medical health care services was identified as the key systemic modification needed in order for these services to effectively engage this target population.
    Recommendation: Develop an integrated services design and offer service providers the opportunity to participate in model implementation as a pilot project. Increase promotion and direct the development of skills and evidence based practices that have shown effective at engaging this high need homeless dual diagnosis population into recovery based sources.

 

  1. Consideration of Coverage for Methadone Treatment Services Under Illinois Medicaid Program

Today, Methadone is not covered by Illinois Medicaid. Methadone is an opioid pain reliever that is used with medical supervision and counseling to treat opiate drug addiction and to help control withdrawal symptoms in patients being treated for opiate addiction. Methadone treatment is currently listed on the Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Registry of Evidence-Based Programs and Practices (NREPP). It has been proven to be an effective treatment for helping patients maintain long-term recovery from addiction and years of research provide evidence that this treatment significantly reduces the costs of healthcare, criminal justice services, and other social welfare costs associated with opiate addiction.

Methadone programs are certified by the federal Department of Health and Human Services' Center for Substance Abuse Treatment (HHS/CSAT), registered by the Drug Enforcement Administration (DEA), and licensed by the Illinois Department of Human Services' Division of Alcoholism and Substance Abuse (IDHS/DASA). In addition, CSAT requires Methadone treatment programs to be accredited by one of the private accrediting organizations, i.e., Joint Commission for the Accreditation of Healthcare Organizations (Joint Commission), Commission on the Accreditation of Rehabilitation Facilities (CARF), or Council on Accreditation (COA), within one year of regulatory approval.

Methadone has been utilized for opiate treatment in Illinois since the 1960s and supported by the state with the creation of the Illinois Drug Abuse Program (IDAP) in 1969. IDAP evolved to become, in turn, the Illinois Dangerous Drugs Commission, the Department of Alcoholism and Substance Abuse, and the current Division of Alcoholism and Substance Abuse within the Illinois Department of Human Services.

There are currently 63 opiate treatment (Methadone) programs in Illinois. Thirty-two programs receive funding through a combination of Federal Block Grant and state General Revenue Funds. Thirty-one programs are fully private, self-pay. Of these 63 programs, 27 are in Chicago, 17 are in suburban Cook County, 8 are in the collar counties, and 11 are located in Alton, Champaign, Decatur, East St. Louis, Galena, Normal, Peoria, Peoria Heights, Rockford, Rock Island, and Springfield.

There are approximately 11,600 patients currently receiving Methadone services in Illinois, with approximately 5,500 of these patients in a DASA-funded Methadone slot. It is expected that nearly all of the 11,600 current Methadone patients will be eligible for Medicaid-funded services in 2014. For patients receiving outpatient methadone services, continued stay reviews occur every 30 days for patients during their first 90 days of treatment, and every 90 days thereafter for patients who demonstrate 90 days of stable participation.

The State is considering methadone coverage for Medicaid clients with an opiate addiction. In development of that policy, the following issues should be first addressed:

     

    1. Overview of a Recommended System Delivery Design to More Effectively Serve Clients/Patients Receiving Hospital and Community-Based Provider Substance Abuse Services and Treatment

    In developing a plan for detoxification that utilizes a broader, more clinically diverse continuum of substance abuse treatment and recovery support services, significant challenges were identified during the planning process. These challenges include:

    • Availability of housing and transportation
    • Availability and efficacy of case management
    • Creating incentives for programs to improve patient linkage to next appropriate level of care

    In addition to the challenges listed above, hospital-based detoxification programs and substance abuse treatment providers reported difficulty in identifying and addressing the varying levels of patients' openness to change and willingness to accept treatment. The workgroup developed a service model that would address these issues, given that they all have a direct impact on the state's ability to successfully reform detoxification services in Illinois. What follows is a description of a recommended model for service delivery improvements for "Individuals Presenting to Hospital-Based Detoxification and Community-Based Provider Programs."

    Tier 1: Recommendations for the Hospital-Based Program Setting

    1.1 All hospitals should be required to provide linkages to community-based treatment. Hospitals should have linkage agreements with community substance abuse agencies in their communities and there should be a mechanism to monitor that linkages are being made.

    1.2 Patients who are appropriate for DASA detoxification services per the American Society of Addiction Medicine (ASAM) admission criteria should be referred to a DASA provider of Level III.7 services. Training and technical assistance should be provided to hospital staff so that medical detoxification is provided to patients requiring medical stabilization, but less expensive services (ambulatory detox and social setting detox) are provided to those not requiring medical stabilization.

    1.3 Patients need a high level of engagement in the recovery process, especially in the first weeks of care. Patients should be screened for their readiness for change and patients who are not ready to accept a referral for substance abuse treatment should be provided Brief Intervention (BI) services. Those who are ready to accept a referral to treatment should receive a preliminary level of care placement prior to discharge from hospital-based detoxification.

    Tier 2: Recommendations for Substance Abuse Treatment Program Service System

    2.1 Increased Capacity for Residential Treatment.

    2.2 Increased Capacity for Recovery Homes, Halfway Houses and Oxford Houses.

    2.3 Increased Capacity for Medication Assisted Treatment. It is now widely understood that for some addicted persons, medications are critical to treat drug-induced brain deficits in order to help sustain a symptom-free lifestyle and long-term recovery. Given the gap between when patients are discharged from hospital-based detoxification programs and when they are able to enter methadone treatment, there is a need for interim methadone services, to bridge this gap in services. In addition, there is a need for greater access to other medications used to treat addictions, including Suboxone (Buprehorphine) and Vivitrol (Naltrexone).

    Tier 3: Recommendations for Recovery Support Service System

    3.1 Increase Capacity for Supportive Housing for Individuals with Substance Use Disorders. Increased capacity for supported housing for individuals in recovery should include a variety of housing settings, including the following:

    3.2 Increased Access to Recovery Coaching. Recovery coaches have been found to play an instrumental role in helping people in addiction treatment acquire the resources and skills they need to sustain recovery over time. In this model, a recovery coach meets with clients individually at least once a week for six months, which bridges their transition from treatment into the community, and then at least once a month for an additional six months.

    3.3 Increased Access to Recovery Supports, including Vocational Services, Peer-to-Peer Services, and Pastoral Counseling.

    The workgroup recommendations resulted in the Screening, Intervention and Engagement (SIE) Continuum of Care service model which will be piloted in Cook County beginning in January 2014. The full description of model components and time frame may be found in the SIE Pilot Project Description (Section D). The following flowchart details key elements of the proposed model:

    Screening, Intervention and Engagement (SIE) Continuum of Care Service Model for Patients Receiving Hospital-Based Detoxification Services


     

    1. A Continuum of Care Model for the Future: Screening, Intervention and Engagement Continuum of Care Pilot

    To implement the proposed new delivery system, the Illinois Department of Human Services Division of Behavioral Health (inclusive of DASA and DMH) will implement a Screening, Intervention and Engagement Continuum of Care pilot project. Services are designed to assist patients discharged from acute care detox programs in selected Cook County Hospitals into an appropriate level of substance abuse or mental health treatment and recovery support services.

    Partners in the pilot project include: the Illinois Department of Human Services, Division of Behavioral Health; selected substance abuse treatment programs, hospital based detox programs, recovery support programs, Great Lakes Addiction Technology Transfer Center and the Illinois Department of Healthcare and Family Services.

    Statement of Need

    In developing a plan to meet the treatment and recovery support needs of individuals receiving inpatient detox services, several significant challenges were identified by hospital detox staff, substance abuse providers and state agencies.

    These challenges include the following: 1) lack of access to substance abuse treatment services, including medication assisted treatment; 2) ineffective linkages to the next appropriate level of care; 3) problems with transportation; and 4) lack of access to recovery homes or other sober housing.

    In addition to the challenges listed above, hospital-based detoxification programs and substance abuse treatment providers reported difficulty in identifying and addressing the varying levels of patients' openness to change and willingness to accept treatment.

    Objectives

    The general objectives of the Screening, Intervention and Engagement Continuum of Care pilot project are designed to reduce barriers to accessing substance abuse and primary care and enhance opportunities for long term recovery.

    1. Identify hospital detox patients who are willing to accept the next appropriate level of substance abuse treatment using Stages of Change Model before discharge.
    2. Provide preliminary level of care placement for patients ready to enter community based treatment.
    3. Link individuals with co-occurring and substance use disorders to mental health programs.
    4. Transport willing patients from hospital site to substance abuse treatment programs.
    5. Link individuals to recovery support services.
    6. Link individuals in substance abuse and recovery support treatment to primary care services.
    7. Provide medication assisted treatment as appropriate.

     

    Requirements of Substance Abuse Treatment Programs Participating in the Pilot Project

    Treatment programs participating in the Pilot must adhere to the following conditions.

      1. Provider organizations must have an agreement with the hospital detox program to:
        1. Alert the provider organization once a patient has been admitted.
        2. Provide private space for the Screening, Intervention and Engagement counselor to meet with the patient.
        3. Include the provider organization as appropriate in developing the patient's discharge plan.

      2. Provider organizations must identify dedicated clinical staff to provide screening, intervention and engagement (SIE) service to patients on the detox unit (weekdays and Saturdays). The SIE counselor will use the Stages of Change Model to identify where patients are in their "readiness" to progress in the change process. Screening will be used to build rapport, decrease resistance and promote change.
      3. Staff must provide screening, intervention and engagement services to patients prior to discharge from inpatient hospital detox unit.
      4. Staff must undergo Stages of Change and Brief Intervention training.
      5. Provider organizations must provide transportation upon discharge for individuals from hospital-based detoxification to community-based services.
      6. Provider organizations must demonstrate linkages and/or the ability to integrate substance abuse services with ongoing primary medical care.
      7. Provider organizations must have access to full continuum of treatment services, including Level III.5, Level II, Level I, opiod treatment and recovery support services either provided directly or through linkage agreement.
      8. Provider organizations must have access to mental health services for individuals with co-occurring substance abuse and mental health services (either provided directly or through linkage agreement).
      9. Provider organizations must have the ability to place individuals in recovery home and/or halfway house (provided directly or through linkage agreement).

    Illinois Department of Human Services, Division of Behavioral Health Screening,
    Intervention and Engagement (SIE) Continuum of Care Pilot Project Activity Timeline

     

    Pilot Project Year(months)
    Start Date: January 2014

     

    1

    2

    3

    4

    5

    6

    7

    8

    9

    10

    11

    12

    Objective 1: Identify hospital detox patients who are willing to accept the next appropriate level of substance abuse treatment.

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Activity 1.1: Train hospital staff and treatment provider staff on Stages of Change Model

    X

     

     

     

     

     

     

     

     

     

     

     

    Activity 1.2: Select screening tool to be used to identify patients’ readiness for change and train provider staff on administering and scoring the screening tool

    X

    X

     

     

     

     

     

     

     

     

     

     

    Activity 1.3 Screen all detox patients at selected hospitals using the readiness for change screening tool

     

     

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Objective 2: Provide preliminary level of care placement for patients ready to enter community based treatment.

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Activity 2.1: Provider organizations identify clinical staff to provide SIE services to patients on detox units

    X

     

     

     

     

     

     

     

     

     

     

     

    Activity 2.2: Train provider clinical staff on Brief Intervention (BI) Model 

    X

    X

     

     

     

     

     

     

     

     

     

     

    Activity 2.3 Provide BI services to patients unwilling to enter substance abuse treatment service

     

     

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Activity 2.4: Provide level of care placement prior to hospital discharge for patients willing to enter substance abuse treatment

     

     

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Objective 3: Link individuals with co-occurring and substance use disorders to mental health programs.

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Activity 3.1: Identify mental health screening tool to be used with all hospital detox patients and train provider staff on administering and scoring the screening tool

    X

     

     

     

     

     

     

     

     

     

     

     

    Activity 3.2: Provide full mental health evaluations (by psychiatrist or LPHA) for patients with a positive mental health screen

     

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Objective 4: Transport willing patients from hospital site to substance abuse treatment programs.

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Activity 4.1: Establish discharge hand-off procedures between hospitals and treatment providers

    X

    X

     

     

     

     

     

     

     

     

     

     

    Activity 4.2: Provide transportation on day of discharge for all patients willing to enter substance abuse treatment

     

     

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Objective 5: Link individuals to recovery support services.

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X

    Activity 5.1: Identify recovery homes to participate in SIE pilot

    X

    X

     

     

     

     

     

     

     

     

     

     

    Activity 5.2: Provide 90 days of Recovery Home services for 75 patients discharged from hospital-based detox

     

     

    X

    X

    X

    X

    X

    X

    X

    X

    X

    X