MassHealth Continuum of Care for Substance Use Disorders and Addiction Treatment
Shields, Julia C (EHS)
OK. And I'm going to share my screen and then hand it over to Tracy.
MassHealth Continuum of Care for Substance Use Disorders and Addiction Treatment (Slide 1)
Nicolosi, Tracey E. (EHS)
Thanks Julia.
So given that this is going to be recorded, my opening remark, I probably won't make.
My name is Tracy Nicolosi and I'm the Director of Addiction Services here at the Office of Accountable Care and Behavioral Health.
Anthony, would you like to introduce yourself?
Liburdi, Anthony (EHS)
Afternoon everyone.
I'm Anthony Liburdi. I'm the Deputy Director of Addiction Services at the Office of Accountable Care and Behavioral Health.
Shields, Julia C (EHS)
Great. I just want to make sure everyone can see these slides, right?
Great.
Addiction Is..... (Slide 2)
Nicolosi, Tracey E. (EHS)
Amazing.
So, the purpose of today's presentation is to give a broad overview of what the services are that MassHealth currently reimburses for in the treatment of substance use disorders.
I wanted to start today's presentation off with two bullet points.
One, explaining what addiction is.
And the other, basically saying what addiction is not.
When we talk about addiction, we're actually talking about a chronic medical disorder.
There are physical attributes to substance use disorders and addiction.
There are symptoms that can be seen and can be measured when it comes to substance use disorders and addiction.
The thing with Substance Use Disorders, is that it's not that individuals don't understand that what they're doing is harmful. It's about the individual developing a compulsion and also a physical dependence to substances that they're using, which means in the event that an individual discontinues, based on the severity of their disease, if an individual discontinues the use of substances, they're going to experience withdrawal, and withdrawal is something that is not very pleasant for individuals to go through.
So I wanted to start off with that piece around what addiction is.
When we describe it as being a disease, addiction looks like other types of chronic health conditions like diabetes or like hypertension. In terms of there is treatment that there is available and the treatment available for substance use disorders is just about as equally effective as insulin might be for diabetes, and also statin drugs for cardiovascular diseases.
The other piece that we really wanted to stress, at the front end of our presentation is what addiction is not.
Addiction is not a moral or character, illogical failing, or a sign of weakness.
The days of “just say no” are gone.
Next slide please.
MassHealth Continuum of Care for Substance Use and Addictive Disorders (Slide 3)
Nicolosi, Tracey E. (EHS)
So, when we talk about the types of services that MassHealth covers for substance use disorders and addictive disorders, we're also often going to reference what's known as ASAM, which is the American Society of Addiction Medicine criteria.
For substance use and co-occurring disorders, it is equivalent to Grey's Anatomy, the book, not the TV show, in terms of being able to describe what each disorder looks like, and what type of treatment is the best match to treat the individual that's seeking treatment.
MassHealth covers both 24-hour levels of care, but also covers non 24-hour levels of care, and the continuum that we have, it includes specialty populations as well as population specific treatment.
Next slide please.
Substance Use and Addictive Disorders (Slide 4)
Nicolosi, Tracey E. (EHS)
Folks often ask, well, what's the difference between substance use and addiction disorders?
Even though we will use these terms interchangeably, it really is a difference between the two.
When we're talking about substance use disorders, we're talking very specifically about drugs or alcohol, and the use of drugs and alcohol causes clinically significant impairment. This includes health problems. It may involve cardiovascular disease.
It may involve things like active liver disease.
Substance use disorders, they cause disability, they cause difficulty meeting major responsibilities, and the majority of times, treatment for substance use disorders requires a stay in a 24-hour level of care.
When we're talking about addictive disorders, we're talking about patterns of repetitive behaviors such as gambling disorders, internet addiction, etcetera, that cause the same clinically significant impairment.
But it's not caused by substance abuse, and it doesn't result in a a physical withdrawal syndrome if an individual discontinues gambling or Internet addiction or other types of addictive disorders.
And addictive disorders are treated most effectively on an outpatient basis, rather than requiring a medical protocol.
That occurs within a 24-hour period.
Next slide.
24-Hour Levels of Care (Slide 5)
Nicolosi, Tracey E. (EHS)
At the beginning I talked about how the substance use addictive disorder continuum of care that MassHealth reimburses includes both 24 and non 24-hour.
I'm going to start with describing the different types of 24-hour levels of care that actually speak to the severity of the substance use that we're talking about.
So, the highest level of care is the type of care that you would actually find on a medical surgical unit that sits within a general hospital.
The reason why an individual requires this highest level of care is because of either the active presence of complex symptoms that are occurring with the substance use, or whether an individual has a history of complex withdrawal symptoms that occur.
So, an example would be an individual that has active liver disease needs to be treated in a a hospital setting so that the liver disease can be controlled.
And treatment for withdrawal from the substances of abuse can occur at the same time.
It occurs within the unit where there's a physician that checks in on an individual daily and there's 24-hour nursing care.
The next level of care down is what people are probably most familiar with as being detox.
We don't really use the word detox anymore and the reason is that it's our bodies, and our liver in particular, that detoxify us from substances.
It's actually programs and clinicians and docs and nurses that help individuals manage withdrawal.
In Massachusetts, we describe detox services as acute treatment services, or in the terms of how ASAM describes this level of care, it's known as Medically Monitored Intensive Inpatient Treatment.
So again, these are protocols that are implemented under the direction of a physician.
They involve taking vital signs, they involve using empirical tools to be able to assess an individual's level of withdrawal, there's 24/7 nursing that is available, and the types of withdrawal that occur within detox settings are far less complicated than those that will occur in a hospital level of care.
The average length of stay for individuals in a detox or an ATS program, it's about six to seven days. And the reason being is that the focus of care within these programs is to help an individual manage the withdrawal process, meaning manage and basically, get through the process of no longer relying on substances to be able to feel normal.
The next level of care down is what we refer to as clinical stabilization services. Sometimes this level of care will be referred to as a step-down program.
In terms of how the American Society of Addiction Medicine describes this, they describe it as a three point five.
You'll notice that the difference between the other two levels of care that we've discussed in that those are either medically managed or medically monitored levels of care when we talk about clinical stabilization services, we're talking about clinically managed levels of care.
So what does that mean?
What that means is by and large, whatever medical conditions were being treated in higher levels of care have been resolved, and when an individual gets to this level of care, this clinical stabilization service level of care, while there is a physician, there's a medical director, and there is nursing staff that are available it's not twenty four seven because in in the physical sense and the withdrawal sense, the individual is stable enough to not need to be monitored to go through the withdrawal process.
When the symptoms of withdrawal are largely resolved, the things that an individual may have been suppressing or managing through the use of substances, they're all now going to come back up and we refer to this as post acute withdrawal syndrome.
So for example, an individual who manages their depression through the use of substances, if those substances are no longer circulating around an individual's body, then that individual is really going to struggle with how to manage their depression.
So it's not unusual for the co-occurring disorders to start to appear once the withdrawal process has ended, and because of that, length of stay in this level of care tends to be longer because an individual needs to have more time in treatment to be able to start to manage all of those things that happened and weren't taken care of while an individual was actively using substances.
Next slide please.
24-hour Levels of Care cont. (Slide 6)
Nicolosi, Tracey E. (EHS)
I wanna be able to talk about two specialty levels of care, or two specialty types of treatment that aren't necessarily captured in the American Society of Addiction Medicine criteria.
So, folks may be familiar with what the section 35 process is here in Massachusetts.
The section 35 process is basically a court order that requires an individual to be involuntarily committed to treatment for substance use disorders.
There's a very specific front door to section 35 treatment.
So, what we have done in Massachusetts is we have integrated two types of treatment, meaning the ATS, the acute treatment services or the Clinical stabilization services, into one single program.
And within these programs, withdrawal management services occur.
So, there's the physician and there's 24/7 nursing staff, but given the severity of the substance use itself, the clinical services are enhanced in these levels of care.
So, when we talk about section 35 services, the process is a legal one, right?
It's not the same as section 12, which is when an individual is committed to treatment involuntarily because their risk up to themselves or others by reason of mental illness.
With section 35, the involuntary commitment is based on an individual's risk of harm to themselves or others by reason of substance use, and the reason why I'm spending a little bit of time on this particular topic is that the process involves sending out a bench warrant for an individual, which further criminalizes substance use disorders.
So, section 35 in and of itself is not a clinical level of care, but what we've done is we have developed a pretty intensive program to be able to help those individuals that have been committed against their will.
The other level of care that we wanted to spend a little time talking about is what happens when you have youth and adolescence that needs some sort of substance abuse treatment.
Services for kiddos and for youth and for adolescents need to intentionally be different from the services that are provided to adults.
In Massachusetts, what we have is a single program, but it very much looks like the Section 35 program for adults in that it's a blended program that actually requires some sort of withdrawal management services can get those services in this program and they can also get those step-down services as well.
The number of youth that actually require youth withdrawal management or detox is it's relatively low, but for those kiddos and youth that actually are requiring substance withdrawal management, we want to make sure that they're getting access to the services that they actually need.
When we talk about substances that require medical intervention versus substances that may not require medical intervention, particularly with youth and adolescents, we're talking about the difference between youth and kiddos abusing alcohol and youth and kiddos abusing marijuana with alcohol. That that is a definitive substance that requires medical intervention.
Marijuana doesn't necessarily require some sort of withdrawal management protocol, so we just wanted to call out those two different types of services and the specialized population.
The next level of care down is what we call residential rehabilitation services or resi services.
In terms of ASAM, this is actually the last of the 24-hour levels of care.
When we're talking about residential or resi services, these, there's still 24-hour treatment programs, but the length of stay tends to be significantly longer than the levels of care that are treating more acute substance use disorders.
It's here in the residential programs that an individual is able to take the skills that they started to learn in the higher levels of care and start to apply them on a daily basis while they're in the community.
So, they're focusing on things like relapse prevention skills, they're focusing on resolving any sort of legal issues that may have come up, resolving family issues, finding employment, finding some sort of productive activity that allows them to help maintain their recovery and reintegrate back into the community.
In Massachusetts, we actually have a few different flavors of residential treatment, which is a good thing.
We have adult residential treatment, we have residential treatment that is specific to families, specific to youth, specific to transitional age youth, and also specific to individuals that have not just a substance use disorder, but they also have a mental health disorder and that mental health disorder can be moderate to severe.
The average length of stay in residential is it's generally about 90 days, but depending on the type of program could be a little longer. Could be a little bit less.
Next slide.
Non-24-Hour Levels of Care: (Slide 7)
Nicolosi, Tracey E. (EHS)
So we finished describing the types of services that happen in either hospital or something that is pretty close to a hospital in terms of rehab, we want to spend some time discussing the non 24-hour levels of care.
Mostly because I think that when people are talking about someone needs treatment for substance use disorders, the immediate thinking is that that requires a bed.
Given they the breadth of services that we now have to treat substance use disorders, treatment doesn't always mean that an individual needs to be in a bed.
So, we do want to spend some time talking about these outpatient levels of care.
So, we're going to start with something that is known as an intensive outpatient service.
So what does this mean?
So, an intensive outpatient service is more than what an individual would get in a traditional outpatient program.
It is largely consisting of group treatment.
There are mental health clinicians that are available.
There are case managers that are available, but it's 9 to 20 hours per week of treatment, which means an individual can continue things like whatever their home responsibilities are, or their employment, or educational responsibilities are.
So, the amount of services that occur in this type of a program are such that, like I said, it's more than outpatient, but it doesn't take place in the levels of care that are designed to treat acute substance use disorders.
When we talk about outpatient treatment, we're talking about, I think what folks would generally describe as counselling and therapy.
Counseling and therapy for substance use disorders is effective.
It's generally more effective when you combine it with other types of treatment.
The individuals that are appropriate for outpatient treatment, they're more stable.
They don't require the intensity of a 24-hour program, and this is a a less intense vehicle to be able to not just talk about relapse prevention, but talk about maybe what are some of the things that an individual is experiencing that may increase the likelihood of relapse.
The next level of care is opioid treatment services.
These tend to be known more as methadone clinics.
I want to spend a little bit of time talking about the types of medications that are available to treat opioid use disorders.
The first medication is methadone.
Methadone is a medication that's been around for decades.
It's also a medication for which there is a large body of scientific and evidence-based work that talks about the efficacy of the medication.
In addition to methadone, we have two other types of medications.
We have buprenorphine, or suboxone, which is the brand name, and we also have naltrexone.
The active ingredient in naltrexone is pretty similar to the active ingredient in Narcan.
So, when we're talking about naltrexone, we're talking about a medication that is offered.
After an individual has either an extremely low level of opioids in their system or no level of opioids in their system, the significance of having outpatient treatment services that are providing medication is that it doesn't require admission to like a detox program or a hospital level of care.
Massachusetts has done a pretty good job of ensuring that there's access to these medications in the community.
And you might ask, why do we know that?
We know that because we can see that, by and large, the individuals that are now gravitating towards the 24-hour levels of care are far less for opioid use and far more now for alcohol use.
And that speaks to the availability of treatment that is in the Community that doesn't require a stay in a 24-hour level of care.
The other thing that we are starting to see is that individuals with SUD that are presenting to the emergency rooms, the substance abuse is shifting, meaning that fewer people with an opioid use disorder are now presenting to emergency departments, and more individuals with alcohol use disorder are presenting to emergency departments.
While much of the focus across the country has been on opioid use disorders, largely because of fentanyl and how quickly people can succumb to an overdose when using opioids in particularly opioids that involve fentanyl, there consistently are more individuals that succumb to death from alcohol use disorders than from opioid use disorders.
The last group of treatment services that we want to talk about are what folks are probably pretty familiar with as recovery coaching and recovery support navigation.
So these types of services we do not consider them to be clinical services.
We consider these to be supportive services.
So what does that mean?
It means that a recovery coach is not going to be providing individual or group therapy.
For counseling services, the value of having a peer recovery coach is that a peer recovery coach has lived experience and can be instrumental in approaching an individual who is not sure that they need any sort of treatment for their substance use disorder, or even is unaware that they might need any sort of treatment because they're not in a place where they can understand that they actually have a substance, use disorder.
Recovery support NAVs are specialized care coordinators that have expertise and understanding in how to navigate the SUD treatment system.
Because the SUD treatment system can be very convoluted, and it can be very complicated.
Next slide please.
Enrolling as a MassHealth SUD Provider (Slide 8)
Nicolosi, Tracey E. (EHS)
So how do providers become a provider specifically for MassHealth?
Like the majority of MassHealth services, we have what's known as provider types.
The same is true for substance use disorders.
We have a very specific set of regulations that providers who are enrolled as SUD programs, or who want to be enrolled as SUD programs, are required to follow.
A lot of our regulations line up with the regulations that the Department of Public Health and the Bureau of Substance Addiction Services put out for licensure.
For SUD services, BSAS licensure is a requirement to be able to come into MassHealth as a fee for service provider, but also as a managed care provider.
So, for providers that want to provide SUD care, it starts with reaching out to Maximus, who can provide the applications in the guidance on what the necessary information is and once those applications are complete, they will actually come to Anthony, and Anthony will review the information and either approve or say some additional information is required.
In order for providers to enroll in managed care, they have to 1st enroll in fee for service because in fee for service we're going to give them that provider ID that is necessary for them to be able to enroll in managed care.
With SUD services, referrals are not necessary, and prior authorization is actually prohibited by law.
In 2014, there was legislation that was passed that was called Chapter 258, and what that legislation did was it prohibited insurance companies from requiring a prior authorization for someone to be able to get treatment for substance use disorders.
It was an unnecessary barrier and given the opioid epidemic and given that access to evidence-based quality care often saves lives.
Prior authorization was just something that that really stood in the way.
Referrals from M.D.s, or from other types of providers, whether they're behavioral health or medical providers, referrals are not necessary.
We have worked really hard with our partners in BSAS and across MassHealth to make these services as low threshold and low barrier as possible, and part of that really is connected to stigma and discrimination of individuals with substance use disorders, and we can dive more deeply into that at the end of the presentation.
All MassHealth coverage types are accepted for substance use disorder treatment, and that includes fee for service, it includes the PCC plan, it includes ACOs and MCOs. It includes OneCare, and in many cases it includes PACE.
The only type of MassHealth coverage that does not include these specific services are members that have MassHealth limited.
Next slide please.
Resources (Slide 9)
Nicolosi, Tracey E. (EHS)
I wanted to round out the more didactic kind of like speaking at you part of the presentation with some resources that I think if folks have time are really helpful to reinforce some of the information that that we're discussing today and the first is what's known as Words Matter.
When we're talking about addiction, we're talking about Substance Use Disorders.
Individuals that are struggling and are experiencing addiction and Substance Use Disorders, they're often going to refer to themselves as being clean or being dirty.
And when individuals refer to themselves in that way, that speaks to how they've internalized what it means to struggle from a substance use disorder or from addiction.
Essentially, they are either clean or they are dirty.
Clean or dirty is not an appropriate way to describe an individual that is in care for any sort of treatment.
So, if you have a chance, please take a look at that that article about how to start to replace terms like clean and dirty with more appropriate ways to be able to talk about the disease, to talk about addiction and to also talk about folks that are trying to recover or are in recovery from addiction.
The other really valuable resource is SAMHSA, which is a substance abuse and mental health services administration.
There are many, many different types of resources, not just for substance use, but also for mental health and for co-occurring disorders.
It's a really valuable website.
It talks about how to start to engage individuals.
It talks about how to treat individuals, and it also talks about how to integrate care for individuals.
The third resource is NIDA, which is the National Institute on Drug Abuse.
NIDA supports and funds many of the grants for both substance use disorders and for mental health disorders and also does a substantial amount of research on both.
In fact, the very first studies that demonstrated differences in the PET scans of the brain of individuals that are experiencing substance use disorders, that actually came from the National Institute on Drug Abuse. On NIDA, where you could actually see what the differences are between an individual that wasn't experiencing substance use and an individual that was experiencing substance use, and the reason why that's significant is that that lead the foundation for us to be able to start to talk about substance use disorders in a more medicalized, disease oriented way.
And then the last resource that I think folks would benefit from taking a look at is for the Bureau of Substance Addiction Services or, what we refer to as BSAS.
So, BSAS really is a public health arm of substance use disorders that sits within the Department of Public Health.
So, BSAS by and large sets the requirements for providers that want to provide substance use disorder treatment by saying you need to be able to do all of these different things before we give you a license.
And then here at MassHealth, we say you need to have that license to be able to provide services to MassHealth members.
So, I want to, and I'm pretty sure that's the last slide I'd like to end there so that we can really start to use the time that we have left to have a more in-depth conversation about what all of this means and how we put this together in a way that makes sense.
Thing about treating folks with substance use disorders within MassHealth.
So, I think that there were some questions that came up.