Los Angeles County

The DMC-ODS Waiver – A Two Year Review

Gary Tsai, MD, FAPA, FASAMgtsai@ph.lacounty.govMedical Director & Science OfficerSubstance Abuse Prevention and ControlCounty of Los Angeles Department of Public Health

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Outline• Access

– Substance Abuse Service Helpline (SASH)– Expanding Access to Medications for Addiction Treatment (MAT)– Better Serving Individuals with Disabilities

• Process Improvement Project (PIP)• Residential Medical Support (RMS) Pilot

• Workforce Development Efforts– Tuition Incentive Program (TIP) Pilot– SUD Workforce Recruitment Campaign– SUD Workforce Enhancement for Longitudinal Learning (SWELL)

Initiative

• Change – A Call to Action

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• The SASH is a toll-free call line that helps connect callers seeking specialty SUD services with appropriate specialty SUD providers throughout Los Angeles County. – Launched 7/1/17, concurrent with implementation of DMC-ODS– Operates 24/7/365– Facilitates SUD treatment access by removing the need for an in-

person, pre-treatment appointment– Staffed by SUD counselors with LPHA

supervisors, in collaboration with the Los Angeles County -Department of Health Services

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3. SUD SCREENINGDetermine appropriate

provisional ASAM level of care• Young Adults/Adults – ASAM CO-

Triage® Tool • Youth/Parent – Youth Engagement

Screener

Walking through a SASH call…

4. FIND PROVIDERUse Service & Bed

Availability Tool (SBAT) to identify

SUD provider that offers necessary services that match individual service needs and preferences

5. REFER & LINK3-way call with caller and

provider to schedule intake appointment

1. ENGAGEMENTUse Motivational

Interviewing techniques to support completion of the screening and connection with treatment providers

2. ELIGIBILITYConduct eligibility review

for services –Medi-Cal, My Health LA, and Los Angeles County

residency

6. RESOURCESProvide other resources to

callers, as needed

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Expanding Access to Medications for Addiction Treatment (MAT)

• DPH-SAPC working with CIBHS to implement MAT Expansion Strategic Plan

• Vision– Similar to how any medical clinic that treats diabetes is able to offer both

behavioral counseling and medications for the treatment of diabetes, the ultimate goal is for County residents to be able to obtain MAT from any publicly-funded SUD treatment provider site, regardless of the level of SUD care (either directly or through referral).

• Rationale– SUD providers can often be organized into 3 broad categories of MAT

readiness:• MAT-Reluctant• MAT-Contemplative• MAT-Active

– Goal is to move SUD providers along the MAT readiness continuum

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MAT Access Models1. Direct Model2. Referral & Support Model

Expanding Access to MAT (cont’d)

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• 3-phase approach to MAT capacity-building and moving providers along the MAT continuum

– Phase 1 – Recruitment & Engagement• Regional engagement meetings with providers• Focus on MAT-Reluctant providers

– Phase 2 – Training & Implementation• Hands-on implementation support via training and technical

assistance (developing P&Ps, MOUs to facilitate Referral & Support Model for those who are unable to directly offer MAT, etc)

• Focus on MAT-Contemplative providers

– Phase 3 – MAT Implementation• Refining MAT implementation and sustainability through continuous

quality improvement projects, improving direct MAT provision or care coordination workflow, etc

• Focus on MAT-Active providers

Better Serving Individuals with Disabilities• Performance Improvement Project (PIP)

– Fundamental Assumptions• Some providers have specialized expertise in addressing the unique needs of people

with disabilities (PWD).• Filters on SBAT can be used to help match patient needs with provider expertise.• Providers want to better serve persons with disabilities, but unsure how.• More culturally-appropriate services will result in better SUD treatment outcomes.

– Interventions• Developed criteria defining expertise in serving PWD.• Administered survey to provider network to self-report expertise based on these

criteria allowing DPH SAPC to apply population-specific filters on SBAT• Added disability status question to Treatment Perception Survey (TPS) to track

satisfaction of patients with physical disabilities.• Will provide trainings on the unique needs of persons with disabilities.• Will conduct focus groups of patients with disabilities and providers to better assess

needs and challenges.

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38%

30% 31%34%

46% 44%

0%

10%

20%

30%

40%

50%

60%

70%

Physical withother disability

Physicaldisability alone

Total PhysicalDisability

Positive Treatment Compliance Among Physically Disabled Patients by Year and Specialization

63%

42%

0%

10%

20%

30%

40%

50%

60%

70%

Total Physical Disability (FY1718)

Specialization for the physical disabilitiesNo specialization for physical disabilities

FY1617FY1718

Percent Agreement by Disability Status (N=6,325)

Q1. The location was convenient (public transportation, distance, parking, etc.). Q8. Staff here work with my physical health care providers to support my wellness.

Q2. Services were available when I needed them. Q9. Staff here work with my mental health care providers to support my wellness.

Q3. I chose the treatment goals with my provider's help. Q10. As a direct result of the services I am receiving, I am better able to do things that I want to do.Q4. Staff gave me enough time in my treatment sessions. Q11. I felt welcomed here.Q5. Staff treated me with respect. Q12. Overall, I am satisfied with the services I received.Q6. Staff spoke to me in a way I understood. Q13. I was able to get all the help/services that I needed.Q7. Staff were sensitive to my cultural background (race/ethnicity, religion, language, etc.). Q14. I would recommend this agency to a friend or family member.

Treatment Perception Survey (Oct. 2018)

Note: Individuals can have more than one disability condition. *Examples of “other” disability include deaf, blind, developmentally disabled, or unspecified.

70

75

80

85

90

95

100

Overall Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q13 Q14

% A

gree

/Stro

ngly

Agr

ee

LAC Total (n=6,325) None (n=3,419) Co-Occurring Mental Health Condition (n=1,106) Physical (n=825) Other * (n=607)

Better Serving Individuals with Disabilities (cont’d)

• Residential Medical Support (RMS) Pilot– 12-month pilot between DPH-SAPC, LA Care, DHS, and participating

hospitals and residential SUD treatment agencies.– Designed to enhance access to residential SUD treatment for

medically stable patients.– Create a direct path from a hospital settings to residential SUD

providers approved for Incidental Medical Services (IMS).

11Hospital Residential SUD Treatment

Better Serving Individuals with Disabilities (cont’d)

• Residential Medical Support (RMS) Pilot– 2 Key Goals

1. To improve access to SUD treatment and patient outcomes for patients with stable medical conditions and ready to receive SUD treatment upon hospital discharge.

2. To support and grow the capabilities of residential SUD treatment providers across LA County.

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The RMS Pilot also has the potential to demonstrate to residential SUD providers that

they can safely accommodate patients with adequate care coordination and possible

medical support at SUD provider sites

Better Serving Individuals with Disabilities (cont’d)

• Residential Medical Support (RMS) Pilot– Eligibility Criteria

• Patients must be eligible members of DPH-SAPC, LA Care, and/or DHS.

• Physical health: • The medical condition must be stable enough to be safely

managed in a residential SUD treatment setting. • Patients must be able to perform activities of daily living (ADL).

• SUD: • Patients must voluntarily agree to residential SUD treatment.

• Patients must meet medical necessity for residential SUD treatment (DSM-5 + ASAM) and be authorized by the DPH-SAPC Utilization Management Unit, per standard protocol.

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RMS Pilot – Workflow

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Participating residential SUD treatment facility (with IMS approval) performs field-based ASAM assessment while patient is hospitalized and submits residential treatment

authorization request to DPH-SAPC

Eligible patient is transported to and treated in residential SUD treatment

facility with medical support provided through pilot

Eligible patient does not meet residential SUD treatment and is referred to a more

appropriate SUD facilities

L.A. Care, DHS, and/or hospital partners identify patients eligible and willing to participate in pilot program

Data from pilot is collected by DPH-SAPC, L.A. Care, DHS, and residential SUD provider, and is analyzed to inform current pilot and future expansion efforts

Initial data collection by residential SUD provider

& DPH-SAPC

Initial data collection by hospital participants and sent to DPH-SAPC

Workforce Development Efforts

• WORKFORCE DEVELOPMENT IS THE SINGLE MOST IMPORTANT THING WE CAN DO TO IMPROVE SPECIALTY SUD SERVICES!!

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↑ Quantity• SUD Workforce Recruitment Campaign• Tuition Incentive Program (TIP) Pilot

↑ Quality• SUD Workforce Enhancement

for Longitudinal Learning (SWELL) Initiative

• ODS-related training topics

2 Critical SUD Workforce Needs

Workforce Development Efforts (cont’d)• Efforts to Increase QUANTITY of SUD Workforce

– SUD Workforce Recruitment Campaign• Purpose Media campaign to inspire people to consider careers working in

the substance use field, whether it be as a SUD counselor or a licensed clinician.

• Target Audience The general public, students in local academic institutions who are formalizing their career pursuits, patients from SUD treatment provider network who are in early recovery and may be considering a career in the substance use field to help others in similar situations.

• Anticipated launch in late 2019 / early 2020

– Tuition Incentive Program (TIP) Pilot• Partnership with DHS and training institutions to increase the quantity of

registered and certified SUD counselors in LAC by providing tuition vouchers to help prospective candidates who are interested in pursuing careers in SUD counseling but have financial challenges related to paying for the necessary coursework to become a registered and certified SUD counselor. 16

Workforce Development Efforts (cont’d)

• Efforts to Increase QUALITY of SUD Workforce– The SUD Workforce Enhancement for Longitudinal Learning (SWELL)

Initiative is a collaborative workforce and curriculum modernization effort that began in 2016 between DPH-SAPC and the SUD counselor certifying bodies – CAADE, CADTP, and CCAPP.

– Purpose of the SWELL Initiative To enhance the SUD counselor workforce to ensure that it is work-ready upon completion of training, with the knowledge, competency, and skills to provide comprehensive, patient-centered, and high quality SUD treatment services across California.

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Workforce Development Efforts (cont’d)

• 3 Fundamental Focuses of the SWELL Initiative1. TRAINING CONTENT – Align core training curriculum topics with

evolving/current priority areas for SUD systems.2. DISTRIBUTION OF TRAINING TOPICS ACROSS COURSES – Disperse

relevant training topics across the span of the curriculum to achieve prerequisite relationship that builds upon and advances understanding of concepts and enhances the practical application of concepts learned.

3. SKILLS- AND COMPETENCY-BASED APPROACHES – Shift SUD counselor training to a competency- and skills-based training curriculum model, whereby SUD counselor trainees need to demonstrate not just knowledge, but competency at training topics.

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1. Key Training Content

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• ASAM Criteria• ASAM Assessments• ASAM Continuum of Care• DSM-5• Documentation• Case Management• Motivational Interviewing (MI)

• Cognitive Behavioral Therapy (CBT)• Medications for Addiction

Treatment (MAT)• Cultural Competence and Humility• Co-Occurring Conditions (Mental

and Physical Health)• Law/Ethics/Boundaries

The following topics should be covered IN ADDITION TO some of the core topics already included in SUD counselor certifying body training curriculum:

SWELL Initiative Focuses

2. Distribution of Training Topics Across Courses

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• Interwoven training curriculum topics to support practice-based learning… repetition and covering training topics in practice-based ways are helpful.

Development of Addiction

Psychoactive Drugs

SUD & Co-Occurring Disorders

Assessment, Tx Planning, Counseling

Pharmacology of MAT

Crisis Intervention

& Patient Education

Case Management,

Referral, Record Keeping

Law & Ethics

Screening, Intake,

Orientation

Assessment, Treatment Planning, & Counseling Law, Ethics, & BoundariesOpportunity to focus on the following topics:• ASAM Criteria• ASAM assessments• ASAM Continuum (Levels) of Care• DSM-5• MAT• MI• CBT

Opportunity to focus on the following topics:• MAT: Informed consent should involve all

treatment options available to clients, including MAT

• Examples of how to handle individual or group counseling sessions when participants are testing boundaries

• Examples of how to handle common ethical challenges in SUD treatment

Summarized curriculum from CCAPP-approved academic institution

SWELL Initiative Focuses

3. Skills- and Competency-Based Approach

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• Incorporating more:– Role-based and observational learning– Supervised practicums to emphasize practical application of learning

topics– Evaluation and grading based on demonstration of knowledge and skill

acquisition

VS.

SWELL Initiative Focuses

SWELL Initiative – Pilot Design

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• Initial training topic will focus on documentation– ASAM assessment with accompanying Narrative Summary– Treatment Plan– Progress Note

• 4 Phases1. Development of Beta Training 2. Pilot Beta Training (in process)3. Implement Trainings in CCAPP Academies4. Scaling Trainings to Other CCAPP-Approved Institutions

In summary, the SWELL Initiative provides a unified strategy and blueprint for preparing the SUD counselor workforce of the future, and how SUD counselor certifying bodies can design and structure modernized SUD counselor training curriculums.

“Sandwich Approach” to SUD Counselor Workforce Development

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• Cultivating a strong SUD workforce requires both an upstream and downstream workforce development focus– Upstream

• What the SUD counselor certifying bodies (CAADE, CADTP, CCAPP) are doing to ensure that counselors that get registered/certified have a standard knowledge base and skillset when they enter the workforce

– Downstream• What counties and providers are doing to ensure that their SUD

counselors have the knowledge and skills to perform necessary work in SUD systems (e.g., trainings on ASAM Criteria, documentation, Treatment Planning, etc.)

Focusing on downstream trainings without adequate focus on the upstream training process creates inefficiencies due to SUD systems needing to play catch-up and “training-up” their counselors as opposed to having confidence that SUD counselors are work-ready once they become registered or certified. 24

“Upstream” training of future SUD counselors by certifying bodies Counties & providers

performing “downstream” trainings to ensure their SUD counselors are “work-ready”

Change – A Call to Action• Foundational Principles

– How the SUD workforce views itself• SUD = health• SUD providers = health providers• Health providers = Hold themselves to the highest quality standards that

they would want for themselves and their family– Recognizing the importance of informed consent (e.g., MAT, withdrawal

management, etc).– We need to leverage the full power of lived experience, while recognizing

that recovery looks different for everyone.• Most Compelling Reasons for Change in the SUD Field

– 95% of people with an SUD either don’t think they need or don’t want treatment.1

– Typical annual penetration rate for SUD treatment is ~10%.2

• “If you always do what you’ve always done, you’ll always get what you’ve always got.” - Anonymous

251. https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR2-2016/NSDUH-DR-FFR2-2016.htm2. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf

“The opposite of addiction is NOT sobriety; the opposite of addiction is connection.”

- Johann Hari 26