Crisis Response Programs
Actions Taken to Date
Alliance operates 3 crisis facilities – one each in Wake, Durham and Cumberland counties, as an alternative to emergency department care for individuals with behavioral health and substance use disorder in need of an urgent or emergent response. These facilities offer a detox unit, 23-hour observation chairs and Facility Based Crisis residential beds. An Alliance provider offers transportation to the facilities in Wake, Cumberland and Durham counties. Alliance will open a Facility Based Crisis Center for children in the Fuquay Varina area in Spring 2023. When this facility opens, children will also have an alternative place for care.
Alliance currently offers several programs offering treatment and transport to sites as an alternative to emergency department response. Alliance offers community paramedicine in partnership with emergency medical services (EMS) to transport members in Wake and Johnston counties using the 911 call system. Alliance began the Community Paramedicine program 3 years ago, in an effort to divert individuals from the ED. The primary objective of the Community Paramedicine program is to ensure that an assessment on the individual in completed once EMS is dispatched. If the individual needs treatment, EMS transports the member to an alternative treatment site such as a facility based crisis center. Use of community paramedicine has almost doubled since its inception in 2017. In fiscal year 2017 there were 2,417 individuals served. For fiscal year 2021 4,494 individuals were served. On average, 25% of individuals who receive paramedicine services are diverted from the ED.
In 2019, Alliance began a pilot in Wake County that embeds mobile crisis team members with First Responders. The pilot consists of 2 clinical teams at 2 different EMS site locations. When EMS responds to a call they respond and assess whether there is a behavioral health or substance use issue to which the mobile crisis team could provide a more effective response. Initially the call to the mobile response team was by pager, causing a delay in the response time. Using that data, Alliance now has the mobile crisis team embedded with EMS, responding to the call when EMS is dispatched and arriving after the assessment for need of the behavioral health mobile crisis unit. Alliance has also improved the service by adding geo-access to the team closest to the call location. Alliance is currently reviewing data to improve this service engagement and to empower the program to better serve the needs of the community.
Planned Implementation Steps and Timeframes
Alliance plans to open the child Facility Based Crisis Center in Fuquay-Varina in 2022. Alliance will monitor the data in Wake, Cumberland, Johnston and Orange counties to assess community needs and if they are being met.
As Alliance aligns itself with Mecklenburg County, Alliance will assess what Facility Based Crisis programs are available in that area. Along with the review of what is currently available, Alliance will conduct a needs assessment to determine if the needs of the community are being met. Once the assessments are complete, Alliance will review the gaps between services and needs and create a plan for the future of Facility Based Crisis programs in Mecklenburg County.
Within the first year of being a Tailored Plan, Alliance will partner with all the counties in its catchment area to determine, based on the data, the need and support to expand paramedicine.
During fiscal year 2022, Alliance will collect data and collaborate with its county partners to determine the need to expand embedded crisis teams with EMS in other counties in its catchment area. If other counties allot funding for embedding mobile crisis within EMS, Alliance will work with the county to assess, plan and implement the program.
Prevention and Diversion Programs
Actions Taken to date
Alliance has partnered with Wake County for a program called “Familiar Faces” since 2017. This program is part of Live Well Wake and assists individuals by offering integrated services, including transportation to treatment services. The Familiar Faces programs identifies members who are at risk for being drivers of high-cost service utilization. Using the data from an initial study by SAS Institute, Alliance partnered with Wake County to create a multisystem design of community resources to better meet the community’s needs. Once an individual is identified, Alliance care managers work with members to determine how best to divert them from the ED, jail, crisis facilities and EMS usage and proactively manage this population.
In addition to embedding mobile crisis team within the EMS teams, Alliance has worked with and provides technical assistance to the Raleigh Police Department (RPD) on a program called Addressing Crises through Outreach, Referrals, Networking and Service (ACORNS). The objective of this program is to divert individuals from jail and provide referrals and linkages to community services. ACORNS dispatches a social worker with law enforcement officers to assess, refer and provide non-emergency transportation for individuals.
Alliance has also been instrumental in Crisis Intervention Team (CIT) training for law enforcement officers and other first responders. This training, along with Mental Health First Aid, has been helpful in responding to members in the community and diverting them from the ED and getting them to the appropriate community resource.
Since its inception as an LME/MCO, Alliance has provided mobile crisis in all 4 counties in its catchment area. Members can call the provider crisis line or the Alliance Access line when in crisis or to ask for this service to transport them to care.
Alliance provides Behavioral Health Urgent Care (BHUC) services in Cumberland, Durham and Wake County. Alliance began providing BHUC services in 2015 and has expanded from 1 county to 3 over the past 6 years. Goals for BHUC include ED diversion and linkage to follow-up community-based services. The BHUCs quickly and safely serve individuals triaged as Emergent and Urgent and allow an expedited process of law enforcement to “drop off” individuals in need of services. Alliance not only expects BHUCs to divert from ED usage but also expects an overall decrease in the recurrent crisis episodes.
Another support that Alliance provides is a program for Specialty Mental Health Probation Officers. This program started 8 years ago and provides training for adult probation officers on serious and persistent mental illness (SPMI) and dually diagnosed individuals. This training helps probation officers ensure that individuals they serve are receiving community services and that the Social Determinants of Health (SDoH) are addressed to decrease the recidivism rate. During the SDoH assessment, officers can determine any transportation and alternative treatment needs. The technical assistance creates a preventative approach to linking individuals on probation with community services, including transportation services.
Planned Implementation Steps and Timeframes
Alliance is working with each county in its catchment area on their Community Health Needs Assessments that are done every 4 years. These assessments include substance use as a top priority. Alliance will use these assessments and the data they provide to guide its future programing, interventions and alternative treatment.
Alliance will continue to partner with the RPD to determine how to support and expand the ACORNS program. Once the program is fully implemented, Alliance can take lessons learned from this program and recommend to other cities within its catchment area.
Alliance plans to continue mobile crisis services, and ensure the service is provided for Orange and Mecklenburg counties, as Alliance expands into those counties.
Alliance is joining with the University of North Carolina in planning for a multisystem design for care in Orange County. Alliance is also actively planning with Mecklenburg County and enlisting the county and other large providers in creating the vision for Mecklenburg County.
Alliance is researching and assessing the Mobile Outreach Response Engagement Stabilization (MORES) program for implementation in its catchment area. MORES would provide crisis and stabilization for children and families in need of alternative treatment for substance use issues.
Currently there is no BHUC in Mecklenburg County. Alliance will begin assessment and discussions with the county about the need for this service. Once determined there is a gap in services, Alliance will plan for implementation and bringing online a BHUC.
Alliance would like to expand the Specialty Mental Health Probation Officers throughout its catchment area. Using the SDoH screening tool with the dual diagnosis will assist in proactively identifying individuals with transportation and alternative treatment needs who are on probation.
Plans for Meeting Network Adequacy Standards for MAT
Actions Taken to Date
Since 2016, Alliance has made significant progress in expansion of its provider network to address the opioid epidemic. With the support of the Federal State Targeted Response (STR) and State Opioid Response (SOR) grants, Alliance has expanded Medicaid Opioid Treatment Program (OTP) options in all Alliance counties, growing from 2 contracted providers in 2016 to 10 providers at the current time. Alliance has also expanded State-funded OTPs from a single provider in Durham County in 2016 to 6 providers in all counties currently. Alliance has also expanded access to Medicaid-funded OBOT by developing a new service option with an enhanced rate. This has allowed Alliance to expand opioid treatment access throughout the Alliance catchment area for its Medicaid-funded members. Alliance has also piloted State-funded OBOT programs in Durham and Wake counties.
Planned Implementation Steps and Timeframes
Alliance has already taken steps to meet network adequacy standards by adding provider contracts and anticipates further expansion of contracted OTP programs for Medicaid-funded services as Alliance transitions to a Tailored Plan. Alliance will also be reaching out to non-contracted OTPs within the current Alliance catchment area and OTP providers in Mecklenburg and Orange counties. The Alliance network is currently open for OBOT providers and Alliance will be reaching out to non-psychiatrist OBOTs before Tailored Plan launch to assess their interest in contracting with Alliance.
Alliance is evaluating alternative funding models for OTP and OBOT services to promote evidence-based, recovery-oriented models of care. Alliance plans to collaborate with other similar efforts and is working with the Opioid Response Network to research potential funding models. State-funded OBOT is more challenging to implement due to funding limitations for medication and laboratory services. Alliance plans to use the results of its 2 State-funded OBOT pilots to develop alternative funding models that may be more sustainable than the current approach.
As Alliance prepares for the addition of Mecklenburg and Orange counties, Alliance will review network capacity for these counties and identify any areas, if any, that require additional network expansion. In addition to OTP and OBOT services, Alliance will evaluate network adequacy for other SUD services, including Substance Abuse Intensive Outpatient Program (SAIOP) and Substance Abuse Comprehensive Outpatient Treatment (SACOT). Alliance is also tracking the status of multiple new services that NCDHHS will be developing within fiscal year 2022 to align its service array with the requirements of the section 1115 Substance Use Disorder Waiver. Alliance is aware of multiple new services that will require additional network development and will work with its current provider network initially to evaluate capacity for service expansion.
Non-Emergency Medical Transportation to SUD Treatment
In November 2018, Alliance implemented a Non-Emergency Medical Transportation pilot with provider Logisticare (now Modivcare) to offer non-emergency transportation to first appointments for individuals in need of urgent care and those in need of a 7-day follow up after discharge from a hospital or facility-based crisis. The goal was to increase engagement in services in a timely manner. The pilot expanded to add people seeking routine care and those discharging from emergency departments. Early results were promising with 51% of members coming out of facilities and 61% who contacted the Alliance call center attended their appointment on time. In 2020, COVID impacted this option significantly because members were being served virtually. This pilot continues to be an intervention used to support member engagement in services in a timely manner. This pilot provided the opportunity to build a working relationship with Alliance’s provider in preparation for expansion when Non-Emergency Medical Transportation is offered as a part of the benefit plan.
Future Plans for Non-Emergency Medical Transportation (NEMT)
Alliance will ensure all care managers, including care management agencies (CMA) and Advanced Medical Home Plus (AMH+) practices, receive training on the use of the Modivcare platform. Alliance created an educational flyer for the Modivcare transportation platform. The one page document is stored on the Practice Transformation page of the Alliance website for all providers to access.
Alliance will also provide member education on how to use the platform. As Alliance onboards members for the Tailored Plan, a multi facet approach to educate eligible members on the changes occurring for NEMT, including the new options and supports that will be available to them to access their transportation benefit. Alliance will initially engage in a general campaign to educate its Tailored Plan eligible members of the NEMT changes through community stakeholder sessions and information provided on the Alliance Tailored Plan website. Within 14 days of go-live, members who contact the Member Services line for a referral for health care services will be asked about transportation barriers, offered information about how to access NEMT and assistance with scheduling.
Within 90 days of the scheduled go-live, Alliance will implement a more targeted educational approach to individuals who have accessed NEMT over the past 18 months as identified through the analysis of Medicaid claims data that Alliance receives from NCDHHS. Planned activities include:
- Direct mailing of information to Members or their Legally Responsible Person (LRP) informing them of the change and options for accessing NEMT for their health care appointments that are scheduled on or after December, 1, 2022
- Through Alliance’s Member engagement partner, HealthCrowd, implement a texting campaign that provides initial information on changes and ways to access transportation followed by a series of follow-up reminders and links to the ModivCare ride scheduling portal, scheduling app and call center number used for transportation
Members engaged with Alliance care management before go-live will receive additional education from their assigned care manager. Care managers will assist Members with downloading the available ride reservation application and demonstrate how to use the online ride scheduling portal.
As Alliance moves into other counties and transition to the tailored plan, Alliance will work with local communities to educate and create transportation services to better serve its disabled members.
Implementation of STOP Act Requirements
North Carolina implemented the Strengthen Opioid Misuse Prevention (STOP) Act of 2017 as one step toward reducing misuse of opioids. Many of the provisions of this law apply to services covered by Tailored Plans, including prescription reporting by pharmacies through the NC Controlled Substances Reporting System (NC CSRS), limitations on prescriptions for acute pain, requirements for electronic prescribing and promotion of the distribution of naloxone. Alliance will ensure adherence to STOP Act requirements through multiple approaches, including:
- Alignment of utilization management strategy and formulary policies with NC Stop Act and work with the PBM to implement mandatory use of the NC Prescription Drug Monitoring Program (NC CSRS) before prescribing certain controlled substances
- Requirement that prescribers review patients’ 12-month prescription history before prescribing any Schedule II/III opioid or narcotic and that subsequent reviews must be conducted every 3 months, for as long as the Schedule II/III opioid or narcotic remains part of the patient’s treatment regimen
- Ensuring that prescribers adhere to requirements for mandatory E-prescribing of all targeted controlled substances, limitations on initial prescriptions for Schedule II/III opioids or narcotics (4-5 day supply for acute pain, 7-day limit for post-operative pain) and limit of 90 cumulative morphine milligram equivalent for short-term and long-acting opioid prescriptions
Use of Data Analytics to Identify and Address Opioid Prescription Outliers
Alliance’s PBM partner will provide to Alliance an opioid-focused Prescriber Insights report as part of the Prospective DUR program. This quarterly report helps prescribers understand their prescribing habits and displays peer-to-peer comparisons. Alliance will use the report to identify outlier prescribers and provide educational support, as needed.
Regarding opioid fraud, a PBM in-house pharmacy audit and special investigation unit (SIU) programs prevent potential FWA (e.g., unlawful opioid prescriptions, over-prescribing) by providing a reliable point of contact for members or clients any time FWA is suspected. The Navitus Customer Care department is available 24 hours a day, 7 days a week (except Thanksgiving and Christmas Day) and the SIU takes referrals at any time by its hotline and its email address.
The Jiva Application includes a machine learning tool that analyzes claims (pharmacy, physical and behavioral health), authorizations, lab data and general population health information to predict which members may be at higher risk for overdose secondary to opioid use. This predictive modeling will allow Alliance to engage members with targeted interventions to mitigate identified risks.
Data will be monitored to ensure interventions in the plan are effective. The following nationally recognized quality measures will be considered to evaluate performance:
- Concurrent use of prescription opioids and benzodiazepines
- Use of opioids at high dosage in persons without cancer
- Use of opioids from multiple providers in persons without cancer
- Follow-up after Emergency Department visit for alcohol and other drug abuse or dependence – 7 days – total
- Continuity of pharmacotherapy for opioid use disorder
- Initiation and engagement of alcohol and other drug abuse or dependence treatment – engagement – total
Alliance will also analyze data from the following sources to identify, monitor and support patient and prescriber outliers:
- Identification of outliers/high opioid prescribers by Navitus’ Prescriber Insights report
- Logic built into Jiva to identify members at high risk of opioid misuse
Secure Storage Initiatives
In 2019 Alliance distributed more than 400 medication lock boxes purchased by the state. These were strategically distributed to OTPs and Alliance OBOT pilot sites and crisis facilities in the Alliance catchment area. Care managers also had access to medication lock boxes to members needed to facilitate discharge/placements. In June 2021 Alliance advocated for the purchase of 150 medication lock boxes through the Durham Indigent Pharmacy Program (administered by Alliance) for the OTP, OBOT and crisis facility in Durham. In June 2021 Alliance advocated for and received Cumberland County funds for overdose prevention which were used to purchase naloxone and medication lock boxes for contracted OTPs and the crisis facility.
Alliance’s Alliance for Action Against Opioids website has been in operation for over three years, since spring 2018. This site lists strategies and other simple steps all citizens (providers and individuals) can take to fight opioid misuse and addiction and provides information about preventing overdose deaths. For individuals, the first of the 3 basic steps are to lock or dispose; second step is information about naloxone and third is red flags to identify opioid misuse and addiction. Regarding the Lock or Dispose information, the site provides information on keeping medications secure, with a link to Lock Your Meds. The site has a searchable list of permanent medication drop box sites in North Carolina. Take Back days are listed on social media and county community partners share information before an event and these are posted on Twitter and Facebook. The site links to the FDA site Where and How to Dispose of Unused Medicines. In addition, the site discusses use of disposal packets. The Alliance for Action site allows an individual to order their own DisposeRx packet (can dispose up to 45 pills) which Alliance will ship to the member/recipient (order form on website). This product will permanently deactivate the drug, rendering it unavailable for abuse or diversion.
Alliance Community Education and Outreach played a large role in these prevention efforts. Drug Disposal packets were also distributed by Alliance Community Education and Outreach staff at community outreach events and always given away during trainings. The packet always includes verbal and written educational information on safer drug disposal and the opioid epidemic. In all, 25,483 disposal kits have been distributed through a combination of distribution to the community and to organizations including sheriffs’ offices and behavioral health provider agencies and care by managers distributing to members. COVID has limited distribution of these packets.
Alliance Community Education and Outreach also distributed lock boxes with or without the disposal packs. This was part of their participation in the media marketing campaign (ncdhhs.gov) which involved the distribution of several boxes of rack cards and posters to the community and was included on the Alliance table at community events. Also promoted to the community in these venues was the Alliance opioid campaign using the website in trainings, e.g., the videos and content. Another venue for community education around the opioid epidemic was through Alliance educators giving Mental Health First Aid training, which contains a specialty module to address substance use disorders and the opioid epidemic.
PHP Lock-in Program
Alliance will work with its PBM Partner Navitus to develop the pharmacy benefit to comply with the NCDHHS requirements of 5.14 Beneficiary Management Lock-In Program in the NC Medicaid Pharmacy Services Clinical Coverage Policy 9 A member who qualifies for the program will be notified and locked in for 2 years. After 2 years of lock-in, members will be reassessed, and only if they continue to meet the criteria will they then be locked in for another 2 years. Once released from the lock-in program, prescription claims continue to be monitored. If a member meets the criteria again after being released from the program, they shall be re-identified for the lock-in program. Alliance will monitor members in the lock-in program to include ED visits and opioid misuse and other potential indicators, and report outcomes in a format specified by NCDHHS. Members who want to change the pharmacy or prescriber to which they are locked-in, will call the Alliance Member Access line where a staff member will take down the member’s information and their current and requested new lock-in provider/pharmacy; the Alliance call center staff member will then share this information by a phone call with the Navitus client account executive.