Opioid Misuse Prevention and Treatment Program

In response to the national crisis associated with increased opioid use and fatal overdoses, North Carolina developed a statewide Opioid Action Plan in 2017, which was later revised in 2019 and 2021 to reflect trends in substance use, current needs of the community and actions that are expected to be the most effective. The most recent revision, Opioid Action Plan 3.0, was broadened to include polysubstance use, in part due to rising rates of stimulant use, and was renamed the Opioid and Substance Use Action Plan.

Although North Carolina has seen progress with respect to opioid prescriptions and treatment access, the COVID-19 pandemic has led to a resurgence in overdoses, which have increased significantly across the United States during the pandemic, and many communities have seen increases in rates of use of stimulants such as methamphetamine and cocaine. For the past 5 years, Alliance Health has participated in efforts at all levels to address the opioid crisis, and the following plan provides additional information about its current and planned initiatives to continue this effort. This document serves as a project plan for Alliance and will be submitted annually to the NC Department of Health and Human Services (NCDHHS) for approval, posted on the Alliance website, and incorporated into the Alliance Provider Manual.

Consistent with the NC Opioid and Substance Use Action Plan (OSUAP) and the recommendations of the NC Payers Council, this plan acknowledges that opioid use does not occur in isolation from other substance use, co-occurring mental illness, and comorbid medical conditions. To effectively address this crisis, Alliance recognizes that multiple approaches are needed to address prevention, harm reduction and access to treatment, within a context that addresses social determinants of health and barriers such as stigma and systemic inequities and healthcare disparities.

As the NC Opioid and Substance Use Action Plan describes, multiple approaches are necessary to address the current crisis, and Alliance has taken steps to implement initiatives that correspond to each of the three primary categories: prevention, harm reduction and connection to care. This document provides an overview of Alliance’s past and current activities in each area as well as its plans for future actions as a Tailored Plan.

As a behavioral health LME/MCO, Alliance historically has not managed utilization of prescription medications for the Medicaid population, but has taken steps to prepare for effective monitoring of potential abuse or inappropriate utilization of targeted medications. Alliance has contracted with pharmacy benefits manager (PBM) Navitus to assist with its pharmacy needs as it moves toward the Tailored Plan. Navitus has an active system to report fraud, waste and abuse . This uses a methodology developed for prescribers, members and pharmacies that may indicate high risk behaviors in transaction activities.  Some of those behaviors that could be found in data mining are:

• Member use of multiple prescribers
• Member use of multiple pharmacies
• High percentage of controlled substances
• High percentage of drugs frequently associated with FWA schemes
• Number of rejections for specific rejection codes
• Number of prescriptions per member
• Number of members, pharmacies and/or prescribers associated with the target

Claims will be monitored monthly and a report will be submitted during a timeframe agreeable to both parties. These reports will provide baseline data to recognize trends that may be unusual such as drug utilization and prescription ordering patterns. Any potential errors, inaccurate billing practices and activities may pose a higher risk for fraud, waste and abuse.

Alliance also has contracted with ZeOmega to provide predictive analytics for misuse of opioids, which will identify members most at risk for potential misuse of opioids. This will assist with identifying members who need case management prioritization, higher risk of potential abuse of opioids and provide artificial intelligence (AI) to identify those who are at higher risk of overdose and provide messaging to the care manager to complete an assessment which may trigger a care plan.

As the opioid epidemic continues to be a public health crisis, medical providers play a crucial role in safe opioid use. The risk of addiction, overdose and death are increased when opioids are prescribed at higher doses, in extended-release forms or combined with another central nervous system (CNS) depressant. Safe opioid prescribing plays an important role in stopping the opioid overdose epidemic. As a behavioral health network, Alliance contributes to safer opioid prescribing by educating its providers and promoting access to naloxone and using letters of health and safety consideration (LOHSC) to alert providers if a member obtains opioids from multiple providers, takes high doses of opioids or combines opioids with benzodiazepines or other CNS depressants. Alliance also uses the emergency case escalation process to elevate health concerns to the medical team. As Alliance broadens its network to include management of medical and pharmacy services, Alliance is committed to ensuring that its policies are aligned with the NC Strengthen Opioid Misuse Prevention (STOP) Act and promote safe opioid prescribing. Alliance has planned interventions at the member, provider and system level.

Member Level

• Communicate age-appropriate education on risk of opioid misuse and pain management/substance misuse, use of naloxone, safe storage and disposal, risk of unintentional overdose. This information will be included in the Member Handbook, Innovations Member and Family Handbook and Traumatic Brain Injury (TBI) Handbook.
• Implement a PHP lock-in program as defined in NC Gen. Stat. § 108A-68.2 that requires selection of 1 prescriber and 1 pharmacy for prescription of controlled substances
• Maintain and expand public education efforts such as the Allianceforaction.org website, and community training and education events
• Use PBM adherence reporting products (first-fill reporting, primary medication reporting, etc.) to identify members who are prescribed opioids and would benefit from close care management
• Implement processes for using Navitus Drug Utilization Review products, including:
  • Concurrent Drug Utilization Review (CDUR) Program, which offers many ways to alert pharmacies to potential opioid abuse at the point of sale, such as the High Cumulative Dose edit, Concurrent Use of Opioids and Benzodiazepines edit, Long-acting Opioid Duplicate Therapy edit, Opioid Prenatal edit and the Buprenorphine Therapeutic Duplication edit
  • Retrospective Drug Utilization Review (RDUR) Safety-Focused Program, which includes mailed interventions with patient profiles that alert prescribers to cases of possible misuse or abuse. These include controlled substance monitoring, multi-prescriber, multi-prescription, morphine milligram equivalent, triple-threat, duplicate therapy, and expanded fraud, waste and abuse.
• Leverage primary care team patient relationships to negotiate behavioral changes and refer to treatment

Provider Level

• Alliance will establish and provide training on prescribing guidelines, including maximum morphine milligram equivalent dosage limits. Educate providers on best practices in chronic opioid therapy with the use of opioid risk tools, pain management agreements, urine drug screens, function-based pain rating scales such as the Defense and Veterans Pain Rating Scale, co-prescribing naloxone to members at high risk, tapering protocols and timely referrals to specialists.
• Focused outreach and educational interventions with high-opioid prescribers. Alliance will work with its PBM, Navitus, to continuously monitor opioid prescriptions and identify high opioid prescribers. The medical team will develop plans for targeted communication, outreach, education and technical assistance with identified prescribers.
• PBM (Navitus) will provide to Alliance an opioid-focused prescriber Insights report as part of the Prospective Drug Utilization Review (DUR) program. This quarterly report helps prescribers understand their prescribing habits and displays peer-to-peer comparisons
• Promote NC Governors Institute website and other provider education materials
• Encourage using essential safety information provided by the FDA Risk Evaluation and Mitigation Strategy (REMS) for Opioid Analgesics

System Level

• Alliance will align utilization management strategy and formulary policies with the NC Stop Act and work with its PBM to implement:
  • Short acting opioid quantity limits and daily dose and days supply maximum limits for new starts consistent with opioid safety criteria/prior approval criteria for opioid analgesics
  • Long-acting opioids: Implement formulary dose limits and days supply limits, requiring prior trial within 45 days of short-acting opioids and moderate to severe pain requiring around the clock analgesia with prompt authorization review, including the diagnosis to manage exceptions.
  • Limit the use of long-acting/extended-release opioids for treatment of acute pain per the prior approval criteria for long-acting opioid analgesics
  • Limit the use of methadone as a treatment for acute pain per the prior approval criteria for long-acting opioid analgesics
  • Prescribe the lowest effective dosage
  • Limit concurrent prescriptions for opioids and benzodiazepines by creating an edit in pharmacy claim processing system mirroring that currently in NCTracks which will deny an opioid or benzodiazepine claim when it is determined that there is overlapping use of a different opioid or benzodiazepine within the previous 68 days.
  • Promote co-prescribing of naloxone

Management of pain is one of the oldest medical challenges. The intertwined issue of opioid pain management and the risks of opioid use and misuse requires a balanced approach. Alliance is committed to providing access to comprehensive biopsychosocial pain treatment. To reduce use and minimize misuse of opioids, Alliance will promote evidence-based therapies and adherence to Centers for Disease Control (CDC), American Academy of Pain Medicine AAPM, American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) guidelines. As Alliance expands its Medical Team to include physical health and pain management experts, Alliance will work on the following strategies:

• Promote use of non-opioid medications first
• Cover a range of evidence-supported non-pharmacologic pain treatment options such as exercise, massage, acupuncture, spinal manipulations and physical therapy in line with the state benefit plan
• Before initiating opioids, establish treatment goals with patient
• Reevaluate risk and benefits often, taper or discontinue opiates when indicated
• Promote urine drug screen (UDS) as a risk mitigation tool. UDS can be used for compliance/diversion monitoring and identification of concurrent use of CNS depressants or other drugs
• Collaborate with Standard Plan carrier WellCare of North Carolina, Inc. on pain management program in pregnancy, cancer, palliative care and transplant patients
• Alliance will align its PBM, Navitus to be consistent with CDC guidelines and prior approval criteria for opioid analgesics in pain treatment in addition to implemented DMA Opioid Safety Criteria
• Develop multi-modal and interdisciplinary pain management programs
• Increasing awareness of psychological component of pain and timely referral to psychological treatment
• Pain management in children and adolescents
• Address needs and coordinate services for members with intellectual/developmental disability (I/DD) and TBI

Actions Taken to Date

Early detection of opioid misuse can help stop the progression from misuse of opioids to the development of an opioid use disorder. Opioid misuse is highly stigmatized, which can be a barrier to reporting, especially for pregnant women. Through the use of systems-level interventions that promote screening at multiple points of contact and practices such as Screening, Brief Intervention and Referral to Treatment (SBIRT), Alliance has worked to increase early identification of opioid misuse. Alliance’s past efforts have included partnerships with WakeMed and Duke Hospital to provide SBIRT interventions for individuals with opioid use disorders and to initiate medication-assisted treatment(MAT) and/or refer to outpatient MAT, with the assistance of peer support specialists. Part of this support includes access to medications for opioid use disorder, low-threshold access to community treatment, and access to harm reduction supports such as naloxone.

Planned Implementation Steps and Timeframes

In addition to maintaining its partnership with behavioral health providers, Alliance plans to partner with medical providers and practices, community health organizations and pediatric practices to expand implementation of SBIRT. Alliance will promote SBIRT as a standard practice in all clinical settings by increasing awareness, offering educational resources and providing reimbursement (H0049 and H0050). Alliance will also advance utilization of objective screening methods (UDS) and tools (Opioid Risk Tool [ORT], Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] for adults and Brief Screener for Tobacco, Alcohol and other Drugs (BSTAD), Screening to Brief Intervention (S2BI) and Community Reinforcement and Family Training (CRAFT) for adolescents) for early detection of use and misuse of substances. Across settings, Alliance will encourage family involvement when possible to provide ancillary information, strengthen support and improve communication.

Alliance will continue exploring various funding options for developing a workforce of peer support specialists and integrating them into emergency departments, crisis centers and criminal justice system settings. They can serve as a supportive first point of contact for those using opiates and assist them in engagement in treatment.

Alliance also plans to use a data analytic process to identify individuals who may be misusing opiates or who are at risk. This process will use the Jiva 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 care management entities (Alliance) to engage members with targeted interventions to mitigate identified risks.

Actions Taken to Date

Alliance has worked collaboratively with local health departments, community opioid prevention coalitions, the State Opioid and Prescription Drug Abuse Committee, the NC Harm Reduction Coalition, post-overdose response teams, peer supports and syringe services programs (SSPs) to promote efforts that minimize harm associated with opioid use. Alliance has been very involved with promotion of naloxone. In 2017, Alliance purchased $100,000 of naloxone and distributed it through the Harm Reduction Coalition (HRC). Subsequently, Alliance received a large supply of naloxone (400+ kits). HRC also assisted in the distribution of those kits, including hosting a naloxone kit making party which was well attended by Alliance staff before HRC took the kits for distribution. Over the past 3 years, Alliance has been collaborating with the state which fulfills the naloxone requests obtained through Alliance staff solicitation from community organizations in need of naloxone. These organizations included Alliance crisis facilities, Office-Based Opioid Treatment (OBOT) pilot sites, Healing Transitions and even a Duke Buprenorphine Emergency Department Initiation Pilot. In addition, Alliance has worked with its single county, Cumberland, that was not distributing naloxone through the health department to obtain start-up funding and then supported Cumberland through the naloxone dispensing and distribution process through its health department pharmacy.

Pharmacist awareness of the importance of naloxone and participation in the standing order is critical. The Alliance pharmacist has worked with NC Association of Pharmacists to improve pharmacist awareness and understanding of the need for naloxone through the creation of continuing education videos and live continuing education programs since 2016.  Alliance has also collaborated with the NC Association of Pharmacists student Opioid Stewardship program whereby students do brief educational interventions with community pharmacists in the retail setting to educate the pharmacists on harm reduction strategies including syringe exchange/selling syringes and naloxone and the standing order and encouraging participation. This program was interrupted by the pandemic and plans to resume.

Planned Implementation Steps and Timeframes

Alliance will continue to leverage the accessibility of the pharmacy to help improve access to naloxone available through the standing order, and support pharmacies’ role as accessible harm reduction partners by directing those without insurance and needing naloxone to free naloxone sources such as the local health department or harm reduction coalition (if eligible).  Local partners such as pharmacy students with NC Association of Pharmacists, and others in the process of being identified such as the Community Pharmacy Enhanced Services Network (CPESN), can help Alliance educate more pharmacies to be harm reduction/naloxone partners. In addition, Alliance’s geo mapping will help to identify those pharmacies serving its members, especially high-risk members. Having access to naloxone claims could further help Alliance identify pharmacies’ naloxone volume in high-risk areas/serving more high- risk members to be targeted for educational interventions.

While naloxone prescription claims might be helpful, much of the naloxone distribution occurs with grant funded naloxone that is not trackable through prescription claims (currently scrubbed from Alliance data claims) so regular communication with Alliance’s community health organizations is also essential. This communication is facilitated through Alliance’s Substance Use Disorder (SUD) Collaborative and the Alliance Provider Quality’s monthly meeting with provider agencies and the work of Practice Outreach Specialists. The latter department is recruiting form the current 1 staff to at least 7.

Alliance will continue to promote the Naloxone Saves website and its materials provided. This will help direct the public to get naloxone from pharmacies in North Carolina, especially if they have insurance, and from health departments if they do not. Alliance will promote the Naloxone Saves website through multiple channels such as the Alliance for Action website and social media. With Alliance’s anticipated expanded catchment area, Alliance will need to check on the new catchment areas local health departments’ role in naloxone distribution and encourage their increased involvement.

With the Alliance for Action website and excellent communication team, Alliance will use the Prescription Drug Overdose Prevention Messaging and Marketing Toolkit (source: NC Injury and Violence Prevention Branch, NC DHHS) to engage acute and chronic pain patients and their support systems in overdose prevention which also includes the critical role of naloxone.

Actions Taken to Date

Alliance has taken multiple steps over the past 5 years to expand access to SUD treatment, with an emphasis on improving access to treatment for opioid use disorder. Alliance has used multiple approaches to improving access, including:

• Development of network Opioid Treatment Program (OTP) capacity. Since 2016, Alliance has added contracts for OTP providers in each county, expanding from a single provider in Durham and Wake counties to a total of 8 providers covering Alliance’s 4 counties. This expansion has included contracts for Medicaid and state-funded services, the latter using Federal State Targeted Response and State Opioid Response grant funds.
• Addition of Office-Based Opioid Treatment to network array. In response to limited availability of OTP providers, Alliance developed a Medicaid service definition modifier with an enhanced reimbursement rate and opened this service to new network providers. This service remains open to new providers of this service. Alliance has also piloted 2 state-funded OBOT programs and developed processes to reimburse lab testing costs and to purchase MAT medication to support these programs.
• Implementation of MAT in correctional and hospital emergency department (ED) settings. Alliance has collaborated with the Durham Detention Center, Duke and WakeMed hospitals, and community providers to provide and initiate MAT within these settings. Alliance’s objective is to support MAT initiation within multiple access points within the community, and each of these projects has included systems coordination efforts that require partnership between multiple community stakeholders and providers to improve timely access to treatment.
• Promotion of low-threshold access to treatment. Efforts to reduce barriers to initiation and engagement in treatment include removal of prior authorization requirements for MAT, assistance of peer supports in transition between providers and levels of care, and provider education and technical assistance. Alliance has also collaborated with Duke Hospital to assist with treatment engagement for individuals who are receiving inpatient medical care for conditions such as infectious endocarditis that are associated with IV drug use.
• Increased awareness of opioid treatment resources. Alliance has created a listing of MAT programs (OBOT and OTP) in the Alliance catchment area. This list includes the medications offered in OTPs, hours of operation, intake days, days from intake to first dose, insurances accepted, self-pay costs, program requirements as well if transportation is offered. This document will be housed on the Alliance for Action website and the link shared with community partners such as local overdose prevention coalitions, emergency departments, crisis facilities, harm reduction coalitions etc. This list will be updated regularly. This document will also reference the Atlas Treatment Locator (source: Shatterproof) which is being built with the intention to provide information about program quality and assist with comparisons of treatment programs.

Planned Implementation Steps and Timeframes

As a Tailored Plan, Alliance will have an opportunity to expand the breadth of its provider network and its capacity to identify and initiate treatment for individuals with opioid use disorders. Alliance’s network development efforts will include education of providers about SBIRT, opioid treatment resources and elements of this plan, and Alliance plans to develop targeted provider outreach initiatives to medical providers that have a higher volume of contacts with members who have opioid use disorders.

One important network enhancement will be the identification of OBOT providers who are not currently enrolled in the LME-MCO network. Since Alliance’s current OBOT contracts are with psychiatrists only, Alliance will be adding OBOT programs that have non-psychiatrist prescribers, which is expected to increase its network capacity for this service in all counties. Alliance plans to survey these providers to gather information about their services, capacity, treatment approach and other information that will be used to assist with referrals and system navigation. Alliance will also invite new OBOT providers to participate in provider meetings and collaboratives that promote evidence-based treatment approaches and effective treatment access and engagement.

Alliance plans to expand its collaboration with hospitals and medical practices that provide treatment for medical comorbidities of IV drug use such as infectious endocarditis, hepatitis, HIV and other conditions. These efforts will include streamlining treatment referrals and supporting low threshold access to care to improve engagement in opioid treatment.

Alliance also plans to maintain and expand system-level interventions such as add systemic interventions such as initiation of MAT in hospital ED and correctional settings. Alliance’s next steps for the Durham Detention Center are to support its plans to move from phase 1 (continuation of MAT for those who were receiving treatment before arrest) to the second phase, in which individuals with opioid use disorder may begin treatment in the jail setting. This is one of the first of its kind in North Carolina, and Alliance believes its experience will be helpful in planning for future implementation of MAT in other correctional settings.

Finally, Alliance has recognized a gap in adolescent treatment options within its provider network and will work to contract with providers to mitigate the gap. This gap is not unique to opioid use disorder, but represents a broader gap for adolescent SUD services in general. Alliance plans to gather additional information in the upcoming year to increase its understanding of service capacity and access barriers for adolescents who would benefit from adolescent SUD services.

Actions Taken to Date

Alliance has been very involved with promotion of naloxone.  In 2017, Alliance purchased $100,000 of naloxone and distributed through the Harm Reduction Coalition (HRC).  Subsequently, Alliance received a large supply of naloxone (400+ kits). HRC also assisted in the distribution of those kits, including hosting a naloxone kit making party which was well attended by Alliance staff before HRC took the kits for distribution.  Over the past 3 years, Alliance has been collaborating with the state which fulfills the naloxone requests obtained through Alliance staff solicitation from community organizations in need of naloxone.  These organizations included Alliance’s crisis facilities, OBOT pilot sites, Healing Transitions and even a Duke Buprenorphine Emergency Department Initiation Pilot. In addition, Alliance has worked with its one single, Cumberland, that was not distributing naloxone through the health department to obtain start-up funding and then supported Cumberland through the naloxone dispensing and distribution process through its health department pharmacy.

Pharmacist awareness of the importance of naloxone and participation in the standing order is critical. The Alliance pharmacist has worked with NC Association of Pharmacists to improve pharmacist awareness and understanding of the need for naloxone through the creation of continuing education videos and live continuing education programs since 2016.  Alliance has also collaborated with the NC Association of Pharmacists student Opioid Stewardship program whereby students do brief educational interventions with community pharmacists in the retail setting to educate the pharmacists on harm reduction strategies including syringe exchange/selling syringes and naloxone and the standing order and encouraging participation. This program was interrupted by the pandemic and plans to resume.

Planned Implementation Steps and Timeframes  

Alliance will continue to leverage the accessibility of the pharmacy to help improve access to naloxone available through the standing order, and support pharmacies’ role as accessible harm reduction partners by directing those without insurance and needing naloxone to free naloxone sources such as the local health department or harm reduction coalition (if eligible).  Local partners such as pharmacy students with NC Association of Pharmacists, and others in the process of being identified such as the Community Pharmacy Enhanced Services Network (CPESN), can help Alliance educate more pharmacies to be harm reduction/naloxone partners. In addition, Alliance’s geo mapping will help us identify those pharmacies serving its members, especially high-risk members. Having access to naloxone claims could further help Alliance identify pharmacies’ naloxone volume in high-risk areas/serving more high-risk members to be targeted for educational interventions.

While naloxone prescription claims might be helpful, much of the naloxone distribution occurs with grant funded naloxone that is not trackable through prescription claims (currently scrubbed from Alliance data claims) so regular communication with Alliance’s community health organizations is also essential. This communication is facilitated through Alliance’s SUD Collaborative and the Alliance Provider Quality’s monthly meeting with provider agencies and the work of Practice Outreach Specialists.; the latter department is recruiting form the current 1 staff to at least 7.

Alliance will continue to promote the Naloxone Saves website and its materials provided; this will help direct the public to get naloxone from pharmacies in North Carolina, especially if they have insurance, and from health departments if they do not. Alliance will promote the Naloxone Saves website through multiple channels such as the Alliance for Action website and social media. With Alliance’s anticipated expanded catchment area, Alliance will need to check on the new catchment areas local health departments’ role in naloxone distribution and encourage their increased involvement.

With the Alliance for Action website and excellent communication team, Alliance will use the Prescription Drug Overdose Prevention Messaging and Marketing Toolkit to engage acute and chronic pain patients and their support systems in overdose prevention which also includes the critical role of naloxone.

Actions Taken to Date

Alliance is committed to continued access to care related to treatment of substance use issues, including opioid use. As an initial response to the COVID-19 pandemic, Alliance added additional codes reflecting telehealth modifiers to all providers’ contracts for services that could be delivered by telehealth or telephonic delivery methods. In doing so, it allowed a possible gap to be bridged when face-to-face delivery was not possible, or when group services were not permitted. Alliance will work to ensure that these codes are maintained in the provider contracts post-pandemic for substance specific services, such as Substance Abuse Intensive Outpatient Program (SAIOP), Substance Abuse Comprehensive Outpatient Treatment (SACOT), Outpatient Therapy (OPT) individual and group services, so that providers can continue to request authorization and submit claims for these services.

Planned Implementation Steps and Timeframes

In an effort to ensure that these telehealth services can continue to effectively meet the needs of its members, Alliance will review available treatment models and evidence based guidelines for telehealth services for Substance Use Disorders.  Alliance will publish the best practice guidelines on its “For Providers” Resource page, and publishing key elements in its “For Members” section. In addition to the information updated to its website, Alliance will also reach out to providers to increase awareness of these best practice guidelines through Provider News, and including special discussion topics in the Substance Use Disorder and Opioid Use Disorder Provider Collaborative meetings related to these guidelines.

Further, Alliance will use survey, discussion during the aforementioned Provider Collaborative meetings, and routine/targeted monitoring efforts to review telehealth service delivery to ensure HIPAA compliance and feasibility. Provider surveys and discussion in collaborative meetings can assist in gathering information related to clinical and cost effectiveness, by having providers examine cost measures for pre-telehealth and post-telehealth implementation.  Program metrics related to telehealth will be established to review potential markers such as engagement in services, member satisfaction (determined by member survey), admission/readmission to hospital/detox/crisis services or change to higher level of care for members receiving telehealth services versus traditional office/face-to-face services. Monitoring can also review Urine Drug Screen tests, HEDIS measure performance and goal achievement/progress on Person Centered Plans (PCPs).

Finally, with the ongoing availability of telehealth services, Alliance will continue to complete network adequacy reviews. These reviews will help Alliance clearly maintain an understanding of service availability and capacity for its entire service area. With the current review for expansion of OBOT, continued telehealth options will allow more individuals to readily access care as needed and when office-based care is not always an option.

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.

Quality Measurement

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.