Individuals who are dually eligible for Medicare and Medicaid have high rates of chronic illness: 60 percent have three or more chronic conditions, and 41 percent have at least one mental health diagnosis.[i] This may make them particularly vulnerable to opioid addiction or misuse. The prevalence of co-occurring substance use disorder (SUD) and chronic pain is twice as high among dually eligible individuals as compared to individuals with Medicare-only and about six times higher relative to Medicaid-only adults with disabilities.[ii] Health plans serving dually eligible individuals are seeking ways to improve access to SUD treatment and supports for their enrollees.
One such plan is UCare, an independent, not-for-profit health plan, serving over 400,000 individuals in Minnesota and western Wisconsin through Medicare and Medicaid as well as through MNsure, Minnesota’s public insurance marketplace. UCare offers two products specifically for dually eligible beneficiaries in Minnesota — UCare’s Minnesota Senior Health Options for beneficiaries age 65 and older, and UCare Connect + Medicare for beneficiaries younger than age 65 who have a disability. Together these plans enroll more than 16,000 people.
UCare is based in Minneapolis, which is located in Hennepin County. Like many parts of the U.S., Hennepin County has seen a dramatic rise in opioid use.[iii] Hennepin County’s Health and Human Services Department (referenced in this profile as Hennepin County) operates the county’s only non-private detoxification center. This case study, made possible by The Commonwealth Fund, describes a partnership between UCare and Hennepin County to improve access to community-based treatment for individuals with SUD by modernizing the county’s detoxification services to a person-centered withdrawal management services model.[iv]
Impetus for the Program
The partnership between UCare and Hennepin County developed at a time when Minnesota was planning a new approach to SUD treatment. Although the state has a long-standing Medicaid waiver to combine federal and state funding into a Consolidated Chemical Dependency Treatment Fund,[v] it sought to further streamline access to a continuum of care. Based on extensive stakeholder engagement, the state proposed a series of recommendations to expand access to SUD treatment, including withdrawal management, which was passed by the legislature in 2017.[vi] One of those recommendations is a Medicaid 1115 waiver demonstration, approved by the Centers for Medicare & Medicaid Services in June 2019, which will allow participating residential Institutions for Mental Disease (IMD) providers to bill Medicaid for a portion of services.[vii]
While the state was working to make detoxification services a Medicaid benefit, Hennepin County approached local health plans to make the case for plan investment by demonstrating that they were spending money on avoidable emergency department (ED) visits and hospital stays for members whose detoxification needs could be met in an outpatient setting. Because of its own commitment to improving SUD treatment for its members, UCare decided to partner with Hennepin County. UCare provided a grant to Hennepin Healthcare to embed Licensed Alcohol and Drug Counselors in the ED (see Treating Individuals with SUD in the Most Appropriate Setting, page 3). In addition, along with other plans that contributed varying amounts, UCare gave Hennepin County $200,000 in grant funding, effective January 1, 2018, to support the development of withdrawal management services at Hennepin County’s downtown Minneapolis location at 1800 Chicago Avenue.
The goal of this new endeavor was to provide more person-centered, coordinated withdrawal management services to reduce ED visits and other high-cost crisis service use. Hennepin County sought to achieve this goal by reframing SUD as a chronic condition and better connecting members with necessary medical care as well as community-based services for their behavioral health and social service needs.
Hennepin County identified two major systems issues that would need to be addressed to achieve its goal. First, Hennepin County wanted to change its approach to detoxification services. Similar to many other programs across the country, SUD-related intoxication was viewed as an acute event, as opposed to part of a chronic illness requiring long-term treatment. Moreover, individuals were often taken to the facility involuntarily and then restrained or placed in seclusion while undergoing treatment.
Second, although Hennepin County had a service-rich environment, services for individuals with mental illness and chemical dependency were fragmented across different providers and funding sources. For example, the state’s Consolidated Chemical Dependency Treatment Fund did not cover detoxification/ withdrawal management services, which were funded by the counties. This meant that, at a systems level, the state, the Medicaid plans, and the counties had little knowledge of who was being treated, when, or by whom. Providers, health plans, and their care managers did not have a holistic view of their patients’ care and did not know if the services they were providing were helping their patients toward recovery.
Key Program Elements
Key elements of the program that Hennepin County proposed to UCare include: (1) building the staffing model needed to provide medically monitored withdrawal management services; (2) making physical renovations to the 1800 Chicago Avenue location to provide services in a more person-centered and dignified setting; and (3) bringing in additional services to provide a continuum of care in one location.
Building the Staffing Model
In the program, Hennepin County sought to provide services to satisfy the American Society of Addiction Medicine’s (ASAM) criteria for Level 3.7 Medically Monitored Inpatient Withdrawal Management[viii] as well as Minnesota state statute 245f, which instituted withdrawal management reform. To do so, it must provide:[ix]
- A comprehensive substance use assessment;[x]
- A health assessment with consultation by a qualified medical professional, if medically necessary;
- On-site monitoring, seven days a week by a qualified medical professional;
- Medication administration;
- 24-hour a day nursing care, including daily medical evaluation;
- Treatment coordination;
- Individual and group therapy; and
- Peer recovery support services.
To add new or expand existing services to meet these guidelines, Hennepin County used its grant funding from UCare to hire 1.5 FTE registered nurses, 0.75 FTE peer support workers, and 0.10 FTE program administrators to supplement the detoxification center’s existing staff. In addition, it arranged for medical residents to conduct daily rounds under the supervision of the center’s medical director. The center’s leadership noted the high demand for individuals with skills in treating SUD made it difficult to find and retain qualified people to staff the program.
Making Physical Renovations
Hennepin County staff believed that the detoxification center’s 1800 Chicago Avenue location was the ideal place to provide not just withdrawal management services, but also a variety of other community-based services.[xi] It is near hospitals, public safety, Social Security Administration offices, homeless shelter services, and is on the bus route. Many of the center’s potential patients have reason to frequent the area on a regular basis.
However, despite its excellent location, the center’s physical layout was unwelcoming. Individuals who could benefit from its services were likely reluctant to enter both because of the stigma associated with being seen entering the detoxification center and its institutional atmosphere. Historically, detoxification facilities had the look and feel of detention centers. Also, due to limited funding, budgets focused on operations not aesthetics.
Hennepin County renovated the 1800 Chicago Avenue location in 2018, redesigning the space to convey respect and dignity and creating a comfortable and welcoming atmosphere. A new single entryway allows individuals seeking withdrawal management services to use the same door as people coming to the building to receive other health care and community services. The redesigned treatment space includes conference and group rooms, a lunchroom, and lounges decorated with pictures and books. It has 65 beds — 47 for men and 18 for women — that are more comfortable and less institutional.
Bringing in Additional Services
Another key element of the program was to provide patients with a wider array of services to support treatment and recovery. Detoxification services at 1800 Chicago Avenue were redesigned to use evidence-based behavior change models. Services now include peer recovery support and care coordination, including comprehensive discharge planning to facilitate placement in the least intensive community-based environment.[xii] Practices involving restraint or seclusion have been discontinued. Of note, when UCare and Hennepin began their partnership, peer services and care coordination were provided through county programs. Now that Level 3.7 Medically Monitored Inpatient Withdrawal Management (as described above) has been added to Minnesota’s Medicaid benefit set, peer services and care coordination will be funded through Medicaid, which will allow Hennepin County to expand the array of supportive services it provides.
Individuals now also receive a health assessment completed by a registered nurse, daily physician visits, a comprehensive substance use assessment, and a care plan with daily assessment of their progress. In addition, the center offers services onsite to address patients’ medical and social needs, including:
- A Special Care Unit for people in immediate need of detoxification services, those at-risk of an overdose, and those who will need to enter the criminal justice system;
- Social services, including vocational, case management, housing and income support, SNAP, etc.; and
- A 12-bed mental health crisis stabilization unit.
Through the use of these services, Hennepin County seeks to implement comprehensive care plans that holistically address patients’ needs including social risk factors.
UCare’s overall goal for its partnership with Hennepin County was to reduce the use of acute care services (i.e., ED visits and inpatient admissions/readmissions, crisis services) for its members with SUD. UCare anticipated that it would have access to data showing which of its members:
- Received withdrawal management services (and used these services more than once);
- Used care management services;
- Followed through on referrals to community-based treatment; and
- Obtained housing services.
UCare planned to analyze this data to measure any change in its members’ service use and cost of care.
As the program launched, UCare encountered a challenge with obtaining the data it needed to analyze the results. Because withdrawal management services were not covered by Medicaid at that point, Hennepin County’s detoxification center could not enroll as a Medicaid provider, and thus could not access the Minnesota Department of Human Service information system to verify patients’ insurance coverage. It did try to obtain this information by patient self-report, but acknowledged that it may not be fully accurate. As a result, UCare was not able to obtain data from Hennepin County that would allow it to evaluate the effectiveness of the program in changing the utilization patterns of UCare members with SUD.
Despite the lack of data specific to UCare members, Hennepin County reported that between January and December 2018, it provided withdrawal management services to 1,908 unique individuals. By its own estimate, approximately one-third were UCare members.
The withdrawal management services program has had notable impacts on the experiences of individuals in accessing care. Hennepin County has seen an increase in the number of people self-referring for treatment, whereas previously most people receiving detoxification services were referred by the police or by hospitals. Program staff credit this increase to the more welcoming environment of the renovated facility. Also, program staff noted that the use of physical restraints and seclusion rooms has been essentially eliminated with the change in culture and focus on providing person-centered care. Before implementation of the program, approximately 20 percent of patients were restrained or placed in seclusion. Now less than one percent require these measures.[xiii]
Hennepin County surveys patients receiving withdrawal management services and reports that 87.5 percent respond favorably about the overall value of the services they received. The county also conducts patient focus groups. Participants in these groups report an appreciation for the dignified environment, person-centered approaches to care, and staff efforts to coordinate care following discharge from the withdrawal management program. Participants agree that the program and its staff are actually providing helpful support, rather than simply “processing” people through a revolving door. They noted the transformation from a locked facility with a prescribed length of stay to a facility that identifies individual needs and provides hope.
In evaluating program results, UCare found that from 2018 to the first five months of 2019, the number of inpatient admissions for SUD and mental health-related diagnoses declined, while the rate of residential SUD treatment stays increased. This shift in utilization could be due to positive effects from the withdrawal management services program.
Hennepin County continues to build on its withdrawal management services program. In a major step forward, it used state grant funding to contract with the Kai Shin Clinic to offer medication for addiction treatment at the 1800 Chicago Avenue location.[xiv] Using Kai Shin’s physicians and physician assistants, patients can now begin receiving Suboxone while at the facility and then obtain a referral for ongoing treatment in the community.
UCare and Hennepin County’s experiences in implementing the withdrawal management services program offer insights that may be helpful to other health plans seeking to implement similar projects with public sector partners.
1. Determine Data Availability and Establish Data Sharing Agreements
In creating the withdrawal management services program, both UCare and Hennepin County were responding to an urgent community need. Their priority was to get the program launched so that it could begin providing services. The inclusion of withdrawal management services as a state Medicaid benefit was anticipated and would have facilitated access to utilization data, but federal approval was delayed. UCare staff agree that, if data were available, they would have established data-sharing agreements to ensure that they could evaluate the grant program’s effectiveness; however, given the critical need for the services in question, they decided to move forward knowing that they would not be able to access the data they wanted.
2. Offer a Continuum of Person-Centered Services in a Single Location
A significant contributor to the early success of the withdrawal management services program is that it offers a continuum of services in a single location. By moving from an acute care-focused detoxification model to a chronic care withdrawal management services model, the program was able to bring a continuum of medical, behavioral, and recovery services into a single location. This was beneficial in reducing or eliminating time lag between referral to services and a face-to-face meeting with the service provider, which increased the rate at which individuals with SUD actually engage in treatment. This is especially true now that medication for addiction treatment can begin onsite.
In addition, renovations to the physical space and a change in program culture created an environment where individuals felt more welcome and respected. This has increased the willingness of individuals with SUD to seek treatment.
3. Examine the Business Case for Pooled Funding
Hennepin County’s efforts to create the withdrawal management service program show the importance of making the business case for pooled funding across different public and private entities to solve shared problems. By demonstrating to health plans the potential cost savings of providing treatment at the right time in the right location, Hennepin County was able to achieve important public health gains and reduce costs for health plans — a “win-win” proposition. No one health plan likely would have developed this type of service on its own, but pooling funds created new flexibilities and opportunities that benefit all.
Conclusion and Next Steps
UCare and Hennepin County partnered to improve access to community-based treatment for individuals with SUD by modernizing the county’s detoxification services program. With support from UCare, Hennepin County developed a withdrawal management services model by: (1) adding more staff with new skills; (2) making physical renovations to its treatment facility; and (3) bringing in more medical, behavioral health, and social services to one central location. Although quantitative data are limited, the program shows an early trend toward reduced use of SUD-related acute care services and a favorable perception of the program by participants.
Given these positive results, UCare continues to invest in efforts to improve SUD treatment access. It has offered Hennepin Healthcare additional funding to sustain the use of LADCs in its ED while efforts are underway to make this a billable Medicaid service. UCare is also offering small grants to other Minnesota counties to help them get staff credentialed to administer the new comprehensive substance use assessments required by Minnesota Medicaid for individuals to access SUD treatment. The plan is also funding a project with Hennepin Healthcare to train ED physicians to prescribe medication for addiction treatment.
At a time when SUD is a major public health emergency, UCare’s successful partnership with Hennepin County could be a model for health plans, public entities, and other stakeholders to take positive steps to address this issue.