#1OF NORTH GREAT SEAL O THE STATE MAY 20. 1775 THE APRIL 12 1776 ✰ ESSE QUAM VIDERI⭑ CAROLINA The Current and Future State of Behavioral Health in North Carolina Kody Kinsley, Deputy Secretary for Behavioral Health & IDD October 23, 2019#2Overview of Medicaid Managed Care The goal of managed care is to improve the health of North Carolinians through an innovative, whole-person centered, and well-coordinated system of care. NC Medicaid providers will contract with and be reimbursed by prepaid health plans (PHPs) rather than the State directly ✓ Three types of products: ✓ Standard Plans for most Medicaid and NC Health Choice beneficiaries; scheduled to launch in February 2020 ✓ BH I/DD Tailored Plans for qualifying high-need populations with a serious mental illness, serious emotional disturbance, substance use disorder, I/DD, or traumatic brain injury; tentatively scheduled to launch in July 2021 Statewide Foster Care Plan for children in foster care; tentatively scheduled to launch shortly after the launch of BH I/DD Tailored Plans (more information is forthcoming) All three types of products will offer a robust set of behavioral health benefits; however, certain more intensive behavioral health benefits will only be available through BH I/DD Tailored Plans Continued focus on high-quality, local care management in all three types of products#3Draft Timeline for BH I/DD Tailored Plan Until early 2020, DHHS will be conducting intensive planning for both Standard Plans and BH I/DD Tailored Plans. After Standard Plans launch, DHHS will continue implementation planning for BH I/DD Tailored Plans. Aug. 2018 DHHS releases SP RFP Feb. 2019 BH I/DD Tailored Plan design (8/2018-2/2020) SP implementation planning (8/2018-2/2020) Feb. 2020 May Feb. April July 2020 2021 2021 2021 BH I/DD Tailored Plan implementation planning (2/2020-7/2021) DHHS begins BH I/DD Tailored Plan readiness review (tentative) BH I/DD Tailored Plans launch (tentative) DHHS issues SP contracts SPs launch DHHS awards BH DHHS releases BH I/DD 1/DD Tailored Plan Tailored Plan RFA contracts (tentative) DHHS completes BH I/DD Tailored Plan readiness review (tentative)#4Standard Plans for NC Managed Care Statewide Contracts: ✓ AmeriHealth Caritas North Carolina, Inc. ✓ Blue Cross and Blue Shield of North Carolina, Inc. ✓ United Healthcare of North Carolina, Inc. ✓ WellCare of North Carolina, Inc. Regional Contracts: Regions 3, 4*& 5: ✓ Carolina Complete Health, Inc.#5Standard Plan Regions REGION 1 GRAHAM MITCHELL YANCEY MADISON AVERY REGION 2 ALLEGHANY ASHE SURRY STOKES ROCKINGHAM ☐ WATAUGA WILKES YADKIN FORSYTH GUILFORD CALDWELL ALEXANDER BURKE CATAWBA MCDOWELL BUNCOMBE HAYWOOD SWAIN CHEROKEE MACON CLAY JACKSON HENDERSON POLK TRANSYLVANIA RUTHERFORD LINCOLN IREDELL DAVIE ROWAN REGION 4 CASWELL PERSON ALAMANCE ORANGE DURHAM GRANVILLE DAVIDSON WAKE CHATHAM RANDOLPH CABARRUS STANLY CLEVELAND GASTON MECKLENBURG REGION 3 MOORE MONTGOMERY LEE HARNETT VANCE WARREN HALIFAX REGION 6 NORTHAMPTON HERTFORD GATES CURRITUCK CAMDEN PASQUOTANK PERQUIMANS FRANKLIN BERTIE NASH EDGECOMBE MARTIN WASHINGTON TYRRELL DARE JOHNSTON CUMBERLAND SAMPSON RICHMOND HOKE UNION ANSON SCOTLAND ROBESON BLADEN REGION 5 COLUMBUS WILSON WAYNE BRUNSWICK GREENE PITT BEAUFORT HYDE LENOIR CRAVEN JONES PAMLICO DUPLIN ONSLOW CARTERET PENDER NEW HANO 4 Statewide PHP's and Carolina Complete Health in Regions 3, 4* & 5 All will go live in February 2020#6Notices for Final Open Enrollment (OE) Period ✓ Notice about beginning of OE to all mandatory and exempt individuals in 73 counties ✓ Mailing of notices began September 30, 2019, ended October 11, 2019 ✓ Estimate ~50,000 packets were sent per day#766500 66000 65500 65000 64500 Managed Care Member Enrollments 64000 63397 63500 63000 62500 64337 MEMBER ENROLLMENTS 64990 65458 66153 62000 THROUGH 9/30 THROUGH 10/1 THROUGH 10/2 THROUGH 10/3 THROUGH 10/6#8NORTH CAROLINA'S OPIOID ACTION PLAN Updates and Opportunities#9June 2017 Governor Roy Cooper launched the NC Opioid Action Plan. cac#10Since the launch of the Opioid Action Plan, we've advanced many strategies: Received over $54 million in federal funding which provided treatment for over 12,000 people. Increased the number of Syringe Exchange Programs, and served over 5,000 people annually through them. Trained over 3,000 providers on clinical issues related to the epidemic, include safe prescribing of opioids and pain treatment. Funded peer support specialists with lived experience in emergency departments to connect people with substance use disorders (SUDS) to ongoing services and supports. ✓ Launched a medical residency training project that will give over 400 prescribers their DATA 2000 waiver to prescribe buprenorphine, and work with over 20 residency programs to incorporate the DATA 2000 waiver into their curriculum ongoing.#11✓ Funded 34 local organizations to implement action plan strategies in their communities. ✓ Enhanced the Controlled Substances Reporting System (CSRS) to provide data visualizations so providers can make informed decisions at the point of care. Integrated CSRS with electronic health records and established data exchange with 29 states. ✓ Convened a Payers Council which made recommendations for insurance payers to respond to the opioid epidemic. Raised awareness of safe drug storage, disposal and drug take backs. Developed model healthcare worker diversion prevention protocols. ✓ Collected and incinerated over 100,000 pounds of medications through Operation Medicine Drop. ✓ Created a publicly accessible data dashboard to monitor progress. Established an opioid research consortium and created a NC Opioid Research Agenda. Launched multiple public education campaigns.#12THE RESULT#13Since the launch of the Plan: Opioid dispensing has decreased by 24% Buprenorphine dispensing has increased 15% Uninsured and Medicaid beneficiaries who have received opioid use disorder treatment has increased by 20% Buprenorphine is an FDA-approved medication for the treatment of opioid use disorder.#14Opioid overdose emergency department visits have declined for the first time in over a decade. 10,000 9,000 8,000 7,000 6,000 Opioid Overdose Emergency Department Visits 5,000 4,000 3,000 2,000 1,000 0 2008 2009 2010 *Data are preliminary and subject to change Source: NC Division of Public Health, Epidemiology Section, NC DETECT, 2009-2018 Q3 Detailed technical notes on all metrics available from NC DHHS; Updated October 2018 2011 2012 ICD-9-CM ICD-10-CM 2013 2014 2015+ 2016+ 2017+ 2018+ NC Opioid Action Plan 2017-2021 2019+ 2020+ 2021+ Expected*#15Number of unintentional opioid-related overdose deaths, N.C. residents 0 2,000 From 2017 to 2018, N.C. experienced a 9% decrease in unintentional opioid- related overdose deaths 1,500 1,407 (33%) 1,000 1,057 (24%) 853 717 713 731 721 (18%) 648 500 (10%) (3%) (-1%) (-10%) 2009 Analysis by Injury Epidemiology and Surveillance Unit 2010 2011 2012 2013 Technical Notes: Unintentional medication and drug poisoning: X40-X44 and any mention of T40.2 (Other Opioids), T40.3 (Methadone), T40.4 (Other synthetic opioid) and/or T40.6 (Other/unspecified narcotics); Limited to N.C. residents Source: Deaths-N.C. State Center for Health Statistics, Vital Statistics, 2009-2018 2014 2015 2016 2017 2018 1,884 (34%) 1,718 (-9%)#16BUT THERE IS STILL MUCH MORE WORK TO DO ...#17NORTH CAROLINA'S OPIOID ACTION PLAN Updates and Opportunities Version 2.0#18The Opioid Action Plan continues the goal to reduce expected opioid overdose deaths by 20% by 2021. 3,000 2,500 2,000 1,500 Unintentional Opioid Overdose Deaths 1,000 500 0 1999 2000 2001 2002 2003 *Data are preliminary and subject to change Source: NC State Center for Health Statistics, Vital Statistics-Deaths, ICD10 coded data, includes NC Resident deaths occurring out of state, 1999-2018 Q2 Detailed technical notes on all metrics available from NCDHHS; Updated October 2018 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Expected* Goal 2018 data are provisional NC Opioid Action Plan 2017-2021 2018* 2019 2020 2021#19The Opioid Action Plan 2.0 aims to identify impactful, feasible strategies to reduce opioid overdoses in North Carolina and prevent the next wave of the epidemic.#20Opioid Action Plan Version 2.0 Prevent Reduce the supply of inappropriate prescription and illicit opioids Prevent future opioid addiction by supporting children and families Expand access to treatment and recovery supports Track progress and measure our impact Connect to Care Advance harm reduction Address the needs of justice-involved populations Address non- medical drivers of health and eliminate stigma Reduce Harm#21Adulthood (Addiction) Prevent Prenatal (Mother's experiences) Infant (Neonatal Abstinence Syndrome) Adolescence (Experiences with drugs) Childhood (Adverse Childhood Experiences) The epidemic is part of an intergenerational cycle of trauma and harm.#22Prevent: Plan Priorities Increase judicious opioid prescribing and the use of non- opioid pain treatments. Prevent youth misuse by addressing the upstream causes of substance use disorders, including trauma and adverse childhood experiences (ACES).#23Number of unintentional opioid overdose deaths, NC residents 0 2,000 Reduce Harm Over 80% of unintentional opioid overdose deaths now involve illicit opioids. 1,500 1,000 500 1999 2000 2001 2002 2003 2004 .2005 Heroin and/or Other Synthetic Narcotics Commonly Prescribed Opioids AND Heroin and/or Other Synthetic Narcotics Commonly Prescribed Opioids 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017#24Most overdose deaths now involve multiple substances. 50% 40% Percent of unintentional medication, drug and alcohol poisoning deaths involving multiple substances 30% 70% 2 substances 3 substances 4+ substances 60% 22% 23% 21% 22% 20% 20% 17% 18% 17% 17% 10% 0% 1999 2000 2001 2002 2003 2004 2005 24% 22% 23% 24% 27% 2006 2007 2008 2009 2010 2011 2012 2013 25% 2014 2015 38% 59% 53% 48% 2016 2017#25STIGMA KILLS PEOPLE#26Reduce Harm: Plan Priorities Prevent overdoses by reducing the harms associated with drug use through expansion of syringe exchange programs and naloxone access. Focus on non-medical drivers of health for people with substance use disorders and eliminate stigma.#27Connect to Care AN ESTIMATED 89% OF PEOPLE DON'T RECEIVE THE SUBSTANCE USE DISORDER TREATMENT THEY NEED. PEOPLE ARE 40 TIMES MORE LIKELY TO DIE OF AN OVERDOSE IN THE TWO WEEKS POST INCARCERATION THAN THE GENERAL POPULATION.#28Connect to Care: Plan Priorities ■ Expand access to treatment and recovery supports by piloting an alternative payment model, developing low-threshold buprenorphine guidelines, and training the next generation of doctors to provide substance use disorder treatment. Address the needs of high-risk populations including justice- involved persons.#29STRATEGIES#30Prevent: Reduce the supply of prescription and illicit opioids Increase the use of opioid-sparing pain treatment Increase adoption of model safe opioid prescribing policies in hospitals and health systems. Identify and educate high opioid prescribers on safe opioid prescribing practices. Develop provider trainings on multi-modal evidence-based pain treatment for different populations including the elderly and people with substance use disorders. Use the Controlled Substances Reporting System (CSRS) to reduce opioid overprescribing Register 100% of eligible prescribers and dispensers in the CSRS. Report data to NC professional boards so they can investigate aberrant prescribing or dispensing of opioids. Reduce the supply of diverted and illicit opioids Provide tools to community coalitions about safe storage and disposal of opioids. Conduct trafficking investigation and enforcement to curb the flow of diverted prescription drugs and illicit drugs.#31Prevent: Avert future opioid addiction by supporting youth and families Reduce youth misuse of drugs Launch a youth-oriented campaign to reduce drug and medication misuse. Identify and disseminate evidence-based curriculum to address mental health needs in youth, including emotional modulation and resiliency. Prevent trauma, including ACEs, and increase resiliency to trauma Increase publicly-funded behavioral healthcare integration, and early identification, screening and referral for social resource needs. Prevent Adverse Childhood Experiences (ACES) and increase resiliency by supporting the NC Perinatal Strategic Health Plan and the NC Early Childhood Action Plan. Pilot a new program to address the impact of family substance use on children by working with families with children in foster care or at risk of having children placed out of the home. This program would connect parents to evidence-based substance use disorder treatment, recovery support services, peer support, and other services such as transportation and housing. Improve prenatal, maternal and infant care for women with substance use disorders Train providers who work with pregnant women on substance use disorder treatment, eliminating stigma, and implementing plans of safe care.#32Reduce Harm: Advance harm reduction Increase access to harm reduction services Support the creation or expansion of 30 syringe exchange programs, and build the capacity of syringe exchange programs to provide education, testing and referral to care. ■ Train health systems and pharmacists to provide and refer people to harm reduction services. Make naloxone widely available Increase the number of naloxone kits distributed to communities with high overdose rates. Increase naloxone co-prescribing and dispensing to people who are at risk of an overdose.#33Reduce Harm: Address non-medical drivers of health and eliminate stigma Address determinants of health and eliminate stigma for people who use drugs Create a training program on Housing First principles and harm reduction for housing providers, including homeless shelters and emergency housing. Convene an advisory council of current and former opioid users and others in recovery to guide Opioid Action Plan components and implementation. ■ Expand employment support services for people with substance use disorders, and increase workplace policies and employment assistance programs that support people with substance use disorders. Run a stigma reduction education campaign about substance use disorders and people who use drugs.#34Connect to Care: Expand access to treatment and recovery supports Increase coverage of treatment Close the Medicaid coverage gap. Increase the number of people who receive substance use disorder treatment and recovery supports. Pilot alternative payment models that support improved care coordination for patients. Increase linkages to treatment and recovery supports Develop model inpatient, emergency department and discharge policies for people with substance use disorder. Support 10 counties in creating post overdose response teams that link overdose victims to treatment and support. Increase the number of community-based recovery supports, including community-based recovery supports that are inclusive of medication-assisted treatment (MAT). Expand treatment capacity and improve treatment quality Ensure every medical school in North Carolina provides addiction training to students. Incorporate waiver trainings into 25 residencies, nurse practitioners, or physicians assistant training programs, and increase opportunities to work with patients with substance use disorders during training. Develop a best practices guide for low-barrier buprenorphine treatment in different healthcare settings. Increase buprenorphine dispensing by 20%. Explore opportunities to utilizing telehealth and telemedicine to increase rural access to treatment.#35Connect to Care: Address the needs of justice-involved populations Increase pre-arrest diversion of low-level offenders Support counties in adopting pre-arrest diversion programs to divert low-level offenders to community-based programs and services. Maintain and enhance therapeutic (mental health, recovery and veteran) courts. Provide overdose prevention education and medication-assisted treatment (MAT) during incarceration and upon release. Identify model policies to screen for substance use disorders and connect to overdose prevention education and treatment during incarceration or upon release Work with at least six jails to screen for substance use disorders, use FDA- approved medications for treatment, and provide overdose prevention education and connections to care upon release. Expand supports for people after release Train community corrections and Treatment Accountability for Safer Communities (TASC) offices on substance use disorders and connecting to naloxone, harm reduction resources and treatment. Increase education opportunities for those with criminal history by working with institutions of higher education to not screen people out based on criminal records alone. Reduce barriers to employment for those with a criminal history, and provide information on education options, career paths and licensures that are available to people with different classes of convictions.#36Track and Measure: Track progress and measure our impact Improve data infrastructure Improve publicly accessible data dashboard of key metrics for data dissemination to monitor impact of this plan based on stakeholder feedback. Create data warehouse of aggregate opioid data to facilitate data collaborations and external sharing with data partners. Create a case definition for overdose clusters to alert EMS, law enforcement, health care providers and others. Establish a standardized data collection system to track law enforcement, EMS, and community administered naloxone reversal attempts. Research and evaluation Continue the opioid research consortium of state agencies and research institutions, and use the research agenda to inform future work and evaluate existing work. Track outcome data Continue to track key metrics.#37Track progress and measure our impact To track our progress in combatting the epidemic, North Carolina will monitor these 12 metrics as part of the North Carolina's Opioid Action Plan 2.0. Metrics* Track progress and measure our impact 2016 2017 2018 Number of unintentional opioid-related deaths of NC Residents (ICD-10) Number of ED visits that received an opioid overdose diagnosis (all intents) Reduce the supply of prescription and illicit opioids 1,407 1,884 Data pending^ 5,546 7,455 6,772 Total number of opioid pills dispensed 58,014,500 52,137,500 43,348,100 Percent of opioid deaths involving heroin or fentanyl/fentanyl analogues Prevent overdoses by advancing harm reduction, reducing stigma, and addressing non-medical drivers of health Number of community naloxone reversals 59% 75% 80% 3,684 4,176 3,943 Number of newly-diagnosed acute hepatitis C cases 203 188 185 Raise community awareness and increase community prevention and response efforts Percent of children in foster care due to parental substance use disorder 37% 39% 42% Number of hospitalizations associated with drug withdrawal in newborns 1,278 1,392 Data pending Expand access to treatment and recovery supports Number of buprenorphine prescriptions dispensed Number of uninsured individuals and Medicaid beneficiaries with an opioid use disorder served by treatment programs Address the needs of justice-involved populations Number of law enforcement agencies carrying naloxone Number of opioid overdoses deaths among recently released population *Data are continually updated as additional cases, visits, claims, and other data points are finalized in each system. ^1,425 deaths as of May 1, 2019; final number for 2018 not available until the fall of 2019. 478,744 568,233 637,840 28,968 31,758 34,310 136 193 252 Data Pending Data Pending Data Pending#38Getting It Done Legislatively mandated by SL-2015-241. The Opioid and Prescription Drug Abuse Advisory Committee (OPDAAC) serves as the primary convening group to advance this work. OPDAAC members represent a wide variety of agencies and fields including but not limited to: local health departments, healthcare organizations, law enforcement, substance abuse prevention, the recovery community, mental health treatment, harm reduction, emergency medicine, regulatory boards. All are welcome to join the OPDAAC. For more information, visit our website.#39Getting It Done To respond to this epidemic, it is critical that we support local stakeholders in responding to the epidemic in their communities. The Menu of Local Actions identifies impactful strategies that can be implemented at the local level and provides information and resources on each strategy. Local stakeholders can select strategies from the menu based on the needs and resources of their community. The menu will continue to be updated with information and resources as more become available.#40Medicaid Expansion 500,000 90% New projected enrollees due to expansion, including a disproportionate number of rural North Carolinians Share of costs paid by the federal government - no new state appropriation needed to fund the state share 43,000+ Jobs created in the first five years of expansion Put downward pressure on premiums Improve health in NC, reduce rural health disparities Shore up rural hospitals Combat the opioid epidemic#41Big Picture - The Budget Medicaid Expansion New projected enrollees due to expansion, including a 500,000 disproportionate number of rural North Carolinians 90% - Share of costs paid by the federal government — no new state appropriation needed to fund the state share 43,000+ Jobs created in the first five years of expansion Put downward pressure on premiums Improve health in NC, reduce rural health disparities Shore up rural hospitals Combat the opioid epidemic 41#42Peer Support: Feedback & Aligning the State-funded & Medicaid Service Definition The State-funded PSS service definition went live August 1, 2019 NC Medicaid promulgating a consistent PSS policy that is part of the State Plan Amendment (SPA), submitted to CMS September 16, 2019 Anticipate shorter than normal approval time NC Medicaid and DMHDDSAS have worked closely throughout the revision of the PSS service definition and policy NC Medicaid posted the draft policy for 45 day public comment - July 15, 2019 through August 30, 2019 - and shared all feedback received with DMHDDSAS • . Both Divisions will continue to closely collaborate to ensure that the State-funded service definition is revised (as needed) to align with the Medicaid policy that is promulgated. • Incorporating Feedback Webinars with LME/MCOS and stakeholders - 3 webinars in Fall 2018, nearly 600 registrants Questions/comments received from stakeholders and published an FAQ along with the slides: https://www.ncdhhs.gov/documents/peer-support-service-definition Leveraged the NC Certified Peer Support Workgroup & engaged with the Leadership Fellows Academy to gain input and feedback Stakeholders email blast with draft PSS policy during 45 day comment period#43Peer Support: Changes in State- funded Service Definition Services are provided directly by NC Certified Peer Support Specialist (NC CPSS) who identify as being a person in recovery from mental illness and/or substance use disorder . • It can be provided 1:1 or in a group setting Service recipients must be 18 years of age or older Recipients must have a diagnosis of mental illness and/or substance use disorder Staff Requirements include: • • . PSS staff (except for the PSS Program Supervisor) MUST be CPSS The PSS Program Supervisor MUST be a full time QP, they can also be a CPSS The PSS Program Supervisor can supervise up to 8 CPSS, and a CPSS can work with up to 15 individuals (12 individuals in a group setting There are some requirements for - and limitations on - flexibility . . • coverage designed to offer Each individual receives 24 unmanaged units (6 hours) per State fiscal year where there no authorization is required - just a service order. Unmanaged units can be expanded in advance of managed units being planned for and implemented LME-MCOS can offer less restrictive limitations on unmanaged units but cannot impose more restrictive limitations than the State-Funded policy#44Peer Support: Peer Support Services Rates State-funded rate recommendation is $13.26/unit or $53.04/hour. This should support a QP salary at $23/hour and a CPSS salary at $16/hour, and include fringe benefits, paid sick time, paid vacation, and paid holidays DHHS makes rate recommendations, each LME-MCO maintains the authority to set the rates to support their PSS provider network Medicaid rate currently under development, as that's finalized DHHS will work to align state-funded rates Individuals that are currently getting Peer Support Services from (b)(3) can continue to get this service as the Medicaid service definition is finalized#45Substance Use Disorder Waiver As part of the State's multifaceted Opioid Action Plan, DHHS is in the process of implementing its waiver of the institution for mental diseases (IMD) exclusion for SUD treatment to expand access to and Medicaid reimbursement for critical services. Adding four SUD benefits to further expand access to SUD treatment and residential services and offer a complete continuum of services according to the American Society of Addiction Medicine (ASAM):* :** Substance abuse halfway house (ASAM 3.1) Clinically managed population-specific high intensity residential services (ASAM 3.3) Ambulatory withdrawal management with extended on-site monitoring (ASAM 2-WM) Social setting detoxification withdrawal management (ASAM 3.2-WM) ■ Building provider capacity for new and existing SUD services ■ Providing training for SUD providers on ASAM criteria ■ July 1, 2019 start for allowing services in the IMD Updating and incorporating new policies to implement this waiver through October 2020 so that SUD services can be provided in an IMD and in more community-based settings#46EMS Initiated MAT Bridge Program ■ Approximately 16,000 opioid overdose reversals by EMS in NC each year, with 35% of post reversal patients refusing transport to an Emergency Department after reversal. The Program - - Local EMS systems and agencies will begin offering buprenorphine immediately following reversal along with daily follow-ups and dosing by trained Paramedics. Peer support specialists will join Paramedics at the scene of an overdose reversal and accompany the Paramedics on daily follow up visits for up to six (6) additional days to facilitate the individual's entry into MAT. Provides a bridge for overdose survivors as they are awaiting entry into an OBOT program, to be spared the withdrawal symptoms and risk of overdose and reinforces the connection to treatment. So far, four programs are in process, all are grant funded.