Program helps cut drug dependency
CMs support members, work with MDs
A substance abuse case management program developed by CareSource is helping its members with substance abuse problems kick the habit.
CareSource launched CARE4U about six years ago to help members who were abusing controlled substances reduce their overall dependency on drugs. "Instead of just telling our members they can’t have the medications, we wanted to help them get off the drugs," says James Gartner, RPh, MBA, vice president of pharmacy and medical management for the Dayton, OH-based Medicaid managed care company.
CARE4U has helped 15% of the people who completed the 18-month program abstain from narcotics completely. An additional 25% of participants who completed the program have reduced their overall dependence and receive only an average supply of two weeks’ worth of narcotics in a quarter. The program received a Pinnacle Award for Best Practices from the Ohio Association of Health Plans in 2013.
Members eligible for the program are using 12 or more controlled substances in a quarter and are getting prescriptions from four or more providers and filling them at four or more pharmacies. Most of the members in the program are addicted to pain medications. Many have behavioral health issues, as well, Gartner says.
"In a lot of cases, the members have surgery or are injured and are prescribed pain medication. They start abusing the medication and become addicted. Then they start seeking prescriptions for medication from multiple providers. In most cases, the patients no longer need the drugs for the reasons for which they were originally prescribed," he says.
The program is staffed by a team of five RN case managers, most of whom have experience in working with people with addictions. The health plan uses RN case managers because of the knowledge they have about medication and their abilities to work with members, Gartner says.
The nurses work with the members, educating them and supporting them in their efforts to overcome their addiction. In addition, they collaborate with the prescribing physicians, alerting them that their patients are getting multiple prescriptions and keeping them informed on the patients’ progress.
The health plan mines claims data quarterly to identify members for the program. In addition, members are referred by physicians and through the health plan’s prior authorization reviews.
When members are identified as being eligible for the program, a nurse case manager calls them, explains the program, and encourages the member to be enrolled. The health plan also sends members a letter explaining the program.
"We chose not to use technicians to make the outreach calls because if we get the member on the phone, we want to get them engaged right away. The nurses can start working with the members immediately after they agree to enroll," Gartner says.
The nurses start the conversation by letting the member know they are aware that he or she is getting multiple prescriptions from multiple providers and offering to help. "It’s not always an easy conversation. Some members resent that we are interfering with their drug-seeking behavior," he says.
They ask the patients about their specific situation, what their pain is like, and why they think they need multiple prescriptions for controlled substances. They find out if the patients understand the purpose of their medication and the long-term dangers of taking large doses of medicines. "They dig down to find out the type of the pain the members are having, how the medication is working for them, and discuss other opportunities for relief. The conversations are tailored to the individual," he says. For instance, the case managers find out if the members have been referred for physical therapy and encourage them to go. They ask if members have an exercise program that can help with their pain or if their doctors have suggested other ways of dealing with pain, such as losing weight.
The case managers ask the members to identify one physician that they want to see for pain management. "We encourage them to use one doctor and one pharmacy. If they continue to use more than one physician, we may lock them into a pharmacy," he says. When that happens, when the member goes to another pharmacy, the CareSource system will advise the pharmacist that the prescription is not covered.
Members are enrolled in the program for 18 months. The case managers contact the members monthly and follow up on their progress, encouraging them to stay off the drugs and educating them on the dangers of overutilization of medication. They communicate any pertinent information to the patient’s physician.
One key to the success of the program is the collaboration between the case managers and the physicians who are prescribing the medications, he says. "When members enroll, the nurses contact the prescribing physicians to let them know what is going on and get them engaged in the program. No doctor wants to be involved in facilitating addiction, and they are eager to work with us to help the members," Gartner says.
Most of the time, the doctors are not aware that their patients are getting prescriptions for controlled substances from other providers and are unaware of the amount of medication they are taking, Gartner says. "We let the physicians know that we aren’t trying to control what they do but we are monitoring our members’ drug use to make sure it’s appropriate. We don’t want to practice medicine, but we do advise the doctors when members are getting excessive amounts of medications and work with them to try to help the members overcome their addiction," he says.
When the doctors become aware that their patients are seeing multiple doctors and taking multiple medications, they talk with the member about the need for him or her to get off the medication, and the case managers reinforce what the doctors say during their monthly calls, he says.
"It’s a challenge. People who are addicted to controlled substances are not going to change overnight. It’s often difficult to get in touch with them because this is a transient population. The case managers make attempts to reach them every month and keep working at it," he says.