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Creating Care Plans With Patients’ Ideas of Success Front and Center

August 25, 2017
by David Raths
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New Hampshire kicks off Medicaid waiver project integrating primary, behavioral care, community organizations
Mark Belanger

With the opioid crisis directly in their sights, Medicaid providers in New Hampshire are working under a waiver from the Centers for Medicare & Medicaid Services to innovate on ways to better coordinate care between primary care, behavioral health, and substance use disorder (SUD) clinicians.

Mark Belanger, the director of advisory services at the Massachusetts eHealth Collaborative, is consulting on the project and says the clinicians have been very enthusiastic about participating. “These providers have been highly siloed,” he said. “The medical officer I work with said that with one of his cases there were six teams working on that one patient’s behalf, and not one of those six was aware of the other teams. They know the coordination challenges are real and are pretty enthusiastic about solving them.”

Besides bringing provider groups together, the Medicaid project also is focusing on social determinants of health and reaching out to community organizations.

Belanger is working with 21 large and 35 small organizations in the western part of New Hampshire. That includes large hospitals, community behavioral health centers and SUD treatment providers. Also involved are county governments, which handle drug courts and prisons, housing, food security, domestic abuse, legal aid, and transportation. After 10 months of intensive planning, the operational phase is beginning this month and the waiver runs through December 2020.

CMS plans to assess the project along 39 specific clinical quality measures, but in a departure from traditional approaches, the project leaders made a conscious decision to include patients and caregivers in all the planning. “That is easy to say, but not as easy to execute on,” Belanger said.

The idea is to let the patients define what wellness means to them, rather than a medical model of telling them they need to control their hypertension or diabetes. “They have a view of stabilizing their life. It has been chaotic and they have been couch-hopping for three months,” he said. “Their goal may be to just to control anxiety and stabilize. This has led to having care plans that highlight patient goals and patient ideas of success front and center. That is a completely different than medical model the caregivers were expecting.”

Challenge No. 1 is linking groups who don’t have formalized ways of working together and are not used to acting together as a collaborative team.

Working with a core team across mental health and primary care to uncover and track the social determinants requires some informatics innovation. “We are using an external quality reporting tool to track whether someone has anxiety, needs financial assistance or is homeless,” Belanger explained. “The EHRs can flag depression and suicide risk, but they fall down after that. We are using something that can collect those assessments and do some workflow triggering off of them. If we discover somebody needs to go to a domestic abuse center, for instance, we are building a pathway to send what looks like a referral in medical terms to a shelter, and have them be able to receive that via Direct message and be able to do something with it.”

Of course, another challenge is that the providers working together have a wide variety of technological sophistication, ranging from Dartmouth-Hitchcock, a very sophisticated Epic user, all the way down to organizations still working on paper. “We have a housing trust whose software is designed to manage inventory of housing units,” Belanger said. “We have to start thinking about creating something that would be parallel to a lab order for someone who needs housing assistance.”


To help address the opioid crisis, the group is working with a Utah-based vendor called Collective Medical Technologies, whose software is used in Oregon and Washington. Its solution, called the Emergency Department Information Exchange (EDIE), proactively notifies emergency departments when high-utilization or special needs patients register. 

Information stored in patients’ shared care plans is pushed to the emergency department when a patient is admitted. “They get a heads-up if somebody is on a pain contract, for instance,” Belanger explained. They are hoping to automate the integration of the prescription drug monitoring program (PDMP) data into that workflow as well.

Belanger said there are issues with regulatory limitations around confidentiality and sharing of data on substance use disorder patients.

The Substance Abuse and Mental Health Services Administration (SAMHSA) recently made some changes to the regulations, known as 42 CFR Part 2. The way the regulation was written in 1975, it required the patient to consent every time their data was shared or accessed, which health information exchanges and healthcare organizations have found very difficult to implement. Many HIEs have just avoided the issue during their startup phases.

“That is probably the biggest policy hurdle we have,” Belanger said. “The new rule that came out in February made that a little easier, but not completely easy. You are able to define a broader team and put the data in a place where multiple parties can access it. The population that the Medicaid waiver is aimed at has a pretty high co-occurrence with substance use, so we are going to deal with it every day. It basically means we are going to have to get patients to consent to share with a broader set of treatment providers.”


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