State Advocacy Team Summary - Montana
The Montana (MT) state advocacy team was led by chapter lead Brad Benne, Executive Director of The Rocky Mountain Hemophilia & Bleeding Disorders Association; and HTC lead Dr. Emily Wheat, Hemophilia and Thrombosis Center, Children’s Hospital Colorado. The team was also supported by member Bryn Dunham, licensed clinical social worker at the University of Colorado Hemophilia and Thrombosis Center.
Summary of Achievements
In their first year, the BD SUMHAC MT team successfully:
Engaged with representatives from the Behavioral Health Alliance of Montana and state officials from the MT Department of Public Health & Human Services (DPHHS).
Identified a state champion with the Office of Strategy and Transformation, Montana Department of Public Health & Human Services.
Mapped the regulatory landscape of inpatient and residential SUD and MH facilities, with particular attention to policies related to:
Self-administration of infusion and injection medications
Staff assisted administration of infusion and injection medications
External provider assisted administration of infusion and /injection medications
Patients’ ability to bring in their prescribed medications from home (i.e., brown bagging) or from a third party pharmacy (i.e., white bagging)
Patient cherry-picking
Will draft and submit recommendations for the DPHHS update to the Administrative Rules of Montana (ARM) which governs the regulations for MH/SUD facilities.
Regulatory Landscape Mapping
Sorted by landscape area. All regulatory Information is as of August 2024
SUD Facility Information
Self-infusions/ injections
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ARM 37.106.1457 Medication Storage and Administration
(3) For assistance with self-administration of medications outside of the facility, all medications must be in the possession of a staff member trained to assist with the self-administration of medications.
(4) Staff members assisting with medication self-administration must be trained to assist in proper medication procedures.
(11) A SUDF cannot require clients to discontinue the use of any medication prescribed by a licensed health care professional for admission.
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Self-administration of infusion and injection medications are permitted in all SUD facilities. Facility staff must be trained if they are to assist with self-administration of any medication, but there is no current language in the regulations that requires facility staff to be trained in administering and monitoring infusion and injection medications, specifically.
Additionally, MT’s administration code states that a facility cannot require individuals to discontinue any medication in order to gain admission to a SUD facility. Although it is not explicit in the code, this would include infusion and injection medications.
Staff-assisted infusions/ injections
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ARM 37.106.1475 ASAM 3.7 Medically Monitored Intensive Inpatient Requirements
(2) Medical service must be provided, according to written physician approved protocols, 24 hours a day, seven days a week and must include: (c) medication management.
(3) Daily clinical skilled treatment services and medical services must be provided on-site by an interdisciplinary team seven days a week.
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ASAM level 3.5 and 3.7 SUD facilities are required to have staff (typically a nurse) who is able to administer and monitor medications for non-behavioral health indicators. Although it is not specified in the code, administration of infusions and injection medications would qualify as “medical services.”
ASAM level 3.1 and 3.3 SUD facilities are not required to have staff available at all times, but individuals should have access to a nurse who is able to administer infusions and injections as part of their treatment, as appropriate.
External provider-assisted infusions/injections
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All statutes indicate: Coordination of necessary services (medical, laboratory, toxicology, psychiatric, psychological, emergency) or other levels of care must be available through direct affiliation or referral processes.
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ASAM level 3.1, 3.3, and 3.5 level SUD facilities are required to coordinate access to infusion and injection medications if the individual is unable to self-administer. Potential options could include: Permitting an external provider who is legally authorized to administer infusions or injections to do so in the facility or bringing the person to a local emergency department for the infusion or injection.
Since ASAM level 3.7 facilities have staff on hand who are permitted to infuse, the assumption is that they won't need external providers.
White and brown bagging
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ARM 37.106.1457 Medication Storage and Administration
3) For assistance with self-administration of medications outside of the facility, all medications must be in the possession of a staff member trained to assist with the self-administration of medications.
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Individuals are permitted to bring in prescribed medications from home into the facility, including infusion and injection medications, so long as the medication stays in the possession of a staff member that is trained to assist with self-administration of the medication. Medication must be in a pharmacy labeled container and have a valid prescription.
However, staff from Montana Department of Public Health & Human Services are unsure if the regulations permit a facility to deny an individual from bringing a prescribed medication from home into a facility and will follow-up with us with additional information.
Policies to prevent cherry-picking
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(1) The substance use disorder residential facility (SUDF) must develop and maintain a client rights policy that supports and protects the state and federal constitutional and statutory rights, including civil rights, of all clients. These must include the right to:
(a) receive treatment free of unlawful discrimination;
(b) receive reasonable accommodations, consistent with federal and state law;
(c) receive treatment in the least restrictive environment, consistent with law, in a manner sensitive to individual needs and which promotes dignity and self-respect
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MT is working to incorporate the American Society of Addiction Medicine (ASAM) guidelines into their administrative code. ASAM’s 4th edition clarified that if a person can self-manage their condition (and it uses hemophilia as an example) or if their condition can be effectively managed by an external provider, it should not be a reason for exclusion from any level of care. This language should prevent any denials due to stable, well-managed medical conditions.
We were also told there are provisions to prevent cherry-picking in the Medicaid contract. However, we have not been able to identify this language to date.
At a minimum, it is clear that facilities have to comply with state and federal requirements such as Section 504 and provide reasonable accommodations.
MH Facility Information
Self-infusions/ injections
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ARM 37.106.1720 Individualized Treatment Planning
(1) …the facility shall initiate an individualized treatment plan for each patient within 24 hours of admission. The treatment plan must…
(a) identify treatment team members, from within and outside of the facility, who are involved in the patient's treatment or care;(7) Minimum components of treatment plans include:
(a) …medication administration and management -
Although it was not clear in the administrative code, according to DPHHS staff, self-administration of infusion or injection medications is permitted in MH facilities.
If a patient requires injections or infusions, MH facilities are required to make a plan for how the facility will ensure access to the treatment. This could include permitting the individual to self-administer.
Staff-assisted infusions/ injections
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ARM 37.106.1720 Individualized Treatment Planning
(1) …the facility shall initiate an individualized treatment plan for each patient within 24 hours of admission. The treatment plan must…
(a) identify treatment team members, from within and outside of the facility, who are involved in the patient's treatment or care;(7) Minimum components of treatment plans include:
(a) …medication administration and management -
Staff-assisted administration of infusion or injection medication is permitted in MH facilities. Staff must be licensed and trained to administer infusion and injection medications to assist individuals with administration.
If a patient requires injections or infusions, MH facilities are required to make a plan for how the facility will ensure access to the treatment. According to DPHHS staff, this could include a staff-administered infusion or injection, provided the service is within the scope of the staff member’s license.
External provider assisted infusions/injections
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ARM 37.106.1720 Individualized Treatment Planning
(1) …the facility shall initiate an individualized treatment plan for each patient within 24 hours of admission. The treatment plan must…
(a) identify treatment team members, from within and outside of the facility, who are involved in the patient's treatment or care;(7) Minimum components of treatment plans include:
(a) …medication administration and management -
If a patient requires an injection or infusion, MH facilities are required to make a plan for how the facility will ensure access to the treatment. This plan could include permitting an external provider who is legally authorized to administer infusions or injections to do so in the facility or could include bringing the person to a local emergency department for the infusion or injection.
According to DPHHS staff, external providers are permitted to assist with infusion and injection medication administration provided that the service is within the scope of the external provider’s license.
Brown bagging policies
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Staff from Montana Department of Public Health & Human Services (DPHHS) will review and follow-up with us with additional information.
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DPHHS staff shared that individuals are permitted to bring medications from home into the facility, including infusion and injection medications, so long as the medication comes in its original pharmacy labeled container with a valid prescription. However, staff from the DPHHS will follow-up with us on this to provide more information based on the current regulations.
Next Steps for Advocacy
The MT team has determined the following goals for Phase 2:
Draft and submit proposed recommendations for updates to the MT MH/SUD regulations.
Create a step-by-step plan for the BD community in MT in the event of a denial to a MH/SUD facility.
Seek opportunities to educate MH/SUD facilities on BDs and ways facilities can increase equitable access to care and treatment for the BD community.