Last Updated: September 2024

Author: Division of Substance Use Program, Vermont Department of Health

Treatment for substance use disorders is an ongoing process which requires time in order to build the skills needed to address the physical, emotional, social and other factors in addiction and to reduce the risk of relapse. Treatment can happen in a variety of settings and individuals can move between levels of care throughout their time in treatment.  Regardless of the setting, in order for substance use disorder treatment to be effective, the individual must stay in treatment.

Treatment engagement is a measure of the portion of individuals who have two or more alcohol or drug services within 34 days of beginning treatment (initiation). Please note that the calculation for treatment engagement changed in 2017 to include prescriptions for buprenorphine for opioid use disorder and to increase the time period from 30 to 34 days.  

Programs have been struggling to recruit and retain workforce during and after the COVID-19 emergency which may be impacting the initiation and engagement rates.

In addition, the definition of the measure changed for 2022, resulting in significant decreases in  the engagement rate that can't be distinguished from changes in services.

• Primary Care Practices
• Hub and Spokes
• Hospitals
• Medicaid beneficiaries and families
• Community Providers – such as Licensed Alcohol & Drug Counselors (LADCs) and mental health practitioners
• Division of Substance Use Programs (DSU) Preferred Providers
• Recovery Centers
• AHS Departments (Department of Vermont Health Access, Vermont Department of Health DSU, Department Children and Family, Department of Corrections, Department of Disability, Aging and Independent Living, Department of Mental Health)

In addition to being available and accessible, services must match the needs of the person seeking care.  Services should be developmentally matched to the person and should address any co-occurring needs, including trauma.

The Vermont Department of Health, Division of Substance Use Programs (DSU) started the Rapid Treatment Access (RTA) project to respond to individuals seeking treatment and supports for alcohol use disorder (AUD). RTA builds upon the Rapid Access to Medication Assisted Treatment (RAM) for Opioid Use Disorder (OUD) model that was implemented statewide to respond to individuals with OUD. RTA is in the process of being rolled out statewide.
Rapid Treatment Access (RTA) refines Vermont's treatment system for alcohol use disorder (AUD) by:

• Smoothing the pathways for individuals to access treatment.
• Reinforcing evidence-based best practice.
• Recognizing that hospital emergency departments (EDs) may serve as a critical access point for individuals in rural communities and by integrating the ED into the system of care.
• Raising awareness of community-based treatment/recovery services.
• Supporting providers in the application of continuous quality/rapid cycle process improvement tools and techniques.

Other activities that may impact this measure

• Increase focus on this measure
  • Publish provider level data
  • Include treatment engagement as a performance measure in cross-departmental work for substance abuse treatment populations
  • Decrease variability in provider performance
  • Provide technical assistance to providers with low engagement rates
• System Improvements
  • Improve care transitions between different types and levels of behavioral and physical health
  • Improve collaboration between the providers and recovery centers
  • Provide clinical supervisor training to emphasize individual engagement through the recovery process
  • Coordinate efforts between Agency of Human Services Departments to better support individuals in treatment
  • Increase overall system capacity through the addition of Licensed Alcohol and Drug Counselors (LADC) to better address access issues

These rates are based on the Healthcare Effectiveness Data and Information Set (HEDIS) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) access to care measure. The definition of the measure changed in 2017 to include prescriptions of buprenorphine as engagement data points which were not included in previous years.  Substance induced mental disorders were not included. The rates exclude beneficiaries with Medicare or other medical insurance due to incomplete Medicaid claims history.

In Vermont Medicaid, medication assisted treatment (MAT) is currently billed as one unit per month. The HEDIS IET specification looks for one service within 14 days of index event to count as initiation and two services within 34 (2017 and forward) or 30 (2016 and earlier) days of initiation for engagement. An adjustment to the IET rate was used to count the multiple visits each week occurring at the MAT opioid treatment programs. Also, Vermont billing codes for behavioral health residential treatment do not match the IET measure, but for this measure are counted as sub-acute facility visits.

Engagement – the % of Medicaid beneficiaries diagnosed with alcohol and other drug (AOD) dependence who then received two (2) additional AOD services within 34 days after the start of AOD treatment. (The data represented in the chart here is the engagement total rate (13-17 years combined with 18+ years. Separate engagement rates for those population sub-sets are also tracked.)

Please note that treatment services are offered through Community Health Teams and Spoke Staff that may not be reflected in these numbers because the funding mechanism for these teams does not require the generation of a service claim. Since the measure is based on Medicaid claims data, the numbers likely under-represent the rates of initiation and engagement in treatment.

For 2022, the HEDIS code for the measure changed in these ways, resulting :

• We are now looking for SUD episodes as early as Nov. 15^th of the year prior to the measurement year, instead of Jan. 1^st of the measurement year.
• The negative diagnosis/medication history requirement for the denominator has been extended from 60 days to 194 days.
• The continuous enrollment requirement for the denominator has been extended from 108 days to 242 days.