Baltimore Buprenorphine Initiative

1. Baltimore Buprenorphine Initiative Advancing Recovery Project Baltimore City, Maryland January 14, 2010

2. Agenda • Overview of AR Project • Greatest Achievements • Since Tucson – Transfers to Continuing Care • Lessons Learned • Sustaining Change Efforts • Human Impact

3. Goals • AR AIM: Improve the quality of buprenorphine care in the Baltimore Buprenorphine Initiative through increased access to buprenorphine and improved long-term retention of clients. • BBI Goals • Expand access to drug treatment via new system of care. • Increase number of physicians trained and certified to prescribe buprenorphine. • Demonstrate effectiveness of buprenorphine treatment via systematic data collection and analysis.

4. BBI Collaborative • Baltimore City Health Department – Initial vision, promotes physician recruitment and training • Baltimore Substance Abuse Systems – Contracts with providers, oversees clinical services • Baltimore HealthCare Access – Case management, health insurance enrollment • Maryland Alcohol and Drug Abuse Administration – Policy, regulations and funding • Providers – Substance abuse treatment programs and continuing care physicians

6. Greatest Achievements • Developed BBI Clinical Guidelines for Buprenorphine Treatment of Opioid Dependence in the Baltimore Buprenorphine Initiative March 2009 • 4 times as many buprenorphine slots in Baltimore from 112 slots in 2008 to 506 slots in 2009 (State funding tripled during AR grant period) • Patients receive buprenorphine within 48 hours of first treatment appointment • Responded to client feedback and created new treatment models

7. Greatest Achievements • Streamlined critical processes at programs including transfers to continuing care • Innovative Practice by Agency recognition by federal Agency for Healthcare Research and Quality 2008. • Model Practice Award from National Association of County and City Health Officials (NACCHO) 2009.

8. Recent Progress - Transfer Process • AIM: 75% of patients in treatment for 120 days are transferred to continuing care • PURPOSE: Timely transfers critical to open up slots for uninsured patients • CRITERIA FOR TRANSFER: • Insured • Compliant with medication and counseling • Opioid-free; reduced other drug use • Responsible with take home medication and prescriptions

9. Process Issues • Excessive days to obtain health insurance • Inconsistent patient education about the BBI model and transfer expectation • Providers not tracking patients’ length of stay and readiness for transfer • Delays in patients receiving progressive take home medication and prescriptions

10. Process Issues • Patients in treatment with continued opioid use • Patients with poly drug abuse and co-occurring disorders • Counselor concern about patients dropping out of counseling after transfer • Inconsistent attention to transfer disposition forms

11. Data: Number of Patients Transferred

12. Data: Number of Days Before Transfer

13. Data: Reasons Why Clients Did Not Transfer

14. Number of Clients Still in Counseling after Transfer

15. Process Improvements • Enhanced collaboration between health advocates and counselors • Transfer Disposition Forms (TDF) and meetings started December 2008 • Modified TDF to identify specific transfer barriers • Extended TDF process to every 30 days • Program management involved in transfer decisions

16. Process Improvements • Clinical consultation for patients in treatment more than 120 days • Transfer data shared with providers • Walk throughs and chart reviews at programs • Consultation on BBI Clinical Guidelines • BHCA addressed internal process issues • Funded residential treatment for patients needing higher level of care

17. Process Improvements • Enhanced physician education • Nurses buprenorphine training conference • Identified continuing care providers to accept patients with mental health problems and poly-substance use • In Development: • Counselor Forum training event • Patient Orientation Video • Patient Transfer Video • Patient education materials

18. Lessons Learned • Initial partnership building between lead agencies and providers led to trust, collaboration and successful outcomes • Vision and leadership at highest levels critical to achieve buy-in • Case management critical • Customer focus • Data driven

19. Lessons Learned • Clinical quality and evidence-based practices • Culture change to chronic disease model and use of medication • Alternative treatment models needed • Buy-in by medical community requires ongoing efforts

20. Sustaining Change Efforts • Financial Analysis • Medicaid/PAC benefits expanded 1/1/10 – now covers drug treatment and reimbursement rates increased • Over last 3-years, BSAS analyzed costs reported by providers, adjusted awards, and achieved “economies of scale” • BSAS assessment and technical assistance to providers for PAC expansion

21. Sustaining Change Efforts • Purchasing and Contracting Analysis • BSAS planning best use of Block Grant dollars after PAC expansion • Regulatory Analysis • State Buprenorphine Workgroup to ensure regulations include buprenorphine coverage at drug treatment programs

22. Sustaining Change Efforts • Intra-Organizational Analysis • New quality improvement activities institutionalized at BSAS and Programs • Inter-Organizational Analysis • BBI Clinical Guidelines being revised for PAC billing • BBI quality assurance initiative • BBI evaluation

23. Human Impact • 3,000 patients treated • 1,000+ patients helped to obtained health insurance • Patients linked with medical care • Targeted most vulnerable patients – HIV, sex workers, Needle Exchange • Four-fold increase in physicians trained to provide buprenorphine from 50 to 200 • Allied health professionals training

24. Human Impact • Buprenorphine offered in new levels of care • Patients in continuing care being treated similarly to other patients with chronic illnesses • More patients can obtain treatment through expanded slots • Expansion of buprenorphine statewide

25. Provider Perspective • Program culture change • NIATx/AR Process improvement techniques • Use of data • Impact of expanded of buprenorphine on quality of patient care • Partnership with BSAS and State • Buprenorphine Provider Roundtable

26. Baltimore Buprenorphine Initiative Questions? For more information later, contact: Bonnie Campbell Baltimore Substance Abuse Systems bcampbell@bsasinc.org 410-637-1900 x252