Advancing Recovery : Baltimore Buprenorphine Initiative

1. Advancing Recovery:Baltimore Buprenorphine Initiative Tucson Presentation July 29, 2009 Baltimore Substance Abuse Systems

2. Presentation Agenda • Baltimore’s AR Project – • Baltimore Buprenorphine Initiative (BBI) • Collaborative • Evidence-Based Practices • Implementation Status / Accomplishments • Recent Lever Focus • Future Lever Focus

3. Goals • AR AIM: Improve the quality 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, oversight, advocacy and physician recruitment and training • Baltimore Substance Abuse Systems – Oversight of drug treatment providers • Baltimore Health Care Access – Case management, health insurance enrollment • Maryland Alcohol and Drug Abuse Administration – Policy, regulation and funding • Providers – Outpatient substance abuse treatment programs and continuing care physicians

6. EBP’s – Medication & Continuing Care • Increased buprenorphine slots from 112 to 451 (State funding tripled) • 2,277 patients treated since initiation of BBI • 1,000+ patients helped to obtained health insurance • 200+ physicians received buprenorphine waiver training • New alternative models of treatment developed • Low level outpatient treatment • Primary care center physician office based • 28-day ICF followed by halfway house • BBI Clinical Guidelines published and training completed • Federal drug court funding awarded – July, 2009 - Strategic choice is to enhance halfway house and outpatient treatment with buprenorphine • BBI featured on SAMHSA Road to Recovery Series July 2009

7. BBI Video

8. Data as Foundation for Change • Needs assessment: • Opiate use rates • Overdose death rate • Treatment access • Cost of care • Use of medication • Planning process: • Physician data • Cost benefit analysis • Insurance eligibility • Treatment capacity

9. Data as Foundation for Change • Performance Measurement: • Budget modification approval time • Payment processing time • Induction of patient processing time • Mental health screenings and assessments • HIV testing • Transfer processing time • Outcomes of treatment • Evaluation of BBI

10. Recent Focus: Levers of Change • BBI utilizes the intra-organizational and inter-organizational levers to implement change: • Intra-organizational data collection to identify and understand challenges • Inter-organizational collaboration to problem-solve and implement solutions

11. Standardized Care • Challenge: Lack of consistent knowledge about buprenorphine treatment and goals of BBI among patients and staff • Walk-throughs - Inconsistent messages to patients at intake and orientation re: BBI model of care • Patient focus group

12. Standardized Care • Solutions: • BBI Provider Roundtable • Development of Clinical Guidelines with required BBI tools • Quality improvement measurement • Staff training • Orientation video • BBI Summit • Nursing training September 2009 • Dissemination of clinical guidelines

13. Retention in Treatment L L L L • Challenge – 90 day retention: (%)

14. Retention in Treatment • Additional Data: • Focus group findings • Survey of current and former patients • Retention data by length of time in treatment

15. Retention in Treatment • Solutions: • Clinical guidelines with induction and maintenance protocols – training for doctors and nurses • New models • Low threshold office-based • Low level OP • ICF/HW • Long-term residential • Motivational interviewing & incentives • Mental health continuing care

16. Transfer Process LL LL L L L L L L L L L L lllllllllL • Challenge: Days before transfer 289 days (May 2009)

17. Transfer Process • Additional data collection/analysis to understand factors • Patient transition across levels of care • Opiate positives; other drug use • Frequency of take home medication • Insurance status • Other factors (counseling compliance, etc.)

18. Transfer Process • Solutions: • Transfer disposition form & meetings at 30 day intervals • Clinical consultation for patients in treatment more than 120 days • Increase outreach to ensure patients continue in counseling after transfer • Identified continuing care providers to accept patients with mental health problems and poly-substance use

19. Dissemination • Challenge – Limited use of buprenorphine outside of Baltimore City despite state funding • Solution: • Offer BBI educational session for selected high need jurisdictions and follow-up individual consultation • Distribute BBI Clinical Guidelines • BSAS NIATx Coach position (City dissemination)

20. Future Focus: Levers of Change • BBI will utilize the following levels for the implementation, spread and diffusion of the BBI goals: • Regulatory • Financial Analysis

21. New Reimbursement Regulations • Challenges: • City block grants funds are being redirected to expand Maryland Primary Adult Care (PAC) benefits and increase Medicaid reimbursement rates for substance abuse treatment • Proposed PAC regulations and Medicaid reimbursement rates may not be sufficient to support costs • No current PAC regulations for buprenorphine services at treatment programs • Many treatment programs lack contracts with Medicaid MCO’s and billing capacity; and historical difficulty getting paid for services • Role of BSAS/BBI as funder will change, and could impact patient access to treatment and quality of care

22. New Reimbursement Regulations • Solutions: • BSAS and treatment providers on new Medicaid subcommittee to draft regulations for buprenorphine treatment, and State legislative substance abuse workgroup to plan future structure for substance abuse services in Maryland • BSAS hired consultant to increase provider Medicaid billing capacity • BSAS Board of Directors advocacy • BSAS planning underway to proactively respond to changes

23. Baltimore AR Project Questions and Answers