Transcript Med Chi Foundation talk on buprenorphine draft slides by Eric C

Baltimore Buprenorphine Initiative
Advancing Recovery Project
Baltimore City, Maryland
January 14, 2010
Agenda
 Overview of AR Project
 Greatest Achievements
 Since Tucson – Transfers to Continuing Care
 Lessons Learned
 Sustaining Change Efforts
 Human Impact
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.
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
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
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.
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
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
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
20
Ju 08
ly
20
0
A
ug 8
2
Se 0 08
pt
20
O 08
ct
20
0
N
ov 8
20
D 08
ec
20
CH 0 8
A
A NG
pr
il E
2
M 00 9
ay
20
Ju 09
ne
20
Ju 09
ly
20
0
A
ug 9
2
Se 0 09
pt
20
O 09
ct
20
0
N
ov 9
20
09
Ju
ne
# of Patients Transferred
Data: Number of Patients Transferred
Average Number of Patients Transferred Per Month
5
4.5
2
1
4.4
4
3.5
3
3
2.5
1.8
1.4
1.9
2
1.5
1.4
Date
4.4
4
3.5
2.9
1.9
1.5
1.4
0.5
0.5
0
Data: Number of Days Before Transfer
LOS in Treatment before Transfer to Continuing Care
289
300
250
201
200
243
215
212
235
212
209
193
206
177
148
150
137
145
100
50
Date
No
v
Oc
t
t
Se
p
Au
g
Ju
ly
Ju
ne
ay
M
Ap
ril
ar
M
Ch
an
ge
De
c
No
v
Oc
t
t
Se
p
Au
g
Ju
ly
0
Ju
ne
# of Days in Tx
253
240
Data: Reasons Why Clients Did Not
Transfer
120 Days in Tx
150 Days in Tx
180 Days in Tx
Still Using Opioids
27%
29%
27%
Not independent with prescription
19%
11%
27%
Insurance
18%
22%
9%
Still using other substances
14%
15%
0%
Not coming to group regularly
12%
4%
10%
Hospitalization
7%
8%
0%
Pending discharge
2%
11%
18%
Not taking buprenorphine regularly
1%
0%
0%
Mental health impacting treatment
0%
0%
9%
Number of Clients Still in Counseling
after Transfer
Retention in Counseling After Transfer to Continuing Care
30 Days Retained in Counseling Post Transfer
% of Patients Retained in
Counseling
100%
100%
89%
83%
76%
80%
60%
40%
20%
0%
91-120 Days
121-150 Days
151-180 Days
> 180 Days
Number of Days in Treatment Upon Transfer
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
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
Process Improvements
 Enhanced physician education
 Nurses buprenorphine training conference
 Identified continuing care providers to accept
patients with mental health problems and polysubstance use
 In Development:




Counselor Forum training event
Patient Orientation Video
Patient Transfer Video
Patient education materials
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
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
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
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
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
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
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
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
Baltimore Buprenorphine Initiative
Questions?
For more information later, contact:
Bonnie Campbell
Baltimore Substance Abuse Systems
[email protected]
410-637-1900 x252