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

Advancing Recovery:
Baltimore Buprenorphine Initiative
Tucson Presentation
July 29, 2009
Baltimore Substance Abuse Systems
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Presentation Agenda

Baltimore’s AR Project –
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Baltimore Buprenorphine Initiative (BBI)
Collaborative
Evidence-Based Practices

Implementation Status / Accomplishments
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Recent Lever Focus
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Future Lever Focus
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Goals
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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
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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.
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BBI Collaborative
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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
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EBP’s – Medication & Continuing Care
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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
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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
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BBI Video
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Data as Foundation for Change
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Needs assessment:
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Opiate use rates
Overdose death rate
Treatment access
Cost of care
Use of medication
Planning process:
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Physician data
Cost benefit analysis
Insurance eligibility
Treatment capacity
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Data as Foundation for Change
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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
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Evaluation of BBI
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Recent Focus: Levers of Change
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BBI utilizes the intra-organizational and interorganizational levers to implement change:
Intra-organizational data collection to identify and
understand challenges
 Inter-organizational collaboration to problem-solve
and implement solutions
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Standardized Care
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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
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Standardized Care
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Solutions:
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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
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Retention in Treatment
L
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L
L
Challenge – 90 day retention: (%)
Program A
L
Program B
Program C
%of Patients in Treatment for at least 90
Days
100%
92%
90%
86%
80%
80%
68%
70%
62%
60%
56%
55%
50%
65%
61%
51%
50%
53%
48%
40%
30%
57%
40%
40%
34%
20%
20%
10%
0%
Q2 FY '08
Q3 FY '08
Q4 FY '08
Q1 FY '09
Date (quarterly)
Q2 FY '09
Q3 FY '09
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Retention in Treatment
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Additional Data:
Focus group findings
 Survey of current and former patients
 Retention data by length of time in treatment
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Retention in Treatment
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Solutions:
Clinical guidelines with induction and maintenance
protocols – training for doctors and nurses
 New models
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Low threshold office-based
 Low level OP
 ICF/HW
 Long-term residential
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Motivational interviewing & incentives
 Mental health continuing care
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Transfer Process
L
L
L
L
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Challenge: Days before transfer 289 days (May 2009)
L
L
L
305
300
289
281
250
L
233
L
210
208
200
L
264
239
160
L
151
150
146
L
107
100
L
50
L
Date
'0
9
ay
lllllllllL
M
A
pr
il
'0
9
09
ar
'
M
'0
9
Fe
b
'0
9
Ja
n
C
H
AN
G
E
'0
8
N
ov
'0
8
O
ct
08
ep
t'
S
'0
8
A
ug
'0
8
Ju
ly
'0
8
0
Ju
ne
# of Days in Treatment
Prior to Transfer
350
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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.)
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Transfer Process
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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 polysubstance use

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Dissemination
Challenge – Limited use of buprenorphine
outside of Baltimore City despite state funding
 Solution:
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Offer BBI educational session for selected high
need jurisdictions and follow-up individual
consultation
 Distribute BBI Clinical Guidelines
 BSAS NIATx Coach position (City dissemination)
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Future Focus: Levers of Change

BBI will utilize the following levels for the
implementation, spread and diffusion of the
BBI goals:
Regulatory
 Financial Analysis
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New Reimbursement Regulations
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Challenges:
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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
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New Reimbursement Regulations
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Solutions:
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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
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Baltimore AR Project
Questions and Answers
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