Transcript Slide 1 - Nasadad

Division of Alcohol and Drug Abuse Programs
To Bup or not to Bup: was never the question….But rather
how do we best bup?
March 29, 2015
Tony Folland
Vermont SOTA
Vermont Department of Health
Vermont
Population 626,562
1. Northwestern Hub
HowardCenter Chittenden Clinic
Chittenden, Franklin, Addison &
Grand Isle
2. Northeastern Hub
BAART Behavioral Health Services
Essex, Orleans & Caledonia
3. Central Vermont Hub
Central Vermont Addiction Medicine
Washington, Lamoille & Orange
4. Southwestern Hub
Rutland Regional Medical Center
Rutland & Bennington
5. Southeastern Hub
Southeast Regional Comprehensive
Addictions Treatment Center (Habit
OPCO & Brattleboro Retreat)
Windsor and Windham
Brief Evolution of MAT Services
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Late entering MAT services, 1st OTP opened in October
2002
Opened Buprenorphine Induction Hub in 2004
Quickly became #1 nationally in per capita DATA 2000
waivered physicians
Most per capita use of Buprenorphine products…
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2005: Grams per 100,000: 583.56. Next closest was Maine:
324.02, adjusted doses per capita: 82,948 vs. 53,573
3
Vermont Department of Health
Why was buprenorphine so common?
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Vermont Department of Health Alcohol and Drug Abuse Program
(ADAP) was supportive of buprenorphine from the beginning in
2003 due to research at the University of Vermont with
buprenorphine
Committed Medicaid money to cover the cost of treatment
Committed to training MDs/DOs for waivers (500K incentives and
staffing, 350K training)
Vermont first published guidelines for buprenorphine in 2003 with
revisions in 2007, 2010 and 2012 to assist providers in the care of
opioid dependent patients
With one OTP in Burlington, the largest city in VT, buprenorphine
was ideally suited for a decentralized rural state so most opioid
users sought it out
Brooklyn, AATOD 2015
OBOT CONCERNS
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What to do if OBOT patient was not doing well in treatment
due to using illicitly, diverting, missing counseling?
What to do if MD retired, lost license, moved away?
What to do with large programs with 100+ people in OBOT
that were essentially unregulated unlike the OTP programs?
What about increasing access to treatment in OBOT?
What about physicians who did not want to do inductions but
were willing to take people after they were stable?
RESPONSE
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2004-2013 opened Bup Induction Center in Berlin, similar to OBIC
Buprenorphine Practice Guidelines revisions for enhanced care 2003, 2007,
2010, 2012, under review currently
2005-2007: COBMAT training and care management support for
physicians… not so much!!
2010: VT Guidelines for MAT for Pregnant Women
2010: Emergency MAT Rules written, formal adoption 2011 for providers
of 30+ patients. Regulatory structure and ADAP oversight
2011-2012: Hub and Spoke planning process, implementation 2013-2014
statewide
Response continued
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2013-pres. VT Learning Collaborative: 35 OBOT Physician
teams and all Hubs trained using self-selected QI measures,
didactics, training materials and peer support. 9 month
commitment.. Data feedback system to providers
2014-pres: VT Recovery Network Pathway Guides: Specially
trained peers providing supports to individuals receiving MAT
statewide
2014-15: Legislative charge: MAT Rules expansion to cover all
OBOT providers. Under development as we speak…
Vermont Department of Health
Integrated Health System for Addictions Treatment
Corrections
Probation &
Parole
Family
Services
Residential
Services
Spokes
Nurse-Counselor Teams
w/prescribing MD
HUB
Mental
Health
Services
Spokes
Assessment
Care Coordination
Methadone
Complex Addictions
Consultation
Spokes
Substance
Abuse OutPt Treatment
Nurse-Counselor teams
w/prescribing MD
Medical
Homes
Vermont Department of Health
Spokes
In Patient
Services
Pain
Management
Clinics
Care for Complex Addictions – the “Hub”
“HUB”
A Hub is a specialty treatment center responsible for coordinating the
care of individuals with complex addictions and co-occurring substance
abuse and mental health conditions across the health and substance
abuse treatment systems of care. A Hub is designed to do the following:
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Provide comprehensive assessments and treatment protocols.
Provide methadone treatment and supports.
For clinically complex clients, initiate buprenorphine or antagonist
treatment and provide care for initial stabilization period.
Coordinate referral to ongoing care.
Provide specialty addictions consultation and support to ongoing care.
Provide ongoing coordination of care for clinically complex clients.
Vermont Department of Health
Developing The “Hub and Spokes”
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Engaged stakeholders regionally, statewide and within the state system
Introduced concept to community providers and sought participation in
committees
 Pregnant women, Children and Families Workgroup
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Physician Workgroup
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Identify resources, services and connections for women and family supports
Clinically driven algorithm development for matching patients with
pharmacotherapy agents and clinical treatment settings
Guidelines for medical screening and comprehensive assessment
Guideline development for patient structure, if medication other than
Methadone (eg. Daily dosing vs. multitude of OBOT structure options)
Clinical Workgroup
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Behavioral health screening, admission, assessment, and treatment planning
procedures for the hubs
Operationalizing “Health Home” language/definitions with behavioral health
supports (eg. Health Promotion=Treatment and Patient self-management)
Care for Complex Addictions – the “Spoke”
“SPOKE”
A Spoke is the ongoing care system comprised of a
prescribing physician and collaborating health and
addictions professionals who monitor adherence to
treatment, coordinate access to recovery supports, and
provide counseling, contingency management, and case
management services. Spokes can be:
 Blueprint Advanced Practice Medical Homes
 Outpatient substance abuse treatment providers
 Primary care providers
 Federally Qualified Health Centers
 Independent psychiatrists
Vermont Department of Health
Spoke (OBOT physicians with support)
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Polled OBOT physicians regarding most significant
concerns/barriers to expansion or perceptions of
optimal care
Consistent feedback: patients may require more
time/coordination of care than physicians had in
their schedules
Using existing VT Health Home infrastructure
(Blueprint for Health) Community Health Team
model physicians were offered in-office supports
Spokes continued
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Any willing provider
any structure of OBOT provider
New or existing providers
Vermont Department of Health
OBOT Health Home Supports
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ACA funding for 2 FTE, non-billing responsible staff
per 100 patients 90/10 funding split in Spokes
(ACA section 2703 VT SPA)
1 FTE licensed behavioral health provider
1 FTE nurse provider
Any configuration of service providers/service
areas to provide Health Home Services
Vermont Department of Health
The Results so far…..
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80+ nurse and licensed clinicians deployed to
support physician practices
Roughly 2100 Medicaid patients in OBOT providers
Over 65% of all providers ever X waivered in
Vermont still prescribe buprenorphine to Medicaid
patients (roughly 200 waivered since 2002 and
roughly130 prescribed last month)… this
aggregate includes all physicians ever waivered in
VT including retirees, those who left state, etc…
Vermont Department of Health
Department of VT Health Access
VT Department of Health
Start
#
Clients
#
Buprenorphine
#
Methadone
#
Waiting
1/13
936
278
658
278
7/13
394
180
214
67
Habit OPCO / Windsor, Windham
Retreat
7/13
455
129
326
31
West Ridge
Rutland, Bennington
11/1
3
438
164
274
52
BAART NEK
Essex, Orleans,
Caledonia
1/14
500
138
362
51
2723
889
1834
479
Program
Region
Chittenden
Center
Chittenden, Franklin,
Grand Isle & Addison
BAART Central
Vermont
Washington, Lamoille,
Orange
February 2015
Moral of the Vermont Story
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Reasonable regulation, created with providers, doesn’t have to limit access to care!
In fact when a reasonable standard of care is not readily identified, it can be
protective for providers.
Money wasn’t the driver… support and guidance were key.
Develop champions from diverse areas of the field… focus on the process of
change!!
Partner with your partners: DVHA, Blueprint for Health, Pharmacy benefits
administrator, Board of Medical Practice, DEA, Providers, Feds, etc
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Balance access to care with quality of care
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“Nothing about us without us”: providers want to do a good job!
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“I recognize I’m the dumbest person in the room…. And They recognized I’m the
dumbest person in the room”… it levels the playing field!
Medication and treatment structure can be (and should be) 2 different decisions