Transcript Baltimore Buprenorphine Initiative

Baltimore Buprenorphine Initiative:
A Case Study of System Change
Robert P. Schwartz, M.D.
Friends Research Institute
Open Society Institute-Baltimore
Stakeholders & Leaders
Baltimore City Health Department (BCHD)
Joshua Sharfstein, M.D.; Marla Oros, R.N; Vanessa Kuhn
Baltimore Substance Abuse Systems (BSAS)
Adam Brickner; Bonnie Cypull, M.S.W.
Baltimore Health Care Access (BHCA)
Kathleen Westcoat; Tracey Kodek, Sadie Matarazzo
Mid-Atlantic Community Health Center Association
Rebecca Ruggles
Treatment Providers
Tracy Schulden, Wendy Merrick
Maryland Medical Society
Meena Abraham, M.P.H.
Foundations
Abell, Annie E. Casey, Bearman, Kreiger, Open Society Institute-Baltimore, & Weinberg
Heroin Addiction: The Problem
• Baltimore has a storied history of heroin addiction
• Most addicted individuals are not in treatment
• Treatment capacity is inadequate to meet demands
Buprenorphine
• Partial opioid agonist
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Effective in reducing heroin use
•
Longer treatments at higher doses yield better outcomes
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Good safety profile
• Available by prescription since Fall 2002
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Certain restrictions apply
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MD offices, community health clinics, drug-free outpatient treatment,
hospital and STD clinics, needle exchange programs
Infuse the Health System
• Community Health Centers: 2002 – 2005
•
Started 90-day detoxes at 4 centers
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Resistance to longer-term treatment met by compromise
• Medical Society: 2003 -2004
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Increase interest in obtaining the “waiver “
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Educational sessions
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Surveyed members about barriers
• Hospital Outpatient Clinics: 2005 -2006
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Expanded treatment into 4 clinics
Formulary Approval
• Buprenorphine was included in Maryland Department of
Health’s drug formulary (2003) through the effort of
CSAT, the State Health Department, Medicaid Program
and Alcohol and Drug Abuse Administration
•
Medicaid Program
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Primary Adult Care Program
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Ryan White Program
Change the Treatment System
Baltimore Substance Abuse Systems (BSAS)
• 6 providers were offering 3- 10 day buprenorphine detox
• June 2005: Community Health Centers presented outcome data
for their 90-day buprenorphine programs
• BSAS proposed change to a longer-term model
• August 2005: BSAS convened a provider roundtable
•
Some resistant to change
•
Thought their outcomes were good
Data Drives the Plan
November 2005: New Health Commissioner
BSAS presents short-term detox outcome data:
• Completion rate: 66%
• 90-day retention: 18%
BSAS mandates future migration to longer-term treatment
• Continue provider roundtable
• Begin MD meetings
• Seeks to maximize use of public insurance coverage
Goal
• Reduce the city’s heroin-addiction problem
• Transform its buprenorphine treatment model from shortterm detoxification to longer-term treatment
•
•
Expand access to effective treatment
•
build on the existing medical system
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utilize existing public health insurance
Improve patient outcomes
Leadership for Change
Health
Department
BHCA
Physician
Roundatable
BSAS
Provider
Roundatable
Coordinating Committee: Change-Structure
•
Key lead agencies: BCHD, BHCA and BSAS
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Each agency had clear role
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BCHD: recruit physicians, paid for waiver training
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BHCA: case management, benefits coordination, advocated with state and
MCOs, drafted procedures
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BSAS: treatment, practice guidelines, shifted funding
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Each agency dealt with its strength
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Dealt with new issues as they arose
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Buprenorphine urine test, ID cards for benefits, drug testing for health
center, bulk purchasing
Provider Roundtable: Preparing to Change
• Program directors and BCHD, BSAS and BHCA
• Decision-making by consensus
• Minutes distributed
• BHCA wrote protocols and forms for the providers
•
All documents considered drafts
•
Alleviated strain on providers and delay
Protocols
• Counseling and Medication
• Pharmacy relationships
- Billing
• BHCA prepared patients for transfer
• Patient “passport”
-
MD to MD: Transfer criteria, drug testing, med/psych history, dose,
recommended frequency of visits
Switch to Longer-term Treatment: July 2006
• Contract SNAFU needs fixing
• September 2006: Provider pushback
- BSAS doesn’t want to dictate to providers
- Some providers resist longer-term therapy
- Resist cross-site standardization, case managers,
paper work
- Resolved through leadership & consensus building
• BCHD & BHCA met with primary care providers
Outcomes
• 1,367 patients treated
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33%: currently enrolled in treatment
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25%: transferred to primary care
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Average of 163 days in drug program prior to transfer
• 57% retained in treatment at least 90 days
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Includes patients who wanted shorter-term treatment
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MTP retention (83%) short-term detox retention (18%)
• 83 % obtained health benefits
• 82 new MD “waivers”
Principles of
Implementation
Keep Your Eye on the Big Picture
• City’s mission: treatment-on-demand
• Focus on the patient
Chose Intervention Wisely
• Scan national environment for evidence-based treatments
•
NIDA Clinical Trials Network, local University researchers, ATTCs
• Can it impact a major problem?
• Can it be implemented in stages, if necessary?
• Can it be implemented with fidelity?
• Can it be brought to scale?
Effective Leaders
Dedicated staff with allocated time
Good interpersonal skills
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collaborative
Organized
Respected lines of authority
Provided technical assistance during change to all players
Good Communication: Internal
• Provider and MD Roundtables
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Regularly scheduled, rotated site w/food
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Respectful and incorporated feedback to build trust
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Flexible but persistent
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It became a priority for the providers
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BHCA prepared documents and organized meeting
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MDs began to play a more active role in these formerly “drugfree” treatment programs
Good Communication: External
• Get support from community leaders & key stakeholders
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Mayor, Health Commissioner & Congressman wrote letters to
hospital CEOs to get their plan to train MDs
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Garnered support from legislators and judges
• Email list-serve updates
• Release summary reports
• Press conference
• Prepare for challenges at every step
Use External Experts
Expert Advisory Group
Expert MDs to consult with practitioners
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Dosing
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Counseling
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Prescribing practices
Diversify Funding
• Federal, state and local grants
• Health insurance: Medicaid and state programs
• Local and national foundations
• Redirect existing drug treatment money
• Special populations
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HIV
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Criminal justice
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Social Services
Use Meaningful Incentives
Health Centers: free drug testing, patients with benefits,
case management
Drug Treatment Providers: increased funding, case
management, discounted medications through bulk
purchasing
Physicians: BCHD paid for waiver and training
Patients: better treatment, case management, health
benefits
Lesson Learned
One project can teach you about
the strengths and weaknesses of the entire system