Transcript Implementing Medication Assisted Treatment for Opiate Addiction

Addiction Resource Center’s
Experience
Implementing Medication
Assisted Treatment for Opiate
Addiction
The Business Case
April 2005

Addiction Resource Center’s position on the
ever rising opiate addiction problems in Maine.


“We do not know what we are going to do about
the whole opiate thing.”
Our financial outlook was strained.
November 2005
NIATx


ARC receives a PI Grant from the Maine Office
of Substance Abuse (OSA)
Objectives:
Learn Rapid Cycle Process Improvement.
 Use these tools to decrease client wait times and
increase client retention in treatment.
 Report your data and share your experiences.

STAR SI
ARC Business Case
Wait Times Are Down 77% From Baseline
14
12
10
Wait Time OP
8
Wait Time IOP
6
Monthly Average
4
2
Ju
l-0
8
Ja
nu
ar
y- 0
8
Ja
nu
ar
y- 0
7
Ba
se
lin
e
20
06
0
STAR SI
ARC Business Case
IOP Volume Is Up 205% Over Baseline
ARC IOP Volumes 2006-2008
512
452
427 435
427
402 398
372
384
297 305
269 250
256
128
305 297
257
275
199
128
325
391
382 388
367 367
334
443 452
287
262
184
120
8
Ja
n-0
7
n-0
Ja
Ju
rag l-08
e2
00
8
Av
e
Ba
s
eli
ne
20
06
Ma
rch
0
STAR SI
ARC Business Case
Medicaid Net is up 53% Over Baseline 3’rd Party and Private
Net Is Up 50% Over Baseline
Net Revenue
100000
80000
Medicaid
60000
3'rd Party and
Private
40000
20000
0
Q1
2006
Q2
2006
Q3
Q4
Q1
2006 2006 2007
Q2
2007
Q3
2007
A Model for Change

The RWJF and Maine OSA investment in
Performance/Process Improvement has
provided ARC three key assets which enable
larger systems change:
1.
2.
Tools to manage change.
Experience being successful. (Access and
Retention)
3. Institutional Credibility.
November 2006

We still had an opiate problem!

Needed to make a big change!
November 2006

Implement Medication Assisted Treatment
(MAT) for opiate addiction.

Not with 20 consumers, but 400.

We needed a PLAN!
Key Activities




Form team to work on needs, barriers,
staffing model.
Complete draft of “Mission Fit” and
“Business Case.”
Within Maine AR Group, borrow model from
Aroostook Mental Health Center.
Present business plan to Hospital
Administration.
Community Response-Mission Fit

ARC took a 4 month snap shot to trend volumes of
clients seeking treatment for opiate dependence.


Of 15 assessments Dx. with opioid dependence in Jan.
and Feb. 2007



On average 15-20 callers per month request Suboxone
assisted treatment.
Five have admitted to treatment programs and are involved
in MAT.
Those not admitted did not access MAT
Anticipated volume of new ARC clients per year is 100150 clients
Community Response-Mission Fit
Opioid Admits outside ARC Service Area from
w/in ARC Service Area- 2005
115
120
100
80
60
40
20
0
42
47
26
Lincoln
Sagadahoc
N.
Cumberland
Total
Community Response-Business Case



The 115 patients treated by programs in Westbrook
equate to the current volume of ARC Intensive
Outpatient Programs (IOP).
Absorbing this volume equates to an additional 2,300
IOP treatment days per year for ARC.
The funding mix from this population is:
34% private insurance
28% Medicaid
17% Medicare
16% Unfunded
Capacity Planning

20% attrition rate is factored for each change in level of
care. Induction to Med. Management, during IOP
treatment, and from IOP to Aftercare.




Based on national models for suboxone assisted treatment
and three years experience at other Maine Hospital-Based
programs.
Capacity exists for 832 Med. Management visits in first
18 months.
Based upon the data above, we expect to complete 532
Med. Management visits in first 18 months.
This 300 patient buffer exists to assure optimal pt. care
and to avoid overwhelming resources.
Community Response-Business Case
(Cost)
FTE’s
Salary
1.75
$72,800.00
MD Contracts
8 hrs/wk@
$100/hr.
$41,600.00
Equipment
Auto BP Cuff
2 Couches
Exam Table
Fringe
$24,024.00
G&A
Total Cost
$18,493.38
$115,317.38
$7,945.00
$49,545.60
$2,420.00
$1644.00
$804.00
$4868.00
Total Cost
$169,730.98
Community Response-Business Case
(Revenue)
Service
Code
Deliverable
Volume Charge
Gross
Net
Induction 1
99205
Office Visit-New 60 min.
120
230
27,600
12,420
Induction 2
99204
Office Visit-New 45-60 min
120
210
25,200
11,340
Subsequent Visits
90862
Med Management
532
76
40,852
18,218
99213
Office Visit 15 min
67
95
6,365
2,864
99214
Office Visit 25 min
67
124
8,375
3,768
IOP
90853
3 hrs/day 2-5 days/wk.
1536
225
345,600
155,520
OP Group
90853
90 min. 1x/wk.
924
60
55,440
24,948
Assessment
90801
60 min. multi-axial
120
100
12000
5,400
521,065
234,479
ARC Treatment
Totals gross * .45
MeCare Contracts
Post Implementation
Access/Increased Admissions
Access to Buprenorphine services has sustained a 20%
increase in New Business.
Percentage of New Clients Receiving Medications - by Month
Ave. Per Cent

30%
20%
10%
0%
Basline
Dec
8-Jan
Feb
March
April
May
Month
June
July
Aug
Sept
Oct
Nov
Post Implementation
Access/Engagement

Admission Conversion rates for opioid addicted
clients are up 60% over baseline.
Number attending 1'st treatent session following Opioid
MAT Implementation
40
30
34
29
20
20
5
10
0
# admitted
# attending 1'st tx.
session
Baseline
Post Implementation
Post Implementation
Retention/Increased Continuation
Cumulative Measure of active cases by month
Number of Clients
Number of Clients Prescribed Buprenorphine - by Month
80
60
40
20
0
Baseline
Dec
8-Jan
Feb
Mar
April
May
Month
June
July
Aug
Sept
Oct
Nov
Post Implementation
Pit Falls

Access for new bup. pts. is decreasing


Bottlenecks in maintenance apt. schedule begin
drive access for new patients.
Deviation from practice standards to
accommodate rapid pace

Work-arounds that compromise pt. and public
safety.
Business Case
MAT Groups

Increase induction access through use of MAT
management groups
OV New OV New OV Est. Med Psych O/P Med Psych Psych Psych OV Est O/P
Pt. 60" Pt. 45" Pt. 15" Assess. 60" Mngmt 15" 15" 30" Intrvw MD Pt. 25" Med
Jan
3
8
33
0
0
0
0
2
2 40
Feb
10
10
35
0
0
0
0
2
2 40
March
8
10
56
0
0
0
0
5
0 40
April
2
5
43
0
1
0
0
3
0 15
May
1
10 102
0
0
0
2
3
5 25
June
4
8
72
0
1
0
0
6
5 20
July
3
8 101
0
0
35
0
1
0 22
Aug
Sept
Totals 31
59 442
0
2
35
2 22
14 202
Monthly
Totals
0
88
3 102
4 123
2
71
2 150
0 116
8 178
19
820
Business Case
MAT Groups

Used PDCA cycles to pilot one group for 8 wks.



Better use of multidisciplinary team approach
Consistent application of standard of care
Replicate intervention with two 1.5 hour groups per
week.



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2 groups per week takes 12 hours per month vs. 26.5 hours
per month for MD to see same case load individually.
2 groups per week absorbs 112 encounters per month.
Increase monthly average from 8 to 16 inductions.
Increase monthly average from 2 to 7 psychiatric evaluations.
Will result in increase revenues in the amount of $41,000.00
per year-NET.
Access-Patients Drive ARC
Continuum of Care Design
OP 1:1's and FTE's
Intensive Volume and FTE's
5000
4000
3000
2000
1000
0
4000
2.1
2150
2297
3582
2.1
1679
1.7
1994
1.73
2034
20001.4
2.25
1.53
0
2001
2002
2003
2004
Intensive
2005
2006
2007
2.5
2
1.5
1
0.5
0
20000
12313
15000
99925.50
9690
13249
5.50
13136
5.80
5.23
0
15392
2001
2002
2003
2004
7.5
18008
16710
16912
2002
2003
2004
7.18
6.96
6.72
7.5
13428
19116
17664
20196
2005
2006
2007
2008
0
2001
5.25
Group
4
0
10000
0
6
0.00
2008
7.6
8
2
2005
# FTE's Total
2006
# FTE's OP
OP GRP and FTE's
20000
5.19
11800
5000
One to One
7.6
5.78
12870
10000
# of FTE's Intensive
30000
15566
8
6
4
2
0
2007
2008
Business Case-Room to Breathe


Greater self-reliance during times of social service cuts and
legislative unpredictability.
In spite of flat funding, ARC has reduced the percentage it is
underwritten by state dollars from 60% in SFY 06 to 42% in SFY
09.
ARC Revenue
$1,075,211
$1,200,000
$785,579
$786,386
$953,959
$1,000,000
$800,000
$600,000
$400,000
$200,000
$0
SFY2006
(Baseline)
SFY 2007
SFY 2008
SFY 2009
Key System Changes

Integrate suboxone services within ARC continuum of
care.


Bring physicians on-site, single standard of care, improve
communication, decrease staff load.
Working with recovery community to change attitudes.

Focus groups, presentations, well clients.

Maximize billing as the result of State/Payer change
projects.

Work with the Maine formulary committee to reduce
stigma and assure access to buprenorphine products.
 Payer/Provider Partnerships


Support for rapid cycle change approach.
State wants to know barriers to MAT
implementation.
Access
 Flexibility



Advocacy and Credibility
Operational relief

Licensing regulations