Baltimore Buprenorphine Initiative

Advancing Recovery ProjectBaltimore 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

Data: Number of Patients Transferred

Average Number of Patients Transferred Per Month

1.4 1.5

0.5

1.8 1.9 2 1.9

1.4 1.4

3.5

4.44

2.9

4.4

3

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

June

2008

July

2008

Aug 20

08

Sept 2

008

Oct 20

08

Nov 20

08

Dec 200

8

CHANGE

April

2009

May

2009

June

2009

July

2009

Aug 20

09

Sept 2

009

Oct 20

09

Nov 20

09

Date

# of

Pat

ient

s T

rans

ferr

ed

Data: Number of Days Before Transfer

LOS in Treatment before Transfer to Continuing Care

148 145

201 193212

240

215

253

289

243

209 212 206

235

177

137

0

50

100

150

200

250

300

June

Ju

ly Aug

Sept

Oct Nov

Dec

Chang

eM

ar

April

May

Ju

ne July

AugSep

tOct

Nov

Date

# of

Day

s in

Tx

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

83%89%

76%

100%

0%

20%

40%

60%

80%

100%

91-120 Days 121-150 Days 151-180 Days > 180 Days

Number of Days in Treatment Upon Transfer

% o

f P

atie

nts

Ret

aine

d in

C

ouns

elin

g

30 Days Retained in Counseling Post 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 poly-substance 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 CampbellBaltimore Substance Abuse Systemsbcampbell@bsasinc.org 410-637-1900 x252