advancing recovery : baltimore buprenorphine initiative
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Advancing Recovery : Baltimore Buprenorphine Initiative. Tucson Presentation July 29, 2009 Baltimore Substance Abuse Systems. Presentation Agenda. Baltimore’s AR Project – Baltimore Buprenorphine Initiative (BBI) Collaborative Evidence-Based Practices - PowerPoint PPT PresentationTRANSCRIPT
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Advancing Recovery: Baltimore Buprenorphine Initiative
Tucson PresentationJuly 29, 2009Baltimore Substance Abuse Systems
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Presentation Agenda
Baltimore’s AR Project – Baltimore Buprenorphine Initiative (BBI) Collaborative Evidence-Based Practices
Implementation Status / Accomplishments
Recent Lever Focus
Future Lever Focus
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Goals
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 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
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
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
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
Needs assessment: Opiate use rates Overdose death rate Treatment access Cost of care Use of medication
Planning process: Physician data Cost benefit analysis Insurance eligibility Treatment capacity
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Data as Foundation for Change
Performance Measurement:Budget modification approval timePayment processing time Induction of patient processing timeMental health screenings and assessmentsHIV testingTransfer processing timeOutcomes of treatment
Evaluation of BBI
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Recent Focus: Levers of Change
BBI utilizes the intra-organizational and inter-organizational 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
Challenge: Lack of consistent knowledge about buprenorphine treatment and goals of BBI among patients and staffWalk-throughs - Inconsistent messages to patients
at intake and orientation re: BBI model of care Patient focus group
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Standardized Care
Solutions: 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
Challenge – 90 day retention: (%)
86%
62% 65%
48% 40%
61%
34%
51% 50%
40%
57%55%
53%
92%
80%
68%
20%
56%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q2 FY '08 Q3 FY '08 Q4 FY '08 Q1 FY '09 Q2 FY '09 Q3 FY '09
Date (quarterly)
%o
f P
ati
en
ts in
Tre
atm
en
t fo
r at
least
90
Days
Program A Program B Program C
L
L
LL
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Retention in Treatment
Additional Data:Focus group findingsSurvey of current and former patientsRetention data by length of time in treatment
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Retention in Treatment
Solutions:Clinical guidelines with induction and maintenance
protocols – training for doctors and nursesNew models
Low threshold office-basedLow level OP ICF/HWLong-term residential
Motivational interviewing & incentivesMental health continuing care
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Transfer Process
Challenge: Days before transfer 289 days (May 2009)
208
107
239
210
281
233
264
160
289305
146
151
0
50
100
150
200
250
300
350
Date
# o
f D
ay
s in
Tre
atm
en
t P
rio
r to
Tra
ns
fer
L
L
L
L
L
L
L
L
L
L
lllllllllL
LL
L
L
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Transfer Process
Additional data collection/analysis to understand factorsPatient transition across levels of care Opiate positives; other drug useFrequency of take home medication Insurance statusOther factors (counseling compliance, etc.)
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Transfer Process
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 poly-substance use
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Dissemination
Challenge – Limited use of buprenorphine outside of Baltimore City despite state funding
Solution: Offer BBI educational session for selected high
need jurisdictions and follow-up individual consultation
Distribute BBI Clinical GuidelinesBSAS 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:RegulatoryFinancial Analysis
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New Reimbursement Regulations
Challenges: 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
Solutions: 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