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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 [email protected] 410-637-1900 x252