1. Baltimore Buprenorphine Initiative Advancing Recovery Project Baltimore City, Maryland January 14, 2010

2. Agenda Overview of AR Project Greatest Achievements Since Tucson – Transfers to Continuing Care Lessons Learned Sustaining Change Efforts Human Impact

3. 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.

4. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. Data: Number of Patients Transferred

12. Data: Number of Days Before Transfer

13. Data: Reasons Why Clients Did Not Transfer 120 Days in Tx150 Days in Tx180 Days in Tx Still Using Opioids27%29%27% Not independent with prescription19%11%27% Insurance18%22%9% Still using other substances14%15% 0% Not coming to group regularly12%4%10% Hospitalization7%8% 0% Pending discharge2%11%18% Not taking buprenorphine regularly1% 0% Mental health impacting treatment 0% 9%

14. Number of Clients Still in Counseling after Transfer

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Baltimore Buprenorphine Initiative Questions? For more information later, contact: Bonnie Campbell Baltimore Substance Abuse Systems bcampbell@bsasinc.org 410-637-1900 x252