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) ARC receives a PI Grant from the Maine Office of Substance Abuse (OSA) Objectives: Objectives: Learn Rapid Cycle Process Improvement. Learn Rapid Cycle Process Improvement. Use these tools to decrease client wait times and increase client retention in treatment. Use these tools to decrease client wait times and increase client retention in treatment. Report your data and share your experiences. Report your data and share your experiences.

STAR SI ARC Business Case Wait Times Are Down 77% From Baseline

STAR SI ARC Business Case IOP Volume Is Up 205% Over Baseline

STAR SI ARC Business Case Medicaid Net is up 53% Over Baseline 3’rd Party and Private Net Is Up 50% Over Baseline

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: The RWJF and Maine OSA investment in Performance/Process Improvement has provided ARC three key assets which enable larger systems change: 1. Tools to manage change. 2. Experience being successful. (Access and Retention) 3. Institutional Credibility.

November 2006 We still had an opiate problem! We still had an opiate problem! Needed to make a big change! Needed to make a big change!

November 2006 Implement Medication Assisted Treatment (MAT) for opiate addiction. Implement Medication Assisted Treatment (MAT) for opiate addiction. Not with 20 consumers, but 400. Not with 20 consumers, but 400. We needed a PLAN! We needed a PLAN!

Key Activities Form team to work on needs, barriers, staffing model. Form team to work on needs, barriers, staffing model. Complete draft of “Mission Fit” and “Business Case.” Complete draft of “Mission Fit” and “Business Case.” Within Maine AR Group, borrow model from Aroostook Mental Health Center. Within Maine AR Group, borrow model from Aroostook Mental Health Center. Present business plan to Hospital Administration. 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. ARC took a 4 month snap shot to trend volumes of clients seeking treatment for opiate dependence. On average callers per month request Suboxone assisted treatment. On average callers per month request Suboxone assisted treatment. Of 15 assessments Dx. with opioid dependence in Jan. and Feb Of 15 assessments Dx. with opioid dependence in Jan. and Feb Five have admitted to treatment programs and are involved in MAT. Five have admitted to treatment programs and are involved in MAT. Those not admitted did not access MAT Those not admitted did not access MAT Anticipated volume of new ARC clients per year is clients Anticipated volume of new ARC clients per year is clients

Community Response-Mission Fit

Community Response-Business Case The 115 patients treated by programs in Westbrook equate to the current volume of ARC Intensive Outpatient Programs (IOP). 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. Absorbing this volume equates to an additional 2,300 IOP treatment days per year for ARC. The funding mix from this population is: 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. 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. 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. 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. 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. This 300 patient buffer exists to assure optimal pt. care and to avoid overwhelming resources.

Community Response-Business Case (Cost) FTE’sSalaryFringeG&A Total Cost 1.75$72,800.00$24,024.00$18,493.38$115, MD Contracts 8 $100/hr. $41, $7, $7, $49, $49, Equipment Auto BP Cuff 2 Couches Exam Table $2, $2, $ $ $ $ $ $ Total Cost $169,730.98

Community Response-Business Case (Revenue) ServiceCodeDeliverableVolumeChargeGrossNet Induction Office Visit-New 60 min ,60012,420 Induction Office Visit-New min ,20011,340 Subsequent Visits Med Management ,85218, Office Visit 15 min 67956,3652, Office Visit 25 min ,3753,768 ARC Treatment IOP hrs/day 2-5 days/wk ,600155,520 OP Group min. 1x/wk ,44024,948 Assessment min. multi-axial ,400 Totals gross *.45 MeCare Contracts 521,065234,479

Post Implementation Access/Increased Admissions Access to Buprenorphine services has sustained a 20% increase in New Business. Access to Buprenorphine services has sustained a 20% increase in New Business.

Post Implementation Access/Engagement Admission Conversion rates for opioid addicted clients are up 60% over baseline. Admission Conversion rates for opioid addicted clients are up 60% over baseline.

Post Implementation Retention/Increased Continuation Cumulative Measure of active cases by month

Post Implementation Pit Falls Access for new bup. pts. is decreasing Access for new bup. pts. is decreasing Bottlenecks in maintenance apt. schedule begin drive access for new patients. Bottlenecks in maintenance apt. schedule begin drive access for new patients. Deviation from practice standards to accommodate rapid pace Deviation from practice standards to accommodate rapid pace Work-arounds that compromise pt. and public safety. Work-arounds that compromise pt. and public safety.

Business Case MAT Groups Increase induction access through use of MAT management groups Increase induction access through use of MAT management groups

Business Case MAT Groups Used PDCA cycles to pilot one group for 8 wks. Used PDCA cycles to pilot one group for 8 wks. Better use of multidisciplinary team approach Better use of multidisciplinary team approach Consistent application of standard of care Consistent application of standard of care Replicate intervention with two 1.5 hour groups per week. Replicate intervention with two 1.5 hour groups per week. 2 groups per week takes 12 hours per month vs hours per month for MD to see same case load individually. 2 groups per week takes 12 hours per month vs hours per month for MD to see same case load individually. 2 groups per week absorbs 112 encounters per month. 2 groups per week absorbs 112 encounters per month. Increase monthly average from 8 to 16 inductions. Increase monthly average from 8 to 16 inductions. Increase monthly average from 2 to 7 psychiatric evaluations. Increase monthly average from 2 to 7 psychiatric evaluations. Will result in increase revenues in the amount of $41, per year-NET. Will result in increase revenues in the amount of $41, per year-NET.

Access-Patients Drive ARC Continuum of Care Design

Business Case-Room to Breathe Greater self-reliance during times of social service cuts and legislative unpredictability. 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. 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.

Key System Changes Integrate suboxone services within ARC continuum of care. Integrate suboxone services within ARC continuum of care. Bring physicians on-site, single standard of care, improve communication, decrease staff load. Bring physicians on-site, single standard of care, improve communication, decrease staff load. Working with recovery community to change attitudes. Working with recovery community to change attitudes. Focus groups, presentations, well clients. Focus groups, presentations, well clients. Maximize billing as the result of State/Payer change projects. 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. Work with the Maine formulary committee to reduce stigma and assure access to buprenorphine products.

 Payer/Provider Partnerships Support for rapid cycle change approach. Support for rapid cycle change approach. State wants to know barriers to MAT implementation. State wants to know barriers to MAT implementation. Access Access Flexibility Flexibility Advocacy and Credibility Advocacy and Credibility Operational relief Operational relief Licensing regulations Licensing regulations