1. 1 Advancing Recovery: Baltimore Buprenorphine Initiative Tucson Presentation July 29, 2009 Baltimore Substance Abuse Systems

2. 2 Presentation Agenda Baltimore’s AR Project – Baltimore Buprenorphine Initiative (BBI) Collaborative Evidence-Based Practices Implementation Status / Accomplishments Recent Lever Focus Future Lever Focus

3. 3 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.

4. 4 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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6. 6 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

7. 7 BBI Video

8. 8 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

9. 9 Data as Foundation for Change Performance Measurement: Budget modification approval time Payment processing time Induction of patient processing time Mental health screenings and assessments HIV testing Transfer processing time Outcomes of treatment Evaluation of BBI

10. 10 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

11. 11 Standardized Care Challenge: Lack of consistent knowledge about buprenorphine treatment and goals of BBI among patients and staff Walk-throughs - Inconsistent messages to patients at intake and orientation re: BBI model of care Patient focus group

12. 12 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

13. 13 Retention in Treatment Challenge – 90 day retention: (%) LLLLLL L

14. 14 Retention in Treatment Additional Data: Focus group findings Survey of current and former patients Retention data by length of time in treatment

15. 15 Retention in Treatment Solutions: Clinical guidelines with induction and maintenance protocols – training for doctors and nurses New models Low threshold office-based Low level OP ICF/HW Long-term residential Motivational interviewing & incentives Mental health continuing care

16. 16 Transfer Process Challenge: Days before transfer 289 days (May 2009) L lllllllllL L L

17. 17 Transfer Process Additional data collection/analysis to understand factors Patient transition across levels of care Opiate positives; other drug use Frequency of take home medication Insurance status Other factors (counseling compliance, etc.)

18. 18 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

19. 19 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 Guidelines BSAS NIATx Coach position (City dissemination)

20. 20 Future Focus: Levers of Change BBI will utilize the following levels for the implementation, spread and diffusion of the BBI goals: Regulatory Financial Analysis

21. 21 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

22. 22 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

23. 23 Baltimore AR Project Questions and Answers