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Baltimore Buprenorphine Initiative: A Case Study of System Change Robert P. Schwartz, M.D. Friends Research Institute Open Society Institute-Baltimore. Stakeholders & Leaders. Baltimore City Health Department (BCHD) Joshua Sharfstein, M.D.; Marla Oros, R.N; Vanessa Kuhn

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Baltimore Buprenorphine Initiative: A Case Study of System ChangeRobert P. Schwartz, M.D. Friends Research Institute Open Society Institute-Baltimore

stakeholders leaders
Stakeholders & Leaders
  • Baltimore City Health Department (BCHD) Joshua Sharfstein, M.D.; Marla Oros, R.N; Vanessa Kuhn
  • Baltimore Substance Abuse Systems (BSAS) Adam Brickner; Bonnie Cypull, M.S.W.
  • Baltimore Health Care Access (BHCA) Kathleen Westcoat; Tracey Kodek, Sadie Matarazzo
  • Mid-Atlantic Community Health Center Association Rebecca Ruggles
  • Treatment Providers Tracy Schulden, Wendy Merrick
  • Maryland Medical Society Meena Abraham, M.P.H.
  • Foundations Abell, Annie E. Casey, Bearman, Kreiger, Open Society Institute-Baltimore, & Weinberg
heroin addiction the problem
Heroin Addiction: The Problem
  • Baltimore has a storied history of heroin addiction
  • Most addicted individuals are not in treatment
  • Treatment capacity is inadequate to meet demands
  • Partial opioid agonist
    • Effective in reducing heroin use
    • Longer treatments at higher doses yield better outcomes
    • Good safety profile
  • Available by prescription since Fall 2002
    • Certain restrictions apply
    • MD offices, community health clinics, drug-free outpatient treatment, hospital and STD clinics, needle exchange programs
infuse the health system
Infuse the Health System
  • Community Health Centers: 2002 – 2005
    • Started 90-day detoxes at 4 centers
    • Resistance to longer-term treatment met by compromise
  • Medical Society: 2003 -2004
    • Increase interest in obtaining the “waiver “
    • Educational sessions
    • Surveyed members about barriers
  • Hospital Outpatient Clinics: 2005 -2006
    • Expanded treatment into 4 clinics
formulary approval
Formulary Approval
  • Buprenorphine was included in Maryland Department of Health’s drug formulary (2003) through the effort of CSAT, the State Health Department, Medicaid Program and Alcohol and Drug Abuse Administration
    • Medicaid Program
    • Primary Adult Care Program
    • Ryan White Program
change the treatment system baltimore substance abuse systems bsas
Change the Treatment SystemBaltimore Substance Abuse Systems (BSAS)
  • 6 providers were offering 3- 10 day buprenorphine detox
  • June 2005: Community Health Centers presented outcome data for their 90-day buprenorphine programs
  • BSAS proposed change to a longer-term model
  • August 2005: BSAS convened a provider roundtable
    • Some resistant to change
    • Thought their outcomes were good
data drives the plan
Data Drives the Plan
  • November 2005: New Health Commissioner
  • BSAS presents short-term detox outcome data:
  • Completion rate: 66%
  • 90-day retention: 18%
  • BSAS mandates future migration to longer-term treatment
  • Continue provider roundtable
  • Begin MD meetings
  • Seeks to maximize use of public insurance coverage
  • Reduce the city’s heroin-addiction problem
  • Transform its buprenorphine treatment model from short-term detoxification to longer-term treatment
    • Expand access to effective treatment
      • build on the existing medical system
      • utilize existing public health insurance
    • Improve patient outcomes
coordinating committee change structure
Coordinating Committee: Change-Structure
  • Key lead agencies: BCHD, BHCA and BSAS
  • Each agency had clear role
    • BCHD: recruit physicians, paid for waiver training
    • BHCA: case management, benefits coordination, advocated with state and MCOs, drafted procedures
    • BSAS: treatment, practice guidelines, shifted funding
  • Each agency dealt with its strength
  • Dealt with new issues as they arose
    • Buprenorphine urine test, ID cards for benefits, drug testing for health center, bulk purchasing
provider roundtable preparing to change
Provider Roundtable: Preparing to Change
  • Program directors and BCHD, BSAS and BHCA
  • Decision-making by consensus
  • Minutes distributed
  • BHCA wrote protocols and forms for the providers
    • All documents considered drafts
    • Alleviated strain on providers and delay
  • Counseling and Medication
  • Pharmacy relationships
    • Billing
  • BHCA prepared patients for transfer
  • Patient “passport”
      • MD to MD: Transfer criteria, drug testing, med/psych history, dose, recommended frequency of visits
switch to longer term treatment july 2006
Switch to Longer-term Treatment: July 2006
  • Contract SNAFU needs fixing
  • September 2006: Provider pushback
    • BSAS doesn’t want to dictate to providers
    • Some providers resist longer-term therapy
    • Resist cross-site standardization, case managers, paper work
    • Resolved through leadership & consensus building
  • BCHD & BHCA met with primary care providers
  • 1,367 patients treated
    • 33%: currently enrolled in treatment
    • 25%: transferred to primary care
      • Average of 163 days in drug program prior to transfer
  • 57% retained in treatment at least 90 days
    • Includes patients who wanted shorter-term treatment
    • MTP retention (83%) short-term detox retention (18%)
  • 83 % obtained health benefits
  • 82 new MD “waivers”
keep your eye on the big picture
Keep Your Eye on the Big Picture
  • City’s mission: treatment-on-demand
  • Focus on the patient
chose intervention wisely
Chose Intervention Wisely
  • Scan national environment for evidence-based treatments
    • NIDA Clinical Trials Network, local University researchers, ATTCs
  • Can it impact a major problem?
  • Can it be implemented in stages, if necessary?
  • Can it be implemented with fidelity?
  • Can it be brought to scale?
effective leaders
Effective Leaders
  • Dedicated staff with allocated time
  • Good interpersonal skills
    • collaborative
  • Organized
  • Respected lines of authority
  • Provided technical assistance during change to all players
good communication internal
Good Communication: Internal
  • Provider and MD Roundtables
    • Regularly scheduled, rotated site w/food
    • Respectful and incorporated feedback to build trust
    • Flexible but persistent
    • It became a priority for the providers
    • BHCA prepared documents and organized meeting
    • MDs began to play a more active role in these formerly “drug-free” treatment programs
good communication external
Good Communication: External
  • Get support from community leaders & key stakeholders
    • Mayor, Health Commissioner & Congressman wrote letters to hospital CEOs to get their plan to train MDs
    • Garnered support from legislators and judges
  • Email list-serve updates
  • Release summary reports
  • Press conference
  • Prepare for challenges at every step
use external experts
Use External Experts
  • Expert Advisory Group
  • Expert MDs to consult with practitioners
    • Dosing
    • Counseling
    • Prescribing practices
diversify funding
Diversify Funding
  • Federal, state and local grants
  • Health insurance: Medicaid and state programs
  • Local and national foundations
  • Redirect existing drug treatment money
  • Special populations
    • HIV
    • Criminal justice
    • Social Services
use meaningful incentives
Use Meaningful Incentives
  • Health Centers: free drug testing, patients with benefits, case management
  • Drug Treatment Providers: increased funding, case management, discounted medications through bulk purchasing
  • Physicians: BCHD paid for waiver and training
  • Patients: better treatment, case management, health benefits
lesson learned
Lesson Learned
  • One project can teach you about
  • the strengths and weaknesses of the entire system