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Stakeholders & Leaders

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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Stakeholders & Leaders

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

  2. 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

  3. 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

  4. Buprenorphine • 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. Goal • 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

  10. Leadership for Change

  11. 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

  12. 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

  13. Protocols • 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

  14. 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

  15. Outcomes • 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”

  16. Principles of Implementation

  17. Keep Your Eye on the Big Picture • City’s mission: treatment-on-demand • Focus on the patient

  18. 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?

  19. Effective Leaders • Dedicated staff with allocated time • Good interpersonal skills • collaborative • Organized • Respected lines of authority • Provided technical assistance during change to all players

  20. 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

  21. 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

  22. Use External Experts • Expert Advisory Group • Expert MDs to consult with practitioners • Dosing • Counseling • Prescribing practices

  23. 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

  24. 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

  25. Lesson Learned • One project can teach you about • the strengths and weaknesses of the entire system

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