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

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

• Baltimore has a storied history of heroin addiction

• Most addicted individuals are not in treatment

• Treatment capacity is inadequate to meet demands

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

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

• 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 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

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

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

Leadership for Change

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

• 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

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

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

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”

Principles of

Implementation

Keep Your Eye on the Big Picture

• City’s mission: treatment-on-demand

• Focus on the patient

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

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

• 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

• 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

Expert Advisory Group

Expert MDs to consult with practitioners

• Dosing

• Counseling

• Prescribing practices

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

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

One project can teach you about

the strengths and weaknesses of the entire system