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Service Delivery Innovation Profile

Community Partnerships and Provider Training Increase Service Capacity and Access to Long-Term Treatment for Individuals With Heroin Addiction


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Snapshot

Summary

The Baltimore Buprenorphine Initiative expands access to long-term heroin and opioid addiction treatment by developing partnerships between medical facilities, substance abuse treatment centers, and social service agencies, and through training and certification of physicians to administer buprenorphine treatment. The program has enhanced access and adherence to long-term buprenorphine treatment, increased the number of trained and certified physicians and treatment programs, and facilitated access to health insurance coverage.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the amount and type of services provided, the number of trained providers, and the capacity of substance abuse treatment centers. The underlying assumption is that, in the absence of this program, patients would not have had access to such treatment, and providers would not have increased their capacity to serve.
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Developing Organizations

Baltimore City Department of Health; Baltimore Healthcare Access, Inc.; Baltimore Substance Abuse Systems, Inc.; Mid-Atlantic Association of Community Health Centers; Open Society Institute
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Use By Other Organizations

Providers and practitioners from other states have requested and are using the program's clinical guidelines. In addition, the program model and components have been disseminated to several other states through a Robert Wood Johnson Foundation Advancing Recovery Grant.

Date First Implemented

2006
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Patient Population

Vulnerable Populations > Substance abusers; Urban populationsend pp

Problem Addressed

Untreated heroin and opioid addiction leads to the spread of infectious diseases, medical complications, and death. Although new treatments are available, a shortage of trained prescribing physicians and inadequate operating procedures limit access to long-term care.1-5
  • Prevalence of heroin use and addiction: An estimated 3.7 million people have used heroin at some time in their lives, 153,000 in 2007 alone.1 More than 10,000 Baltimore residents were admitted to drug treatment programs for heroin treatment in 2006.2 In 2009, 64 percent of patients admitted to drug treatment programs in Baltimore reported heroin as their primary (56 percent), secondary (6 percent), or tertiary (2 percent) drug of abuse.
  • Significant consequences of untreated addiction: Heroin is highly addictive and its use spreads infectious diseases such as human immunodeficiency virus (HIV), and can cause medical complications and death.3 Approximately 150 people die each year in Baltimore from overdoses involving heroin.4
  • Available, effective treatment: In 2002, the U.S. Food and Drug Administration (FDA) added buprenorphine to the list of approved medications for heroin and opioid addiction. The combination of buprenorphine and naloxone has been found to be safe and effective in reducing cravings, heroin use, and the likelihood of overdose.5 Individuals who receive treatment for heroin addiction are less likely to require hospitalization or urgent care than those not in treatment.6
  • Limited access to long-term treatment: Before 2000, medications for heroin addiction could only be dispensed in a traditional opioid treatment program (i.e., a methadone clinic). The Drug Addiction Treatment Act of 2000 expanded treatment options by allowing qualified physicians to dispense or prescribe approved medications in other treatment settings, including their own offices.7 Although this legislation was intended to promote access, the demand for heroin and opioid treatments still exceeds supply in many areas, including Baltimore, where physicians lack training related to prescribing this medication and community health providers lack the experience and resources needed to offer such treatment.5 Although long-term treatment has been found to be most effective, service duration tends to be shortened when service capacity is insufficient.8

What They Did

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Description of the Innovative Activity

The Baltimore Buprenorphine Initiative seeks to expand access to long-term heroin and opioid addiction treatment by developing partnerships between medical facilities, substance abuse treatment centers, and social service agencies, and by training and certifying physicians to administer buprenorphine treatment. Key program elements are described below:
  • Multiagency leadership: Three agencies work together to oversee program operations: the Baltimore City Health Department, Baltimore Substance Abuse Systems, Inc., and Baltimore Healthcare Access, Inc. (More information on their respective roles can be found in the Planning and Development Process section.)
  • Promoting access to health insurance: Program staff from Baltimore Healthcare Access, Inc., who have specialized knowledge and experience in working with insurers, help patients assess their income and eligibility status and apply for insurance, and then work to expedite the processing of applications. Once insurance coverage takes effect, staff members counsel patients on their choices in selecting a physician and understanding all aspects of their insurance plan.
  • Partnerships with treatment programs for long-term, stage-wise care: The program has partnerships with substance abuse treatment programs and medical facilities to provide access to long-term treatment for patients. Previously, the planned duration of buprenorphine treatment was only 3 to 10 days.
    • Initial counseling and therapeutic services: The substance abuse treatment centers work with patients in the early stages of care to provide individual and group counseling and other therapeutic services, including the initiation of buprenorphine treatment if indicated.
    • Transfer to continuing care provider: Once providers at the center determine that a patient has been stabilized (as indicated by negative drug tests, consistent adherence to the prescribed medication regimen, and regular attendance at counseling sessions) and has insurance coverage, the medical portion of their care (the buprenorphine treatment) transfers to a continuing care provider at a medical facility, such as a primary care physician in a community health center, a psychiatrist at a mental health center, or a physician in an HIV clinic. After this transfer, patients continue to receive counseling for an additional 3 months and case management for up to 6 months through the substance abuse treatment program.
    • Low-intensity program: The program offers a low-intensity treatment program that places greater emphasis on comprehensive case management services and less emphasis on outpatient counseling. This service allows the program to reach a larger number and range of individuals.
  • Social service agency partnerships for high-risk individuals: The program partners with social service agencies to provide high-risk individuals with faster access to buprenorphine treatment. For example, the initiative established a protocol with Power Inside, a community-based organization that provides outreach and case management services to female sex workers. Women referred from this agency receive priority access to program services.
  • Special needs partnerships: The initiative partners with a number of social and medical services agencies to meet the special needs of those with heroin and opioid addiction. For example, the initiative has partnered with mental health centers (to promote the recovery of those with co-occurring disorders), HIV clinics, and long-term residential treatment services (to assist individuals with multiple addictions).
  • Physician training and certification: Physicians must complete a free, online 8-hour training course to administer buprenorphine. Physicians who wish to provide such treatment in an outpatient setting must apply for a waiver and receive approval from the Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA). The program pays for physician training and helps physicians submit their training credentials to meet the waiver requirements.
  • Facilitation of care coordination: The program uses several procedures to facilitate care coordination, including:
    • Regular meetings: Providers meet every other month to discuss patient care, share information, and discuss programmatic issues.
    • Monitoring through forms and database: The program distributes forms to help physicians monitor whether patients are receiving ongoing counseling or other therapeutic services through the substance abuse treatment programs. A program database tracks patients who receive buprenorphine treatment through substance abuse treatment programs and medical facilities. The database not only facilitates care coordination, but also allows the production of biweekly reports on service utilization, which are summarized in quarterly newsletters that go out to partners and participating programs.
    • Clinical guidelines: The program publishes and distributes clinical guidelines to all participating provider sites to help them standardize and improve care. The program's clinical guidelines were revised in June 2013. The revised guidelines include new information on the use of generic buprenorphine and naloxone tablets and includes revised project forms for release of confidential information, Spanish-version of the consent for treatment, and a revised drug testing policy. In May 2013, the project released two new clinical guidelines including “Clinical Guidelines for Continuing Care Physicians in the Baltimore Buprenorphine Initiative” and “Clinical Guidelines for the Use of Benzodiazepines Among Patients Receiving Medication-Assisted Treatment for Opioid Dependence”. The project also revised and reprinted an educational pamphlet for patients titled “Methadone and Buprenorphine Treatment for Pregnant Women.” These documents and other project resources are contained on the project website at www.bsasinc.org.
    • Community of practice Web site: Physicians, nurses, treatment program administrators, counselors, and agency staff involved with the initiative use this Web site to share information and resources about the program and buprenorphine treatment in general. The site encourages information exchange in a professional forum and provides a link between treatment program clinicians and community-based continuing care providers.
    • Integrated team-based care plans: Information provided in May 2012 indicates that these plans detail formal and informal procedures used to improve communication among medical and counseling staff. Formal interdisciplinary team meetings, informal staff “huddles,” and the use of electronic health records are some of the new methods being used by programs to respond quickly and in a coordinated manner to patients who are new in treatment and patients who are experiencing difficulties with medication, drug use, family problems, etc.
    • Manageable caseloads: The program reduced physician and nursing caseloads in 2012 so that these positions could take on expanded duties and have more intensive and frequent contact with both patients and counseling staff. Nurses are now more involved with case management, and physicians have a greater role in coordinating care for patients with co-occurring medical and mental health problems. In addition, physicians and nurses participate in team meetings and treatment planning to a greater degree.
  • Information management: The program revised its data dashboard report in 2012 to better track the achievement of program goals. On a quarterly basis, the revised reports shows the number of active patients, the number discharged patients, reasons for discharge, length of stay (goal is within 90 days), and number of days between patients' first visit to treatment program and first dosage of buprenorphine (goal is within 2 days). The program also revised its monthly case management data report; data is tracked on number of patients who were uninsured at the time of admission, number of patients who obtained health insurance, number of days to obtain insurance, number of days prior to patients being transferred to continuing care, and percentage of patients staying in continuing care for 6 months or more.
  • Patient videos: The program created two educational videos for patients. One video is an overview of the program for new patients, and the other video is about transition to continuing care for patients who are stabilized and preparing to begin receiving their buprenorphine prescriptions from a community physician rather than the substance abuse treatment program physician. The videos are informative and consist primarily of actual patient feedback on experiences in the program.

Context of the Innovation

After the FDA's 2002 policy changes (described earlier), leaders of the Mid-Atlantic Association of Community Health Centers (a primary care association) and the Baltimore Health Centers met with representatives from the Open Society Institute–Baltimore to discuss opportunities to increase the capacity and effectiveness of substance abuse services in Baltimore by engaging and mobilizing the existing community health care system. These stakeholders initiated a variety of early efforts to enhance access to buprenorphine treatment, including pilot testing of clinical protocols, provider training programs, and the development of new infrastructure to serve patients. These early efforts laid the groundwork for the creation of the Baltimore Buprenorphine Initiative.

Did It Work?

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Results

The program has enhanced access and adherence to long-term buprenorphine treatment, increased the number of trained and certified physicians and treatment programs, and facilitated access to health insurance coverage.8
  • Enhanced access, shorter wait times for treatment: At the start of the initiative, 105 patients were receiving buprenorphine treatment. As of February 2011, more than 4,200 patients have accessed buprenorphine treatment as a result of the program. Due to programmatic changes made to scheduling and shifts in physician hours, patients receive buprenorphine no more than 48 hours after initial assessment, with most patients receiving it the same day. Before these changes, individuals typically received their first buprenorphine treatment 7 to 10 days after the initial assessment.
  • High levels of adherence: As of February 2011, 58 percent of participants stayed in treatment for 90 days or more. In addition, 1,141 patients have been transferred to a continuing care provider (for treatment) and 71 percent of these patients have stayed in continuing care for 6 months or longer.
  • More trained and certified physicians, expanded capacity to serve: As of February 2011, more than 250 physicians have signed up for the buprenorphine training course and approximately 60 physicians actively participate as continuing care physicians. The treatment system capacity for buprenorphine services increased fourfold between 2008 and 2011, from 112 to 439 slots, and the number of participating programs has expanded from three at program implementation to nine at present. In addition, a primary care site (part of a Federally qualified community health center) has received funding to provide buprenorphine treatment integrated with primary care.
  • Increased access to health insurance: Over the past 4 years, the program has helped more than 1,300 individuals obtain health insurance and has reduced the processing time needed to assist patients in obtaining such insurance. Applications are now processed within 30 days, which has allowed 83 percent of patients in treatment more than 30 days to have insurance.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the amount and type of services provided, the number of trained providers, and the capacity of substance abuse treatment centers. The underlying assumption is that, in the absence of this program, patients would not have had access to such treatment, and providers would not have increased their capacity to serve.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Assessing system capacity: In 2002, Mid-Atlantic Association of Community Health Centers received a planning grant from the Open Society Institute-Baltimore to conduct an analysis of substance abuse treatment in Baltimore. This assessment provided an indepth understanding of the availability of services and their funding sources.
  • Pilot testing: With support from the Open Society Institute, the Mid-Atlantic Association of Community Health Centers provided technical assistance to six community health centers over a period of 5 years to initiate or expand addiction services, including the administration of buprenorphine treatment. These efforts laid the foundation for the Baltimore Buprenorphine Initiative.
  • Provider training: After finding that providers appeared reluctant to incorporate substance abuse treatment into primary care settings, program leaders in 2004 commissioned Med Chi, the Maryland Medical Society, to conduct a study to better understand the needs of physicians transitioning their practice to include buprenorphine treatment. The study highlighted the need for upfront and ongoing training; adequate reimbursement for services; better ties to substance abuse, mental health and community services; and support with administrative issues. Initiative leaders developed a number of training programs to address these concerns and support physicians in their new role as continuing care providers.
  • Launching city-wide effort: Building on these early efforts, the new Baltimore City Health Commissioner launched the Baltimore Buprenorphine Initiative as a citywide effort in 2006, with a vision that embraced mobilizing the city's strong community health provider system and making medication available as part of the comprehensive services offered.
  • Clarifying partner roles: The three primary partners established clear roles for their collaboration, with the Baltimore City Health Department taking charge of recruiting physicians to administer buprenorphine treatment; Baltimore Substance Abuse Systems, Inc. taking responsibility for providing guidance and overseeing contracts with the substance abuse treatment programs; and Baltimore Healthcare Access, Inc. taking charge of working with health insurers to expedite applications and coordinating care between substance abuse treatment programs and medical facilities. In addition, The Mid-Atlantic Association of Community Health Centers took responsibility for providing ongoing technical assistance.

Resources Used and Skills Needed

  • Staffing: In the first year, the three implementing agencies hired staff to plan and carry out the initiative. The Baltimore City Health Department hired a part-time consultant to lead outreach efforts and oversee the development of clinical protocols; the Baltimore Substance Abuse Systems, Inc. designated a program coordinator; and Baltimore Healthcare Access, Inc. hired a social worker and part-time graduate student. Since that time, staffing has increased to include six treatment advocates who help individuals obtain insurance, conduct additional outreach efforts, and assist patients when transferring from the treatment program to a continuing care physician.
  • Costs: According to data provided in February 2011, annual operating costs in the fourth year of the program totaled approximately $1,900,000, including $1,230,000 for buprenorphine treatment. Other major costs include case management ($400,000), medication ($147,000), drug testing ($60,000), primary care services ($50,000), and physician training ($15,000).
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Funding Sources

City of Baltimore, Baltimore, Maryland; Open Society Institute; Annie E. Casey Foundation
A number of private foundations supported early efforts that laid the groundwork for this initiative, including the Abell Foundation, Herbert Bearman Foundation, Zanvyl and Isabelle Krieger Fund, and the France-Merrick Foundation. In the first year of the program, the city of Baltimore provided $125,000 to assist with implementation, while the Annie E. Casey Foundation provided $60,000 to cover four evaluations of the cost-effectiveness of buprenorphine treatment. The Open Society Institute–Baltimore has provided approximately $200,000 in grants to support the program, due largely to assistance from the Harry and Jeanette Weinberg Foundation. According to information provided in February 2011, the majority of current funding is provided through state block grants and city grant funds. The Robert Wood Johnson Foundation has supported dissemination of the program through an Advancing Recovery Grant.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Establish supportive leadership: Commitment to mission and collaborative relationships proved to be essential to developing and implementing the program. Support for this initiative came from leadership in participating agencies and from the former mayor of Baltimore (now the governor of Maryland) and other elected leaders in Baltimore and throughout the state.
  • Engage providers with ongoing training and technical assistance: Divide outreach and training responsibilities among partner agencies, using existing relationships and expertise. For example, the Baltimore City Health Department reached out to physicians by sending letters to hospital executives, conducting presentations at hospitals and other medical facilities, and working one-on-one with medical administrators to develop action plans for their involvement in the initiative. They also provided clinical training and hands-on technical assistance to engage providers. Assuring physicians that patients will still receive therapeutic services from substance abuse treatment programs also encourages their participation.
  • Develop protocols for collaborative work: As noted previously, various committees developed protocols to facilitate and coordinate the collaborative work. For example, a standardized protocol was created for when and how to transfer stable patients to a medical facility, and for how to limit illicit diversion of buprenorphine. These protocols have been updated to reflect changes and updates in medication formulation and scientific knowledge.

Sustaining This Innovation

  • Develop funding mechanisms: The program has employed a number of mechanisms to secure long-term funding, including reallocating funds initially targeted for short-term detoxification services and expediting insurance applications. In addition, program leaders have worked to expand coverage through public assistance programs. For example, Baltimore Healthcare Access, Inc. developed a fund to assist patients who cannot afford their medication copayments and worked with public programs to cover aspects of service delivery for which there was no previous reimbursement mechanism (e.g., drug testing conducted in community health centers). As a result of these efforts, the state's Primary Adult Care Program and Medicaid/HealthChoice Program began covering outpatient and methadone substance abuse treatment services as part of its benefit package as of January 1, 2010.
  • Monitor results and provide feedback to keep partners engaged: Collect and analyze data on an ongoing basis, and create regular reports on service utilization to share with partners and other stakeholders. Such feedback helps to keep these stakeholders engaged in the program.

Use By Other Organizations

Providers and practitioners from other states have requested and are using the program's clinical guidelines. In addition, the program model and components have been disseminated to several other states through a Robert Wood Johnson Foundation Advancing Recovery Grant.

Additional Considerations

The Baltimore Buprenorphine Initiative received an Innovative Practice Award from the National Association of County and City Health Officials in 2009. This initiative also received an Innovation Award (iAward) from NIATx and the State Associations of Addiction Services in July 2010.

More Information

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Contact the Innovator

Bernard McBride
President/CEO
Behavioral Health System Baltimore
(formerly Baltimore Substance Abuse Systems, Inc.)
One North Charles Street
Suite 1600
Baltimore, MD 21201
(410) 637-1900, x 211
E-mail: bmcbride@bhsbaltimore.org

Innovator Disclosures

Mr. McBride has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The program updated its Web site in 2012; it now contains new patient videos, revised clinical guidelines, an updated treatment program list, and other resources and information. See http://www.bsasinc.org and http://bbi.bsasinc.org/ for more information.

Footnotes

1 Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343; 2008. Available at: http://www.oas.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm.
2 State of Maryland, Department of Health and Mental Hygiene, Alcohol and Drug Abuse Administration. Outlook and Outcomes for Maryland Substance Abuse Prevention, Intervention, and Treatment, State of Maryland, 2006. Available at: http://adaa.dhmh.maryland.gov/Documents/content_documents/OandO/OandO2006.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
3 Institute of Medicine. Federal Regulation of Methadone Treatment, (1st ed). Washington DC: National Academies Press; 1995.
4 Baltimore City Health Department Office of Epidemiology and Planning. Intoxication Deaths Associated with Drugs of Abuse or Alcohol, Baltimore, Maryland; January 1995–September 2007. Baltimore, MD; January 2008. Available at: http://www.baltimorehealth.org/info/2008_01_24.IntoxicationDeaths.pdf.
5 Baltimore City Health Department; Baltimore Healthcare Access, Inc. & Baltimore Substance Abuse System, Inc. The Baltimore Buprenorphine Initiative. Interim progress report. Baltimore, MD; July 2007.
6 Center for Health Program Development and Management. University of Maryland, Baltimore County. Heroin Addiction Treatment Correlates in Maryland. March 12, 2007. Available at: http://www.hilltopinstitute.org/publications
/Heroin_Addiction_Treatment_Correlates_in_Maryland-Revised_March_12_2007.pdf
.
7 Public Law 106-310.
8 Baltimore Substance Abuse Systems, Inc. The Baltimore Buprenorphine Initiative. Second interim progress report. Baltimore, MD; June 2008.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 11, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 14, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.