maryland-adaa

1. �� Baltimore Buprenorphine Initiative Adam Brickner bSAS President/CEO January 3, 2008

3. System Structure: Three Agency Collaborative Effort Baltimore Substance Abuse Systems, Inc. Substance abuse treatment oversight Baltimore HealthCare Access, Inc. Health insurance assistance Case management services Baltimore City Health Department Training and recruitment of physicians Initiative oversight

4. System Structure :Three Pronged Approach Step 1: Buprenorphine induction at treatment program IOP/OP services provided Step 2: Assistance with obtaining health insurance Transition to primary care/medical system Step 3: Continued buprenorphine therapy in primary care Ongoing counseling and case management

6. Implementation Steps:Substance Abuse Treatment System Forming core group of Initiative coordinators Choosing provider (s) Hold regular provider roundtable meetings Produce written policies and guidance Oversight of buprenorphine providers Swift response to unanticipated problems Patient tracking

7. Implementation Steps:Preventing Medication Diversion Begin with 1 week prescriptions Increase duration of prescription once demonstrated capacity to use buprenorphine appropriately Prescription and medication recall Patients bring medication back for pill count Urine testing Test for continued opioid use and illicit drug use Test for buprenorphine with instant dip stick test at least weekly after take-home prescriptions are started

8. Implementation Steps:Case Management Case worker involved from treatment start Special referral consent signed by patient 1:150 Help with obtaining necessary documentation Help with health insurance application, application tracking, and MCO/PCP selection Facilitate transition to primary care Patient tracking

9. Implementation Steps:Transfer to Primary Care Patient must meet transfer criteria Case worker facilitates transfer to certified PCP Makes appointment with selected PCP Sends transfer summary to PCP before appointment Assures transportation for patient Sets up co-pay vouchers for patient if needed Follow up on PCP visit with patient and PCP Patient tracking

12. Implementation Steps:Primary Care Buprenorphine and medical care provided by PCP Continuation of OP treatment for 3 months post transfer Subsidized urine testing Patient tracking for 6 months post transfer Co-pay voucher system set up with PCPs and pharmacies Free training for all Baltimore physicians

13. 701 entered the Initiative since 10/2006 392 (56%) have remained in treatment for 90+ days 134 of 392 (34%) transferred to a PCP 128 days is average LOS in primary care 25 patients (19%) dropped out post-transfer Baltimore Burprenorphine Initiative: Results to Date (12/31/2007)

14. Lessons Learned (1) Maintenance therapy presents philosophical shift Provider as change-leader Develop written protocols and procedures early Use SAMHSA�s evidence based TIP 40 to develop protocols and procedures Regular provider meetings ensure information exchange Training of treatment providers and PCPs

15. Lessons Learned (2) Case management extremely important - holds system together Ensure open communication between all parties Know MCOs� coding and billing procedures Set specific goals, expectations, and benchmarks

16. Lessons Learned (3) Set up patient tracking system Essential for case-management Allows tracking of goals and benchmarks Anticipate problems and seek solutions Documentation requirements Delay in insurance coverage Medication purchasing and storage Co-pay coverage Urine testing Clinical inconsistencies