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Greg Warren
The document discusses Baltimore Substance Abuse Systems' (BSAS) efforts to address opioid addiction in Baltimore through expanding access to medication-assisted treatment (MAT) options like buprenorphine and methadone, improving coordination between behavioral health and criminal justice agencies, and developing a recovery-oriented system of care. BSAS aims to ensure high quality substance abuse prevention and treatment services in Baltimore through strategic planning, advocacy, and creating coordinated networks of community-based recovery services.
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Greg Warren
- 1. Treatment and Recovery inAmerica April 10-12, 2012 Walt Disney World Swan Resort
- 2. Accepted Learning Objectives: 1.Define when and how medication-assisted treatment methodologies for successful recovery of opioid addiction should be used. 2. Explain how to improve access and quality of care through strategic planning and community-wide coordination with local and state agencies. 3. Describe behavioral health issues faced by individuals within the corrections system and devise strategies to adequately address these clinical needs after incarceration.
- 3. Disclosure Statement • Allpresenters for this session, Dr. Elinore McCance-Katz and Gregory C. Warren, have disclosed no relevant, real or apparent personal or professional financial relationships.
- 4. Baltimore Substance Abuse Systems,Inc. Nuts and Bolts of Medication Assisted Treatment and System Coordination
- 5. Baltimore Substance Abuse Systems, Inc. BSAS is a quasi-public agency incorporated in 1990. In 1995, BSAS became responsible for the management of the publicly-funded substance abuse treatment and prevention service system. The Chair of the 27-member Board is the Commissioner of Health.
- 6. Baltimore City’s Challenge • Heroin addiction remains high – Treatment capacity falls short of demand despite expansion in treatment system – Estimated 30,000 individuals with opioid dependence – ~4,000 methadone treatment slots – Over 8,000 treatment admissions for opioids in FY 2008 • Consequences from heroin addiction are severe – Crime – Family and community disruption – Medical complications • 1 in 48 Baltimore City residents are living with HIV and/or AIDS
- 7. , . 57% arrested 71% Unemployed in the 50% < $10,000 per yr. past 2 years Characteristics of Clients in 60% Baltimore City Programs 13% male Homeless FY 2010 77% use Treatment tobacco 45% Episodes less than a 12th n = 21,000 grade education 70% between 83% Black, 30-50 years 16% White of age Less than 1% Hispanic
- 8. Neighborhood Factors • 78%felt drugs was a major problem • 31% felt neighborhood was safe to live • 26% felt neighborhood was a good place to find a job • 59% felt living in the neighborhood made it hard to stay out of jail
- 10. BSAS Vision andMission VISION We envision Baltimore as a city with healthy people, thriving families and safe communities. Mission Baltimore Substance Abuse Systems seeks to ensure that Baltimore residents receive high quality and comprehensive services proved to prevent and reduce substance abuse. HOW WE WILL ACHIEVE THIS We do this by planning, advocating for and helping to create coordinated networks of community-based and recovery focused services that build on the strengths and resilience of individuals, families, and communities.
- 11. Concerns for theFuture • Do our citizens have access to care? • Do our citizens receive quality care? • Individualized, continuous, coordinated care is better than disjointed, acute care which ignores the importance of the family and community • Cultural and clinical diversity of services are better than “cookie cutter treatment”
- 12. Key Philosophical Understandings • Pain and suffering are powerful motivators for change • We need to be where people have their motivational moments • Medication assisted treatment provides the time for counseling to work
- 13. Recovery Oriented Systems of Care (ROSC) Networks of formal and informal services developed and mobilized to sustain long- term recovery for individuals and families impacted by substance abuse. “ The act of asking what the patient wants instead of what will be done to the patient.”
- 14. Buprenorphine: 14 Methadone: 13
- 15. What is differentabout buprenorphine?
- 16. Buprenorphine Formulations Buprenex (forpain only) Subutex (for opioid addiction only) Suboxone (for opioid addiction only, with naloxone)
- 17. How long dopeople need to stay on buprenorphine? • Individualized • Studies demonstrate that staying on medication in combination with counseling results in much better outcomes than detox • 50% relapse rate within a year among patients who came off
- 18. Outcomes for TreatmentAs Usual • Of 3,753 admissions to Level I treatment in FY08, 51% retained for 90 days or more • Of 11,013 treatment discharges in FY08, only Prince George’s county had smaller change in substance use • Relapse rates high – In methadone studies, 50-80% relapse within one year after detoxification – 91% of patients receiving buprenorphine for 4 months had relapsed to prescription opioids within 2 months of taper*
- 19. Business Case forBBI in 2006 • Baltimore needs more effective treatment for opioid dependence • Review of literature and studies by UMBC – Medical costs are increased for patients with drug abuse – Opioid addicts on methadone consume far fewer Medicaid resources than addicts who go untreated – Buprenorphine is economically viable alternative in city with limited methadone treatment capacity 19
- 20. Dept of PublicSafety and Correctional Services • Maryland manages the Detention Center – 4,000 inmates • Men have a LOS of 28 days • Women have a LOS of 60 days • Division of Correction – 22,000 inmate population • 12,000 released annually • 9,000 are Baltimore City residents – Over 70% have a diagnosis of Substance Abuse
- 21. OTP Interventions • Maintainarrested OTP clients during Pre-Trial Status and reconnect them to their OTP at release • Detox heroin-addicted inmates with non-opioids or on methadone • Pregnancy protocol • Buprenorphine conversion
- 22. Criminal History ofPrison-based OTP Patients 1 Mean Age first crime 13.8 Age first arrest 16.5 Age first incarceration 20.6 Lifetime incarcerations 9.1 Past 30 days crime 25.5 Past 30 days crime-profit 24.8 Criminal Income ($/past 8,057 30 days) 1 Kinlock, Schwartz Gordon (2005)
- 23. Treating Prisoners withHeroin Addiction Histories Most detainees with histories of heroin addiction do not receive drug abuse treatment while incarcerated Such inmates typically become re-addicted within one month of release Re-addiction is accompanied by the following: Increased criminal activity Unemployment High risk of HIV infection Greater risk of overdose death Incarceration
- 24. Offenders have moreserious Substance Use & Other Disorders • Offenders Have Higher Rates of Psycho-Social Dysfunctional Than the General Population – Substance Use Disorders – Mental Health and Somatic Health Disorders – Educational Deficiencies • CJ Populations: 4 Times Greater SA Disorders NSDUH 2007
- 25. BBI Results 3,209 patients • Currently, 357 treated patients receiving full BBI services in 2,094 (65%) obtained or had medical assistance treatment program 1,645 (79%) 449 (21%) PAC Health Choice • Approximately 6% drop-out from 796 (38%) continuing care transferred to continuing care
- 26. bSAS and B-MAT:Results • After controlling for baseline group differences, the B-MAT group had less: – Inpatient hospital admissions – Inpatient days in hospital – Outpatient hospital visits – Emergency room visits – Physician visits • However, the only statistically significant differences compared to M-MAT and Abstinence-based treatment was for physician visits • The M-MAT group has more health problems while the B-MAT and Abstinence groups have similar profiles 26
- 27. Factors to ImproveNetworkness? Integration or Boundaryless Processes of SA & CJ Agencies Most Typical Activities: • Share Information with Average Number of agencies Activities Integrated: • Develop Client Eligibility Drug Court=6.1 Across Agencies Probation/Parole=4.5 • Written Program Prison=3.2 Programs Jails=3.7 • Joint Staffing of Program Interagency integration is • Modified Program to Meet associated with more use Correctional and SA of EBPs, more holistic Agencies services, and improved outcomes • Written MOU between agency Fletcher, et al, in press ; Taxman & Perdoni, 2007
- 28. Project ACCESS • Accountability • Communication • Collaboration • Efficiency • Security of Information • Service focus
- 29. BSAS ACCESS Supports BSAS, Vision, Mission and Goals EHRc Information Sharing supports continuity of care. EHRc Information Sharing furthers the goals of a ROSC approach. EHRc Information Sharing frees up funding and staff so that it can be applied to improved Quality of Care. • EHRc Information Sharing expands, consolidates and improves the quality of Public Health Data Repository. • EHRc Information Sharing provides better quality and more complete data for evaluation and outcome reporting.
- 30. BSAS ACCESS Health Information Strategic Planning New ways to collect, share and use data to serve client. Interoperable systems and smooth information flow. “Wherever you go, there you are” • Better Quality data – reliable, consistent, complete. • New partnerships and collaborations in evaluating and applying meaningful data. • Confidentiality and Consent
- 31. What providers tellus they want from their Information Systems (From focus group discussions, interviews and in depth needs analyses) A fully functional, modern and meaningful use certified EHR Consolidation of Information Systems and elimination of redundant applications Access to additional client data and interoperability with other client data systems • Pricing discounts and additional leverage associated with forming an EHR (HIT) consortium • Business practice and clinical practice management Information Systems improvements • HIT advisement – How to get CMS incentive payments and how to avoid penalties
- 32. Draft - ACCESSAdvisory Board • Behavioral Health Treatment Providers (2) • Consumers (2) • BSAS CEO • BSAS CIO • DPSCS CIO • Baltimore City CIO • DHMH CIO • BSAS Epidemiologist • University of Maryland Law Clinic • Health Care Access Maryland
- 33. Treatment Outcomes forthe Criminal Justice Population Criminal Justice Populations Drug Treatment Court Other Criminal Justice N = 1,353 N = 2,745 Completion: 1,068 Completion: 1,687 Incarceration: 21 Incarceration: 71 Terminated: 264 Terminated: 987 Treatment Outcomes Drug Court Non-Drug Court Drug use during treatment 13% 38% Substance use at discharge 10% 25% 90 day retention in outpatient treatment (Level I) 63% 57% Completion of outpatient treatment (Level I) 52% 34% Continuity of care from ICF (Level III.7) to another LOC 73% 35% % change in employment from admission to discharge 183% 52%
- 34. Treatment Outcomes forthe Criminal Justice Population Criminal Justice Populations Drug Treatment Court Other Criminal Justice N = 1,353 N = 2,745 Completion: 1,068 Completion: 1,687 Incarceration: 21 Incarceration: 71 Terminated: 264 Terminated: 987 Treatment Outcomes Drug Court Non-Drug Court Drug use during treatment 13% 38% Substance use at discharge 10% 25% 90 day retention in outpatient treatment (Level I) 63% 57% Completion of outpatient treatment (Level I) 52% 34% Continuity of care from ICF (Level III.7) to another LOC 73% 35% % change in employment from admission to discharge 183% 52%
- 35. Access: The Patient-Centered, Clinical Case Management Approach A Recovery Oriented System of Care Not Constrained by Walls Offender Patient NEEDS NEEDS • Custody • Substance Abuse treatment • Somatic Care • Mental Health treatment • Substance Abuse Treatment • Somatic Care • Mental Health Treatment • Housing • Case Management • Entitlement Benefits • Family Support Services • Faith-Based Services DPDS DOC DPP Health Dept./Community Services
- 36. Shared Critical Understanding • Correctional Services is an expectation of the public • DPSCS is a part of Maryland’s public health system • Our success is measured long after our offenders/patients leave
- 37. DPSCS and BSAShave a Shared Challenge Information must follow the offender/ patient and not reside and remain at the institution for it to do the greatest good. The Patient-Centered Approach
- 38. The Benefits ofa DPSCS/BSAS Partnership • BSAS will champion critical value added linkages which will improve offender’s health outcomes • DPSCS/BSAS health information exchange becomes a higher priority to CRISP • Direct benefit to 9,000 returning Baltimore City offenders annually
- 39. BSAS ACCESS The Value Proposition Full-featured, meaningful use certified EHR for providers and partners. Consolidation of multiple provider applications on a single operating platform. (Replace UP and eliminate SMART data entry.) Information sharing between community resources and DPSCS. Steep discounts for high quality solution to providers and partners. • More efficient and cost effective clinical and practice management for providers and partners • BSAS consultation and assistance in securing Medicaid incentive payments. • Information sharing between BSAS provider network, mental health, primary care providers, and other community resources. • Primary source, comprehensive public health data repository. • Comprehensive statistical evaluation and outcome reporting
- 40. BSAS- ACCESS Design & Implementation • Secure, segregated installations on a common operating platform • Custom module selection and configuration. • Economies of scale and cost reductions • Data sharing and information exchange • Aggregate public health data
- 41. BSAS ACCESS Patient Management Work Flow Intake Administration Client Referral / Client Scheduling and Releases Walk-in AND Consent DATA FROM OTHER CONSORTIUM MEMBERS Methadone (Other Meds) Clinical Case EPrescription Management / Management / Dispensing Documentation Billing /Accounts Standard Practice Compliance Reporting Receivable/Financial Management Management Reporting City, State, Federal
- 42. BSAS Health InformationExchange DPSCS OCMS BSAS BSAS Methadon Residential e Programs BSAS BHCA Outpatien Entitlemen BSAS ACCESS t t Programs Benefits FQHC DHMH GE SMART Centricity Health Health Providers Departme thru CRISP nt