Division of Alcohol and Drug Abuse Programs Vermont Department of Health To Bup or not to Bup: was never the question….But rather how do we best bup? March 29, 2015 Tony Folland Vermont SOTA

1.Northwestern Hub HowardCenter Chittenden Clinic Chittenden, Franklin, Addison & Grand Isle 2.Northeastern Hub BAART Behavioral Health Services Essex, Orleans & Caledonia 3.Central Vermont Hub Central Vermont Addiction Medicine Washington, Lamoille & Orange 4.Southwestern Hub Rutland Regional Medical Center Rutland & Bennington 5.Southeastern Hub Southeast Regional Comprehensive Addictions Treatment Center ( Habit OPCO & Brattleboro Retreat) Windsor and Windham Vermont Population 626,562

Brief Evolution of MAT Services 3  Late entering MAT services, 1 st OTP opened in October 2002  Opened Buprenorphine Induction Hub in 2004  Quickly became #1 nationally in per capita DATA 2000 waivered physicians  Most per capita use of Buprenorphine products…  2005: Grams per 100,000: Next closest was Maine: , adjusted doses per capita: 82,948 vs. 53,573 Vermont Department of Health

Why was buprenorphine so common?  Vermont Department of Health Alcohol and Drug Abuse Program (ADAP) was supportive of buprenorphine from the beginning in 2003 due to research at the University of Vermont with buprenorphine  Committed Medicaid money to cover the cost of treatment  Committed to training MDs/DOs for waivers (500K incentives and staffing, 350K training)  Vermont first published guidelines for buprenorphine in 2003 with revisions in 2007, 2010 and 2012 to assist providers in the care of opioid dependent patients  With one OTP in Burlington, the largest city in VT, buprenorphine was ideally suited for a decentralized rural state so most opioid users sought it out Brooklyn, AATOD 2015

OBOT CONCERNS  What to do if OBOT patient was not doing well in treatment due to using illicitly, diverting, missing counseling?  What to do if MD retired, lost license, moved away?  What to do with large programs with 100+ people in OBOT that were essentially unregulated unlike the OTP programs?  What about increasing access to treatment in OBOT?  What about physicians who did not want to do inductions but were willing to take people after they were stable?

RESPONSE  opened Bup Induction Center in Berlin, similar to OBIC  Buprenorphine Practice Guidelines revisions for enhanced care 2003, 2007, 2010, 2012, under review currently  : COBMAT training and care management support for physicians… not so much!!  2010: VT Guidelines for MAT for Pregnant Women  2010: Emergency MAT Rules written, formal adoption 2011 for providers of 30+ patients. Regulatory structure and ADAP oversight  : Hub and Spoke planning process, implementation statewide

Response continued  2013-pres. VT Learning Collaborative: 35 OBOT Physician teams and all Hubs trained using self-selected QI measures, didactics, training materials and peer support. 9 month commitment.. Data feedback system to providers  2014-pres: VT Recovery Network Pathway Guides: Specially trained peers providing supports to individuals receiving MAT statewide  : Legislative charge: MAT Rules expansion to cover all OBOT providers. Under development as we speak… Vermont Department of Health

Integrated Health System for Addictions Treatment Vermont Department of Health

Care for Complex Addictions – the “Hub” “HUB” A Hub is a specialty treatment center responsible for coordinating the care of individuals with complex addictions and co-occurring substance abuse and mental health conditions across the health and substance abuse treatment systems of care. A Hub is designed to do the following:  Provide comprehensive assessments and treatment protocols.  Provide methadone treatment and supports.  For clinically complex clients, initiate buprenorphine or antagonist treatment and provide care for initial stabilization period.  Coordinate referral to ongoing care.  Provide specialty addictions consultation and support to ongoing care.  Provide ongoing coordination of care for clinically complex clients. Vermont Department of Health

Developing The “Hub and Spokes”  Engaged stakeholders regionally, statewide and within the state system  Introduced concept to community providers and sought participation in committees  Pregnant women, Children and Families Workgroup Identify resources, services and connections for women and family supports  Physician Workgroup Clinically driven algorithm development for matching patients with pharmacotherapy agents and clinical treatment settings Guidelines for medical screening and comprehensive assessment Guideline development for patient structure, if medication other than Methadone (eg. Daily dosing vs. multitude of OBOT structure options)  Clinical Workgroup Behavioral health screening, admission, assessment, and treatment planning procedures for the hubs Operationalizing “Health Home” language/definitions with behavioral health supports (eg. Health Promotion=Treatment and Patient self-management)

“SPOKE” A Spoke is the ongoing care system comprised of a prescribing physician and collaborating health and addictions professionals who monitor adherence to treatment, coordinate access to recovery supports, and provide counseling, contingency management, and case management services. Spokes can be:  Blueprint Advanced Practice Medical Homes  Outpatient substance abuse treatment providers  Primary care providers  Federally Qualified Health Centers  Independent psychiatrists Care for Complex Addictions – the “Spoke” Vermont Department of Health

Spoke (OBOT physicians with support)  Polled OBOT physicians regarding most significant concerns/barriers to expansion or perceptions of optimal care  Consistent feedback: patients may require more time/coordination of care than physicians had in their schedules  Using existing VT Health Home infrastructure (Blueprint for Health) Community Health Team model physicians were offered in-office supports

Spokes continued  Any willing provider  any structure of OBOT provider  New or existing providers Vermont Department of Health

OBOT Health Home Supports  ACA funding for 2 FTE, non-billing responsible staff per 100 patients 90/10 funding split in Spokes (ACA section 2703 VT SPA)  1 FTE licensed behavioral health provider  1 FTE nurse provider  Any configuration of service providers/service areas to provide Health Home Services Vermont Department of Health

The Results so far…..  80+ nurse and licensed clinicians deployed to support physician practices  Roughly 2100 Medicaid patients in OBOT providers  Over 65% of all providers ever X waivered in Vermont still prescribe buprenorphine to Medicaid patients (roughly 200 waivered since 2002 and roughly130 prescribed last month)… this aggregate includes all physicians ever waivered in VT including retirees, those who left state, etc… Vermont Department of Health

Program RegionStart# Clients # Buprenorphine # Methadone # Waiting Chittenden Center Chittenden, Franklin, Grand Isle & Addison 1/ BAART Central Vermont Washington, Lamoille, Orange 7/ Habit OPCO / Retreat Windsor, Windham 7/ West Ridge Rutland, Bennington 11/ BAART NEK Essex, Orleans, Caledonia 1/ February VT Department of Health Department of VT Health Access

Moral of the Vermont Story  Reasonable regulation, created with providers, doesn’t have to limit access to care! In fact when a reasonable standard of care is not readily identified, it can be protective for providers.  Money wasn’t the driver… support and guidance were key.  Develop champions from diverse areas of the field… focus on the process of change!!  Partner with your partners: DVHA, Blueprint for Health, Pharmacy benefits administrator, Board of Medical Practice, DEA, Providers, Feds, etc  Balance access to care with quality of care  “Nothing about us without us”: providers want to do a good job!  “I recognize I’m the dumbest person in the room…. And They recognized I’m the dumbest person in the room”… it levels the playing field!  Medication and treatment structure can be (and should be) 2 different decisions