1. “I feel safe here” Mariya Masyukova, Sc. B. Medical Student Aaron Fox, M.D., M.S. Assistant Professor of Medicine, Division of General Internal Medicine Group medical visits in buprenorphine treatment

2. Outline Introduction Development of Group Medical Visits for Buprenorphine Treatment Implementation of Group Medical Visits for Buprenorphine Treatment Preliminary evaluation

3. Division of General Internal Medicine Science at the heart of medicine Defining the Problem Buprenorphine maintenance is an effective treatment for opiate dependence, but is limited by: ● Provider capacity ● Institutional resources ● Patient competing needs ● Patient comorbidities How to intensify treatment?

4. Group Medical Visits for Buprenorphine aka Shared Medical Appointments Rationale: Social support Structure for skill-building and education Patient-provider time Multidisciplinary, patient-centered

5. DEVELOPMENT

6. Division of General Internal Medicine Science at the heart of medicine Setting Federally-Qualified Health Center in South Bronx, NY - 10 attending general internists prescribe buprenorphine in primary care - Clinical pharmacist coordinator - Social workers available for counseling

9. The core team

10. IMPLEMENTATION

11. Division of General Internal Medicine Science at the heart of medicine Group patients Patients in buprenorphine treatment referred by their provider if: – Ongoing substance use – Extensive psychosocial needs – Sub-optimal outcomes despite individual buprenorphine treatment

12. Division of General Internal Medicine Science at the heart of medicine Group day 30 minutes: Nursing assessment Urine toxicology Self-assessment materials 90 minutes: Group session 30 minutes: Individual needs

13. Session Content

14. PRELIMINARY EVALUATION

15. Division of General Internal Medicine Science at the heart of medicine Patient characteristics N=20 patients (attended at least 1 group visit in the first 6 months) Age (years) 53 (34-66) Male sex15 (75%) Race 10 Hispanic (50%) 10 black (50%) Public Insurance20 (100%) Chronic illness diagnosis18 (90%) Axis I diagnosis16 (80%) HIV+6 (30%)

16. Division of General Internal Medicine Science at the heart of medicine Feasibility In the first 6 months... ● 13 group visits ● 33 patients were referred and contacted ● 20 patients attended at least 1 session ● 13 patients attended ≥ 2 sessions In each group.... ● 4 to 10 attendees (median of 6) Median attendance per patient: 3 sessions

17. Division of General Internal Medicine Science at the heart of medicine Challenges 1. Administrative – Space, staffing, structure 2. For patients – Time, unmet needs, group dynamics 3. For providers – Time, care coordination

18. Division of General Internal Medicine Science at the heart of medicine Conclusions Group medical visits are an acceptable model of buprenorphine maintenance treatment intensification. Implementing group medical visits for buprenorphine treatment is feasible in an urban FQHC.

19. Division of General Internal Medicine Science at the heart of medicine “We're coming here cause we want to. If we just had to see that one doctor, that works all right for a little while, but we need more. So the group comes in...” -56 year-old male participant “At least every other Wednesday, I know for a certain amount of time, I’m gonna be here, I’m gonna feel safe, I’m gonna learn something, and be around people I feel comfortable with.” -59 year-old female participant Feedback from patients

20. Future directions Add more sessions (e.g. Spanish speaking group) Optimize structure and content Assess effectiveness Improve collaboration with patients' individual primary care providers Apply for R34 to evaluate model effectiveness with RCT

21. Acknowledgments Mentors/Advisors: Dr. Aaron Fox Montefiore DGIM Substance Abuse Affinity Group Dr. Sara Doorley Team: Dr. Aaron Fox, Dr. Angela Giovanniello, Maritza Casillas, and Jennifer Sanchez Araceli Diaz, Elenita D'Aloia, and the other nursing and support staff. Administrative: Dr. Joseph DeLuca and the CHCC. Funders K23 DA034541 Clinical Research Training Program at Albert Einstein Our patients and participants.