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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, 2015Tony 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 HubRutland 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, 1st 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: 583.56. Next closest
was Maine: 324.02, 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
2004-2013 opened Bup Induction Center in Berlin, similar to OBIC
Buprenorphine Practice Guidelines revisions for enhanced care 2003, 2007, 2010, 2012, under review currently
2005-2007: 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
2011-2012: Hub and Spoke planning process, implementation 2013-2014 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
2014-15: 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
HUBAssessment
Care CoordinationMethadone
Complex AddictionsConsultation
SpokesNurse-Counselor Teams
w/prescribing MD
SpokesNurse-Counselor teams
w/prescribing MD
CorrectionsProbation &
Parole
SpokesSpokes
Residential Services
In Patient Services
Pain Management
Clinics
Medical Homes
Substance Abuse Out-
Pt Treatment
Family Services
Mental Health
Services
HUBAssessment
Care CoordinationMethadone
Complex AddictionsConsultation
SpokesNurse-Counselor Teams
w/prescribing MD
SpokesNurse-Counselor teams
w/prescribing MD
CorrectionsProbation &
Parole
SpokesSpokes
Residential Services
In Patient Services
Pain Management
Clinics
Medical Homes
Substance Abuse Out-
Pt Treatment
Family Services
Mental Health
Services
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 Region Start # Clien
ts
#
Buprenorphine
# Methadon
e
# Waiting
Chittenden Center
Chittenden, Franklin, Grand Isle & Addison
1/13 936 278 658 278
BAART Central Vermont
Washington, Lamoille, Orange
7/13 394 180 214 67
Habit OPCO / Retreat
Windsor, Windham
7/13 455 129 326 31
West Ridge Rutland, Bennington
11/13
438 164 274 52
BAART NEK Essex, Orleans, Caledonia
1/14 500 138 362 51
February 2015 2723 889 1834 479
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
