An impoverished section of Washington, D.C., is serving as the laboratory for an innovative integrated care initiative featuring what could be characterized as unlikely partners. The driver of the Buprenorphine Integrated Care Delivery Project from Howard University's Urban Health Initiative is neither an addiction specialist nor a primary care doctor, but a urologist. The community-based medical practice that serves as the nexus of care under the initiative is run by a former methadone clinic medical director who now calls buprenorphine “the greatest drug I've ever used as a physician.”
The conditions that have brought these partners together are the grossly underserved needs of the northeast Washington, D.C., community surrounding Edwin Chapman, M.D.'s medical practice. His treatment population has an average age of 52, an average 10-year history of incarceration, a 60% prevalence of hepatitis C (around 10% of the patients are HIV-positive), and a longtime history of opioid use (mainly heroin).
Chapman was finding that buprenorphine could quickly stabilize these multi-need patients and prepare them to work on the other challenges in their lives, but these individuals generally lacked access to comprehensive care that includes psychiatric support. At the same time, the urologist, Howard University professor Chiledum Ahaghotu, M.D., was looking for opportunities to design patient-centered care models and to leverage Howard's tradition of community partnership; Ahaghotu had begun working on his idea as a student in Brown University's Executive Master of Healthcare Leadership program.
“I was looking to improve care for vulnerable populations, and to avoid an overutilization of [high-cost] resources,” such as emergency care, says Ahaghotu.
The partners hope that the project, which is being funded by a four-year grant from the District's Department of Health, will show results in patient satisfaction, cost benefits, and clinical and quality-of-life outcomes.
“If we can get reductions in criminal activity, ER visits, and hospitalization, and if these monies can be reinvested in community support, we can save money,” says Chapman.
Ahaghotu explains that the Buprenorphine Integrated Care Delivery Project's model is predicated on three critical components:
The efforts of comprehensive care coordinators who work closely with both primary care and behavioral health providers to help develop patient-centered care plans. Engagement of providers is designed to occur much earlier than what is typically seen in care coordination efforts.
A shared electronic health record platform across all providers delivering services to the patient. “We get all of our patients to consent to allow care providers to share information in the system,” Ahaghotu says.
A telehealth program that allows Chapman's patients to see him as well as a behavioral health specialist during the same office visit.
Ahaghotu explains that because the program's resources did not support the hiring of nurses to fill the care coordination role, leaders have had to identify non-traditional care coordinators: community health workers, foreign medical graduates working on their certification, and social work and nursing students.
Chapman says that his buprenorphine patients often will tell him within two weeks of initiating the medication, “I feel normal for the first time.” His patients' typical daily dose is 24 mg, and he says he can exceed the federally mandated restrictions on how many patients one physician can treat because this initiative is a research project. Opportunities to treat area heroin addicts with buprenorphine were enhanced around five years ago when the Medicaid system in the District began covering office-based treatment with the drug, Chapman says.
The stability that the medication brings, with what Chapman says are minimal side effects, paves the way for patients to begin working on the life factors that have such a profound impact on long-term outcome.
Patients can see a behavioral health specialist via the telehealth technology at Chapman's office, both for initial assessments and ongoing services. “This focuses on patients with low-acuity behavioral health issues, not highly complex issues,” Ahaghotu says of the telehealth component. “We also try to get all of the patients into individual or group therapy.”
In addition, “We haven't rolled it out yet, but we also will be setting up telehealth for dermatology, urology and cardiology,” Ahaghotu says.
The initiative officially launched in April, and 73 patients have been enrolled so far. With around two-thirds of the cohort experiencing some form of homelessness/housing instability, placement in housing becomes a crucial element of the effort, Ahaghotu says.
With these patients usually costing the Medicaid system five times what it costs to serve a typical Medicaid patient, utilization and cost outcomes will be closely watched as part of an overall outcomes matrix. Clinical outcomes such as mortality rates are also an important part of the equation, as is patient satisfaction with the care coordinators and the telehealth services.
The National Center for Healthcare Leadership has recognized the project as one of eight initiatives selected in its “Leading Together” leadership challenge for 2015, honoring efforts that enhance leadership competencies and collaboration. Ahaghotu this week will deliver a presentation on the initiative at the center's Human Capital Investment Conference in Chicago.
He says of the national recognition's impact, “It helps solidify our commitment to the strategy of collaborative leadership.”