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LoginAnne Arundel County Health Department
Be Well Maryland Mobile Wellness "Wellmobile"
Tracy Schulden
Deputy Director
hdschu77@aacounty.org
410-222-4166
Annapolis
Maryland
21401
Your summary must address all the questions below:
The Anne Arundel County Department of Health is the sole government agency responsible for improving the health of Anne Arundel County. The mission of the department is to preserve, promote and protect the health of all people who live, work and play in the county. The Department is located in the capital city of Maryland, Annapolis, and serves a population of over 550,000. Anne Arundel County is centrally located between Washington and Baltimore and borders over 533 miles of coastline with areas that are rural and suburban.
Despite tremendous efforts by the State and local jurisdictions, Maryland’s drug and alcohol overdose deaths continued to increase, rising from 2,089 in 2016 to 2,282 in 2017, and 2406 in 2018. In Anne Arundel County, opioid overdose deaths increased from 116 in 2016 to 198 in 2017. In 2018, there was a slight decrease in overdose deaths with this trend continuing in 2019. While Anne Arundel County is the fifth largest county by population in Maryland, it has the third highest number of overdose deaths in the State after Baltimore City and Baltimore County. The opioid crisis continues to devastate not only those with active use, but also countless friends, family, neighbors and coworkers. While overdoses occur in virtually every zip code in the County, there is a concentration of opioid-related overdoses and fatalities in the County’s northern area, bordering on Baltimore City and in Annapolis City.
To effectively address the outcomes that opioid use has had on Anne Arundel County, tremendous effort has been put into making treatment and naloxone available and easier to access. While these efforts are believed to be making an impact in 2019, data and field reports suggested the need to broaden the scope of the department’s harm reduction services designed to not only mitigated the harms associated with use but to meet individuals "where they are" in their use. Harm reduction activities, initially limited to naloxone distribution, expanded to include peer door knocks, the emergency responder "leave-behind" program, AA Power initiative that engages people with lived experience and mobilizes community members to conduct brief overdose prevention trainings and distribute fentanyl strips, safe injection materials and naloxone kits, and the "Wellmobile".
The Wellmobile is a comprehensive approach to reaching more individuals in their communities by offering a low-threshold approach to fostering engagement and access to buprenorphine, naloxone, fentanyl test strips, safe injection materials, and Hep C and STD testing. The overall goal of the program was to expand access to services that support recovery and prevent death and disease progression.
The Wellmobile is staffed with a nurse practitioner that has an established waiver from the DEA to prescribe buprenorphine. The provider is supported by a nurse and peer recovery specialist who, working as a team, provide patient assessment, HIV/STI testing, prescriptions for home induction using buprenorphine, initial MAT stabilization services, recovery support planning and referral and linkage to a community provider for buprenorphine maintenance and if desired, counseling. Staff meet individuals where they are in their readiness to accept treatment in order to maximize chances for increased length of stay with MAT and to promote long-term recovery. The Wellmobile provides several treatment options for patients depending on their interest and willingness to engage. For some patients, the Wellmobile may be an initial point of entry for induction and they will be willing and ready to accept a referral to ta community provider for continued buprenorphine medication stabilization, maintenance and counseling. Other patients may not yet be ready to enter treatment but will continue to visit the Wellmobile to receive buprenorphine, prevention and peer support services.
The Wellmobile provides services two days a week, Tuesday and Friday, from 9:00 a.m. to 3:00 p.m. while parked at the Arundel House of Hope parking lot. Arundel House of Hope is a non-profit ecumenical organization that provides emergency, transitional, and permanent affordable housing for the poor and those experiencing homelessness in Anne Arundel County and is located near the most impacted communities..
The Wellmobile began providing services in April 2019 and has seen an immediate demand for services; this demand only increasing with each month in operation. Currently, there are plans to expand the services to Annapolis City. To date, 122 individuals were provided ongoing services with 79% linked to community providers and 67% retained in treatment 30+ days after transfer. Of those linked, 71% transferred within 14 days of admission to the Wellmobile.
Public Health impact of the practice is a reduction of risk of overdose deaths
LHD website - www.aahealth.org
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
The opioid crisis experienced in Anne Arundel County is disproportionate to its population and continues to devastate not only those with active use, but countless friends, family, neighbors and coworkers.
While overdoses have been reported in virtually every zip code in the County, there is a concentration of opioid-related overdoses and fatalities in the County’s northern area, bordering on Baltimore City. Over one-third (36%) of these overdoses since January 1, 2017 have occurred in North County communities of Brooklyn Park and Glen Burnie. The hospital systems have also felt the impact of the opioid crisis seeing a 79% increase in opioid-involved overdose visits since 2015 resulting in AACDOH adding additional peer support staff in the local emergency departments to provide coverage daily from 8 a.m. till 12:30 a.m. In addition, the County SUD-related services have experienced much higher than expected utilization.
Recognizing the disproportionate impact of the State’s opioid crisis on the County, along with the County’s capable infrastructure, the State awarded two significant grants:
The hundreds of residents who have sought care through the Safe Stations Initiative demonstrate that having a nearby, safe and trusted location can make all the difference for a person deciding to voluntarily come forward to seek help. Given the overwhelming stigma and isolation typically felt by users and their families, it is far easier to take the first step to recovery by entering a local, nonthreatening environment. A significant level of engagement and readiness is often required before the decision to voluntarily enter treatment.
The Anne Arundel County Department of Health (AACDOH), with the support of the Maryland Opioid Operational Command Center and the Maryland Behavioral Health Administration (MDH), established the Be Well Maryland Mobile Wellness (Wellmobile) project to address the unprecedented public health crisis plaguing the county’s communities.
The Wellmobile, operating in a familiar, neutral and very close-by location, offers residents a safe, nonthreatening and non-stigmatizing setting highly conducive to engagement. Further, this model brings community-based buprenorphine treatment to Anne Arundel County, where there are notably few such providers. The effectiveness of buprenorphine-assisted treatment for SUD consistently demonstrates significantly improved outcomes compared to the traditional non-medication approaches. Buprenorphine, orally administered and available by prescription, is safe and very well accepted by patients, many of whom find the regime to be far less intrusive than methadone maintenance therapy. The AACDOH actively promotes buprenorphine—provided in primary care settings with access to wrap-around counseling and other services -- as an effective treatment modality. Despite ongoing efforts, there are very few outpatient treatment centers and few primary care providers of buprenorphine in the County; in fact, there are less than a dozen locations as of the latest survey. Many of the current providers have stringent requirements and/or hours of operation that make it difficult for many individuals to even seek the services let alone remain successful. Additionally, many of the primary care providers were reluctant to start a patient on buprenorphine but were receptive to taking on a stabilized patient. This has led to a low census of patients on buprenorphine within the county’s treatment system. Additionally, the data obtained from safe stations, the crisis providers and the peers providing services in the emergency departments; continue to support the need for a model of immediate access to buprenorphine other than the traditional prescribed one. Linkage to these services were continually identified as a major barrier.
The Wellmobile offers a major boost to this effort by increasing access to this evidence based practice by providing a low-threshold model while building engagement and motivation for any positive change.
Given the stigma often attached to harm reduction activities and medication-assisted treatment, the Wellmobile launched by word of mouth, soft approach. The initial referral sources coming from Safe Stations and the peers working in the emergency departments. Therefore, the numbers reached were expected to be small initially and then build over time. This proved to be true as the demand continued to increase. In the first three months of operation, 48 individuals were provided services. The following three months showed an increase of 58% with numbers continuing to rise resulting in strong community support for an expansion of services to the Annapolis City area. Over the past 5 months, the community walk-ins have accounted for approximately 70% of those served.
Since implementing the various services and strategies mentioned above including the Wellmobile, total opioid overdoses in Anne Arundel County have decreased by 25% and fatal overdoses have decreased by nearly 30%. Using county level data on opioid overdose locations, we were able to locate areas in Anne Arundel County that were at a greater need for services and deploy our resources to these areas first. While expansion to Annapolis is the next action step, AACDOH is also exploring the possibility of making the services available at least one day a week in other parts of the county.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
Goal: Expand access to services that support recovery and prevent death and disease progression.
Objective 1: Increase access to treatment by offering low threshold buprenorphine in high risk communities 2x/week in North County and 2x/week in Annapolis City.
Objective 2: Provide overdose response training and naloxone kits to 90% of individuals receiving treatment who do not have a kit via Wellmobile.
Objective 3: Engage 100% of individuals seeking treatment on Wellmobile with Peer Support Specialist.
Objective 4: Link 75% individuals initiating treatment on Wellmobile with community MAT providers.
Sub goal: Integrate a range of services needed by the difficult to reach PWUD/PWID (People who use/inject drugs) population
Objective 1: Develop internal stakeholder workgroup to identify existing services that can be delivered remotely with minimal additional funding (HIV, Immunizations, SSP, etc) by December 2020
Objective 2: Develop workflow for SSP services on wellmobile by January 31, 2020
Objective 3: Implement billing for all eligible services by March 31, 2020
Program Measurement/Performance Indicators:
# of individuals receiving treatment on Wellmobile
# of individuals referred to community treatment providers for MAT
# of individuals enrolled in community MAT
# of individuals receiving HIV/STD testing services
# of individuals trained in naloxone and receiving a naloxone kit
# of individuals referred to Peer Support Specialist
# of individuals provided ancillary referrals by Peer Support Specialist
# of individuals referred to community providers within 14 days
Discussions on the Wellmobile began in 2017 and included the Disease Prevention Management Bureau and the Behavioral Health Bureau of AACDOH as well as collaborations during the design and implementation stage with the following entities:
The Maryland Opioid Operational Command Center
The Maryland Behavioral Health Administration (MDH)
The University Of Maryland School Of Nursing
The Anne Arundel County Mental Health Agency, Inc.
Local community pharmacies
Baltimore Washington Medical Center
Community Treatment and Recovery Support Organizations
Arundel House of Hope
Mosaic Group
City of Annapolis EMS
The initial protocols were developed in collaboration with the Mosaic Group. The Bureau of Behavioral Health modified the protocols in partnership with front line staff and feedback from prospective recipients. RTR utilizes an electronic medical record. The Wellmobile was entered as a sub-program and the system configured for these services.
The biggest obstacle to implementing this service was the purchase or use of an available mobile unit. Originally, the plan was to revitalize the Governor’s health mobile currently in use by the University School of Nursing. Due to limited flexibility in coordinating the work provided by the School of Nursing and the proposed work of this project, funding was secured through the Maryland Opioid Operational Command Center and MDH to purchase a new vehicle. The vehicle is the property of AACDOH.
Another potential obstacle was the location. The original plan was to locate the vehicle onsite at one of the local fire stations in the area. This proved difficult because the stations that had the space were located off the main highway. Arundel House of Hope (AHOH) was identified given its location and the population being served. Leadership of AHOH was very supportive and offered the parking lot. Recently, AACDOH and Anne Arundel County Library System have been in discussions about using a library parking lot in Annapolis and/or other county locations. The Library actually reached out to AADOH to make this offer after hearing about the services.
AACDOH is the recipient of grant funds from the State and local jurisdiction funds to provide the services. The Wellmobile program is under the umbrella program, Road to Recovery, which consists of AACDOH’s three opioid treatment programs. The staff on the Wellmobile including the driver are all AACDOH employees. The practitioner and nurse are directly supervised by the Medical Director and Nurse Supervisor under the RTR program. The Peer Support Supervisor under the AACDOH’s Recovery Community Support Services program supervises the peer support specialist.
In addition to these funds, the Bureau of Disease Prevention and Management contributes HIV/STD testing and prevention supplies. If ongoing HIV/STD services are needed, individuals are seen at their convenience at one of the clinics, in their home or on the Wellmmobile.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
Objective 1: Increase access to treatment by offering low threshold buprenorphine in high risk communities 2x/week in North County and 2x/week in Annapolis City.
Currently the services are being provided two days a week in North County. Funding is being sought to expand the services to Annapollis. It is hoped that this can be achieved within FY2020.
Objective 2: Provide overdose response training and naloxone kits to 90% of individuals receiving treatment who do not have a kit via Wellmobile.
Currently 100% of those served in need are provided training and kits. All kits are recorded in the electronic medical record as well as reported to the State as required by the AACDOH Opioid Response Program.
Objective 3: Engage 100% of individuals seeking treatment on Wellmobile with Peer Support Specialist.
100% of the individuals are provided peer support services. The Peer Support Specialist is the one that does the initial contact with the individual and provides the naloxone, other prevention materials and follow up with receiving services. Should the individual want to continue with peer support services, the peer will link them with a community peer.
Objective 4: Link 75% individuals initiating treatment on Wellmobile with community MAT providers.
79% of individuals are linked to community providers. This linkage is done in coordination with the nurse and the peer support specialist. The data on this linkage is entered into the electronic medical record which provides ease of reporting.
Sub goal: Integrate a range of services needed by the difficult to reach PWUD/PWID (People who use/inject drugs) population
Objective 1: Develop internal stakeholder workgroup to identify existing services that can be delivered remotely with minimal additional funding (HIV, Immunizations, SSP, etc) by December 2020
Objective 2: Develop workflow for SSP services on wellmobile by January 31, 2020
Objective 3: Implement billing for all eligible services by March 31, 2020
Protocols for syringe services are currently being developed with projected implementation within FY2020. These services are being developed in colloboration with the System Training, Education and Prevention program of the Bureau of Behavioral Health in AACDOH.
Discussions with Maryland Medicaid and the Administrative Service Organization have led to the Wellmobile being able to bill for the practitioner's services. The electronic medical record is currently being configured to bill for these services. Originally, they were set up under the Wellmobile as non-billable.
Program Measurement/Performance Indicators:
# of individuals receiving treatment on Wellmobile
# of individuals referred to community treatment providers for MAT
# of individuals enrolled in community MAT
# of individuals receiving HIV/STD testing services
# of individuals trained in naloxone and receiving a naloxone kit
# of individuals referred to Peer Support Specialist
# of individuals provided ancillary referrals by Peer Support Specialist
# of individuals referred to community providers within 14 days
# of individuals still engaged in services after linkage to community provider.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
Sustainability is an inherently critical element to this project. Given the unrestrained trajectory of the crisis in the county, there is no reason to plan for an appreciable decline in the need for community based engagement and referral services in the near future. The demand for treatment by those already experienceing problems with use is likely to continue as more people are educated regarding the positive outcomes that can result from treatment. The county's culture continues to shift in the observed direction of much greater awareness of the pervasiveness of substance use and acceptance of harm reduction activities is also likely to increase of the demand for these services.
The Wellmobile was supported with funds from the Maryland Opioid Operational Command Center, the Maryland Department of Health and the local jurisdiction. It's continued financial support comes from State and Local grant dollars. In FY2020, the program will begin to bill medicaid for the billable services. Nonbillable services, such as the Peer Support Specialist will continue to be incorporated into budgets/programs supported by revenue generation. Since the Wellmobile has great potential for service delivery, outside of behavioral health, partnerships with other departments will be explored to share costs.
