Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Behavioral Health Leadership Institute

Name of Innovative Program: 
Project Connections Buprenorphine Program: Gateway to Health [PC]
Sponsoring Organization
Behavioral Health Leadership Institute
Name of Innovative Program Lead: 
Deborah Agus
E-mail Address of Innovative Program Lead:
Physical Address of Innovative Program: 
Project Description: 

Heroin addiction and deaths by overdose present a serious crisis in public health that is especially devastating to vulnerable populations including individuals recently released form incarceration and living in poverty. The situation is complicated by a dearth of accessible treatment for this marginalized group. PC creates a professional, clinical team that partners with grassroots community recovery centers to provide buprenorphine induction and stabilization [MAT]supported by peer outreach and recovery. For 5 years, PC has continued the program and expanded to 3 sites  providing low barrier access to treatment. Peers outreach to community and build trust to reach persons with opioid disorders . The doctor, nurse, SU counselor and peer coaches comprise the clinical team. On day one, clients receive a full health eval and begin treatment. Once stable, as defined by the team for each individual, the client is transitioned to a primary care clinic. 

How does the innovative program work to improve behavioral health access?: 

PC works within the community. The BHLI trained peer team builds trust and explains the program. The partner sites are a community resource. For these reasons, the PC program is reaching people who had been left out of treatment.Current enrollees explain how critical the access is and the extent of their need, even buying bupe on the street. Enrollees are largely uninsured at intake, unemployed and indigent. There is a high incidence of chronic medical conditions (68%) as well as HIV( 10% ) and Hepatitis C (22% ) as self-reported . Doctor says nos. actually higher . Most enrollees have co-occurring mental health issues that seriously compromise treatment.Many are seeing a doctor for the first time even if they have Medicaid and been assigned a provider - they don't access. The PC program provides drug treatment but also is a gateway to health. Access is enhanced by location, trust and the low barrier, harm-reduction model that continues treatment despite "full compliance"

How does the innovative program work to improve behavioral health quality? : 

PC brings a traditional high-quality medical team to non-traditional settings. The success of our approach can be measured by retention, rates of opiate negative drug screens and the amazingly positive feedback received from both current and former clients. PC doctors and nurses have primary care certification with substance use speciality. Lead doctor heads a primary care clinic at Johns Hopkins (Ryan White program too) and our Hopkins trained nurses have  community experience including volunteering at needle exchange program. Peer coaches are certified by City and BHLI provides additional on-going training and oversight. Partner meetings occur every month to review issues and problems and brainstorm solutions to improve treatment while retaining values. All treatment and protocols defer to individual needs and each person's progress is reviewed weekly. When there are problems, the client comes to team meeting to work with team to improve treatment.



How does the innovative program work to address behavioral health costs? : 

PC, by design, specifically targets health, social and behavioral determinants and thereby prevents avoidable hospitalizations. Although PC is funded only for bupe treatment, the team continues to identify all medical and mental health issues and works with the clients to improve their outcomes. The peer staff identifies housing and family issues so that linkges can be made. More importantly, PC targets the opioid epidemic by using highly qualified professionals but only as needed . The synergistic partnership with community recovery sites means that the services of both the site and the medical team are enhanced without additional costs. Phones are used for continued daily support allowing flexibility for the client and reduced clinical costs while ensuring support. The waste, both monetary and personal, caused by overdose deaths and untreated Hep C and HIV are reduced by  reaching out to this highly marginalized population. PC makes Medicaid enrollment real. 

Creativity and Innovation: 

In the words of an early funder: "PC has proven to be a "cutting edge" and dynamic initiative creating meaningful access to behavioral and primary health services for many of Baltimore's most vulnerable citizens". PC co-locates in recovery settings. It attracts many who have never made previous attempts at recovery or only attended NA meetings. PC educates peers about stigma, harm-reduction, health and leadership. PC marries the grassroots to the highly professional and creates partners in treatment. PC brings exposure, without mandates,to yoga, storytelling and other innovative ideas for health. PC is creating a new model for peer led recovery groups that promotes recovery through MAT and health [AIM Recovery]. PC links public health graduate students. JH med. residents and nurses- in training to community initiatives. PC treats the uninsured and leverages Medicaid and grant funds for its goals. PC links values, people and data to policy and program.


Both the PC physician and the BHLI Exec. Dir. are faculty at Johns Hopkins Univ. and are committed to mentoring about true community-based innovative innovations. BHLI 's mission includes a "training" component that is integral to PC for professionals, students and community partners. PC Partners have created models to allow for replication such as statement of values, model and individualized protocols and educational materials. BHLI and PC staff are educating others about rewards of integrated holistic, harm-reduction principles into treatment settings and integrating MAT into shelters, e.g Helping Up Mission, and homeless programs with innovative approaches. PC staff have published papers and posters for national conferences. The ASAM conference is sending a bus of phsycians from conf. in Baltimore to see a PC site, and to observe an AIM meeting. BHLI participates in local and state task forces to spread the message of training and peer partnership. 


BHLI was formed in 2003 at the initiative of Baltimore Mental Health Systems, mental health authority of Baltimore City. It convened leaders in the academic community to address service gaps and workforce development in community behavioral health. Out of these discussions BHLI,  a non-profit corporation,  was formed. BHLI's Board is comprised of educators, clinicians and community partners all of whom are committed to the mission to improve service delivery by filling  gaps in services with innovative and high-quality programs while focusing on training and workforce development and policy supported by research. BHLI is currently in discussions with the City on ways to expand the model and continue the Medicaid support and grant funding. As well, BHLI is successful in garnering continued private support for its innovations. BHLI remains  a partner in the JHU Source program serving as a practicum and training sites for graduate students.


This innovation will work anywhere that there is leadership invested in expanding MAT and integrating MH and primary care by reaching out to vulnerable populations and doing what it takes to partner. If there is a commitment to flexibility,individualized services and harm reduction then this innovation will work. BHLI has materials and the ability to teach and to provide leadership and technical assistance. The model provides the format that can then be individualized to urban or rural settings and to sites that differ one from another. Attached please find some of the materials developed by BHLI for the PC program and for training that can be used by other jurisdictions interested in this model.  Replicability is enhanced by a robust Medicaid program and additional funding from public and private sources as well as linkages to an academic training center but can be replicated as necessary without these supplements. 


BHLI has no funding for data collection or analysis. However, the goal of creating a high-quality and ever improving program means that data must be created and evaluation must be on-going. Using some administrative dollars and links with graduate students, the BHLI PC program has a relatively robust data collection system. We hope to enhance qualitative interviewing services in the next year with a practicum partnership.

Current quantitative measures:

  • demographic information
  • medical psychiatric history
  • prior hosp. and ER
  • prior SUD or MH treatment
  • involvement with criminal justice system
  • Numbers of persons enrolled
  • test results (e.g.,weekly urine tests)
  • length of active program involvement
  • disposition (transition or discharge)
  • linkages to benefits pre and post
  • housing situation

Qualitative measures include evaluations and interviews.