Clinicians and social workers at Beth Israel Deaconess Hospital in Plymouth, MA, (BID-Plymouth) have found that by working closely with the Plymouth Police Department and other community partners, they can connect many more patients with treatment for their opioid addictions than they have in the past. In fact, the Integrated Health Care and Substance Use Collaborative, as their program is called, began with recognition by law enforcement that something needed to change in the way the community dealt with its opioid abuse problem.
Michael Botieri, Plymouth’s chief of police, explains that the opioid crisis became so alarming back in 2014 that he requested to hire nine officers so that he could create a division to deal with the issue.
“We looked at it as having a front row seat to the problem since we were the police and we were going out on all these calls [involving drug overdoses],” Botieri notes.
But the officers responding to these calls saw a clear need to do more on the treatment side.
“Traditionally, in law enforcement, we go to a scene, and we hope things are better when we leave,” Botieri explains. “We wanted to be more engaged and more involved in that rehab piece.”
Consequently, the police department prepared a brochure that outlined all the different alternatives and treatment providers in the region that patients and families could consider in getting help for an opioid addiction, and officers began handing out the brochure when they responded to calls related to opioids. This effort didn’t solve the problem, but it started the community down the path toward a more comprehensive approach.
“It took the collaboration of different stakeholders,” Botieri observes. “We started sharing best practices, and trying to figure out how we can deal with this.”
Develop an Outreach Team
One of the stakeholders involved with these discussions was BID-Plymouth. In October 2015, the hospital developed a behavioral health (BH) team to work with overdose patients who present to the ED. The team, which is embedded in the ED, consists of nurse practitioners and substance abuse clinicians, explains Sara Cloud, LICSW, the director of social work at BID-Plymouth.
“We do a substance abuse disorder evaluation while patients are in the ED. We also meet with the family, offer support, and offer to connect them with appropriate levels of care based on the assessment and the findings of the evaluation,” she explains. “We offer them printed materials in terms of resources, and we follow up with them the next day ... to see if they got linked, whether there are any barriers, and if there are any problems we can help them with.”
While the BH team provides a big assist in helping emergency personnel manage the increasing volume of patients with opioid addictions, administrators note that the vast majority of these individuals decline treatment referrals while they are in the ED. However, rather than give up on connecting these patients with addiction treatment services, BID-Plymouth and the Plymouth Police Department have formed an outreach team that will visit these patients at home.
“We have a much higher success rate of people accepting treatment from that vantage point in the community than when they are in the ED and they are signing out against medical advice,” Cloud observes. “Because we have clinicians right there on the scene doing the opioid follow-ups, we can do an assessment of what people need. If it is inpatient detox ... the detectives can drive them there if they need or want that. Others may be much more appropriate for medication-assisted treatment [MAT] on an outpatient basis. We have flexibility based on what is needed, what we can link them to, and what they might be agreeable to.”
This aspect of the program, called Project Outreach, is a collaboration of not just the police and hospital, but also substance abuse treatment providers in the region.
“The Plymouth Police Department really worked on pulling together a team of collaborators and meeting that charge,” Cloud notes. “That was effortless on our part. They had done all that work.”
The goal of the outreach team is to visit patients in their homes within 12 to 24 hours of their discharge from the hospital.
“We started on Dec. 1, 2015, and the statistics are good,” Botieri explains. “We are going to measure our success in small doses, but roughly 80% of the people we visit are [accepting treatment] ... within a week or two of the visit.”
There definitely is a law enforcement component to this approach, Botieri explains.
“We make sure that the person [who overdosed] is not wanted for anything. If they are, we take care of that first. We make an arrest, bring them to court, and try to get them help through that process,” he says. “If they aren’t [wanted for anything], then we can do a follow-up the next day.”
Another important role for law enforcement has to do with confidentiality.
“The way the program is structured, first responders identify a case and confirm that Narcan [naloxone] was administered. They flag the case for the police department and the police department then sends a response that [outreach] is needed. Then we go out,” Cloud explains. “When we go into the community, we are going with a detective, and the detective is the one telling the family that we are there because their son overdosed last night. The detective is disclosing that information based on the information he or she received from the first responders.”
As a hospital employee, Cloud notes that she is not revealing the information from the hospital medical records, which would be problematic from a patient privacy standpoint.
“The first responders are sharing that information. They have a lot more flexibility and leeway than we would have as healthcare providers,” she explains.
The confidentiality piece was one of the thornier issues the collaborators had to work through in designing the outreach approach, Botieri acknowledges.
“We are basically making the introduction. We are taking the confidentiality piece out, and saying it is public safety,” he explains. “That is why we are there. We actually have someone with us who can talk about the options and actually put [the person in need of addiction treatment] in a bed.”
Leverage Specialized Skills, Expertise
To succeed with such an approach, both the hospital and the community partners involved need to break down silos, Cloud stresses.
“The team has representatives from a very specialized area. We have representatives from MAT programs, we have recovery coaches, we have the hospital, and we have detox facilities,” she explains. Other stakeholders include mental health agencies and the drug court in the region, as well as the school department, Cloud adds.
On the hospital’s part, embedding a new behavioral health team within the ED came with some growing pains, acknowledges Peter Smulowitz, MD, the associate chief in the department of emergency medicine at BID-Plymouth.
“As we brought in some new providers, there was some getting used to who they are, what they are offering, and what their role is, but I would say that was a fairly short-lived process of trying to understand the team, and once that was all in place, I think it has been only positive,” he explains. “Emergency providers are incredibly busy trying to manage everything that is coming through our doors, and we want to give these folks who are really needing and sometimes seeking treatment the best treatment that we can provide.”
Employing staff members who are specially trained at handling patients with behavioral health issues, not just addiction, but all behavioral health issues, has been a big gain for the department, Smulowitz adds.
“They are able to spend time with patients and provide resources that we just don’t have the expertise in, so we really rely [on the behavioral health team] at this point and look to the team as a huge success.”
While much of the impetus for the creation of the embedded behavioral health team was the opiate problem, the team works with all behavioral health presentations as well as social work needs, Cloud notes.
“If someone comes in who is homeless or there is a question of abuse or neglect, we help,” she says. “We work with a full range of need in the ED.”
Smulowitz explains that the substance abuse piece of this intervention is very connected to the mental health piece.
“We have two psychiatric nurse practitioners who are with us Monday through Friday from 9 a.m. until 5 p.m. who are really dedicated to helping the patients with mostly mental health issues, although obviously substance use dovetails into that as well,” he says. “They’re helping to expedite dispositions to the extent possible.”
Cloud notes that colleagues interested in developing a similar ED-based behavioral health team should think through the logistics thoroughly beforehand.
“I think having frequent meetings, transparency, and really defining the roles as clearly as possible are the best words of advice in terms of the transition and culture shift within the ED itself,” she says.
Address Opioid Prescribing
Emergency providers at BID-Plymouth have decided that one thing they will not do is start patients with opiate addictions on MAT in the ED.
“We decided not to do that piece of it, and there are a variety of reasons why,” Smulowitz says. “I think the main thing is that if we start treatment, then we basically need to have the patients connected with [an addiction treatment] provider the very next day to continue that treatment, and, logistically, that is challenging.”
Further, in terms of providing prescriptions for medications such as buprenorphine, ED leaders were concerned about the potential for abuse because of the street value of such drugs. They also were concerned about the effect on patient volume.
“We weren’t prepared because we are already overloaded with patients that we are trying to help. We were concerned about the if-you-build-it-they-will-come phenomenon of offering treatment and then people coming that would max out our resources,” Smulowitz explains. “Our main goal is to connect these patients to the next stage of treatment.”
However, one step emergency providers have taken to address the opioid abuse problem is developing their own opioid prescribing guidelines.
“They largely speak to the conditions upon which we don’t think it is appropriate for us to provide prescriptions, and to give providers some support for not providing opioids in these cases,” Smulowitz explains.
The guidelines primarily focus on the appropriate management of acute non-chronic exacerbations of pain, not treating chronic pain with opiates, and not refilling lost or stolen medications, Smulowitz says.
“We’re trying to rein in what we thought was potentially inappropriate access to opioid utilization,” he explains. “The next step is we engaged in a project where we have shared prescribing information with our providers as to their individual prescribing practices as compared to their peers.”
While formal data from this project will not be available for a month or two, Smulowitz notes the project has produced a significant reduction in opioid prescribing.
“People like to compete,” he says. “We started off sharing blinded information so the providers didn’t know who they were being compared with, and now everyone is asking for the information to be non-blinded. They are comfortable looking to see how they are performing among their peers.”
SOURCES
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Michael Botieri, Chief, Police Department, Plymouth, MA. Phone: (508) 830-4218.
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Sara Cloud, LICSW, Director of Social Work, Beth Israel Deaconess Hospital, Plymouth, MA. Email: [email protected].
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Peter Smulowitz, MD, Associate Chief, Department of Emergency Medicine, Beth Israel Deaconess Hospital, Plymouth, MA. Email: [email protected].
