Although there are varying perspectives on whether emergency providers should place substance abuse patients on medication-assisted treatment (MAT) while such patients are still in the emergency setting, there is wide agreement that linking all such patients to treatment is important. This mechanism, often referred to as a “warm handoff,” ensures patients can turn to a resource for help in dealing with their substance abuse problem immediately.
Of course, the specifics involved in this transition are critical. That’s why emergency providers at Reading Hospital in West Reading, PA, work closely with the Council on Chemical Abuse (COCA), a non-profit organization that focuses on issues involving substance abuse in Berks County, PA, to develop an effective warm handoff approach.
“We developed the program based on feedback that we received from multiple sources, including COCA and our mental health services, as well as emergency providers and the staff here,” explains Kristen Sandel, MD, associate director of emergency medicine at Reading Hospital.
The resulting warm handoff program includes several components, all designed to ensure patients with addiction problems are connected to a treatment plan as soon as their medical emergency has been addressed.
At first, the program was targeted specifically toward patients who had overdosed on heroin because there was an epidemic of heroin overdoses in Berks County and surrounding areas, Sandel says.
“As the program evolved, we recognized that there are many more patients who could benefit from these services, so we approached COCA to see if we could offer the same program to patients who wanted assistance with their addictions involving other opioids,” she explains. “We have not been able to extend it to other substances beyond opioids at this point, but our successes with the program thus far have made it clear that this may be a program we can expand in the future.”
The new program, which has been up and running since February, has gained steam.
“Initially it was a little bit slow and we had a few glitches, but as the program has become more robust and more mature, our providers have been very active in offering these services,” Sandel says. “We are averaging one patient [taking part in the warm handoff program] every two days ... and it is a resource that didn’t used to be available.”
What happens when a patient with an addiction problem presents to the ED?
“The initial focus is stabilization of the patient and treatment of their acute, life-threatening medical condition,” Sandel notes. “At that point, we have a frank discussion with the patient about the reason he or she is in the ED if it was a heroin overdose, or we ask the patient about his or her substance use history and social history, and if we see that this person has an issue with a controlled substance, including opioids or heroin, then we offer the program.”
Sandel emphasizes that emergency providers are instructed to treat these patients like they would treat any patient with any other medical condition, whether it is a heart attack or appendicitis.
“Addiction is a disease, and part of the treatment is offering recovery, just like we would offer a cardiac catheterization to a patient having a heart attack or medication for a patient who is having a stroke,” she says.
The warm handoff program is voluntary, so patients certainly can decline, but if they do accept the warm handoff the provider will contact a mental health liaison and a hospital social services representative.
“At that point, the mental health liaison will call the consultant/recovery expert from COCA,” Sandel explains. “In most cases, they will come to the ED within 30 minutes to an hour to meet with the patient before they are discharged home, or [the patient] will be offered an inpatient treatment program if that is the best option.”
To make sure emergency providers were aware of the warm handoff program, administrators inserted a prompt into the electronic referral process.
“When someone consults our mental health services regarding a patient, the first question that is asked is whether this is a warm handoff,” Sandel says. “The provider has to answer that question, so it is always in the forefront of their mind: Do I need to offer this patient warm handoff services for an opiate or heroin addiction?”
If the provider says, “yes,” that triggers the mental health worker to recognize not only the mental health issues that the patient may have, but also the substance abuse issue, Sandel explains.
“The reason we put the hard stop in [the electronic process] was to ensure that our providers are thinking about [substance abuse] and asking patients about it,” she says.
Additionally, administrators held an information session with emergency providers to explain the warm handoff process and to review the types of conversations in which providers might engage with substance abuse patients. Sandel stresses communication with patients is key.
“This isn’t just an option that patients can take or not. It is something that could change their lives,” she says. “It is telling a patient that he almost died today or that he lost his heartbeat and wasn’t breathing, and that you had to provide lifesaving treatment to ensure that you could be having this discussion.”
At the same time, it is important to convey that you are there to help and that addiction is a disease, Sandel adds.
“We are not pointing fingers or blaming patients for this. We want to help them, and many times the best option is getting them into a recovery program, whether that is in an inpatient setting or an outpatient setting with the help of recovery specialists,” she explains. “That communication piece, where we actually have the discussion with the patient or the patient and their family, is critical.”
For the warm handoff process to work, there must be treatment providers in the region ready to accept patients. That was not always the case in Berks County, Sandel notes.
“In the past, when patients wanted to go into recovery, if we didn’t have a bed or we couldn’t find a bed somewhere in one of the surrounding areas, we would discharge a patient with a phone number or an address,” she explains. “It really was a disjointed effort, and one of the reasons was because there were limited resources.”
Pennsylvania authorities have been improving access to recovery programs, including both outpatient and inpatient approaches.
“The state is also looking at both mental health and substance use because they are so intertwined and making sure we have the resources to meet both the mental health needs and substance use issues,” Sandel notes.
While it’s important to build relationships with treatment providers, you also have to finesse how the ED will communicate and interact with these services, Sandel advises.
“We had some growing pains [in this area] in the beginning, but once we worked those out, it has been a very smooth process,” she says.
Another critical element of success is making sure that everyone is on board with the process, from the physicians and nursing staff to mental health services, social services, and allied staff throughout the ED.
“This is a process where everyone has a piece,” Sandel says.