EXECUTIVE SUMMARY

To address the growing incidence of substance abuse, some EDs are going beyond offering referrals for treatment to actually installing addiction counselors on site. The approach is seen as an opportunity to engage with patients who might not otherwise opt for treatment alternatives that could lead them toward recovery. It also provides emergency providers with assistance in meeting the needs of patients with complex addiction issues.

  • The San Mateo County Behavioral Health and Recovery Services in San Mateo, CA, has partnered with the San Mateo Medical Center to provide on-site addiction counselors/case managers to engage with patients who present with alcohol abuse problems, and now is working to expand the approach to include patients with opiate addictions.
  • The Integrated Medication Assisted Treatment program links patients to detox programs as well as treatment that can help reduce cravings. Case managers also address social needs such as housing.
  • Riverview Medical Center in Red Bank, NJ, is piloting the use of on-site addiction counselors to work with patients and families who present with a primary substance abuse problem with no comorbid psychiatric issues. The addiction counselors also will provide consults to patients admitted to medical or surgical floors and provide some assistance to patients in the inpatient psychiatric unit. Administrators hope the counselors will help improve coordination of care to patients with addiction problems.

There has been significant discussion in recent years about the importance of providing a “warm handoff” to patients who present to the ED with substance abuse problems. The concept of immediately linking these patients with help for their addictions rather than merely giving them a list of phone numbers is widely acknowledged as a best practice, not only for its potential effect on outcomes, but also because it can make a dent on repeat visits to the ED.

However, some EDs are going a step beyond warm handoffs by embedding addiction counselors in the emergency setting, and in some cases even beginning treatment for an addiction in the ED. The approach takes some of the burden off busy emergency providers by providing them with immediate assistance for patients who present with complex addiction problems. Further, some EDs have found that the chances for recovery are far greater when trained addiction specialists are on hand to guide patients toward positive change. (See also: “Emergency Physicians Can Play a Role" below)

Engage with Patients

Administrators of the San Mateo County Behavioral Health and Recovery Services (BHRS) in San Mateo, CA, recognized the potential for offering on-site assistance to high-risk, high-need patients presenting with alcohol use disorders in 2013, launching a pilot to test the efficacy of a comprehensive approach, explains Clara Boyden, a program manager at BHRS.

“We really wanted to expand access to other treatments like medications and do more engagement with case management to help people get better,” she explains. “Through this pilot, we served 10 to 15 patients with really good outcomes, so we were able to work with our local health plan and proposed a much larger program that would build on this pilot; part of our proposal [involved having] staff embedded in our ED [at San Mateo Medical Center].”

The resulting Integrated Medication Assisted Treatment (IMAT) program began in 2015, and includes placing a behavioral health alcohol and drug services case manager on site in the ED at San Mateo Medical Center ED and Psychiatric ED around 18 hours a day, seven days a week. Case managers also are available at satellite primary care clinics and in the field to visit treatment centers and jails. Roberto Donlucas is an addiction counselor and case manager stationed in the ED as part of the IMAT program.

“There is a lot of collaboration going on between BHRS and the medical staff in the ED, and it is really focused on client-centered care,” he explains.

When patients report during triage that they consume large quantities of alcohol, the IMAT case management specialist on duty is alerted.

“I read the information on their charts and try to get as much background information about the clients as possible before engaging with them,” Donlucas notes. “Once the nurse speaks with them and does their triage and assessment, that is when I meet with [the patients] at the bedside.”

Often, these patients are acutely intoxicated or incoherent, so it is difficult to engage in free-flowing conversation, Donlucas observes, but he will address their immediate needs, which often include housing.

“We offer a linkage to detox where they can receive withdrawal management services, and then once they are a little bit sober, then we follow up,” he says. “We do screening assessments, and then we introduce them to the option of perhaps utilizing IMAT as a way of reducing their alcohol consumption.”

In addition to IMAT, services offered through the program include basic primary care, peer coaching and support, an 18-hour sobering station, inpatient detox, and transportation assistance so patients can get to their appointments. The program is paid for by the local Medi-Cal health plan.

To date, the program has been available only for patients with alcohol use problems, but plans are in progress to expand the approach to include patients who present with opiate addiction issues.

“We have been having preliminary discussions with the ED and one of our providers from our pain clinic,” explains Matthew Boyle, a program analyst with the IMAT team. “It will be phase two of our IMAT program, and we are hoping that early next year we will have that program in place.”

Key to the success of phase two will be putting all the necessary pieces in place to sustain the program.

“We have been working to build the infrastructure to be able to support the work that would need to happen with opioid disorders, especially the expansion of access to medications such as Suboxone,” Boyden observes. “At the end of the day, our goal is to have people able to transition back into primary care where they can continue receiving ongoing medication support, if that is what is needed.”

The ED providers and administrators have shown a willingness to start the conversation about potentially beginning treatment for opiate addiction in the emergency setting, Boyle says.

“The next step is to get that buy-in because we then need to shift [the patients] over to primary care, and our primary care system at this point in time is just beginning the conversation as well,” he says. “We have a community-based organization that could temporarily perhaps partner with the ED and hold these people, and continue providing medication, but ultimately we want to transition these clients back into our regular primary care clinics.”

Expand Existing Services

The model already in place to assist patients who present to the ED with alcohol use problems also should work well for patients presenting with opiate use problems, Boyden suggests.

“We feel good about the model and the partnership, and we just need to adapt it for opiates and other substances,” she says. “There would probably need to be some changes.”

Until phase two of the IMAT program is rolled out, patients who present to the ED with opiate use problems are offered referrals to treatment. However, Boyden is eager to add engagement and potentially ED-based inductions to IMAT, where appropriate.

“When you look at the issue of substance use disorder, so many people who meet the diagnostic criteria are not wanting to go to treatment,” Boyden says, noting one reason for such resistance is that many programs are abstinence based. “[Patients] may reject the idea of full abstinence, but they may be interested in addressing their substance use and changing it,” she says. “They may not want to stop [altogether], but they may want to cut down and control it better, and that is the place I think where we can start working with them and change that relationship, connect them with medications that can help address cravings, help them find stability through housing, and help them address other things that are important to them.”

Supportive leadership has been hugely beneficial to pushing the IMAT approach forward, Boyden adds.

“The quality of the partnership [between BHRS and San Mateo Medical Center] has been phenomenal, and it is helping our ED folks see the change that is happening to individuals who have worked with our team,” she says. “It is really the quality of the partnership and the feedback on people who have improved that have started to change ... perspectives and bring hope for healing and recovery back to some of our most disillusioned and frustrated staff who are kind of in the trenches in the ED.”

Placing an assigned case manager in the ED who offers a program and links to resources makes a big difference, according to Boyle.

“We have been really well received, and it has been an honor to partner with [emergency personnel] and be embedded there,” he says.

In fact, Donlucas notes that emergency providers keep asking him when the IMAT team is going to expand services to patients with opiate addictions.

“The general consensus here is that there is a vested interest from direct service providers in the ED all the way up to leadership staff to address this national epidemic,” he says. “So we are working on it behind the scenes. We are really trying to lay out the foundation so that we can properly treat this population.”

Target Gaps in Care

With the help of a $120,000 gift from the Tigger House Foundation, Riverview Medical Center in Red Bank, NJ, also is in the process of deploying addiction counselors in the ED to work with patients who have a primary substance abuse issue.

“Patients who come in depressed and have problems with alcohol or opiates ... are handled pretty well by our system and by the mental health system in general, but where the real deficit has been is if the patient is coming in with a primary substance use issue and no comorbid psychiatric issues,” explains Ramon Solhkhah, MD, the chairman of psychiatry at Jersey Shore University Medical Center in Neptune, NJ, and corporate medical director at Meridian Behavioral Health, both part of the Hackensack Meridian Health System. “So that is really what the addiction counselor’s role is going to be — working with those patients and helping them get into treatment, and providing families with support and education.”

The plan is for the addiction counselors to be on site in the ED seven days a week, primarily during a late afternoon/early evening shift. They also will be available to provide consults to patients who have been admitted to the hospital on medical or surgical floors, and to spend some time running groups and providing education to patients who have been admitted to the hospital’s inpatient psychiatric unit.

The intervention is just a pilot project at one hospital out of 11 adult hospitals and two children’s hospitals in the Hackensack Meridian Health System at this point, but Solhkhah notes that administrators are hoping that with proof of concept, they will be able to expand the ED-based addiction counselors across the system. There certainly is a huge need in the region, he says.

“Substance use disorders are a huge problem for us here in central New Jersey. We are sort of the epicenter in the country for the prescription opiate and heroin problem,” Solhkhah notes. “We are in between the ports at Newark and Philadelphia, so we’ve got, unfortunately, very pure drugs that tend to come into the country right through us, so that tends to lead to a lot of opiate problems for us.”

To date, psychiatric clinicians have been taking on the patients who present with primary substance abuse problems, but this has not been their main focus.

“The real elegance of this new program is we will have people who are specially trained in techniques like motivational interviewing and are able to work with patients where they are and engage them in treatment,” Solhkhah says. “We think that is a specialized skill set. We have been doing it as well as we can, and maybe better than most, but we still think that isn’t really the level of care that our patients deserve.”

Solhkhah suggests the addiction counselors are part of an effort to make the coordination of care between the ED, the inpatient units, and outpatient providers as seamless as possible.

“We are certainly embracing that concept on the mental health side. Our [mental health] patients often times need [this coordination] even more than the other medical specialties,” Solhkhah explains. “Mental health providers across the country are in short supply, let alone those who are trained in addiction; there can be long waiting lists to get people into treatment, so every little bit that we can do and engage the community to help us with supporting these sorts of endeavors we are very grateful for.”

SOURCES

  • Clara Boyden, Program Manager, San Mateo County Behavioral Health and Recovery Services, San Mateo, CA. Email: cboyden@smcgov.org.
  • Matthew Boyle, Program Analyst, Integrated Medication Assisted Treatment Team, San Mateo County Behavioral Health and Recovery Services, San Mateo, CA. Email: mboyle@smcgov.org.
  • Roberto Donlucas, Addiction Counselor/Case Management Assessment Specialist, Integrated Medication Assisted Treatment Team, San Mateo County Behavioral Health and Recovery Services, San Mateo, CA. Email: rdonlucas@smcgov.org.
  • Kenneth Saffier, MD, Family Physician, Addiction Specialty, Affiliated with Contra Costa Regional Medical Center, Martinez, CA. Email:
    ksaffier@yahoo.com.
  • Ramon Solhkhah, MD, Chairman of Psychiatry, Jersey Shore University Medical Center, Neptune, NJ; Corporate Medical Director, Meridian Behavioral Health. Phone: (732) 776-4930.

Emergency Physicians Can Play a Role

Although some emergency physicians are resistant to offering addiction treatment, there is growing recognition by many providers that they can play a role in facilitating care. For instance, Kenneth Saffier, MD, a family physician who specializes in addiction medicine, has had good success working with emergency physicians in his region to perform medical screening exams on patients presenting with addiction issues and, in some cases, to provide a dose of medication in situations in which it will be a day or two before Saffier is able to see the patient.

“We have a lot of people, and we don’t have enough clinics,” he says. “We generally have one to five referrals on any particular day, and we just can’t always get someone in.”

In his practice, Saffier treats more than 250 patients with buprenorphine, and some of them have been successfully inducted or given their first dose while in the ED, he explains.

“It basically involves me working with the [emergency] physician and coaching him or her on what they can do,” he says.

Saffier uses computerized forms that outline a buprenorphine treatment agreement; additionally, he has a clinical opioid withdrawal scale that an emergency physician can use to assess a patient’s degree of withdrawal and provide a good faith exam, he explains.

“Many of these patients are in an adequate degree of withdrawal so they can be given a dose [of buprenorphine] in the ED and be discharged, sometimes within minutes to an hour after observation,” he says.

Frequently, these patients return to a social detoxification facility, a residential facility in which people are sequestered from alcohol or drugs and are observed by staff. However, by collaborating with emergency providers, Saffier can ensure these patients are managed safely until he is able to see them.

“It helps to know the emergency providers,” Saffier notes. “There are some doctors that just haven’t learned yet, but there are many who have compassion and will do what they can, especially if someone is going to follow-up.”

Saffier acknowledges that all sides need to be flexible in the arrangement.

“I have to be cognizant of the fact that the ED is sometimes full of patients waiting to be admitted to the hospital, and there can be delays,” he says. Also, space sometimes is in short supply so that it is not practical to observe a patient after he has been given a dose of buprenorphine in the ED.

“I have to triage my patients and they have to triage their patients so that it works for all concerned,” Saffier says. “These are important details and pathways that have to be worked out.”

Saffier would like to see more ED leaders develop connections with the outside medical community so that there can be improvements in meeting the needs of patients with addiction problems, and so that appropriate treatment can be a standard of care.