Baltimore has struggled mightily with substance misuse, and much of this burden has fallen on EDs in the region. Indeed, statistics from 2014 suggest that the city registered the highest rate of ED use due to opioid use disorder in the country, and the volume has not let up.
This has prompted hospitals and public health authorities to create innovative solutions to address the problem in a comprehensive way. For example, two years ago, the ED at University of Maryland Medical Center (UMMC) in Baltimore decided it needed a fresh approach toward connecting patients with effective treatment. The impetus for action on this front stemmed from the realization that substance use was a key contributing factor to a growing number of diagnoses.
“Many of the patients ... were coming in with a medical complaint, but really when we got studies done and [figured out] why they were there, we recognized that substance use was ... at the heart of whatever their medical issue was,” explains Andrea Smith, DNP, CRNP, the director of urgent care and advanced practice emergency services at UMMC.
Eric Weintraub, MD, director of the division of alcohol and drug abuse and co-director of adult psychiatry at UMMC, notes that some of these patients presented with psychiatric issues while others arrived with medical concerns, but they were not treated for substance misuse.
“They were getting patched up and sent on their way, and we were seeing high rates of recidivism,” Weintraub says.
Part of the problem was that many of these patients were reluctant to discuss their issues around substance use with the emergency clinicians. “When I would try to approach this subject with patients, they just weren’t opening up to me, and I wasn’t able to build that relationship,” Smith observes.
To get around this barrier, UMMC became the first hospital in Maryland selected to pilot the idea of leveraging peer recovery coaches — people who are in long-term recovery themselves and have received training in how to assess the readiness of patients to consider treatment. Peer recovery coaches work with patients to find a solution most likely to succeed, and facilitate patients’ transition into an appropriate program.
“I was able to secure funding for our hospital to hire three peer recovery coaches, and that is how [the program] started,” Weintraub observes. “They have been working here for two years now, doing SBIRT [screening, brief intervention, and referral to treatment]. [Coaches] see anybody in the ED who screens positive for substance misuse, and it has worked pretty well. We have seen thousands of patients and gotten people into treatment, which has been really helpful.”
Meanwhile, the need for such services has only grown. “As a university-owned medical system, we have gone from a couple of years ago seeing an overdose every other day to having two overdoses per day now,” Weintraub laments.
In the beginning stages of this effort, the focus was on embedding the peer recovery coaches into the emergency team.
“When [coaches] came in to train and orient, one of the things I did strategically ... was have them shadow a resident, a nurse, and an attending [physician],” Smith shares. “This was to have a walk-through so that they could see the workflow, but also start to ... build the relationships so that the clinical team understood what the peer coaches were all about and vice versa.”
Still, it was challenging to integrate the peer recovery coaches and their work with patients into the overall flow of the ED.
“That was difficult because this is a fast-paced environment,” Smith explains. “You’ve got a million things going on at once, and a lot of times [in the past] ... substance use was something we would maybe bring up once and then not talk about [again], but we really put that [issue] at the forefront.”
Now, every patient who comes through the door of the ED undergoes a brief screening at triage that includes four questions regarding drug and alcohol use.
“Based on the responses, if a patient’s score is above seven, then the peer recovery coach will get a flag to go see that patient,” Smith says. “About 25% of the patients we see in the ED in Baltimore have a positive screen, and that means their substance use or their risk of harm is so great that we need to [have them seen].”
Use Disclosure to Open Doors
Archie Rhyne, a peer recovery coach at UMMC, notes that the flag, indicating that a patient needs to be seen, appears on a computer screen in his office.
“That is when I will first talk to the nurse [caring for the patient] and find out if there is anything [he or she] needs to let me know about the patient,” he explains. For example, the patient may be sedated or irritable, or it may be best to wait a few minutes because the patient is about to go to radiology for X-rays. The nurse will convey any information that can help the peer recovery coach engage in a more productive discussion with the patient.
“Also, the nurse will always let the patient know the hospital has a peer recovery coach that would like to come around and talk to them and may be of some assistance,” Rhyne says.
Typically, Rhyne will introduce himself to the patient and ask if it is acceptable if he provides the patient with some self-disclosure. “That is my door in because I start disclosing that I have been exactly where they are. It loosens the patient up a little bit, and they will start talking,” he says.
Rhyne explains that his conversation always has to be about what the patient wants, but he will guide the patient toward questions relating to what his or her life might be like without the drugs or alcohol that the patient is misusing. “A lot of times patients just take a moment to think,” he says. “Me being in recovery myself, I know that when I was caught up, there were moments I couldn’t have ... because it was always about where I was going to get my next [fix], and I was always filled with shame about what I did to get one.”
When patients hear about Rhyne’s experiences, he says they tend to relax and share more information with him. “I will find a patient who may have been in treatment four or five times, and then gave up on himself. Then, I will disclose that it took me 40 [attempts], and we talk,” he says. “When I get that one moment when a patient starts to feel something for himself again, that’s when I will [ask] what was the last type of treatment that he had.”
Rhyne will explore with the patient how the treatment worked, and whether an alternative approach might be worth a try. “A lot of times, for a person who has been in and out of treatment, and has tried the same thing over and over, a different approach will work better,” he says. “Basically, though, it is always about what the patient thinks will work for them because [treatment] is not being imposed or forced on them. If it is what they think will work ... I know from experience they will give it their best shot.”
Rhyne emphasizes to patients that there are many resources available to them — a reality that many patients have not experienced.
“Most addicts are out of touch with what is going on as far as what is available to them,” he says. For example, they may have called treatment centers in the past and learned that they would be put on a four-week waiting list. But for this program, UMMC has connected with treatment facilities throughout Baltimore, including 11 fast-track treatment providers that will accept patients right away or the very next day.
Consequently, once Rhyne and a patient have decided on a treatment path, Rhyne will leave the room and start making calls.
“Sometimes, we can get the patient into treatment as soon as he or she is discharged from the ED,” Rhyne observes. “We have funds here at the hospital where we can send them by Lyft or Uber because a lot of times, if we put them on public transportation by themselves, they will change their mind before they get there. If we can get [patients] right there and sign them up, they will stay.”
Before taking any action on treatment, Rhyne always confers with the patient’s emergency providers to share what he has learned from the patient and offer his recommendations.
“I may have been able to get more information from the patient than [the clinicians] did ... and then they are able to understand the patient a little bit better,” he says. “They work right along with us. The physicians, nurses — everybody. It is like one big team now. And we have a great relationship with the outside providers — the treatment centers and the IOPs [intensive outpatient programs].”
Among the treatment options available to appropriate patients is ED-based induction of Suboxone, a prescription medication that includes buprenorphine and naloxone. Under this approach, patients receive their first dose while they are still in the ED, and then they are connected to a treatment facility for subsequent doses. In fact, Weintraub obtained a grant for UMMC to train emergency physicians throughout Baltimore to provide this intervention, and he is trying to get the approach expanded to EDs throughout the state.
“Part of it depends on the willingness of emergency physicians to follow the protocols,” he says. “And it is work trying to destigmatize and encourage physicians to do this type of treatment.”
Smith observes that peer recovery coaches can connect on a deep level with patients who have substance use problems.
“They can get from these patients in five minutes what it would take me hours to get just because of the lived experience that they share with them,” she says, adding that there is constant demand for their services. “It is not uncommon to have 10 to 15 patients on the board that the peer recovery coaches need to go see. We have three peer recovery coaches on staff in the ED, and one peer recovery coach is in our psych ED.”
The peer recovery coaches cover the ED from 6:30 a.m. to 1 a.m. Monday through Friday, and from 11 a.m. to 9 p.m. on the weekends.
“They work in 10-hour shifts, and we are actually in the process of hiring more individuals so that we can offer 24/7 coverage,” Smith adds. “The peer recovery coach in the psych ED covers 8 a.m. to 5 p.m., Monday through Friday.”
However, for patients who have been brought to the ED because of an overdose, it is often difficult to engage them in discussions regarding treatment while they are in the hospital, Weintraub explains. “They have received Narcan [naloxone], and it will wake them up and reverse the overdose, and it frequently puts them into pretty severe withdrawal,” he says. “They are very angry and irritable, and oftentimes are not that interested in talking to anybody.”
Consequently, in cases in which these patients decline interactions with the ED-based peer recovery coaches, they are referred to an outreach worker who is part of the Overdose Survivors Outreach Program (OSOP), an effort supported by the Maryland Department of Health’s Behavioral Health Administration. (For more information on the program, visit: https://bit.ly/2J0b13U.)
The OSOP workers have a similar background and similar responsibilities to the ED-based peer recovery coaches, but will primarily follow and work with overdose survivors who have been discharged.
“We provide a spot for [the outreach workers] in the hospital, and they are employed by the hospital ... but most of their time is spent out in the community,” Weintraub shares.
The goal of the outreach workers is to stay in touch with overdose survivors and eventually link survivors into needed treatment for their addiction. The outreach workers also follow up with overdose patients originally referred into treatment by the ED-based peer recovery coaches.
“Anyone who overdoses is automatically transitioned to the outreach worker,” Weintraub notes. “If you have someone who is actually cooperative and feels like they want treatment after the overdose while they are still in the ED, then our in-house peer recovery coaches can refer the person for treatment, but the follow-up is done by an outreach worker.”
However, many overdose patients initially decline any discussions about treatment, leave the ED, and then the outreach worker tracks them down in the community. There is some blurring of the responsibilities between the peer recovery coaches and the outreach workers, Weintraub acknowledges.
“We try not to be too rigid. We just want to make sure the patients get the treatment they need.”
Usually within 30 days of discharge, an outreach worker is able to link overdose survivors with some type of assistance, whether that involves transitional housing or another appropriate program, Smith says. “The program has been very successful.”
Smith acknowledges that she was initially very concerned about the prospects of integrating the peer recovery coaches and the outreach workers into the ED. “Being involved in emergency medicine for almost 15 years, I knew how difficult it is to say that, ‘oh, by the way, we are now going to be adding [something] else to the care of patients,’” she says.
However, Smith’s concerns were dispelled quickly. “We were very strategic and very careful in how we implemented the program, and it was well-received almost immediately because there was such a need,” she says, adding that collaborating with the peer recovery coaches and the outreach workers has delivered dividends over time.
Smith says that emergency staff members have seen the difference the program has made in patients, including some who have been coming in for years and are now in long-term recovery. “The peer recovery coaches and outreach workers are part of the medical team now, and if they are not there for some reason, it is noticeable.” In fact, Smith says providers sometimes ask for peer recovery consults for patients who have not screened positive during triage. In the past year, peer recovery coaches have seen just shy of 30,000 patients who have presented to the ED. Roughly 3,000 of those patients have gone on to receive some type of intervention.
“We have confirmed entry for 433 patients ... which means they are active in recovery,” she says, adding that at least one of the patients who has been referred into treatment through this program has become a peer recovery coach himself.
While peer recovery coaches have worked well in the ED at UMMC, Smith notes that other EDs interested in implementing a similar approach should first consider some of the hurdles involved.
For example, hiring recovering addicts raises all kinds of red flags to the people in human resources, so the issue must be addressed beforehand.
“Usually, everybody goes through drug tests and things like that, so we had to be very sensitive to how we onboard these individuals and what that process looks like,” Smith recalls. “Make sure there is a close relationship with your human resources partners in starting this program because [these individuals] are not going to look like your [typical] employees, and that is very important to understand at the beginning. It was a lesson learned for me.” Further, Smith reiterates that it is hard work integrating the peer recovery coaches into the medical team to ensure there is effective collaboration.
“You have to embed these peer coaches as part of the team or it will be just another service that is underutilized,” Smith cautions.
Funding the peer recovery coaches is a challenge, too, and UMMC has not yet found a way to bill for their services, although treatment typically is covered by public and private payers. To date, the peer recovery coaches have been supported through grant funding.
Smith notes that any ED that implements a peer coaching model with the idea that it will reduce readmissions should not be looking for quick returns.
“When we initially brought this program on, we thought it would help us reduce our readmissions,” Smith says. “What we found is that if patients were seen by our peer recovery coaches, they were actually three times more likely to return to the ED.”
Investigators discovered the reason for the return trips was simply that the patients had received help in the ED for their substance use, so they were returning to the same place for help with their other health issues.
“Once patients are engaged, they will come back to you,” Smith says. “What we found is that after the third visit, generally, there is a steep decline in the number of times the patient will return to the ED.”
Now, ED staff are working toward connecting patients with a primary care physician and other needed social or behavioral health resources as part of the initial recovery piece so that they won’t feel the need to come back to the ED for subsequent healthcare needs.
“That was a really important lesson learned for us,” Smith adds.
Weintraub’s advice to his emergency medicine colleagues is that before they implement peer recovery into the ED workflow, they first should consider whether the area has adequate resources for treatment of substance use disorders.
“It is all good and well to have an intervention ... but if you don’t have anyone to refer patients to, that is a problem,” he says. “We have a fair amount of treatment in Baltimore, so getting someone into treatment is generally doable.”
Weintraub adds that it is important not to oversell the potential benefits or outcomes from a peer recovery coach program.
“The literature on the effectiveness and outcomes of peer recovery coaches in severely dependent opioid use disorder patients is pretty weak or nonexistent,” he says. “There is a general sense that this is effective, and that it helps get people into treatment, but I don’t think there is a good study on economic outcomes and things like that ... so you don’t want to oversell what you are going to get.”
However, the peer recovery coaches at UMMC have made a positive impact on morale in the ED because staff see patients getting help for their substance use disorders when they haven’t been able to help those patients before, says Weintraub, adding that there are not as many hostile interactions with patients. Further, Weintraub says data show that SBIRT interventions can significantly affect recidivism.
Rhyne advises that on the front end of any program implementation, physicians and nurses need to better understand the people who present with opioid use disorders. “I know from my own experience, because I have been there, that [addicts] reach a point where all we hear is the stigma and all we get is the neglect ... we are just a problem to the world,” he says. “The biggest thing peer [recovery coaches] have working for them is their experience and their ability for self-disclosure ... because patients can’t deny the truth once you start speaking it, and it works.”