EXECUTIVE SUMMARY

Research has shown a highly personalized intervention designed for hospitalized patients with comorbid substance use problems can significantly reduce subsequent readmissions and ED visits. After testing, investigators are exploring whether Navigation Services to Avoid Rehospitalization (NavSTAR) might prove beneficial in the ED.

  • NavSTAR pairs motivational interviewing and hands-on navigational assistance, beginning while patients are hospitalized, but extending for three months after discharge.
  • During a 12-week observation period, patients in the NavSTAR group recorded 26% fewer inpatient admissions than patients in the usual care group. Investigators also reported the intervention reduced the risk for ED visits by 44% vs. usual care for the year following the intervention.
  • Aspects of the NavSTAR approach could bolster some existing efforts, although there are differences in medical severity and workflow between inpatient and ED settings.

Investigators have concluded a personalized intervention that pairs motivational interviewing with hands-on navigation assistance can benefit hospitalized patients with comorbid substance use problems.

The approach, called Navigation Services to Avoid Rehospitalization (NavSTAR), was put to the test in a randomized, controlled trial at the University of Maryland (UMD) Medical Center in Baltimore. Researchers observed strong evidence indicating the intervention produces valuable returns on a range of metrics when deployed in the inpatient setting.1

NavSTAR was implemented at a site that had already made significant strides toward identifying and addressing patients with substance use problems who present to the ED. Now, investigators are thinking about how aspects of the NavSTAR approach could be added to the mix in the ED to enhance the screening and linkage-to-care processes clinicians there already use.

Address Barriers

“The idea for NavSTAR came from the fact that we saw patients with comorbid substance use disorders being hospitalized over and over again, with addiction relapse often a contributing factor,” explains Jan Gryczynski, PhD, lead author and senior research scientist at the Friends Research Institute in Baltimore. “We needed something that could strengthen engagement and service linkage after patients left the hospital.”

The approach builds on previous work by James Sorensen, PhD, a professor at the University of California, San Francisco who has worked on opioid linkage, Harold Freeman, MD, who developed the first patient navigation program for patients with cancer at Harlem Hospital Center in New York City, and others. “It focuses on helping patients to access services and support for substance use disorders, medical recovery, self-care, and basic needs, recognizing that these aspects are inherently interconnected,” Gryczynski says.

To examine the effect of the intervention, Gryczynski and colleagues studied 400 adult patients who were hospitalized with comorbid substance disorders involving opioids, cocaine, or alcohol. Half the patients received usual care, and the other half received NavSTAR. In this highly personalized intervention, a social worker would meet with each patient at the bedside during his or her hospitalization. This engagement would continue weekly for four weeks after discharge, then biweekly for the following two months.

“NavSTAR works by addressing the patient’s internal barriers, like motivation and ambivalence about treatment, in tandem with practical external barriers like transportation or access to basic resources,” Gryczynski explains. “NavSTAR combines motivational interviewing principles with a very proactive model of case management to resolve these various barriers to service engagement.”

For example, navigators will help patients traverse the healthcare/service landscape by using supportive coaching, advocating on patients’ behalf, providing help with required paperwork, and more. “Proactivity and persistence are guiding principles,” Gryczynski says.

Bolster Resources

During the 12-week observation period, patients in the NavSTAR group recorded 26% fewer inpatient admissions than patients in the usual care group. Investigators also reported the intervention reduced the risk for ED visits by 44% when compared to usual care for the year following the intervention.

Gryczynski and colleagues noted patients receiving NavSTAR were roughly half as likely as the usual care participants to require a subsequent hospital admission within 30 days of discharge. Also, NavSTAR patients were more likely to enter treatment for their substance use within three months of discharge from the original inpatient admission. About half the NavSTAR group entered substance use treatment vs. just over one-third of the usual care group.

Results from the NavSTAR study were promising, but Gryczynski says feedback from both patients and navigators suggests the intervention may have been too short.

“This is because some patients were difficult to find and engage in the community,” Gryczynski explains. “Others had a more complicated post-discharge trajectory involving skilled nursing facilities, emergency shelters, and readmissions. Many experienced an array of deep needs that take a long time to address.”

Nonetheless, it is notable that NavSTAR produced positive outcomes in in a clinically challenging population. Gryczynski hopes other hospitals will adopt the approach.

“They stand to improve patient outcomes and also help ... avoid costly readmissions — a win/win for everyone,” Gryczynski says. “We are looking into several avenues of future research on this approach, including a larger study to see how [NavSTAR] works in different hospitals and communities.”

Gryczynski acknowledges hospitals interested in the approach may need to strengthen their addiction medicine infrastructures to realize the full potential of NavSTAR. Ideally, this would include creating the capacity to start appropriate patients (i.e., those who are willing and clinically suitable) on medications for opioid use disorder. For instance, the services offered in the study by Gryczynski and colleagues were built on an experienced addiction consultation service in place at UMD Medical Center.

“We were fortunate to hire very dedicated and mission-driven patient navigators, as some elements of the work can be unglamorous and discouraging, such as when patients miss appointments, leave treatment, or experience an avoidable readmission,” Gryczynski shares. “In orienting the patient navigators, it’s important for them to get a good handle on the service system in the community, including medical services like skilled nursing facilities, substance use disorder treatment providers, and things like housing.”

Gryczynski adds the patient navigators involved with the study played a defined role in NavSTAR without contending with competing obligations. “They maintained a relatively low rolling patient caseload. We also made sure they had access to regular clinical supervision and support from the broader team,” he says.

Consider ED Options

If intervening with hospitalized patients with comorbid substance use issues works well, would an intervention employed in the ED offer similar, if possibly even greater, potential? Gryczynski agrees the ED offers a critical opportunity to help patients with substance use disorders, but notes there are some differences from the inpatient setting in terms of the patients’ medical severity and workflow.

For example, inpatient hospitalization offers more time for navigators to develop an initial rapport with patients at the bedside and to develop initial plans. Gryczynski notes there also are several points of compatibility between the inpatient and emergency settings. Investigators hope to explore this area in the future.

In fact, many EDs throughout Maryland, including UMD Medical Center, are already initiating appropriate patients on medication-assisted treatment (MAT) and using recovery coaches to rapidly link people to treatment. “Those sorts of interventions are very promising,” Gryczynski says. “We are currently thinking about how elements of the NavSTAR approach could be used in EDs to enhance the great work being done in these settings.”

Much of this ED work was pioneered at hospitals in Baltimore in collaboration with Mosaic Group, a small consulting firm that responded to the opioid crisis by working with hospitals to develop a “reverse the cycle” comprehensive ED response program.

As with the NavSTAR program, the “reverse the cycle” approach works in partnership with the addiction consultation service at UMD Medical Center. “The peer [recovery coaches] actually report to a supervisor with the consult service, and there are protocols that were developed as part of the planning process work that we do,” says Marla Oros, RN, MS, founder and president of Mosaic Group. “A lot of the hospitals don’t have that consult service, so [the program] looks a little bit different at UMD Medical Center because of the terrific resource that they have.”

Begin with Screening

The “reverse the cycle” approach may be different from an operational standpoint, depending on a hospital’s resources, but the basic components are similar. First, Oros explains there is a universal screening model aimed at identifying any patient with a substance use disorder regardless of why he or she presented to the ED. “[We] put in place validated screening instruments as part of the EMR [electronic medical record], and we put in place a protocol for nursing to be able to do that screening,” she says.

Then, Mosaic works with hospitals to install teams of peer recovery coaches who staff the ED seven days a week. “We build in triggers in the EMR for a positive screen to notify the peer coach [indicating] that there is a positive patient in the ED,” Oros notes. “We train the peers for this role, and they engage with the patient.”

If a peer coach determines a patient is motivated and desires treatment, the coach will make an appointment with a treatment provider and take steps to address any barriers. “If a patient does not want treatment, we still do telephonic follow-up and harm-reduction education,” Oros says.

Another aspect of the program involves working with hospitals to institute an order set so appropriate opiate-using patients who desire treatment can receive an initial dose of Suboxone in the ED. “The patients are screened by nursing ... they are identified as opiate-using, the peers engage with them, and if the patients are motivated, they are evaluated by the clinical team,” Oros explains. “Clinicians go through the order set. [If appropriate], they will give [the patient] a single dose ... of Suboxone.”

Mosaic works with hospitals to develop a network of fast-track treatment providers. “These are MAT providers who work with us to develop protocols to accept patients the same day or the next day,” Oros says. “That might even happen in the middle of the night. We have a mechanism to send them.”

The final piece of the “reverse the cycle” program is for overdose survivors. “These patients typically can’t be screened; they are not vocal when they first present,” Oros observes. “They have been given Narcan, and there is an alert sent to the peer recovery coach who will go in and talk to the patient [as soon as possible]. We know we don’t usually have a lot of time. These patients usually want to leave the ED very quickly.”

The peer recovery coach will contact a community-based peer who will follow up with the patient for three to four months. The goal is to keep the patient alive, prevent subsequent overdoses, and engage the patient into treatment as quickly as possible.

Gain High-Level Support

Oros reports the “reverse the cycle” program that began in Maryland has spread to 53 hospitals across the country, with much of the work paid for through city, state, or federal funds. For emergency personnel interested in implementing a similar approach in their own settings, Oros recommends they bring top leaders on board.

“It is to really assure that there is a commitment to do this,” Oros says. “That can be a stumbling block to achieving what you want.” Next, identify champions who can spearhead the work. These should be individuals with influence, according to Oros. Then, clarify goals, the steps required to reach those goals, and the range of methods the organization will use to address the issues involved.

“Those are the natural planning steps that we often take for granted. [These steps] are really important if you are going to try to really have a culture change around how you as an organization are going to address patients with substance use issues,” Oros stresses. “I think people often underestimate what it takes to put these programs in place if they are going to be lasting programs that truly are aimed at shifting the way hospitals respond.” 

REFERENCE

  1. Gryczynski J, Nordeck CD, Welsh C, et al. Preventing hospital readmission for patients with comorbid substance use disorder: A randomized trial. Ann Intern Med 2021; Apr 6. doi: 10.7326/M20-5475. [Online ahead of print].