Health Systems Look to Duplicate California Substance Use Disorder Treatment Model
By Dorothy Brooks
Few states have made as much progress in helping their emergency providers identify and treat patients with substance use disorders (SUD) as California. This is thanks to California (CA) Bridge, a program that launched in 2018 with the aim of expanding access to medication-assisted treatment (MAT) through EDs.
“Our mission was and still is to create high-quality care for SUDs in every ED in California by 2024,” explains Arianna Campbell, PA-C, director and a co-principal investigator for CA Bridge. “We have been able to reach 95% of all hospital EDs in California ... that are at least having some sort of implementation of the program.”
Further, even while the work continues to fully implement the Bridge program in EDs throughout California, Campbell and colleagues have been receiving queries from other health systems. Administrators in several states want to leverage their EDs as a critical point of access to identify and treat SUD. “We were already doing some webinars, and we were talking to physicians in other states, but we have started doing this with more intention, and we found that [this work] is very valuable,” shares Campbell, an emergency provider at Marshall Medical Center in Placerville, CA.
The demand for help has been such that CA Bridge has established a second entity, simply called “Bridge,” to work with healthcare entities out of state that are interested in implementing the Bridge model, but need some help on the front end to start. For example, Melissa Stainback, PhD, Louisiana Office of Public Health’s regional opioid coordinator for the southwest region of the state, contacted CA Bridge two years ago.
“We dove into the research that CA Bridge had done with their model,” Stainbeck says. Furthermore, Stainback says she had some funding to work with that was earmarked for a hospital navigator program, a key part of the CA Bridge model.
Lacey Cavanaugh, MD, regional medical director for the Louisiana Office of Public Heath’s southwest region, explains the model’s focus on leveraging the ED to address SUDs was a good fit for what was needed in that part of the state. “We had a lot of conversations with our coroner’s office to really get a good sense of who in our community was dying from overdoses,” Cavanaugh says. “Many of the people who were dying were not people who were just taking a singular, one-time dose of something; these were people who struggled with chronic addiction.”
Considering many of these patients had experienced previous overdoses, it was clear the ED could be a critical intervention point.
Thus far, work toward implementing the Bridge model is focused on three hospitals in the Lake Charles, LA, region. “One of the vital, key components is having a clinical champion in the ED. You have to have a physician, a prescriber, or someone in the ED who really pushes forward change,” Stainback explains. “As an external entity, we can’t go in and tell the EDs what they should do; it doesn’t happen. It really has to be driven, in part at least, internally.”
Placing a navigator in the ED is a critical element of the model as well. However, Stainback notes that while California funds hospitals directly to embed navigators in the ED, medical facilities in Louisiana do not necessarily have the resources to fund these positions. To overcome this hurdle, the Office of Public Health has worked with a nonprofit healthcare organization to provide the navigators to the three EDs that are participating in the model.
“The navigators have a contract [with the hospitals] in place to enable them to work in the ED, but we really see the navigators being driven by the EDs,” Stainback explains. “The program champions oversee the day-to-day operations of the navigators in their facilities.”
Stainback acknowledges other hurdles remain. “Our critical piece has been convincing the hospitals that we need space in their EDs for the navigators. We have two hospitals that have provided that space, and the third one is working on [that aspect],” she says. “We realize that the visibility of the navigator on a regular basis is what is going to propel the program forward; it is a necessity.”
There have been other complications to work through, too. For example, while the navigators working in California EDs can access electronic medical records (EMR), enabling them to be proactive in identifying and engaging with patients with SUDs, that is not the case in Louisiana. “We have had conversations with some of our hospitals about how we could use data from the EMR to drive our next steps in the identification of potential missed opportunities, but we haven’t been able to do that yet,” Cavanaugh says.
Further, state regulations affect implementation of some Bridge elements. Thus, health systems in different states may find they have to take a slightly different pathway than EDs in CA. This has affected the harm reduction aspect of the Bridge model in Louisiana.
“Our navigators had to get hospital badges and credentials because they have access to Narcan. Right now in Louisiana, unlike in California, we do not have an exemption from the state board of pharmacy on Narcan distribution,” Cavanaugh explains.
“Any Narcan that is distributed to our hospitals has to go through the normal processes and channels, which means that there is some level of accountability that the hospitals have.”
However, even with the extra hoops involved, Cavanaugh says nearly every patient who interacts with a navigator goes home with Narcan (95%). “It is a huge part of our success, I believe, but there definitely were some processes we had to put in place for the navigators to be able to do that,” Cavanaugh says.
“We are also tracking how many patients are linked to services following their ED visit, and that number is at about 70%,” adds Stainback, noting such resources could include a detox center, an inpatient facility, or outpatient care.
With more time and experience with the model, Stainback is hoping see more patients initiated on buprenorphine during their ED visit. Unfortunately, this has been a bit harder to accomplish. “I think we still need to spend some time doing training,” she says. “Physicians are still afraid to prescribe.”
The recent elimination of the X waiver requirement may be helpful for emergency physicians who want to initiate patients on MAT, but Cavanaugh cautions this move alone will not necessarily ensure physicians understand the importance of engaging patients in this treatment. “When I went to medical school [2009 graduate], we didn’t learn about buprenorphine. The opioid epidemic wasn’t driven by the same things that are driving it now,” Cavanaugh says. “This is a totally new concept and a new way for prescribers to think about addiction. I think it is going to take time and ongoing outreach education.”
To that end, Cavanaugh is focused on holding educational sessions about the Bridge program for ED physicians as well as ED staff. “That is one of the things that our clinical champions are tasked with helping us on,” she says. Another key piece of the puzzle is creating more access in the community where patients can be bridged to ongoing SUD treatment. “We are in a position where we don’t yet have the infrastructure or capacity to fully execute that,” Cavanaugh says. “We are looking internally at grant opportunities either at the local or state level so that we can devote some resources to that.”
Stainback observes the idea of creating Bridge clinics close to the participating EDs would be ideal, but that is not realistic in the near future. “We are probably going to be doing some work around increasing the capacity of [treatment providers] that we already have. Longer term, I would definitely love to see it,” she says.
Stainback’s advice to anyone interested in implementing the Bridge model is to gather the right partners. “That was critical to our success,” she says. “We had the Office of Public Health and our behavioral health organization ... at the table, and we also had our ambulance partners, the coroner’s office, and our hospital partners all at the table to make this program work.”
However, Cavanaugh stresses not to wait until everything is perfect to start. “Just start somewhere. Take a step in some direction, and then it will be a continuous learning process,” she advises. “We have been at this for a little over a year now, and we still make modifications and learn something new on a weekly basis.”
That advice is a frequent refrain of Campbell’s as well in her outreach to health systems in other states. She notes that the CA Bridge organization and its national outreach arm, Bridge, are not just willing to offer a helping hand to organizations in other states that want to implement their model to leverage EDs in the care and treatment of patients with substance use disorders (SUD); they’re also working with funding partners on a larger plan to ensure that there are more resources in place to sustain this work in the future.
“There are many states that don’t necessarily have an ED or hospital that is doing this work; or if a hospital is doing this work, [clinicians and staff] are doing it on their own quietly,” observes Campbell. “We are working to build leadership and effective programs in states that may not have them now.”
This work, which is funded through the Opioid Response Network (ORN), is designed to build leaders and at least one reference hospital in each state that others in the region can look to for advice and technical assistance in developing their own ED-based programs. (Learn more about the ORN program at: https://opioidresponsenetwork.org/.)
In addition to the work with ORN, Bridge is working with funding from the Foundation for Opioid Response Efforts (FORE). The goal is to develop a comprehensive Bridge network consisting of leaders across the country. The idea behind the network is to be able to quickly respond to any changes in regulation, drug usage trends, new treatment options, or other factors of importance related to caring for patients with SUDs. (Learn more about the FORE program at: https://forefdn.org/.)
“Many people are doing amazing work, but we found there is a gap in connecting all of these folks,” Campbell says. “We are in a good place to [build this network] because our work is very mission-driven. The resources we have built over the last five or six years have become so widely used ... that we have some visibility to connect people nationally.”
How might emergency leaders ask for help from Bridge? Campbell notes there are multiple links on the CA Bridge website where anyone can access information and resources. (Learn more here: https://cabridge.org/) For example, there is a “join us” tab where users can sign up to receive newsletters and other information from Bridge via email. Also, the website includes a link that allows visitors to ask for any technical assistance.