MGH Substance Use Disorder Initiative. Dawn Williamson, RN, DNP, PMHCNS-BC, CARN-AP MGH ED Christopher Shaw, RN, ANP, PMHNP-BC, CARN-AP MGH ACT

Transcription

1 Bridging the Gap: Bridging the Gaps to addiction treatment through comprehensive collaborative practice among Advanced Practice Nurses in a large urban Medical Center Dawn Williamson, RN, DNP, PMHCNS-BC, CARN-AP MGH ED Christopher Shaw, RN, ANP, PMHNP-BC, CARN-AP MGH ACT MGH Substance Use Disorder Initiative

2 Disclosures Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose. 2

3 Overview Brief Overview of the MGH SUD Initiative Substance Use Assessment in the Emergency Department (ED) Addictions Consult Team (ACT) Bridge Clinic ED - Bridge Clinic rapid access collaboration Patient Example Questions and Answers 3

4 SUDs Initiative Mission To improve the quality, clinical outcomes and value of addiction treatment for all MGH patients with SUD. To accomplish this mission, patients must have access to evidence based treatment that is readily available and standardized across the system.

5 Traditional Model of SUD Care Traditional care of substance use disorders has been in silos Acute Care Inpatient Care Outpatient Care Community Based Care

6 Traditional Model: Example patient experience Patient presents to the ED a week later with heart failure and fever No appt made, PCP/health center not involved, patient does not follow through Patient given phone numbers of other programs to call Fractures in Care Patient admitted with endocarditis due to injection drug use Medical team pages Psychiatry Consult Liaison service Consult service develops inpatient management plan, refers to outpatient psychiatry program Patient lives in a community too far from referral clinic

7 Substance Use Disorder Strategic Initiative: Our Mission Treatment & Access Education & Prevention Increase quality and decrease cost of care for patients with substance use disorders Philosophy & Culture Change Community Supports & Linkages 7

8 Integrated Model Philosophy The MGH SUD Advanced Practice Nurses Help foster a culture of change in SUD care. Shift from acute, episodic approach to chronic care management. Utilize hospitalization as reachable moment. Share the care: multidisciplinary involvement. Focus on transitions through system. Increase collaboration with the patient in designing treatment. Provide ongoing education and support to frontline staff nurses

9 APRN Role in managing Acute Episodes to Chronic Disease Management across a continuum Discharge needs assessed and patient connected to community services or discharge/intake clinic PCP and Coach follow patient Community based recovery coach meets patient in hospital Patient admitted with endocarditis due to injection drug use Patient assessed & treatment plan determinedcommunication with PCP Team calls Addictions Consult Team (ACT) New Serivc e at MG H

10 Nurses Critical to Substance Use Disorders Initiative From Education to Prevention to Management APRN Addictions Specialist Emergency Department & Cochair of SUD Education Committee APRN Addictions Cert. Team Lead of Inpatient (ACT) APRN Psych Bridge Clinic Outpatient Increases Access Prevention, Education & Evaluation Staff nurses working on units training for Addictions Certification NP s and RN s in the Community Are part of Multidisciplinary Teams 10

11 Advanced Practice Nurses Facilitate Immediate Access, linkages to Care and Treatment Engagement Emergency Department Inpatient (ACT) Bridge Clinic Outpatient Evaluation, Immediate Treatment, Engagement 11

12 ED Initiatives for patients with SUD The ED cares for over 9,000 substance use disorder (SUD) patients each year Represents 9% of the total ED population Standing agenda item at monthly ED Quality & Safety Committee Ongoing networking with other hospitals and outside groups Facilitates Section 35 commitments Opioid treatment Bridge Clinic rapid access Narcotics Prescribing Guideline for the ED Developed Acute Care Plan concept and tool Evaluation and monitoring process for intoxicated patients Overdose evaluation and recommendations ED based SUD education and participation in hospital SUD educational programs Created Addictions Medicine APRN role in ED

13 Emergency Department Addiction Consultation APRN for Addictions Medicine ED Pharmacist APS consult service for dual diagnosis Police & Security Case management Social work

14 Patient Example 35 year old man 20+ year IV heroin addiction Multiple detoxes, inpatient and outpatient programs Long periods of remission/sobriety 30 day detox, weaned off his Buprenorphine Day of discharge, returned to home Overdosed Naloxone (Narcan) à brought to MGH ER

15 Traditional Post Overdose Care +/- Intranasal Naloxone (Narcan) Brief medical evaluation in ER No medication to prevent relapse or repeat overdose Patient discharged with list of area detoxes If referred to outpatient addiction program, long wait Ongoing drug use and active, untreated disease High risk for repeat overdose or other complication of drug use

16 Current Post Overdose Care at MGH Assessed by Addiction APRN in ER APRN provides Family Support and Education Communication w/addiction Consult Inpatient Team for ongoing assessment and treatment If ready for discharge from ER APRN confers with Bridge Clinic Patient Escorted to Bridge Clinic by ED staff member or by inpatient ACT and gains Immediate access to and assessment by Bridge Clinic NP and medication to prevent ongoing drug use and engagement with Bridge Clinic Recovery Coach Linkage with MGH affiliated Community clinic APRN, Methadone clinics and OBOT.

17 Treatment in the ER is effective Opioid dependent patients often use ER for care Yale study of 329 patients randomized to ER initiated Buprenorphine treatment, or Referral to service or Brief Intervention 78% who engaged in buprenorphine treatment vs 37% referred and 45 % BI Fewer days of self-reported opioid use D'Onofrio et al. JAMA 2015 Apr 28;313(16):

18 Inpatient Consult Service (ACT) Universal SUD screening by multidisciplinary team led by NP Standardized Withdrawal Protocols Discharge Clinic Recovery Coaches Increase access to medication based treatment and counseling services in health centers Hospital and health center provider education Community-based prevention coalitions

19 ACT Provides: Framework of strong linkages between ER, inpatient, outpatient, and community based services. Improved treatment access and smooth transitions between care levels, resulting in < relapse rates and readmissions. Standardized treatment for SUDs with buprenorphine or methadone & withdrawal management Enhanced treatment plan on discharge Recovery coaches

20 Methadone Clinic Direct Referrals Addiction Consult Team Bridge Clinic ARMS West End Clinic Massachusetts General Hospital Substance Use Disorder Initiative Emergency Department Office Based Opioid Treatment Program (OBOT) Infectious Disease Clinic Other Community Partners Community Health Centers Hepatitis C HERO Study

21 Hospitals Have Opportunity to Initiate Treatment Initiating methadone in hospital: 82% present for follow-up addiction care Buprenorphine vs. detox among inpatients: Bupe: 72.2% enter into treatment after discharge Detox : 11.9% enter treatment after discharge Buprenorphine vs. referral in ED: Bupe: 78% engaged in treatment at 30 days Referral: 37% engaged in treatment at 30 days J Gen Intern Med. Aug 2010; 25(8): ; JAMA Intern Med 2014 Aug;174(8): ; D'Onofrio et al. JAMA 2015 Apr 28;313(16):

22 Outcomes: Patients Seen by Addiction Consult Team Have Lower Readmission Rates, Increased Abstinence ACT Consults: Over 5000 consults on 3,500 unique patients 32% involved opioids 70% male, mean age 47 Receiving an ACT consult lowers the odds of readmission by about 25%. Length of Stay < by 0.75 days for patients Change in Days Abstinent 2 Intervention Control Initial 30 Day Follow-Up 1 Among patients with SUD Dx code on floors where ACT available; Controlled for type of substance, gender, age 2 remained statistically significant in intention-to-treat analysis and after controlling for age, gender, employment status, smoking status, and baseline days abstinent (p=0.02)

23 Bridge Clinic Transitional clinic (up to 3-6 months) for patients who needing addiction care but lacking community based providers Immediate engagement, immediate medication management, stabilization and linkage to outpatient treatment providers Referrals from Addiction Consult Team, Emergency Department, Primary Care Clinics, Oncology Unit, Freedom Clinic and Inpatient Psychiatry Unit

24 Bridge Clinic Provided over 4,000 On Demand Visits for 505 Patients Flexible model crucial: 50% visits not scheduled ahead Support for ED, providing same day or next day medication for OD patients; served 60 patients to date Expanding to 7 day/wk coverage For recent inpatients, 10.4% readmitted within 30 days Overall, 16% of Bridge Clinic patients had subsequent inpatient stay, 33% had ED visit

25 ACT/Bridge Clinic - ED Collaboration: Patients receive care on demand Patients connect Patients engage Patients recover Teams communicate Team ensures safe follow up Bridge Clinic door always open

26 Patient Experience Patient Experience Day 1 ED referral to Bridge Clinic: Had my first overdose after 20 years of IV drug use. I can describe my thought and feelings, after being saved by Narcan in one word along grateful! This medication is saving lives. I spent two weeks in hospital and now I have a place to go to get care afterward. Day 2 Bridge Clinic follow up: Today is my birthday and I have received the best present ever... Another chance at life. So grateful for my family, my health, so grateful for the Bridge clinic. -Nick

27 Paradigm Shift in Culture Words Matter Campaign Destigmatizing chronic illness Active communication between care teams Flexibility Destigmatizing chronic illness Understanding the disease process and path to recovery Relapses happen we deconstruct them Low threshold access to care Team sharing and communication is critical Follow up Supportive resource management Finding the right fit for the patient s needs and promoting community based supports

28 Traditional Expectation

29 The Road to Health and Recovery often circuitous

30 Advanced Practice Role in Prescribing Apply/train for your buprenorphine waiver Consider specialty certificationhttp://

31 References Alford DP. Handbook of Office-Based Buprenorphine Treatment of Opioid Dependence. American Society of Addiction Medicine. April 12, Goodman RA, et al. Prev Chronic Dis 2013;10: Massachusetts General Hospital Psychiatric Academy, 2018 Martic CM. Can Fam Physician Dec; 53(12): National Institute on Drug Abuse. Trends & Statistics Retrieved from on November 9, 2015 NIDA. August, Peng PW, Tumber PS, Gourlay D: Can J. Anaesthesia 2005 Substance Abuse and Mental Health Services Administration (SAMHSA). (October 2014). Health care and health systems integration. Retrieved from Substance Abuse and Mental Health Services Administration (SAMHSA). (September, 2015). SAMSA behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Retrieved from