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Overcoming Barriers to the Inpatient Care of Substance Use Disorders:
Genesis of the MGH SUD Initiative
James Morrill, MD, PhD
MGH Charlestown HealthCare Center
Massachusetts General Hospital
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Disclosures
Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest
to disclose.
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A Typical Case
August, 2014: 26 year old woman admitted to MGH for 4 days with an asthma exacerbation. Relapse to injection heroin, often associated in her case with asthma exacerbations
Chief complaint: Asthma Exacerbation; Associated Diagnosis: “Substance Abuse”
Other PMH:
1- Multiple episodes of polymicrobial endocarditis, complicated by (2013) septic emboli to kidney, spleen, brain, destruction of mitral valve. On long antibiotic tail.
2- Opioid overdose
3- Hepatitis C infection
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A Typical Case
Home meds:
• Inhalers, Buprenorphine/naloxone, Bupropion, Clonazepam, Sertraline, Fioricet, Trazodone
Hospital Course:
• Given inhalers and oral steroids for asthma, w/ gradual improvement
• Blood cultures negative; no fever
• Continued on Suboxone
• Restrictions placed on visitors because she was drowsier than usual after one visit (urine tox screen showed cocaine, benzodiazepine, opiates, but no baseline prior to admission)
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A Typical Case
Addiction Service Consult:
• Pt visited by clinician prior to hospital discharge.
• Pt provided history of DCF involvement, cited strong motivation to reunite w 4.5 y old son
• Route to reunion: referral to “dry shelter.”
• List of shelter options provided.
• Clinician gave contact info for f/u.
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A Typical Case
Disposition:
• On discharge, pt was encouraged to self-refer to dry shelter, but she goes home to her Mother’s.
• Provided f/u appointment with PCP who provides Suboxone and other refills.
• Comes to appts one and two weeks after d/c. Wants to remain ‘clean’; frustrated by DCF scrutiny / shelter intake rules and has increased anxiety.
• 4 weeks after discharge mother brings her to clinic intoxicated and she is admitted again.
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Usual Hospital SUD Care: “Before”
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• We detoxify patients in the hospital and they may remain abstinent (but it’s beyond my control).
• If patients don’t get better they are not motivated.
• These patients don’t want help; they don’t like me.
• I can’t help them because I don’t have the resources.
• Even when I make a referral, they don’t show up.
• There is a disconnect between inpatient and future outpatient care.
• It’s inevitable that this patient will be back for another admission.
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SUD is a Top Priority for the Communities Served by MGH
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62% 61%
75%
57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Revere Chelsea Charlestown Winthrop
Revere Chelsea Charlestown Winthrop
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High Prevalence and Cost of SUD Nationally, Locally and at MGH
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• Major problem nationally and locally
• 22% of general medical inpatients patients nationally have a SUD
• Boston ER rates for conditions related to opioid use disorder are four times US average
• Impact of SUD at MGH
• ~30% higher cost per admission when SUD present
• High rates of ED utilization
$5,506
$6,885$6,498
$9,666
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
COPD PNA HF SUD-MED Only
N=2,583 medical and surgical patients (20% homeless); 10/12-10/13
Average Direct Patient Cost Considerably Higher for SUD vs. Other Conditions
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Traditional SUD Care has been in Silos
Acute Care
Inpatient Care
Outpatient Care
Community Based Care
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Patient Experience in the old model
Patient admitted with endocarditis due to injection drug use
Medical team pages Psychiatry Consult Liaison service
Consult service develops inpatient management plan. Patient referred to MGH-based outpatient program.
Patient lives in Chelsea, cannot get to program
Patient given phone numbers of other programs to call
No appt made, PCP/health center not involved, patient does not follow through
Patient presents to the ED a week later with heart failure and fever
Fractures in Care
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The MGH SUD Initiative: A New Approach
The new MGH model includes the following: • Expert inpatient addiction consultation
• Continued involvement after discharge
• Coordination of dispositions with community health centers
• Direct navigation within the system
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Acute Care
Inpatient Care
Outpatient Care
Community Based Care
The MGH SUD Initiative Encompasses Treatment Settings
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“Body Plan” of the MGH SUD Initiative
Inpatient (Addiction Consult
Team = ACT)
Outpatient Community
Recovery Coaches
Bridge Clinic
Prevention, Education & Evaluation
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Patient experience in the new model
Team calls Addictions Consult Team (ACT)
Patient assessed & treatment plan determined- communication with PCP
Community based recovery coach meets patient in hospital
Discharge needs assessed and patient connected to community services or discharge/intake clinic
PCP and Coach follow patient
Patient admitted with endocarditis due to injection drug use
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Addiction Consult Team (ACT)
• Specialized multidisciplinary approach - Medicine, Psychiatry, Nursing, & Social Work - APRN as Team Leader - Involvement of Community Health Center physicians
• Hospital admission is “reachable moment”
- Motivational enhancements, engagement, pharmacotherapy, forming connections
• Focus on effective after-care plans, including direct referrals (e.g.,
Methadone maintenance, TSS, IOP) • Phase one (10/2014 – 1/2016): 8 medical floors
• Hospital-based Bridge Clinic
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Strong Links to Our Community Health Centers
• Multi-disciplinary teams of SUD champions
• Increased access to pharmacotherapy, readiness and evidence based approaches
• Twice monthly risk rounds
• Care coordination with ACT
• Recovery Coaches based in ACT and CHCs • Newly established agreements with community-based
treatment providers
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Recovery Coaches
• Forming peer to peer connections • Engagement regardless of recovery status
• Warm hand-off’s
• Ongoing follow-up • Advocacy
• Informal provider education
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MGH SUD Initiative: Roll-out Strategy
18 18h
Inpatient
Bridge Clinic
Emergency Department
Research
Outpatient Education
Oversight Committee
Implementation Group
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Example: SUD Education Committee
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• Co-Leadership by Medicine and Psychiatry
• Diverse group of clinician-educators: Medicine, Psychiatry, Nursing, and Social Work
• Four primary activities in Year 1:
1) Direct roll-out support
2) Development of resource web site
3) Initiation of hospital-wide needs assessment
4) Development of educational principles / goals
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Our Typical Case– Revisited
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December, 2014: Readmission with SOB, asthma exacerbation, in the setting of IV heroin relapse. Lost nebulizer while couch surfing and lost inhaler during arrest for illicits. Hospital course: • Admitted to observation, but c/o chest pressure prompting
echo new vegetation Admission • ACT sees and engages with patient • After review and discussion, Bup tapered and Methadone
started in house • Recovery Coach meets patient, visits daily • Patient transferred to rehab for 6 wks of IV antibiotics • Directly referred to MMT for immediate enrollment after
rehab, facilitated by respite stay given homelessness
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The MGH SUD Initiative: What is the Value?
Increase quality and
decrease cost of care for
patients with substance use
disorders
Treatment & Access
Philosophy & Culture Change
Community Supports &
Linkages
Education & Prevention
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The MGH SUD Initiative: What is the Value?
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• Patient experience
• Clinical care
• Hospital metrics
• Culture change
• Provider experience: hope instead of therapeutic nihilism
• Training the next generation of providers
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In Summary: Key Building Blocks of our SUD Initiative
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• Strong economic argument to reinvent SUD care within the academic medical center
• Strong community outcry for better SUD care
• Internal Medicine / Psychiatry collaboration
• A landing place to facilitate discharge: the Bridge Clinic
• Mobile role that can provide care coordination across the treatment landscape– Recovery Coaches
• Local innovation, in parallel, at Community Health Centers
• Explicit and implicit effort to change a culture of stigma into one of shared mission and respect
