Bridge to Care: Better Care Transitions for Opioid Use

00:00:00:22 - 00:00:19:08
Tom Haederle
Welcome to Advancing Health. For patients dealing with opioid or stimulant use disorders, a lot depends on how smoothly they can transition through the health care system to access the care they need. Today, we hear from two experts on effective ways to improve their navigation.

00:00:19:10 - 00:00:55:18
Jordan Steiger
Hi everyone, and welcome to AHA's Advancing Health podcast. My name is Jordan Steiger, and I'm the director of Behavioral Health and Violence Prevention at the AHA. Really happy to be joined today by Dr. Ben Springgate and Dr. Seth Viens, who are both here from joining us from New Orleans. And they are going to tell us a little bit more about the work that they're doing at their organization around improving care transitions for patients with opioid use disorder and stimulant use disorder, and how their work just kind of touches all patients that are experiencing substance use disorders and helping them just get where they need to go and get the care that they need.

00:00:55:19 - 00:00:59:07
Jordan Steiger
So Dr. Vignes and Dr. Springgate, thank you for being here today.

00:00:59:09 - 00:01:03:09
Seth Vignes, M.D.
Thanks, Jordan. We're really excited to be here. Thank you Jordan. Excited to join us.

00:01:03:12 - 00:01:12:04
Jordan Steiger
Before we jump in, I would love the audience to get to know you a little bit. So, Doctor Viens, could you just introduce yourself and let us know who you are and what you do?

00:01:12:07 - 00:01:26:14
Seth Vignes, M.D.
Yeah. Thanks, Jordan. My name is Seth Vignes. I'm an assistant professor of internal medicine. I primarily work as a hospitalist in New Orleans at a few different hospitals, but I'm also an addiction medicine researcher on the Louisiana Department of Health public grant.

00:01:26:14 - 00:01:28:28
Jordan Steiger
And, Ben, what about you?

00:01:29:01 - 00:01:43:10
Benjamin Springgate, M.D.
I'm an internal medicine and addiction medicine doctor-professor here at LSU School of Medicine and active in clinical care, principally for patients with opioid use disorder and other addictive disorders, but also research and education.

00:01:43:15 - 00:02:04:21
Jordan Steiger
I just want to make sure everybody in our audience is aware of some of the work that we've been doing together on our Bridge to Care collaborative. So this is a CDC funded project that we have been working on for the past few years, and the CDC really asked us to find ways to improve linkage and retention for patients with opioid use disorder and stimulant use disorder.

00:02:04:21 - 00:02:33:12
Jordan Steiger
So one of the ways we've been doing that is through the use of our Bridge to Care guide, which lays out lots of different options for organizations to kind of consider and think about how they can adapt those things into their own practices. Focusing on the inpatient setting, primary care setting, the role of pharmacy, and really thinking about what some of those leadership roles are, how we can improve education and communication around care transitions, and how we ultimately can improve access to care.

00:02:33:14 - 00:02:48:12
Jordan Steiger
Before we kind of jump into that, I would love to hear just based on some of the things that are we really are focusing on in this collaborative together, where are some of the biggest breakdowns in care transitions that you see with your patients? Ben, let's start with you.

00:02:48:14 - 00:03:13:03
Benjamin Springgate, M.D.
Thanks so much, Jordan. It's a great question. One of the things that we, you know, see is that breakdowns occur across the continuum of care. So breakdowns occur when patients enter the emergency department once they're admitted to the hospital, when they're discharged, and when they're navigating follow up after a hospital admission. So in the emergency department, for example, opioid use disorder and stimulant use disorder are under-recognized.

00:03:13:04 - 00:03:39:06
Benjamin Springgate, M.D.
They're frequently under-treated, and this can result in delayed care in patients boarding in the emergency department, in patients leaving prior to engaging in treatment, or completing treatment. On the inpatient side, following an admission, many patients across the country are not met with the kind of empathy and patient centered care we'd like to see for patients with substance use disorders. Many are not receiving evidence based care.

00:03:39:08 - 00:04:17:08
Benjamin Springgate, M.D.
Most don't receive standard of care life saving medication for opioid use disorder, for example, medications like buprenorphine or methadone, which can prevent withdrawal and increase retention and care, as well as decrease the likelihood of death. And most don't receive expert inpatient support from addiction consult services or addiction board certified specialists. And with each missed opportunity, that means that the patients who we are trying to care for have a greater likelihood of worse outcomes, a greater likelihood of relapse to substance use, and a greater likelihood of disease progression, including risk of death.

00:04:17:09 - 00:04:46:21
Benjamin Springgate, M.D.
We know that many hospitals across the country don't carry buprenorphine on formulary, even though it's standard of care, even though the World Health Organization has designated it as an essential medication. And we know that even more hospitals don't carry methadone or create barriers to initiation of use of methadone for opioid use disorder. And methadone, as well as buprenorphine, are the two medications demonstrated to save lives in the treatment and care for patients with opioid use disorder.

00:04:46:26 - 00:05:31:09
Benjamin Springgate, M.D.
Following up further on those transitions of care opportunities, many people who come through our care settings, in our hospital and in other hospitals may not have a telephone. They may not have transportation. They may really struggle with costs of care. And those things make a difference when we're trying to anticipate facilitating follow up. So although the likelihood of a really bad outcome, such as death for someone who's had an opioid overdose is about the same as for someone who's had a heart attack, the likelihood that someone gets standard of care and receives evidence based care across each of these care settings on the continuum and during the care transitions is much, much lower for someone

00:05:31:09 - 00:05:51:12
Benjamin Springgate, M.D.
with opioid use disorder or stimulant use disorder compared to a heart attack. If you've had a heart attack and you look at the quality metrics that all our hospitals across the country care about, the likelihood of getting standard of care exceeds 95%, and the likelihood of getting standard of care for opioid use disorder or stimulant use disorder is abysmally low by comparison.

00:05:51:13 - 00:06:11:25
Jordan Steiger
Wow, I did not know that. I think that's a really great way to frame this conversation, and I'm hearing some of the threads through everything you said. It sounds like there's a lot of stigma that exists out there in the world. And then just like we were talking about with access, you know, some of those social aspects of care that are really affecting your patients in the way that they're able to transition.

00:06:11:27 - 00:06:13:22
Jordan Steiger
Doctor Viens, what do you think?

00:06:13:25 - 00:06:41:03
Seth Vignes, M.D.
You know, one of the biggest challenges we see in our region is that our addiction care is very siloed. It's highly siloed. Inpatient teams, outpatient providers, community care workers. They're often operating as a separate systems rather than a coordinated continuum. In that environment, I really find that a lot of times, the responsibility for connecting the dots between them falls on the patient at a really, you know, a time when they should be spending their energy and focus on recovery.

00:06:41:06 - 00:07:06:25
Seth Vignes, M.D.
From a hospitalist perspective, it's really evident in a subset of patients that are having injection related infections, things like endocarditis, skin and soft tissue infections. Back to (?) Those cases, they have introduced additional transition points where they're going to skilled nursing facilities or LTACS before eventually reentering the outpatient system. And so each of those transition points is another potential point of failure.

00:07:07:01 - 00:07:39:07
Seth Vignes, M.D.
So building a cohesive like really long term care plan that spans inpatient, post-acute to outpatient to medication access while also addressing housing and transportation and phones, it's really time consuming and incredibly complex, and each of those aspects are in a different silo with a different EMR, different providers, different knowledge bases and capacities. And so without coordination across it, even our best inpatient interventions can fail to reach sustainable engagement.

00:07:39:08 - 00:07:45:25
Seth Vignes, M.D.
And so that's when we see those heightened readmission rates and long lengths of stay and preventable overdoses.

00:07:45:27 - 00:08:05:14
Jordan Steiger
I'm really glad you brought up some of the physical aspects of substance use. I feel like that's not something that's always a part of the conversation when people aren't in this world and kind of experiencing it every day. And I know that there can be some additional challenges sometimes, you know, with getting patients to LTACs, getting people to skilled nursing facilities because of their substance use.

00:08:05:14 - 00:08:29:01
Jordan Steiger
So I think that's a really important thing to bring up. And also, for listeners, a really good thing to think about - how can they improve those partnerships and maybe provide some of that education and reduce some of the stigma. So thank you. I know one of the ways that you all have really done some great work is by creating an integrated clinic that treats physical health and substance use at the same time.

00:08:29:03 - 00:08:34:05
Jordan Steiger
Tell us a little bit more about that, because I think we could all really learn from that model.

00:08:34:07 - 00:09:20:03
Benjamin Springgate, M.D.
Yeah. The LSU Integrated Health Clinic draws on the medical evidence showing that patients who received integrated care of their substance use disorders, their physical health, their behavioral health are more likely to achieve improved outcomes, more likely to stay engaged in care, more likely to receive evidence based care. And that really is our goal. So this enables a patient who perhaps has chronic medical conditions like diabetes or hypertension, as well as mental health conditions like depression and post-traumatic stress disorder, as well as conditions associated with drug use like chronic hepatitis C to receive care all in one place, even as they're getting care for their substance use disorder. And providing that combined care with addiction specialty

00:09:20:04 - 00:09:43:22
Benjamin Springgate, M.D.
care, primary care, medical services, psychiatric or mental health services in an accessible, non stigmatizing, supportive clinical environment really makes all the difference in terms of facilitating the likelihood of people staying in care, facilitating the likelihood that they're going to get the types of evidence based care that we know actually work and that reduce the likelihood of relapse and overdose risk.

00:09:43:22 - 00:10:06:03
Benjamin Springgate, M.D.
And so this type of a model has been advanced by national organizations across the country, and really represents a sharp contrast to a lot of settings across the country where, as Seth was describing earlier, there are such silos. And patients with addictive disorders really perceive a lot of a lot of barriers and potentially a lot of bias.

00:10:06:10 - 00:10:29:02
Seth Vignes, M.D.
The hospitalists love the integrated health clinic. You know, when my patients nearing discharge, I can call Dr. Springgate. I can call his clinic staff scheduler and have an appointment in hand for my patient. I can tell them who they're going to see and what date and time. And that also allows me to leverage the in hospital case managers and social workers, if things arise, that are going to be a barrier for my patient transportation,

00:10:29:02 - 00:10:50:16
Seth Vignes, M.D.
for one. It also is nice because it's proximity right next to us. And so I can I can tell my patient where it is. So it just lowers those barriers for access. And I think the other thing that's really important is that the staff at Integrated Health Clinic really recognize that this is a time sensitive appointment, and they can really coordinate with you to get it urgently and get your patient and when they need to.

00:10:50:19 - 00:11:06:27
Jordan Steiger
That makes so much sense. And I mean, I'm hearing from both of you just, you know, addressing all of those barriers that we're talking about at the beginning, you know, getting that appointment in hand before the patient actually leaves the hospital, helping them to address all of their needs at one time with one appointment as much as possible.

00:11:06:27 - 00:11:14:04
Jordan Steiger
I think this is amazing. And I'll ask the question I'm sure a lot of people are thinking is, how do you pay for this? How do you make this happen?

00:11:14:07 - 00:11:39:01
Benjamin Springgate, M.D.
We were fortunate to advocate 8 or 9 years ago to our hospital leadership that we really wanted to try to expand access to services for patients with substance use disorder in our primary care center in a non stigmatizing environment. Leadership at that time bought in and we're thankful for that. And I think that they realize there are a number of beneficial outcomes for the system, for the hospital

00:11:39:02 - 00:12:07:07
Benjamin Springgate, M.D.
beyond just for the patient you know. So yes we all want to help the patient. But if we can reduce the likelihood that the patient is going to come back into the emergency department and, you know, be a border in the emergency department and see that bottleneck to other emergency care. If we can reduce the likelihood of a readmission, which many of our hospital leaders are concerned about, if we can reduce the likelihood of a prolonged length of stay because we have an adequate opportunity for follow up.

00:12:07:08 - 00:12:19:27
Benjamin Springgate, M.D.
These are things which really speak to hospital administrators across the country. And fortunately, we were able to see some residents from our leadership as they made this decision to allow us to open up this clinic.

00:12:20:00 - 00:12:39:14
Jordan Steiger
I think that is a great example of bringing in that that leadership component, really getting that buy-in and then just going from there, you know, and building on the success and the outcomes that you're showing through the work that you're doing. I want to change topic a little bit here. So a lot of the work that we are doing together is really focused on opioid use disorder.

00:12:39:16 - 00:12:53:12
Jordan Steiger
But the other component of this work is around stimulant use disorder. So could you tell us just a little bit, maybe some of your experience with treating patients with stimulant use disorder - how that could be a little different than the approaches you would use with opioids.

00:12:53:14 - 00:13:17:21
Benjamin Springgate, M.D.
It's a great question, and it is important to recognize that frequently we do see patients with stimulant use disorder. Frequently these people who are using stimulants are also using other drugs concurrently. The toolkit for clinical treatment of stimulant use disorder isn't quite as robust as the toolkit for treating opioid use disorder. The medications that are available are used off label in many environments, including our own.

00:13:17:22 - 00:13:42:25
Benjamin Springgate, M.D.
The standard of care contingency management isn't covered by many insurances or most insurances, so this makes a big difference. What we try to do is engage those patients who are using stimulants in a way that we can help them with all of their substance use problems, and perhaps if we're supporting them in the care with evidence based medication and treatment for their opioid use disorder, that increases the likelihood that they're not going to go back to stimulant use.

00:13:42:25 - 00:14:03:02
Benjamin Springgate, M.D.
If we can concurrently offer them mental health services for something else that they're concerned about, their anxiety, their depression, their PTSD, perhaps that increases the likelihood that they're not going to go back to use of stimulants. And engaging them where they are, helping them to identify their priorities for treatment and their goals can facilitate the likelihood that they'll remain in care

00:14:03:03 - 00:14:07:04
Benjamin Springgate, M.D.
following a care transition from the inpatient to the outpatient settings.

00:14:07:06 - 00:14:11:19
Jordan Steiger
Makes a lot of sense. Dr. Viens, what about your perspective from the hospitalist side?

00:14:11:21 - 00:14:31:09
Seth Vignes, M.D.
You know, what we're seeing is that we need to recognize that it's a growing problem. And it's especially in our location we're seeing a rise. And so a lot of our education right now is just on recognition because like Dr. Springgate mentioned, our toolkit for treatment is limited. And so recognizing counseling, referring to care for more expertise is really important.

00:14:31:09 - 00:14:37:27
Seth Vignes, M.D.
But I think the first step that we're kind of currently undergoing is just recognition and education to our providers.

00:14:38:03 - 00:14:56:00
Jordan Steiger
Really, really important component of all of this. So as we wrap up, Dr. Viens, I'd like to start with you. What is one thing that you think a hospital leader or maybe a health system leader listening to this podcast really needs to know about care transitions, and if they could kind of walk away with one thing from this, what would it be?

00:14:56:02 - 00:15:20:28
Seth Vignes, M.D.
Yeah, it's a great question. I think for me, one of the highest impact practical interventions you can think about for a health system is investing in peer navigators, I would say is something I think is really important. These are trained professionals. They oftentimes have lived experience. They understand kind of both the clinical system and how to navigate it in the local community resources in a way that most providers can't.

00:15:21:01 - 00:15:39:19
Seth Vignes, M.D.
And as we talked about before, you know, our systems struggle at the transition point. So even when we initiate medications for opioid use disorder and we stabilize that patient on the inpatient side to follow through can fall apart without dedicated support. And so peer navigators kind of help bridge that gap, and they serve as a trusted guide.

00:15:39:20 - 00:16:03:02
Seth Vignes, M.D.
They support follow up. They troubleshoot the barriers like transportation. And they just maintain engagement at a really vulnerable point. There's a growing body of evidence that peer support improves linkage across a lot of different settings. That's post hospitalization, post carceral. And so as we think about like scaling the model, I think we should be amplifying the message that these services should be sustainably funded.

00:16:03:02 - 00:16:20:09
Seth Vignes, M.D.
So expanding reimbursement particularly through CMS would be really important. And so if I had to recommend one intervention, I would say you should pair your addiction kind of infrastructure with well integrated peer navigation support and then advocate for policy change to make it sustainable.

00:16:20:12 - 00:16:28:18
Jordan Steiger
That is a great point. We are big fans of peer support over here, and I'm so glad you brought that into the conversation. Dr. Springgate, what about you?

00:16:28:20 - 00:17:15:14
Benjamin Springgate, M.D.
Great point, Seth. I think that in addition, you know, I know that many of our hospital leaders are concerned about things like overcrowded emergency departments. They're concerned about things like preventable readmissions and reducing preventable readmissions. They're concerned about things like ensuring follow up care. And the scientific evidence, you know, that's come out in the last several years shows that patients who are engaged in care in inpatient settings inside the hospital by addiction medicine specialists like an addiction consult service, are 700% more likely to receive life saving standard of care medications like buprenorphine, likewise 7 to 8 times more likely to follow up and remain in care after discharge.

00:17:15:14 - 00:18:08:02
Benjamin Springgate, M.D.
So that's a tremendous benefit that can be associated with having an inpatient addiction consult service that can result in reduced crowding from substance use and overdose patients in the emergency department. That can result in reduced readmissions from substance use, comorbidities, and overdose, and that can facilitate that sustained engagement and care. So whether a patient is coming in with endocarditis or other sequelae of substance use, then follow the evidence. The medical evidence, the health services evidence shows that meeting your inpatient addiction specialist face to face, giving them the opportunity to engage in that discussion with the patient and giving them the opportunity to receive recommendation of evidence based care and facilitate timely follow up in

00:18:08:02 - 00:18:25:17
Benjamin Springgate, M.D.
a way that helps the patient overcome some of their challenges, is really what's going to result in improvements in length of stay, decrease readmissions, decrease boarding in the emergency department, things that we should all care about, even as it's also dramatically improving the likelihood of good clinical outcomes.

00:18:25:24 - 00:18:44:13
Jordan Steiger
I don't think there's a better way to wrap up this episode than what you just said. I think that pulls it all together perfectly. So thank you both so much for being here and sharing just a little bit of your knowledge. I feel like we could talk about this all day, but just thank you for your support of the work that AHA is doing and your participation.

00:18:44:13 - 00:18:48:14
Jordan Steiger
And we couldn't do any of this work without you in the way that you serve your patients.

00:18:48:16 - 00:18:52:08
Benjamin Springgate, M.D.
We're grateful to you and to the AHA and everyone involved in this. Thank you so much.

00:18:52:14 - 00:18:54:00
Seth Vignes, M.D.
Thanks, Jordan.

00:18:54:02 - 00:19:02:25
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.