The COVID-19 pandemic has drastically altered health systems’ priorities, leading to the redistribution and reallocation of human and financial resources towards pandemic-related prevention and treatment efforts. During this time, a parallel public health emergency — the national epidemic of opioid-related morbidity and mortality — has continued unabated, with almost 450,000 opioid overdose-related deaths from 1999-2018.
The latest evidence from 2020 indicates that the opioid crisis has continued to worsen, with over 40 states reporting increases in opioid overdose fatalities. While the ongoing increase in overdose deaths pre-dates the COVID-19 pandemic, this problem has likely been exacerbated by pandemic-related increases in stress, grief and anxiety from social isolation, loss of economic opportunity, and illness and deaths among loved ones, coupled with decreased service utilization due to fear of COVID-19 infection. Understandably, during the initial crisis, health systems had to make COVID-19 response their top priority. Now, however, in spite of the ongoing COVID-19 pandemic, it is imperative that organizations, as part of recovery and resurgence planning, continue to focus their efforts to readdress the opioid crisis, as a lack of attention and resources can result in more morbidity and mortality for this vulnerable population.
While many healthcare organizations have understandably struggled to balance this among myriad competing priorities, some have capitalized on the COVID-19 pandemic as a unique opportunity to innovate and rethink how to provide care for substance use disorder both inside and outside the walls of healthcare institutions. Over the past year, the Institute for Healthcare Improvement’s Leadership Alliance, a collaboration of healthcare executives from 53 leading healthcare delivery systems and payers, has collaborated with Boston Medical Center's Grayken Center for Addiction to convene a working group dedicated to making progress toward equitable and sustainable systematic changes in prevention and treatment of opioid use disorder. The members of this workgroup have advanced creative strategies to continue to provide high-quality, compassionate care for patients with opioid use disorder, leading to improvements that will, in some cases, fundamentally change the way care is provided going forward with significant benefits for patients, families and clinicians. These strategies can be grouped into three overarching themes: 1) providing new services; 2) leveraging existing services in new ways; and 3) enhancing relationships with community partners. Below, we share recommendations and examples from member organizations with the hope that other health systems can adapt and adopt these interventions in their own settings.
1. Providing new services. The unprecedented adoption of telehealth services during the pandemic has been well-documented. Many healthcare organizations have leveraged changes in telehealth regulations to drastically improve access to care for substance use disorder, allowing patients to conveniently and safely receive care in their homes. Southcentral Foundation in Alaska now provides primarily telephonic and video visits for intake, home induction and maintenance visits for patients receiving medication-assisted treatment. Tampa (Fla.) General Hospital has developed a telehealth and peer specialist-supported home-based buprenorphine induction program for individuals who visit the emergency department. While still in the ED, the patient works with a peer specialist to enroll in the program, providing informed consent and receiving education about home induction and information about how they will connect with their provider via telehealth. Boston Medical Center, a safety net hospital, has provided treatment access for patients living on the street by using telehealth to pair an outreach worker on the street with an addiction treatment provider in the hospital, offering new starts or continuation of buprenorphine treatment to patients experiencing homelessness. The ability to provide treatment entirely by remote connection, without needing a face-to-face visit, was authorized for the first time by the Substance Abuse and Mental Health Services Administration during the pandemic.
At WellSpan Health in York, Pa., a local recovery group that provides warm handoffs for patients in EDs switched to a virtual model during the COVID-19 pandemic. In this model, a patient interacts with the recovery staff via a phone or tablet that is brought into the patient’s room. This has shown to be helpful at reducing the risk of patients leaving against medical advice before the recovery team can make it into the ED for an in-person visit. The recovery group hopes to continue this model post-pandemic, and now is examining how to extend this virtual recovery outreach to emergency responders who are doing more revivals in the field with patients who decline transport to the ED. Similarly, at Boston Medical Center, the inpatient Addiction Consult team recognized that overwhelmed medical teams who were caring for COVID patients might not have treatment of substance use at the top of their minds. The consult team reviewed the hospital’s list of admitting diagnoses and began proactively reaching out to medical teams caring for patients with substance use disorders offering to provide virtual video or phone consultations for these patients.
Several organizations started providing increased bridging doses (e.g. three days) of buprenorphine after an ED visit to patients who agree to enroll in MAT. While these take-home doses were often not standard practice pre-pandemic, providing longer duration bridging doses for all patients has increased retention in treatment during the transition from the hospital by keeping patients stable. Other organizations have started providing longer take-home doses of methadone, allowing patients to decrease potential viral exposure from daily visits to methadone clinics.
2. Leveraging existing services in new ways. COVID-19-related interventions have provided new opportunities to reach vulnerable patients, allowing health systems to piggyback on new procedures and approaches. SCAN Health Plan, a Medicare Advantage insurer in Southern California, revised an existing triage process to escalate issues related to accessing medications and coordinated communications between the health plan, retail pharmacy and prescribers to provide refill authorizations for any medication, including certain opioids and medications for treating opioid use disorder, as allowed in emergency situations per state law. Boston Medical Center began handing out naloxone at the mask pick-up station where patients enter the hospital, creating an opportunity to reach a wider range of patients. Similarly, their harm reduction outreach workers hand out hand sanitizer and masks, as well as sterile injection equipment and naloxone. New Hyde Park, N.Y.-based Northwell Health, the state's largest healthcare organization, diversified its existing universal screening program embedded in 18 hospitals by creating a telephonic-based pathway for emergency departments, inpatient units and ambulatory practices to seek navigational support for patients in need of substance use care and treatment, on-demand, seven days per week. The Telephonic SBIRT (Screening, Brief Intervention, and Referral to Treatment) program is now a sustained element in Northwell’s “Addressing Substance Use” portfolio.
3. Enhancing relationships with community partners. Several organizations have been able to strengthen their relationships with community partners during the pandemic, which they hope will continue after the pandemic subsides. The pandemic has highlighted the need to coordinate and collaborate across a community; being able to innovate and strengthen relationships out of necessity has led to many positive changes for patients and care teams. WellSpan Health has realized that, given the combination of decreased service utilization and increased overdose deaths, its caregivers needed to shift from a reactive to a proactive, preventative approach that extends into the community. WellSpan has leveraged its existing relationships in the community to enhance outreach efforts, distributing a one-page document in English and Spanish at food pantries, shelters and churches with information to help navigate addiction treatment and community support. WellSpan also has continued to engage its community partners in different ways. Medical providers at Boston Medical Center worked with the Massachusetts Bureau of Substance Addiction Services to identify substance use disorder rehabilitation providers who had converted their facilities to accept patients who were COVID-19-positive, providing the hospital and patients a discharge option that addressed both COVID-19 and substance use disorders. Finally, Northwell Health continued care navigation services via Project CONNECT, a collaborative program developed in partnership with a community-based organization, where patients with substance use disorder are advocated for and supported for up to 120 days as they seek well-being and recovery. As patient volumes decreased throughout the system, Project CONNECT staff began calling all previously enrolled participants to check-in and explore opportunities to aid those in need.
These are just some examples of how the COVID-19 pandemic has changed the way in which health systems address the opioid crisis in their communities; there are certainly others. But for many, the opioid crisis has receded as a top priority. It is our obligation as leaders and healthcare providers to recognize the need to fight the COVID-19 and opioid crisis simultaneously. Permanently changing the federal regulations and payer reimbursement that allowed for these effective innovations is needed to accelerate and sustain this work. The voracity of the first wave of COVID-19 took us by surprise, but we should not be distracted twice. We should learn from this the past spring and summer what we need to do in the fall and winter. The healthcare system, despite its shortcomings, is still robust enough to protect and care for all of our vulnerable populations.
Mara Laderman, MSPH, Senior Director, Institute for Healthcare Improvement
Miriam Komaromy, MD, Medical Director of the Grayken Center for Addiction at Boston Medical Center; member of the Boston University Faculty in the Division of General Internal Medicine
James Moses, MD, MPH, Chief Quality Officer & VP of Quality and Safety, Boston Medical Center
Mark Jarrett, MD, MBA, Senior Vice President and Chief Quality Officer, Northwell Health