367 Emergency Department Warm Handoff Program: Using Peers to Improve Emergency Department Patient Engagement and Linkages to Community-Based Substance Use Disorder Services

Abstract

1) To improve emergency department (ED) patient engagement and linkages to substance-use disorder (SUD) services in the community by strengthening existing workflows 2) To move from pilot to program by integrating Certified Recovery Peer Advocates (CRPA) into ED workflow and culture 3) To reduce avoidable ED visits by moving SUD care from the ED into community settings In the initial 6 months of the pilot phase, Certified Addiction Recovery Coaches (CARC) and Certified Recovery Peer Advocates (CRPA) were introduced and integrated in the ED as hospital staff to engage, educate, and advocate for patients and support clinicians in making connections to appropriate SUD services. Using Motivational Interviewing skills and lived experience, peers supported the enhanced workflow by engaging and connecting patients with substance use needs, who typically decline services, to the appropriate level of care. ED clinicians activated peers through in-person requests and by placing orders for peer services through the electronic health record (EHR), which ensured that patients met with the peer before discharge. In addition, peers participated in routine medical rounds to case find and engage individuals coming to the ED with falls, car crashes, and other injuries to determine if SUD was the underlying cause for their ED visit. After a successful pilot period, the implementation team scaled up the intervention to become a program of the hospital ED. The implementation team convened hospital leadership and the hospital’s outpatient SUD clinic to develop a sustainability plan. This plan included guidance on reimbursement for CRPA services, enhanced CRPA responsibilities in the ED at the outpatient clinic, revised ED workflows, and guidelines for continued engagement with the SUD population. Peers, which were previously employed through an outside agency, were hired as hospital staff and re-introduced into the ED with expanded roles and responsibilities to ensure patient engagement and linkages remained person centered and patient driven. In 1 year of program implementation (November 2016 to November 2017, including the pilot phase), there have been 1,049 patient engagements of which 659 were unique patients. 16% of those engagements resulted from case finds. Over 130 handoffs (12.4% of engagements) were made to SUD providers, which is a significantly higher (p-value < 0.0001) than the Substance Abuse and Mental Health Services (SAMHSA) reported national average of people who accepted treatment (1.5%). There was a 27% reduction in avoidable ED visits for people with SUD and other behavioral health diagnoses from November 2016 to August 2017. 3 full-time peers were integrated as hospital employees (2 assigned to the ED, 1 in the outpatient clinic). To move towards integration, peers were granted access to the EHR to support clinicians in coordinating linkages between the ED and the hospital’s outpatient clinic as well as additional community based programs. The WHP was an innovative approach to transform ED workflow and reduce avoidable ED visits using peers. As demonstrated by positive outcomes in patient engagement, linkages to community-based care and ED visits, peers are an essential component to providing patient-driven care for the SUD population. Cross-training peers in best practices for mental health, substance use, HIV, and social determinants of health is an area for further investigation.