CORE

Comprehensive support for individuals struggling with opioid use disorder

Opportunity

Penn Medicine is on the frontlines of the opioid crisis. Thousands of patients with opioid use disorder (OUD) visit our downtown emergency departments (EDs) each year. In 2018, more than 1,100 people died of accidental overdoses in Philadelphia, and the city's drug overdose death rate was among the highest in the nation - more than triple that of its homicide rate. 

Treating OUD is not easy. Historically, rehab and detox were the standard treatment, but the success rate for these modalities alone is only 5 to 10 percent. ED visits for OUD present a critical opportunity to link patients to evidence-based interventions, such as medication-assisted treatment (MAT) and peer support from certified recovery specialists (CRSs).

When we started this work, MAT and CRS services were significantly underutilized. On average, 175 patients with OUD visited the ED at Penn Presbyterian Medical Center (PPMC) each month. Of those, only ten were started on MAT, and only four were referred to a CRS.

Intervention

The Center for Opioid Recovery and Engagement (CORE) provides comprehensive support for ED patients struggling with OUD by focusing on three key touchpoints.

  • Identification and engagement: CORE leverages an algorithmic patient identification system to identify OUD patients in the ED in real-time and alert care team members using secure text messaging. When a patient is identified, a CRS intervenes to discuss treatment goals and options.  

  • ED treatment: If the patient is amenable, a physician gets them started on Buprenorphine, or bupe, a medicine that can be administered in the ED. Bupe lowers the potential for opioid misuse, diminishes withdrawal symptoms, and increases safety in overdose cases. Research shows that ED-initiated bupe can double patient engagement in treatment 30 days after discharge.

  • Support after discharge: Before patients leave the ED, follow-up appointments are scheduled and "bridge scripts" placed to cover medication needs in the short-term. After discharge, CRSs act as role models, mentors, advocates, and motivators to promote long-term recovery. CRSs check-in with patients via text or call and conduct rounds out in the community.

Impact

CORE ensures that ED patients struggling with OUD consistently receive evidence-based treatment to promote long-term recovery.

With CORE's new patient pathways in place, the number of ED patients started on bupe has increased threefold, and CRS involvement has increased twelvefold at Penn Medicine's downtown hospitals. We're also seeing more patients in treatment at 30 days - 68 percent compared to less than 5 percent pre-launch - and fewer returns to the ED within 30 days of discharge. It is estimated that CORE prevents more than 180 overdoses each year in Philadelphia.

CORE is the standard of care in the EDs at PPMC, Pennsylvania Hospital, and the Hospital of the University of Pennsylvania, as well as the Hall Mercer Crisis Response Center.

In the future, the CORE team aims to increase its bandwidth and extend its reach to new clinical settings.

COVID-19

COVID-19 puts OUD patients at significantly higher risk as many of the services they depend on (drop-in clinics, group meetings, etc.) have been severely scaled back or stopped entirely. In addition, CORE's primary sites for patient engagement – hospitals and EDs – have changed dramatically.  

In response to these challenges, the CORE team developed a virtual bridge clinic to enable providers to engage, monitor, and deliver care to OUD patients remotely. CRSs provide support and connections to ongoing treatment as they would in-person, and thanks to temporarily relaxed regulations surrounding the prescribing of bupe, CORE providers can issue prescriptions for MAT over the phone. This work is possible thanks to a generous contribution from the William Penn Foundation Special Gifts Program. 

Phase 3: How we work
Collaborators

Julie Dees, MA, LPC
Jeanmarie Perrone, MD, FACMT
Nicole O'Donnell, CRS
Bryant Rivera, CRS
Kelli Murray-Garant, CRS
Devin Yastro, MA, CAADC
Lauren Carbone, MA
Margaret Lowenstein, MD, MPhil, MSHP

Innovation leads

Davis Hermann, MiD
Roy Rosin, MBA

Platforms
Funding

Innovation Accelerator Program
William Penn Foundation Special Gifts Program

Awards

Safety Award Winner, Health Care Improvement Foundation, 2019
UPHS Quality and Patient Safety Award, 2019

Innovation Methods

Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
 
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
 
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
 
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end

We hypothesized that an automated system could proactively identify OUD patients in the ED and notify CRSs in a timely way.

To test this hypothesis, we manually reviewed the EHR to find patients with OUD and notified CRSs upon identification. Not only were we able to identify more patients during the pilot, but we also validated that CRSs could take fast and meaningful action.

Insights from this pilot led to the development of an algorithm to identify OUD patients and alert CRSs via secure text message.

Nudge

Human decisions and behaviors are heavily influenced by the environment in which they occur.

A nudge is an intervention that gently steers individuals towards a desired action. Nudges change the way choices are presented, or information is framed without restricting choice - although some nudges do change available offerings to drive behavior change.

To learn more about types of nudges like defaults, active choice, financial and social incentives, and more, visit the Nudge Unit website.

Nudge
When we started this work, few doctors at the pilot location had completed their x-waiver training, a requirement to allow for bupe prescribing in the ED.
 
We launched a campaign that leveraged financial incentives to increase the proportion of x-waivered ED faculty from 5 percent to over 85 percent.
 
We also leveraged social norming to signal that bupe is a standard part of ED care. Public messages were displayed on screens in the ED, and physicians wore pins that said, "I have my x-waiver, and I use it!"

Commentary

The power of storytelling
During the initial pilot, we shared brief stories with ED providers about what happened to CORE patients after they were discharged. These narratives helped providers understand the effectiveness and value of MAT and CRS support and motivated them to continue to leverage evidence-based tools to treat OUD. 
 
Storytelling was also used to address stigma within the Penn community. We partnered with The College of Physicians to host a Narcan Story Slam. Clinicians, patients, and others who have been impacted by opioid use shared a wide range of stories, with an emphasis on overdose reversal.

Videos

Pitch Day 2019

  • Before CORE, patients left the ED with aftercare instructions that simply instructed them to “Please stop abusing multiple drugs.”
  • To account for the difficulties our patients face staying in touch, we turned to a low-tech, but appropriate solution. We gave patients wristbands with our contact information so they could reach us when they needed support.
  • We used social norming strategies like public messages and pins to celebrate and encourage the use of bupe as an evidence-based treatment.
  • We developed an automated system to monitor the ED and alert care teams of likely OUD patients.
  • Narcan Story Slam. Photo courtesy of Peter Tobia and Philly Respond.
  • Nicole O’Donnell (CRS) reviews incoming patient alerts while on the move.
  • CORE’s CRSs conducting outreach