Nurse autonomy and peer support for patients are some of the components of RWJBarnabas Health's substance use disorder recovery initiative.
The opioid epidemic has been costly in terms of both lives and economics, but New Jersey's RWJBarnabas Health has taken the initiative to address the epidemic by improving patient access to recovery services at their organization.
"The national opioid crisis has been in the headlines for many years now, and we were seeing more and more patients in our emergency departments with overdoses," says Nancy E. Holecek, RN, MHA, MAS, senior vice president and chief nursing officer, Northern Region at RWJBarnabas Health. "We were able to do immediate treatment but those first few days of support and then long-term support were lacking. It was really a revolving door, and we realized that we needed to do something much more than what we were doing."
From 2015 to 2018, the total economic cost of the opioid crisis reached at least $631 billion, according to an analysis from the Society of Actuaries. And the Centers for Disease Control and Prevention reports that in 2017, 70,237 drug overdose deaths occurred in the United States. Opioids made up the almost 68% (47,600) of drug overdose deaths in 2017.
In 2016, RWJBarnabas Health created a program to provide intervention to patients who presented to the emergency department with an opioid overdose reversed by Narcan. In that first year, the program served 720 individuals.
Thanks to the program's connection with this particular patient population, the program expanded to include all patients who presented to the emergency department with signs of any type of substance abuse disorder.
"We expanded the program in 2018 to be a 24/7 emergency department and hospital-based program that would serve anyone coming in to our facilities with substance use disorder. That would include opioids, alcohol abuse, pain medication addiction, etc.," Holecek says. “Since the program's expansion in 2018, we have served 23,737 individuals.”Holecek recently spoke with HealthLeaders about four key components of the program and how nurses play a role in connecting patients with much needed recovery services.
Immediate peer intervention
Connecting patients facing substance use disorder with an individual who has been in their shoes is an essential part of the program. RWJBarnabas Health hospitals have a 24/7 support team of over 100 Peer Recovery Specialists who are each in long-term recovery themselves.
"The purpose of the program is to provide site intervention immediately. The Peer Recovery Specialists are former substance abusers and have been through recovery, so they provide the immediate connection to the patient," Holecek says. "Because the initial contact comes from someone who is in peer recovery it's much more easily accepted by the patient."
Participation in the program is voluntary, she says, but if a patient is willing, a patient navigator will assist that person in providing appropriate recovery support and placement.
"It is important that Peer Recovery Specialists are always on-site," Holecek says. "When we trigger one of the Peer Recovery Specialists, they come right to the patient's bedside and they make face-to-face contact with the patient and establish a bit of a relationship with them. Then they continue to follow up with that patient."
Additionally, it helps the Peer Recovery Specialists become part of the clinical care team.
"I think that made a big difference that [the Peer Recovery Specialists] go to the bedside. …There's nobody better to relate to the patients that are coming in," Holecek says.
Educating the nurses and physicians on how to utilize the Peer Recovery Specialists' services as well as teaching them the clinical aspects of substance abuse disorder is another component of the program.
"The education piece was absolutely key for physician leadership and for our nursing staff. The introduction of the peer recovery support specialists as part of the team [was important] because we wanted to make sure that we just didn't have them in an office somewhere. [We wanted] the nurses and physicians actively triggering them to come and see patients," Holecek says.
In-depth education on the physiological effects of substance abuse disorder as a disease state was also provided to clinical staff.
"It was a scientific, educational program so nurses and clinicians can really understand the etiology of substance abuse in patients and why it's something that [the patients] can't control. This is a physiological illness, a disease for them," she says. "[Clinicians'] knowledge base around substance abuse disorder has increased significantly and that makes them better practitioners and caregivers [who can] better assess and refer folks to the program."
Nurses have been given greater autonomy in referring patients to the peer recovery support specialists.
"We don't need a physician order to call in the Peer Recovery Specialist," Holecek explains. "Nurses are able to do that using their assessment and critical-thinking skills. That, too, has just made it so easy for us to be able to access help for these patients."
This is an important point because nurses are often the first people interacting with the patient. During their initial assessment, nurses can rely on multiple assessment tools such as the Clinical Opiate Withdrawal Scale to determine whether patients have substance use problems and need intervention, she says.
"If we determine that a patient, for example, is drinking a case of beer a week or may need some intervention, the nurse can, without a physician order, activate a recovery specialist to come and talk to the patient," she says.
Long-term follow up
If a patient is receptive to support for substance use disorder, he or she receives further assistance beyond the emergency department via patient navigators or case managers.
"The Peer Recovery Specialist helps get them into the program, talks to them in the crisis, and then the navigators shepherd them through," Holecek says. "The navigators follow up for eight weeks, and then at three months, six months, and nine months just to make sure that the patient is still following their course [of treatment] or if they need some additional intervention."
The Next Step
Over the first three quarters of 2019, there were 75,730 touchpoints of follow up, according to Holecek, and the nursing staff is anecdotally reporting that they are seeing less of the same people returning to the emergency department.
RWJBarnabas Health is also focusing on decreasing the number of opioid prescriptions given at discharge.
“As of October 2019, only 2.56% of our patients discharged from our emergency departments were prescribed opioids compared to the national average of 17%,” Holecek says.
In the first 18 months after the initiative launched, 25,380 fewer ED patients received opioids at discharge and 21,116 fewer inpatients received opioids at discharge.
"I'm very enthused about the program," she says. "I'm so thankful that we have the Peer Recovery Specialists. It's been such a value add to our clinical teams."
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.