July 2018 | Case Study
Writhing in pain from heroin withdrawal, Gabriel lay on a bed in a western Pennsylvania hospital. He had been clean from using OxyContin for 18 months, but had relapsed and started using heroin. “I had this overwhelming feeling that I had let everybody down,” he says. The withdrawal was worse than anything the 26-year-old had gone through before.
Then a health care provider asked Gabriel if he wanted to talk with someone who might help. He agreed, despite thinking that no one would understand his situation and feelings. Minutes later, Matt Russick, CPS, CRS, walked in. He wore no white coat and looked like “a normal person,” said Gabriel. Russick explained that he was part of a peer navigator program and that he was in recovery from substance use. They talked about their experiences and about options for treatment. “He said, ‘I’ve been right where you are, man, and we can find help for you,’” Gabriel recalls. “It felt good that there was somebody in that room who could relate.”
In Pennsylvania, as in much of the United States, substance use disorder (SUD) is taking a significant toll on people, health systems, and health care budgets. Pennsylvania hospitals and emergency departments (ED) are being challenged by an increase in persons with opioid, alcohol, and other substance use, says David Kelley, MD, chief medical officer for the Office of Medical Assistance Programs, Pennsylvania Department of Human Services.
Because people with alcohol and other substance use disorders may come to hospitals for treatment of an injury or chronic medical condition, their underlying SUD might not be recognized. Even when SUD is identified, they may not get meaningful help in connecting with treatment and recovery services. Without such connections, they often continue their alcohol or substance use, suffer deteriorating health, and have costly repeated hospital visits.
Partnering for Improvement
Since Community Outreach Recovery Specialists are based in the community, they can accompany newly discharged individuals to their first 12-step meetings or first outpatient appointments at treatment clinics and also meet with them in other community settings.
In 2015, Pennsylvania received funding from the Centers for Medicare & Medicaid Services (CMS) through the Adult Medicaid Quality Grant Program: Measuring and Improving the Quality of Care. The grant funded a two-year pilot initiative, Coordinating Care for Individuals with Substance Use Disorders (CCISUD) in Allegheny County, to encourage more people to begin and remain in SUD treatment, to promote recovery, and to reduce ED visits as well as inpatient admissions and readmissions.
Allegheny County includes the city of Pittsburgh, suburbs, and small towns. It was chosen for the CCISUD project because alcohol and substance use disorders account for the top three causes of repeat hospitalizations there, with low participation rates in SUD treatment for those being discharged from its hospitals and EDs. During 2015 and 2016, 986 accidental drug overdose deaths occurred in the county — more than 90 percent of which were opioid-related. The county also has a history of multi-stakeholder collaboration and strong data capacity, which would benefit the project.
Led by the Pennsylvania Department of Human Services, the CCISUD initiative was a collaboration between two of the region’s largest health systems, Allegheny Health Network (AHN) and University of Pittsburgh Medical Center (UPMC), in conjunction with the Allegheny County Department of Human Services, Allegheny HealthChoices, Inc. (AHCI), and five managed health care organizations. Consultation and technical support were provided by the Center for Health Care Strategies (CHCS).
Before the project launched, partner agencies and organizations, researchers, and providers, met in brainstorming sessions. Participants identified a key need: to engage people with SUD who may be coming into hospitals for other medical issues. The group decided to focus the initiative on making supportive care connections with people who have SUD before hospital discharge and to help guide them to appropriate treatment and services.
The project used three approaches to accomplish its goal:
- Social Workers. At AHN’s Allegheny General Hospital, social workers helped people with SUD find the resources they needed.
- Peer Navigators. At the three participating UPMC hospitals — UPMC East, UPMC Mercy, and UPMC McKeesport — connections were made by peer navigators, individuals with personal histories of alcohol or substance use who had been in recovery for two years or more. UPMC’s Western Psychiatric Institute and Clinic (WPIC) hired, trained, and managed the peer navigators for the UPMC hospitals.
- Community Outreach Recovery Specialists. After discharge, help outside the hospital was provided through a “warm handoff” from the peer navigators and social workers to Community Outreach Recovery Specialists (CORS) or health plan care managers. The CORS staff were also peers with histories of substance use and recovery. They were hired and managed by Community Care Behavioral Health (Community Care), a managed care organization that managed behavioral health services for individuals with Medicaid on behalf of Allegheny County.
“The whole idea with having the peer is that they have the lived experience,” says Ann Cellurale, MEd, Community Care associate clinical manager. Since CORS staff are based in the community, they can accompany newly discharged individuals to their first 12-step meetings or first outpatient appointments at treatment clinics, Cellurale says and also meet with them in other community settings. With the grant ending, Community Care is in the process of transitioning the CORS workers to other responsibilities.
Shaping the Project
The initiative’s planners talked with experts and researched what had been tried elsewhere. They found a relevant program, Project Engage, at Christiana Care Health System in Delaware. It brought peers in recovery into hospital units to connect people who had SUD to treatment when discharged. The Allegheny County group visited the program and used it as a model for the CCISUD project.
Even with that guide, the Pennsylvania project had to manage multiple partners, four hospitals, administrative complexities, and resistance to integrating peer support on medical units. Interviewing, hiring, training and integrating the peer specialists into hospital workflows took time. Participating hospitals launched their efforts on a rolling basis. Allegheny General Hospital, which used staff social workers, began its program in October 2014. The three UPMC hospitals, each with one peer navigator, started in early to mid-2015. Two CORS workers began shortly after.
According to Curt Bell, RN, BSN, ambulatory nursing manager and project manager for addiction medicine at UPMC, the initiative originally limited its services to people with Medical Assistance (MA). Peer navigators then reported that people with all types of insurance, or no insurance, were asking for help, so restrictions were removed. CORS workers, however, could only help people receiving MA in Allegheny County.
How Peer Navigators Function
Peer navigators are more than people who have maintained recovery and want to help others. Upon hire, they participate in peer specialist and recovery specialist training, with opportunities to gain knowledge through role-playing scenarios, “shadowing” experienced peer navigators, and more. At the heart of the training is learning the art of motivational interviewing. This open-ended questioning is used by peer navigators to help people identify their strengths, needs, what their current situation is, and how comfortable they are with certain treatments or services. “You allow them to lead,” says David Gardner, CPS, CRS, senior peer navigator at UPMC Mercy.
Doctors, nurses, social workers, or any other hospital staff can refer people who might have an alcohol or substance use condition to a peer navigator. Usually, a provider will ask if a person is interested in speaking with someone from the program before making the referral.
An initial meeting with someone may last from 20 minutes to three hours or more. The peer navigator aims to establish a personal connection, discover what the individual finds meaningful (family, friends, religious or spiritual beliefs, skills, etc.), identify barriers to dealing with SUD, provide education about resources, and help the person take steps toward building a recovery and wellness plan. Peers talk about having a “trigger plan” as well, detailing supports to use when difficult challenges arise.
By sharing their personal SUD experiences, peer navigators give people with SUD the reassurance of talking with someone who is supportive, understanding, and a real-world role model of how to manage the same condition. “We work to restore hope,” Gardner says.
Peer navigators offer resources to use after discharge, from information on inpatient and outpatient rehabilitation programs to recovery support, 12-step meetings, and ways to maintain wellness, such as meditation sessions or group walks. They often follow up by phone and give their business cards to people they talk with, even those who decline help initially.
Brianna N., age 40, was injured, unable to walk and her blood-alcohol level was over the legal limit when she was admitted to UPMC Mercy after a car accident. She agreed to talk with a peer navigator. The next day, Gardner came to her room and told her about the peer navigator program. He said that he was in recovery himself. “That made me feel comfortable,” says Brianna, speaking from her hospital room three days later.
“A peer is somebody who has signed up to help individuals face their biggest triggers. They’ve reached back into that fire enough to pull another human being forward. The fact that you smell crack or marijuana or alcohol on someone — as a person in recovery that can be difficult. This is not for everyone.”
She had been in treatment for alcohol use in the past, but never with the help of a peer navigator. Gardner and Brianna talked about treatment possibilities and her worries about what would happen next. He encouraged her to heal, then make a plan for SUD recovery. Gardner connected her with the program’s CORS worker, who could help her find a treatment facility, and gave her his card so they could maintain contact.
“I’m definitely gonna do something,” says Brianna. “After what just happened, I have to, and I want to. I don’t want to keep living like this.”
Because peer navigators often work with people in crisis, the program encourages them to care for themselves as well as for others. Giving them support is important for their physical and emotional health as well as for retaining them in their jobs. “A peer is somebody who has signed up to help individuals face their biggest triggers,” says Keirston Parham, CPS, CPSS, CWF, recovery and peer services coordinator for Western Psychiatric Institute and Clinic. “They’ve reached back into that fire enough to pull another human being forward. The fact that you smell crack or marijuana or alcohol on someone — as a person in recovery that can be difficult.” Peer navigators also sometimes lose people in treatment — Parham notes that one navigator experienced three deaths in a week. “This is not for everyone,” he says.
Integrating Peers into Hospitals
Building internal hospital support for the CCISUD project took time. Finding the right candidates to be peer navigators was vital. “We try to recruit people who are really quick at building rapport and becoming a natural ally — and who are able to identify allies (within the hospital),” Parham says.
To create support for the program, Parham, Bell, and Gardner met with doctors, faculty, board members, and department staff. Although the behavioral health community was familiar with the use of peer navigators in mental health, the concept met resistance from others within hospitals. The barriers were varied, ranging from professional reluctance about having a non-medical person with a history of substance use added to the workflow, to bias about addiction, SUD, and people with the condition. The team learned it was important to get buy-in from people at the top of a hospital or unit to win acceptance.
Within each facility, peer coordinators and navigators found people they called “champions” who supported their effort and helped them work through roadblocks. At times, they had to approach several departments in a hospital before finding that champion.
They discovered that medical personnel could realize the value of working with peer navigators once they saw the program’s clinical benefits. For example, people with SUD often talk more honestly with peer navigators than with health care providers. In one case, a nurse asked a male person with SUD what substance he had used. He said it was three bags of heroin. The peer navigator then talked to the man, building what the program calls the “trust bridge” by sharing past personal substance use and asking about the man’s situation. Once trust was established, the man told the peer navigator that he had actually used 13 bags of heroin, not three. “That is significant information when you’re prescribing medications or thinking about what you need to do for this individual,” Parham says.
In addition to encouraging honest self-reporting, peer navigators support medical staff by engaging with people who may become disruptive, providing extra monitoring to prevent falls or injuries, and helping people get coffee or walk to the bathroom.
Peer navigators publicize their services and the referral process to hospital staff through flyers, posters, email, internal video monitors, meetings, education sessions, and lots of networking, both in person and by phone. Gardner says it is important to build relationships with those who can provide appropriate referrals to peer navigators, including social workers, nurses, and attending psychiatrists. “All departments are different,” he says. “Just to hang out in the ER and see if anybody wants to talk will not cut it. You have to get creative and connect so they [the referral sources] remember you.”
As staff at the UPMC hospitals became more familiar with the peer navigators and their purpose, referrals of people with SUD took off. Some staff also have asked the peer navigators for help for their family members.
Data show the CCISUD initiative’s success. As a comparison, in 2016, as few as 19 percent of individuals identified with SUD engaged in treatment. Yet among UPMC clients who were referred to peer navigators, more than 32 percent were linked to SUD treatment. The program continued beyond the end of the pilot and expanded to include six other hospitals [see next section]. From its start to March 31, 2018, the peer navigator program resulted in:
- 9,276 referrals to peer navigators;
- 5,520 total clients seen;
- 2,621 Medical Assistance clients seen;
- 6,225 follow-up visits while in hospital; and
- 3,041 clients linked to treatment.
After meeting with a peer navigator, emergency department (ED) and inpatient high-utilizers had an 18 percent reduction in ED visits and a 42 percent reduction in inpatient discharges.
“We’re reaching a lot more people than ever before, and it’s because the peer navigators can reach them,” says Bell.
To see if the CCISUD project could reduce frequent ED or hospital visits, UPMC measured utilization rates from May 1, 2015 to April 30, 2016. They saw a significant effect when they looked at individuals with a history of frequent ED and inpatient visits — people who, in the nine months before meeting with a peer navigator, had three or more ED visits or three or more inpatient discharges. After meeting with a peer navigator, the high-utilizer group had an 18 percent reduction in ED visits and a 42 percent reduction in inpatient discharges.
Patient satisfaction scores were also impressive. On a scale of one to four, from least to most, people with MA said the time they spent with the peer navigator was beneficial (3.8 out of 4), that they were likely (3.6 out of 4) to decrease their current substance use, and likely (3.5 out of 4) to seek follow-up services. Among those who met with CORS from Community Care in 2017, 61 percent found the contact very beneficial and 49 percent said it had caused a reduction in their substance use. According to 2017 claims data, about 24 percent of those who met with CORS staff connected with SUD treatment services and about 12 percent connected with mental health treatment services.
Project Expansion and Influence
After the CCISUD pilot project ended in 2017, the intervention using social workers at Allegheny General Hospital became self-sustaining. Whereas the peer navigation program in the hospitals is not yet a billable service, hospitals and managed care organizations are providing continued funding through an array of funding streams, including funding for community-based staff from DHS, targeted at providing care coordination services to high-risk individuals with complex needs, including those with substance use disorders. Community Care has fully integrated the CORS staff into their Care Management team supporting people with SUD to connect to and stay in SUD treatment, as part of each person’s individual recovery and wellness plan.
UPMC has expanded the peer navigator program beyond the original three hospitals, adding Magee-Womens Hospital of UPMC, UPMC Montefiore, and UPMC Presbyterian — all in Allegheny County — as well as UPMC Jameson (New Castle) in Lawrence County and UPMC Horizon (Shenango and Farrell) in rural Mercer County.
Those new areas also have great need for the program. Peer navigator Russick grew up in New Castle and provides services at UPMC Jameson and UPMC Horizon. He works next to doctors and nurses who knew him when he was in active addiction and he also regularly encounters people with whom he once used. They tell him that seeing him now gives them hope that recovery is possible for them as well.
Experiences from creating and implementing the CCISUD project, and early results, helped influence the development of Pennsylvania’s statewide Centers of Excellence (COE) initiative. These centers, under direction of the Pennsylvania Department of Human Services, coordinate care for people with MA who have opioid-related SUD. The COEs use community-based navigators, some of them peers in recovery, to help people find appropriate care, stay in treatment and receive follow-up support.
The CCISUD project “was insightful, with a lot of lessons learned for our COE program,” says Dr. Kelley. COE planners gained guidance on the hiring, training, and retention of peer recovery specialists, and how to connect to the right resources. Moreover, “what we learned from the pilot was that it takes time” to build care management teams and to encourage people to go into treatment, Dr. Kelley adds. “It’s an iterative process.”
It may take months or longer for a person with SUD to call the peer navigator and begin recovery. Others are ready to take the first steps sooner.
“[Peer navigators] have demonstrated over time what they can do, not just for the people in treatment but for the clinical staff. People are now saying, ‘what did we do before without them?’”
Gabriel says that meeting peer navigator Russick at UPMC Jameson, and trusting his advice, changed everything. He had thought he would lose his family, fiancée, and job due to SUD. Eight months after the peer navigator intervention, he is in outpatient treatment, goes to at least four 12-step meetings each week, is planning a wedding, helps others facing SUD, and credits “my faith in God” for propelling his recovery. “It all started from Matt coming into the room,” he says.
The success of the CCISUD initiative, its contribution to statewide Pennsylvania’s Centers of Excellence program focusing on addressing the opioid crisis, and the continued growth of the peer navigator program show the benefits the project brought to Allegheny County and beyond. In addition, as a result of the program, WPIC won a 2017 Fine Award for Teamwork Excellence in Health Care, an annual award from The Fine Foundation and the Jewish Healthcare Federation that recognizes innovative, quality improvement-centered treatment for mental health and substance use problems.
Anthony Lucas, MPH, AHCI manager of quality improvement and project coordinator, notes that attitudes and perspectives within the participating hospitals have changed since the initiative began. The project had “a hard time getting traction,” he says, yet now the program is overwhelmed with referral requests for peer navigators.
“They have demonstrated over time what they can do, not just for the people in treatment but for the clinical staff,” Lucas says. “People are now saying, ‘what did we do before without them?’”
Author Robin Warshaw is an award-winning writer who focuses on medicine, social issues, and health care.