Sarah Wakeman, M.D., is medical director of Massachusetts General Hospital’s Substance Use Disorder Initiative, which aims to improve the outcomes and increase the value of care delivered to patients struggling with addiction. To achieve these goals, the hospital has sought to engage patients at multiple points along the care continuum. In the hospital setting, a multidisciplinary inpatient consult team is available to make recommendations and initiate treatment, as well as to connect patients to ongoing care and community-based support. For those lacking immediate access to outpatient services — especially after discharge, when the risk of overdose is high, Massachusetts General created the Bridge Clinic, a clinic for patients transitioning to outpatient care. Transforming Care spoke to Wakeman about her efforts to make evidence-based treatment more accessible to patients in inpatient and primary care settings, and to educate providers that substance use disorder is a chronic and treatable disease.
Transforming Care: What prompted Massachusetts General to invest in this program?
Wakeman: It came out of our hospital’s strategic planning process as a response to our community health needs assessment. All of the communities where we have our main health centers identified substance use disorder treatment as a priority by a huge margin, both in 2012 and 2015 — more than employment, safety, and housing. At the same time, the hospital was becoming an accountable care organization and beginning to think about how to take better care of populations. When we looked at patients with substance use disorder in the hospital, we found they got admitted more frequently, stayed longer, and got readmitted more frequently than expected. It painted the opposite picture of value. This led the hospital to embrace substance use disorder as its number-one clinical priority, which was really exciting. We spent about a year coming up with a plan, thinking about what was not working and what we could do better. The main conclusion was that, like many hospital systems, we were addressing acute complications of substance use disorder but not the underlying chronic disease of addiction. When patients were admitted for infectious complications related to injection drug use, for instance, we treated the infection but often left it up to the patient to navigate treatment services for addiction.
Transforming Care: What changes did you make at the hospital?
Wakeman: We created the inpatient consult team, which includes physicians from medicine and psychiatry, nurse practitioners, social workers, a clinical pharmacist, a resource specialist, trainees, and people in recovery. It’s provided around 4,000 consults since it was launched in October 2014, and we’re seeing the consults have increased post-discharge abstinence rates and reduced addiction severity.1
Transforming Care: How have you changed services in the primary care clinics?
Wakeman: First, we’ve begun integrating addiction treatment into primary care. This included hiring and embedding in practices recovery coaches—people who are in recovery themselves—to help patients and providers understand what it’s like to navigate health, treatment, and recovery. We’re also training our primary care doctors and residents to prescribe buprenorphine. In our health centers we now have 38 doctors with waivers to prescribe. At each site, we are working to ensure there’s ready access to behavioral health services, and we’ve developed a team of addiction champions — primary care doctors, nurses, and behavioral health clinicians — who meet with us twice a month to talk about patients they are worried about. The idea is to get the whole team to think about how to improve their treatment plan and talk about systemic barriers: where are the gaps? What do we need to address to improve care in primary care settings?
Transforming Care: What are some of the problems they’ve identified?
Wakeman: A couple of things quickly became apparent. There wasn’t a way to seamlessly transition patients from care in the hospital to care in the community unless they were getting care in one of our community health centers. There were long waiting lists. And many patients who were early in treatment were having a hard time fitting into rigid, traditional care settings. They might show up five hours late for an appointment, or three days late, or they might come in still intoxicated, or they weren’t totally sure they wanted to stop using. We created the Bridge Clinic to address both. It’s a no-barrier kind of clinic. People can just show up. They don’t need an appointment. They don’t have to want to stop using. They can come in whatever shape they are in and we try to engage them, whether in group sessions or one-on-one counseling or for medications for addiction treatment. We see people from the emergency department, off the street. They can come as frequently as they want.
Transforming Care: How common are these low-threshold models?
Wakeman: Not very. They need to be more common. With addiction, we have this mistaken notion that people need to prove themselves to get care, and if it doesn’t work for them, we blame them. That approach is part of the reason people stay out and keep using — and die, quite frankly. We need to make treatment the easy choice, so that patients can access it on demand. We are trying to build a system that looks like that. Our Bridge Clinic is small, but we have coffee and snacks, warm clothes, meal vouchers, and transportation vouchers. Our idea is, any positive changes patients can make are a good thing.
Transforming Care: How does the hospital pay for the Bridge Clinic services?
Wakeman: We bill for nurse practitioner and physician visits and for laboratory tests. Everything else — our recovery coaches who offer support, the resource specialist who helps coordinate referrals and address social service needs, the clinical pharmacist, the drop-in groups — all of that is not billed for. These are free services the hospital supports as a way to reduce unnecessary readmission costs and help patients get the care they need. And, in fact, we have seen that patients who come to the clinic after hospitalization get readmitted much less frequently: the readmission rate within 30 days is only 10 percent. We don’t have a control group per se, but readmits among those who have an identified addiction but don’t get seen by the addiction consult team or the Bridge Clinic are around 17.5 percent.
Transforming Care: A survey you conducted before the program redesign found roughly half of general internists at the hospital frequently cared for patents with substance use disorder, but less than 10 percent felt prepared to discuss medication and behavioral health treatments. Nearly a third said they thought substance use disorder was different from other chronic diseases because they believed using substances is a choice. What have you found to be effective in terms of offering training and addressing bias?
Wakeman: We’ve focused our training around building internists’ skill and comfort in caring for their patients with substance use disorder. This has included formal training on motivational interviewing and how to use medications for addiction treatment. We also offer informal teaching through the biweekly meetings, where we provide support for working through complex cases with our practices and ensuring primary care clinicians don’t feel they’re left managing patients on their own. In terms of addressing the stigma around addiction, we use a combination of science and narrative. There’s a tremendous amount of evidence that addiction is a chronic disease, that effective treatment exists, and that people recover. I think doctors are surprised to hear this because, for many of them, the only patients who they identify with addiction are actively ill. They may be coming to the hospital frequently, or be in chaos. Patients who are doing well don’t disclose their addiction history, so doctors often don’t realize that most go on to live long, productive lives. Hearing personal stories is a powerful way to change perception. That’s why recovery coaches who have personal experience with addiction help. Providers who have interacted with the initiative report that they felt much better-prepared to take care of patients and had less negative attitudes about substance use disorder, and were more likely to provide treatment themselves, including by prescribing medication.2
1 S. E. Wakeman, J. P. Metlay, Y. Chang, et al., “Inpatient Addiction Consultation for Hospitalized Patients Increases Post-Discharge Abstinence and Reduces Addiction Severity,” Journal of General Internal Medicine, Aug. 2017 32(8):909–16.
2 S. E. Wakeman, G. P. Kanter, and K. Donelan, “Institutional Substance Use Disorder Intervention Improves General Internist Preparedness, Attitudes, and Clinical Practice,” Journal of Addiction Medicine, July/Aug. 2017 11(4):308–14.