A Capital Effort in the Fight Against the Opioid Epidemic

00;00;01;04 - 00;00;41;27
Tom Haederle
The majority of overdose deaths in the United States involve opioids. Already a huge problem pre-COVID, the pandemic accelerated opioid misuse to epidemic proportions. As we observe International Overdose Awareness Day today, it's worth looking at some efforts, such as one underway in the nation's capital of Washington, DC, that have shown promise and some encouraging results. Welcome to Advancing Health, a podcast from the American Hospital Association.

00;00;41;29 - 00;01;05;05
Tom Haederle
I'm Tom Haederle with AHA Communications. The District of Columbia Hospital Association decided that getting the word out about the medications available to people suffering from opioid addiction was one way, among others, to begin to make a dent in the problem. Another avenue it pursued was offering opioid recovery coaches, people who could talk from personal experience about what it took to overcome addiction.

00;01;05;07 - 00;01;29;24
Tom Haederle
In this podcast, a leader in that effort speaks with The AHA’s Jordan Steiger about the hospital-based peer support program and the impact it has made so far. Gayle Olano Hurt, vice president of Patient Safety and Quality Operations with the District of Columbia Hospital Association, says of their work “it is impacting the population at risk. I can only imagine what the overdose profile would look like if the city was doing nothing.”

00;01;29;26 - 00;01;32;00
Tom Haederle
Let's join the discussion.

00;01;32;03 - 00;01;44;07
Jordan Steiger
Gayle, thank you so much for joining us today. This is a really important topic to our membership, and I'm sure there's going to be a lot of interest in learning about DCHA’s work around the opioid epidemic. So thank you for being here.

00;01;44;11 - 00;01;47;12
Gayle Olano Hurt
Sure. I'm happy to talk about this work. It's exciting.

00;01;47;15 - 00;01;54;22
Jordan Steiger
So tell us a little bit about your role at DCHA and how you are involved in work to combat the opioid epidemic.

00;01;54;24 - 00;02;25;05
Gayle Olano Hurt
So I serve as the VP for Patient Safety and Quality, and my background includes over 20 years working with behavioral health and substance use providers across the country. So this work is not only something that's important to the association and to our hospitals, but it also is near and dear to my heart. At the Hospital Association, our mission is all about supporting initiatives that strengthen the health care system, that initiatives that eliminate disparities and promote better health outcomes.

00;02;25;08 - 00;03;07;26
Gayle Olano Hurt
Quite honestly, when we started this, our hospitals recognized a need to address the growing opioid epidemic. They really wanted to promote initiation of medications for opioid use disorder, particularly during ED and hospital visits, really to improve quality of care for patients struggling and to address the growing number of overdoses that we were seeing in the district. Based on that, we worked with them and some folks in the city to develop a funding source from our Department of Behavioral Health through the Substance Abuse and Mental Health Services Administration on the federal side, and were able to secure funding to support beginning an opioid program.

00;03;08;02 - 00;03;42;14
Gayle Olano Hurt
At the beginning, we had four hospitals on board, starting with Focus on Emergency Department initiation, and then the program is really grown. It includes all acute care hospitals in the district, including their emergency departments and the psychiatric specialty hospital in the district. Really, our role as association members and my role is bringing together subject matter experts, the hospital clinical leaders, other key stakeholders to design and implement the program based on what best practices there are in the field.

00;03;42;16 - 00;04;00;28
Jordan Steiger
That sounds great and you know, one thing that stuck out to me is you said this was really member led. This was something that your member hospitals brought to you and said, we want to focus on this. I'm sure many other people listening can resonate with that because we know that the opioid epidemic is touching all types of communities, urban, rural, everywhere across the country.

00;04;01;03 - 00;04;05;16
Jordan Steiger
So tell us a little bit about what the epidemic looks like in D.C. right now.

00;04;05;18 - 00;04;35;25
Gayle Olano Hurt
You know, in D.C. being an urban center, the opioid epidemic looks a little different than what garners a lot of attention nationally. There were about 281 fatal opioid-related overdoses in 2017 when we were starting these discussions and the majority of deaths occurred in African-American males aged 50 to 69. Folks who may have had a longer history of using opioids or other substances who are really getting caught up in the epidemic.

00;04;35;27 - 00;05;04;22
Gayle Olano Hurt
There was a small dip in 2018, but as fentanyl analogs began to take hold and the supply chain started changing that, you know, it really sort of exacerbated the epidemic here in the district. The COVID 19 pandemic actually also had a big impact and negative results and exasperating the epidemic here in the district. By 2022, there were over 450 overdose deaths in the district.

00;05;04;24 - 00;05;15;14
Gayle Olano Hurt
Deaths remain higher for those African-American males aged 50 to 69. But we're seeing an increase in deaths for those aged 30 to 49.

00;05;15;16 - 00;05;35;09
Jordan Steiger
So the demographics are shifting a little bit, it sounds like. The problem is expanding, but I know you have a lot of really great things in place to support your hospitals. One thing that's really stuck out to me is your hospital based peer support services program. I think it's pretty unique to DCHA and your hospitals. So could you tell us a little bit about that?

00;05;35;11 - 00;06;11;07
Gayle Olano Hurt
Yeah, sure. You know, despite those increases, our programs, which are hospital-based opioid response programs that really involve a key component in peer recovery coaches with lived experience is actually impacting the population at risk. I can only imagine what that overdose profile would look like if the city was doing nothing. And really, the way the program works is it uses the expert evidence based approach, which is a screening, brief intervention and referral to treatment based approach.

00;06;11;10 - 00;06;45;02
Gayle Olano Hurt
Essentially, universal screenings are completed for patients arriving at the hospital to assess for a risky substance use. Patients that screened positive receive a motivational interviewing based intervention from a peer recovery coach, and it's the recovery coaches that have that lived experience and can really discuss their motivations for seeking treatment, where they were, how they got to where they are, and using that sort of motivational interviewing technique that we see as a key to the success of this program.

00;06;45;05 - 00;07;09;23
Gayle Olano Hurt
Essentially following that brief intervention, patients that use opioids are provided an opportunity to receive that medication for opioid use disorder right in the hospital if clinically appropriate. Patients who are willing to be referred to a treatment provider in the community, regardless of whether they want the medication for opioid use disorder in the hospital or not receive a referral to a provider in the community.

00;07;09;26 - 00;07;37;10
Gayle Olano Hurt
And then the coach also calls after a discharge to the treatment provider to confirm that the patient actually arrived at treatment. Another key component to this program is that we have a network of providers in the community who've agreed to offer same day or next day services to ensure that the patients can receive their next dose of medication if they start that initiation in the hospital and need a dose within that 24 hour period for their second dose.

00;07;37;17 - 00;07;58;23
Gayle Olano Hurt
And that really strengthens that connection between what's happening in the hospital and what happens after discharge. It's interesting, You know, patient willingness to engage in treatment, of course, varies month to month. Typically, about a third to half of the patients accept a referral as a treatment, and about half of those are able to actually show up for their referral appointment.

00;07;58;25 - 00;08;44;28
Gayle Olano Hurt
That said, the rates are much higher for folks who are starting medications for opioid use disorder in the hospital. Over 90% of those who receive the MOUD in the hospital receive a referral for induction, post discharge, and 90% of those folks actually show up for treatment after they leave the hospital. There's a reason that is the evidence based practice that is really critical and important, and the results differ so greatly for those where you're actually able to start that medication in the hospital and help make that really strong connection for them to that next treatment provider to ensure that they are able to continue the medications.

00;08;45;01 - 00;09;04;13
Jordan Steiger
That sounds like a great model. And you know, what a smart thing to do, you know, to make sure there's that warm handoff, getting people into treatment, you know, one to two days later. I think that doesn't always happen for behavioral health when we know there's long wait times right now, a lot of different factors that prohibit people from getting to those next appointments.

00;09;04;15 - 00;09;39;24
Gayle Olano Hurt
Yeah, and we looked out at what was there on the evidence. Some work out of Yale, some work actually in Maryland, right across the border from D.C. that was happening and then built upon those programs. One of the other things that we do is actually offer an opioid response symposium every year. This actually includes education for providers both in the hospital and in the community about current trends for use of medications in hospitals and other settings, as well as best practices in emerging innovations such as bridge prescriptions and changes in buprenorphine dosing options.

00;09;39;26 - 00;10;06;19
Gayle Olano Hurt
In that, we also usually feature a peer coach led panel, and through that avenue, those coaches are able to share best practices and success stories like the patient who retired multiple times to the emergency department. And each time they came back, they weren't ready, but they were a little more open. And then that final time when they actually accepted the offer of treatment and were able to make that follow up appointment.

00;10;06;22 - 00;10;23;00
Gayle Olano Hurt
We also hear from patients and families after they successfully enter and stay in treatment, thanking our peer coaches for introducing them to treatment and to their treatment providers and making sure they were connected after discharge. Those are the stories that I think keep us moving and motivated when we hear them.

00;10;23;03 - 00;10;36;26
Jordan Steiger
Absolutely. Just keeping it patient centered. And I really I do love so much how you've incorporated that peer support. I think that's so powerful when you're talking about substance use disorder. Just having that shared live experience is really, really important to patients and families.

00;10;36;28 - 00;10;40;23
Gayle Olano Hurt
Definitely, they are a critical component of this program.

00;10;40;26 - 00;10;50;28
Jordan Steiger
So that leads me to another question. I know you have another piece of this work called the Overdose Survivors Outreach Program. Can you tell us a little bit more about that?

00;10;51;01 - 00;11;14;22
Gayle Olano Hurt
Yeah, sure. Again, this was modeled on a program that began in Maryland, and then we have adapted it over the years and actually began as an overdose survivors program, but expanded to include patients who engage in risky opioid use and stimulant use, essentially, our peer recovery coaches provide outreach support for patients who aren't ready for treatment for 90 days after discharge.

00;11;14;28 - 00;11;48;28
Gayle Olano Hurt
They are in the community. They continue to engage patients to provide referrals for support services such as housing, getting IDs, helping with securing financial stability, and then they connect the individuals to treatment when the patient is ready. And that 90 days of follow up. Peer coaches can often get to the heart of the issues that are contributing to substance use disorder and the issues that are acting as barriers to treatment with those individuals that they're working with and and really can build a strong connection to help ensure that they're able to get them to treatment when the patient is actually ready.

00;11;49;01 - 00;12;17;15
Jordan Steiger
That's great. Really taking that holistic approach, you know, looking at social drivers of health and what could prohibit people from seeking treatment that's so important in substance use. So your perspective on this is a little different than I think most people that we have on our podcasts, because you are from an allied association, So what might you tell to other allied associations who are listening to this and want to support their membership in addressing the opioid epidemic?

00;12;17;18 - 00;12;40;25
Gayle Olano Hurt
I think the first thing I would mention is reiterating something that that you helped repeat throughout, and that is that investing in that peer support to those individuals with lived experience is integral to creating impactful programs. Those folks really are a key to making the program successful. Really based on recommendations from the subject matter experts that we brought in,

00;12;40;25 - 00;13;05;14
Gayle Olano Hurt
initially, we actually encouraged the hospitals to hire the peers directly rather than having a pool, for example, hired by the association. And I would also recommend this as peers are working directly as hospital staff with other hospital staff, they're seen as the hospital care team or part of that hospital care team and better able to sort of effectively integrate services within that hospital setting.

00;13;05;16 - 00;13;29;21
Gayle Olano Hurt
It makes the role really powerful as part of that overall treatment care team. Clearly, there's work to do. I mean, I talked about the increasing deaths from overdoses in our community and we certainly have run into barriers along the way. One thing I would reiterate is we all, those of us who are in quality improvement, know that the role of a champion is critical when you're trying to improve quality of care.

00;13;29;21 - 00;14;13;28
Gayle Olano Hurt
And this is no exception. A solid clinical champion in that hospital setting is absolutely necessary to implement a fully functioning program. Hospitals without that strong leadership role, I can tell you, will struggle with implementation more than those that have the role solidly in place. And your performance can vary based on ebb and flow as far as availability of somebody who can sort of play that role. I'll be honest too, We've also experienced difficulty in hiring a full cohort of peers. As we were lifting this program in the district, the district was lifting multiple other programs, focusing on hiring individuals with lived experience at the same time.

00;14;14;00 - 00;14;57;21
Gayle Olano Hurt
So a number of community health worker community outreach programs, peers and and the FQHCs in the city...so we were all competing for those same limited resources. And certainly these were resources are not immune to the workforce issues that we're facing in the health care industry more broadly now. So one of the things that I would advise folks to think about is that it's really important to work with hospitals to develop a method to have coverage from other staff members to provide services when peer based coverage isn't available, informed by those lived experience peers that you do have available, so that you've got the ability to provide this care and this service

00;14;57;21 - 00;15;20;18
Gayle Olano Hurt
even if a lived experience, peer is not available at the time that somebody hits the door. You also, I would advise, really work with your Department of Health Care Finance or Medicated agency to identify ways in which peer services can be paid for. Right now we have a program that is grant funded and we've been graced by having that grant funding continue.

00;15;20;18 - 00;15;39;28
Gayle Olano Hurt
But we are looking at sustainable ability and trying to figure out if those grant funds go away. How do we make sure that hospitals can sustain the program with the lived peers, whether it be through community benefit or some payment or other grant opportunity? You know, it's really sort of critical to be thinking about that as you're rolling these out.

00;15;40;01 - 00;16;05;29
Gayle Olano Hurt
You know, I've got a couple of other notes of advice. One other one is educating staff on treatment practices is, of course, important, but you need to make sure you have a component on addressing stigma and unconscious bias, both among providers and surprisingly, even peer coaches. There's a lot of history in this space around abstinence based programs and a lot of assumptions, unfortunately, that can be made.

00;16;06;04 - 00;16;32;02
Gayle Olano Hurt
And it's not just about the language and potential assumptions about patients seeking care. It's also about making sure that people are educated on the evolution of current evidence based practices and are really comfortable with adopting them. You've got to educate, you've got to repeat, you've got to have those system in place to make sure that it's easy for people to understand, remember, and do what is considered that best evidence based practice.

00;16;32;05 - 00;17;02;10
Gayle Olano Hurt
And I mentioned those providers in the community? Really engaging them early and often, it's important having them available for that. Follow up appointment within 24 hours of discharge and making sure that referral process is clear is really important. It also takes reinforcement of a relationship, a development. We added a what we call a peer collaborative where the peers can come together, they can ask questions of one another, they can share with one another what they're seeing as best practices, provide support.

00;17;02;13 - 00;17;27;26
Gayle Olano Hurt
And we bring in guests to those collaboratives, either to provide support for the peers as they're doing their work. From a personal perspective, but also from a professional perspective. And that includes meeting with care providers during those meetings so that they can address any barriers that they're running into as they're making referrals. The other thing I would say is we're continuing to explore harm reduction options like distributing naloxone kits upon discharge.

00;17;28;02 - 00;17;44;24
Gayle Olano Hurt
It's a little more complicated than it sounds, depending on how your pharmacies are licensed within your hospitals. But you really need to be thinking about how you might address prevention and harm reduction as a core component of what you're doing in terms of treatment.

00;17;44;26 - 00;17;59;15
Jordan Steiger
Yeah, one thing you mentioned is the sustainability of this program and thinking about how you can continue to move it forward. What do you think the opioid epidemic is going to look like in the next 5 to 10 years? And do you think programs like this are still going to be necessary?

00;17;59;17 - 00;18;25;01
Gayle Olano Hurt
I like to be optimistic, but I'm going to say yes, I do think they're still going to be necessary. I think that these are these kinds of programs are what will develop as best practices treatment, certainly, that hopefully will advance. I do think one of the things that we struggle with when it comes to treating substance use is what's available in, quite frankly, the market.

00;18;25;04 - 00;18;51;22
Gayle Olano Hurt
And it's constantly changing. Folks who are thinking cleverly about how to get their drugs to market and what different drugs they can use. It's seemingly always ahead of the curve. And so I think that was part of the reason I mentioned adaptation being so important. I think that our field is going to have to continue to look to advancing medication options that can potentially treat some of these new things as they come up.

00;18;51;27 - 00;19;15;11
Gayle Olano Hurt
But I always think there is going to be some component that's going to be about engaging that patient where they are, that individual where they are in their motivation to receive treatment and engaging providers and understanding what those new medications and other options are in the field to make sure that we really all stay up to date in terms of what those best practices are.

00;19;15;11 - 00;19;27;28
Gayle Olano Hurt
I think it's going to be a challenge, quite bluntly, simply because of the nature of the disease and what feeds the disease. But I do think there's hope, and I think programs like this can really help and make a difference.

00;19;28;00 - 00;19;37;28
Jordan Steiger
Gayle, thank you so much. As we wrap up, is there anything else that you would like to add or anything that you think is really important for our listeners to take away as we end?

00;19;38;00 - 00;20;10;29
Gayle Olano Hurt
I will say this really is a collaborative effort across hospitals, government agencies, community providers. It requires engagement from hospital clinicians and leaders, but also other leaders in the community. And you'll think about is the drugs available in the community and associated usage patterns change. The program needs to adapt and you need all of those key stakeholders engaged in that process to ensure that your program is not only successful initially, but continues to be successful runs forward.

00;20;11;01 - 00;20;26;25
Jordan Steiger
Gayle, thank you so much for joining us today. I think this sheds light on a really important topic to our membership and we're really appreciative to have your perspective on this as you continue to lead and guide your hospitals through these different programs and approaches. So thank you so much for joining us.