The way emergency medicine physician Andrew Herring sees it, traditional addiction treatment programs too often are organized around the provider’s priorities and expectations—not the patient’s.
“The conventional idea is that you, the patient, need to be ‘ready;’ that you need to express a commitment to abstinence and be held accountable, that you need to present for an appointment at a specific time; in essence, that you need to be disciplined by the provider,’’ he said.
That kind of approach may work for provider organizations. But for someone battling addiction who’s also struggling on the streets to survive, meeting those kinds of expectations can be wildly unrealistic. Even patients with relatively stable life circumstances can have difficulty accommodating traditional programs. Herring points out that one of the most common reasons people quit addiction treatment is that they become employed.
“Isn’t that crazy?,” he said. “It’s like the medical care system says, `No, we don’t care if you have a job. You must show up for your appointment at 11 a.m. Tuesday.’”
A Seamless Transition
Herring’s long-held conviction that there had to be a better way to treat opioid use disorder led him in 2017 to pioneer medication addiction treatment (MAT) with buprenorphine in the emergency department (ED) at Highland Hospital, a public safety net facility in Oakland, CA. Now Herring has taken the next step in expanding Highland’s rapid, low-barrier model of care with an onsite ambulatory addiction clinic that is vertically integrated with the ED. Known as the Bridge Clinic, the facility provides patients with substance use and mental health needs with an opportunity to seamlessly begin receiving follow-up care at the hospital.
The model eliminates the often cumbersome and time-consuming referral, handoff and intake processes that patients traditionally must navigate to receive follow-up care for substance use treatment. Removing these barriers not only makes patients’ lives easier, it also improves the likelihood of treatment success. Studies show that after a patient starts on buprenorphine, the shorter the window before follow-up begins, the better the odds they won’t return to substance use.
“Typically, emergency physicians don’t quite understand what happens in a clinic, and clinic physicians don’t understand what happens in the ER, so with the traditional handoff, you get a lot of confusion, misunderstood treatments, and missed appointments,” said Herring, who’s board-certified in emergency medicine, addiction medicine and pain medicine. “And the patient gets stuck in the middle.”
Born of Necessity
That disconnect—coupled with less-than-optimal referral options for patients he’d started on buprenorphine or needed mental health follow up—led Herring to develop the Bridge clinic.
When Highland began treating emergency room patients with buprenorphine in 2017, Herring initially referred them to a variety of facilities for follow-up care, including methadone, or substance use disorder (SUD), clinics. But the SUD clinics often had long waiting lists, and their highly regimented treatment approach was antithetical to the low-barrier model Herring was attempting to build.
After trying without success to recruit primary care practices as buprenorphine referral sites, Herring instead hit on the idea of repurposing an underused SUD program at Highland. Historically, the facility had received funding from the county’s Drug Medi-Cal program to provide SUD counseling. But it did not offer MAT.
By combining the traditional psychosocial services offered by the Drug Medi-Cal clinic with new hospital outpatient services designed to support patients’ medical treatment for addiction, the Bridge Clinic was born. The hybrid facility was relocated to a vacant area near the ED to provide a seamless, one-stop-shop where patients could access both low-barrier MAT and counseling services as needed.
A Growing Practice
There are approximately a dozen Bridge Clinics in California that provide a seamless transition from the ED to outpatient SUD treatment. These clinics include hospital outpatient clinics, urgent cares, and co-located federally qualified health centers.
Continuity of Care
Today, the Highland Bridge Clinic effectively functions an extension of the emergency department. The clinic shares an electronic health record with the hospital, making patient charts immediately accessible. Equally important is staff continuity: substance use navigators provide the initial point of contact for patients in the ED and stay with them through their transition to the Bridge Clinic.
The navigators, in fact, are the key to successful integration of the ED and Bridge Clinic. Although clinic staff includes a primary care physician, emergency medicine physician, hospitalist, and addiction psychologist, it is the navigator that develops the care coordination plan and links patients with other resources such as mental health services, based on the needs and desires of the patient. They also help patients referred from a variety of other facilities, including jails and shelters.
Many patients view the navigators as more accessible than clinicians, a fact which increases the likelihood the navigator can become an effective and trusted partner over the long-term.
“Many of our patients are struggling with intersecting realities of homelessness, addiction, psychiatric disease, trauma, cultural difference, stigma, racism, all of that,” Herring said. “So having someone they can trust that is available to help manage the unpredictability and the crises they face is essential.”
The Things That Don’t Happen
Four years after its launch, the Bridge clinic is a very busy place. Utilization has increased from just a few people a day in the beginning to 450 patients a month, most of whom make an average of two visits each month. At three-to-six months, 30-40% are still receiving care, an impressive retention rate for a program serving a high-risk population.
Not surprisingly, the clinic’s success has attracted enthusiastic support from the county Medi-Cal health plan, the Alameda Alliance. Plan leaders understand that effective treatment programs meet a pressing need for their members and reduce the total cost of care.
Herring says the clinic’s continued growth is a testament to pent-up demand for opioid treatment programs. When you emphasize immediate access by removing the friction points long associated with SUD care, he said, more people can and will seek treatment. There is also a valuable secondary benefit.
“If you structure it right and you build a clinic that truly fits people’s needs, they’re really happy and grateful,” he said. “And that, in turn, makes this a rewarding experience for staff. So it can actually also be a good tool for attracting and retaining clinicians.”
As important as boosting staff morale and improving the patient experience are, Herring says the clinic’s most vital achievements are marked by what does not occur.
“The way we view success is that individuals facing a really high, short-term risk of death are able to walk in the door and immediately access care,” he said. “And their deaths don’t happen. That’s what counts.”
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