Overview

• This project aimed to demonstrate the value of adding recovery coaches to the multidisciplinary team at Arms Acres in order to improve transitions of care between inpatient and outpatient substance use treatment.

Organization Name

Arms Acres

National/Policy Context

• Substance use disorder (SUD) has become an important national focal point in the face of the opioid crisis. Deaths related to opioid overdoses have continued to rise in the United States, with over 700,000 who have died due to opioid overdose since 1997.
• While opioids in particular have become a recent focus, substance use disorder is a wide umbrella which also encompasses alcohol and other drug use.
• One of the most important concepts in substance use disorder is care transitions. Being able to successfully transition patients from inpatient to outpatient care and continued outpatient follow up decreases the risk for relapse and re-hospitalization.
  • Two systematic reviews of the literature conducted in 2014 and 2016 found that the use of peers in recovery services had a positive impact on patients with results such as improved access to social supports, decreased emergency department utilization, decreased substance use and relapse rates, and increased treatment retention.
  • A study conducted in 2011 showed an approximately 33% increase in outpatient adherence to treatment when using peer services in addition to usual treatment.

Local/Organizational Context

• At Arms Acres, a New York State licensed provider of inpatient and outpatient substance use treatment services, internal data demonstrated that only 47% of patients discharged from inpatient substance use treatment attended their first follow up outpatient treatment visit.
• Given this data, staff at Arms Acres sought to improve transitions of care between inpatient and outpatient treatment, increase the adherence to both the first outpatient follow up appointment and to long term outpatient care, and decrease ED visits and readmission rates.

Patient Population Served and Payor Information

• The population served includes patients who have been hospitalized at the Arms Acres inpatient substance use disorder facility.
• Patients had to be insured by Medicaid to participate in this project and reside within the following seven counties in New York: Westchester, Rockland, Orange, Sullivan, Dutchess, Ulster and Putnam

Leadership

• Eric D’Entrone: a Regional Director and leader at Arms Acres, Eric helped conceptualize and put together an application for the funding of this project.
• Tammy Bender: the Alumni Association Coordinator at Arms Acres, Tammy supervises and provides mentorship and guidance to the Recovery Coaches.
• Montefiore Hudson Valley Collaborative (Tamar Wolinsky, Damara Gutnick) and Woodlock and Associates (Eric Altman, Kristin Woodlock) provided project support and data analysis.

Funding

• With a goal of improving transitions of care between inpatient and outpatient treatment, the Montefiore Hudson Valley Collaborative, one of 25 Performing Provider Systems (PPS) participating in the New York State Delivery System Redesign Incentive Payment (DSRIP) program, provided innovation funding for a novel pilot project that integrated Recovery Coaches into the care team at Arms Acres.
• As of January 2019, states with DSRIP programs include: Alabama, Arizona, California, Kansas, Massachusetts, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Texas, and Washington. Although the program is in different stages of development in all of these states, organizations with ideas to improve population health can find their local Performing Provider Systems and get in touch regarding funding for innovative ideas.

Research + Planning

• The Recovery Coaches needed to be integrated into the team both within the facility as well as on a regional level.
• Inpatient staff were familiarized with this new initiative: overall goals, eligibility criteria, time frame for contacting Recovery Coaches when an eligible patient is identified.
• Since this program would be working with patients who live throughout seven counties in New York, introductions and connections needed to be made with outpatient clinics and services throughout the various counties. The Recovery Coaches met with various regional directors of Arms Acres who helped them make connections to various local outpatient treatment clinics and services that they would be helping to link patients to.

Tools or Products Developed

• Intake form: if identified patients were willing to participate in the program, they were given this form to fill out while still in the inpatient setting. The form included general information regarding needs of the patient (i.e. social services) and goal-setting in areas from recovery to physical and emotional health.
• Excel spreadsheet tracker: An excel tracker was developed in collaboration with the Information Technology department at Arms Acres in order to track patients enrolled in this program. The metrics being followed including time to first follow up appointment, engagement after 30, 60, and 90 days, ED visit rates, and readmission rates of patients in the program.

Training

• The two recovery coaches hired for this project had lived experience and had undergone formal training through the Connecticut Community for Addiction Recovery Center as well as the Office of Alcoholism and Substance Abuse Services of New York State.
• Staff at Arms Acres (physicians, social workers, leadership) had to be alerted to the role of the Recovery Coaches and trained on how to involve them in the care of patients.

Tech Involved

• Excel database

Team Members Involved

• Physicians
• RNs
• Social Worker

Workflow Steps

• In an effort to improve care transitions between inpatient and outpatient substance use disorder treatment providers, Recovery Coaches (peers) were offered to patients who clinicians identified as having a high risk of recidivism. There was no specific formula to this determination, but these patients often included people who had previously been in rehabilitation programs, who generally did not have a strong support network, or who were facing jail or homelessness.
• The Recovery Coaches met with patients prior to discharge to help them develop recovery goals and assist with linkages to outpatient care, harm reduction services, local or online support groups, and/or social services. Recovery Coaches aimed to meet with patients 3-4 times before they transitioned from inpatient to outpatient care in order to build trust and rapport with patients.
• Recovery Coaches had a wide variety of roles they filled for patients. Whether it was accompanying patients to their first outpatient appointment, speaking with patients on the phone during a “crisis”, meeting for a cup of coffee, attending alcoholics anonymous or narcotics anonymous meetings with patients, going to court with them, or helping patients obtain social services (i.e. foodstamps, housing).
• The aim was to eventually connect a patient to a similar peer program in the patient’s county after between 30 days to 3 months after discharge from the inpatient setting via a “warm handoff” (flexible if the patient had, for example, ongoing court proceedings). Keeping the patients connected to a peer program was an important end goal.

Budget

• $100K to $500K

Budget Details

• $100,304. This included cost of personnel (2 certified Recovery Coaches’ salaries and benefits), equipment, mileage reimbursement for travel, and other overhead costs.

Where We Are

• Completed- 9 months of data currently analyzed

Outcomes

• Over the first 9 months of this ongoing innovation pilot project, two Recovery Coaches worked with 106 recoverees.
• Adherence to outpatient treatment: There was high visit adherence at 7 days and 30 days throughout the first 9 months of project implementation.

• Long-term patient engagement in care: engagement was defined as attending group and individual SUD treatment at an NYS Oasis licensed outpatient provider post-discharge. Patient engagement after 30 days was over 75%. Pre-intervention, patients only had a 47% adherence rate to 1^st outpatient appointments (included all aftercare appointments: behavioral, medical, substance use).
• Routine discharge and readmission rates: the intervention improved transition to outpatient care (1^st outpatient appointment adherence) by 89.4%, increased routine discharge from inpatient care by 17.3%, and reduced readmission within 90 days by 63.8%.
  • Note: Intervention Groups only looked at substance use follow up appointments while non-Recovery Coach group looked all aftercare appointments (behavioral, medical, substance use).

• Cost effectiveness: downstream data analysis showed that the utilization of Recovery Coaches prevented an estimated 63 ED visits and 315 inpatient days in the first year, with a return on investment of over $225,000.

Benefits

• The intervention improved adherence to 1^st outpatient visit within 7 days from 47% to 80.18% in patients with Recovery Coaches.
• The Recovery Coach intervention improved transition to outpatient care by 89.4%, increased routine discharge by 17.3%, and reduced readmission by 63.8% in the first nine months of implementation.
• The intervention also proved to be cost-effective, as it was thought to have prevented an estimated 63 ED visits and 315 inpatient days in the first year, with a return on investment of over $225,000.

Unique Challenges

• Because this program was very successful quite quickly, the workload for each of the Recovery Coaches became overwhelming. Without funding to hire more coaches, they had to decrease the number of patients they could take on and begin to try transitioning patients to local peer programs more quickly.
• Recovery Coaches found it difficult to transition patients to local peer programs once they had created a relationship with patients and built trust and rapport. There was also resistance from patients to be transitioned.
• The challenges in moving forward and replicating this project is that much of the success of this pilot was due to the people who were hired into the Recovery Coach positions. They are extraordinarily dedicated to the position, generous with their time, and passionate about what they do.

Glossary

• Opioid Overdose: Understanding the Epidemic, <https://www.cdc.gov/drugoverdose/epidemic/index.html> (2018).
• Peer Supporting Recovery from Substance Use Disorders, <https://www.samhsa.gov/> (2017).
• Reif, S. et al. Peer recovery support for individuals with substance use disorders: assessing the evidence. Psychiatr Serv 65, 853-861, doi:10.1176/appi.ps.201400047 (2014).
• Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M. & Laudet, A. Peer-Delivered Recovery Support Services for Addictions in the United States: A Systematic Review. J Subst Abuse Treat 63, 1-9, doi:10.1016/j.jsat.2016.01.003 (2016).
• Tracy, K., Burton, M., Nich, C. & Rounsaville, B. Utilizing peer mentorship to engage high recidivism substance-abusing patients in treatment. Am J Drug Alcohol Abuse 37, 525-531, doi:10.3109/00952990.2011.600385 (2011).