The opioid epidemic: Mobilizing an academic health center to improve outcomes

Abstract

Since 2000, opioid use disorder (OUD) has become an epidemic in the United States with more than 600,000 total deaths and a $51 billion annual cost. Patients with OUD require services from community-based organizations, local and state health departments, and health systems, all of which necessitate communication and collaboration among these groups to develop an effective strategy for diagnosis, treatment, and coordination of care. Academic health centers (AHCs) are poised to make significant contributions to the care of patients with OUD given in-house expertise across multiple medical specialties and the mission to care for patients in need. Despite the potential for AHCs to provide necessary services and address this public health crisis, progress has been slow. Many AHCs lack a clear roadmap for moving this agenda forward in their local regions. In response to rising deaths due to OUD, the authors’ AHC undertook a significant redesign effort to facilitate the necessary processes and interdepartmental collaboration to provide patient-centered, comprehensive care for patients with OUD. In this article, using an organizational development framework (McKinsey 7S model), the authors describe their transformation process, and articulate strategies and potential barriers to implementing this framework. The goal of the article is to highlight the structural, procedural, and cultural changes that have occurred in one AHC so we can assist other AHCs in addressing the opioid epidemic.

1. Introduction

Between 1999 and 2016, overdose deaths in the U.S. totaled 630,000, surpassing deaths due to homicide, fire arms, motor vehicle crashes, and suicide (Centers for Disease Control, 2018). Cost estimates from these deaths have reached $51 billion annually (Jiang et al., 2017). In 2016 alone, more than 64,000 individuals died from a drug overdose; two-thirds of these deaths involved a prescription opioid, heroin, or fentanyl (Centers for Disease Control, 2018). Opioid overdoses spare no demographic group with all races and socioeconomic classes experiencing similar rates of death, and overdoses take place in rural, semi-urban, and urban areas (Wagner et al., 2019). The opioid epidemic began with health care professionals over-prescribing opioids for nonterminal indications, which led to misuse and overdose from prescribed and illicit opioids and the advent of powerful synthetic opioids. The number of deaths from the opioid epidemic exceeds deaths during the peak of the HIV epidemic, and is associated with a rise in communicable infectious diseases such as Hepatitis C and HIV (Case & Deaton, 2015).

Caring for patients with opioid use disorder (OUD) is complex, and requires coordination of care across community-based organizations, local and state health departments, and health systems. Academic health centers (AHCs) are able to make significant contributions to the care of patients with OUD, since most AHCs have expertise across multiple medical specialties, relationships with community-based organizations, and the mission to care for patients in need (Kohn, 2004). Patients with OUD require services from psychiatry, primary care, and social work; coordination of these services is imperative for these patients’ optimal care. Leading U.S. AHCs, such as Yale Health, Massachusetts General Hospital, Johns Hopkins, and Boston Medical Center, have initiated innovative methods to address OUD, including approaches to facilitate timely initiation of buprenorphine, comprehensive treatment plans for patients receiving methadone in opioid treatment programs, ensuring frontline staff have buprenorphine waivers, and establishing fellowships and teaching platforms for providers in the region (D’Onofrio et al., 2015; Hostetter & Klein, 2017; Stoller, 2015; Grayken Center for Addiction, 2019). Leveraging the full scope of services within AHCs remains a challenge, however. These gaps in care exist, for example because of a lack of organizational infrastructure to coordinate care and an inability to link patients in need with necessary services within communities and AHCs.

To resolve underaddressed issues regarding patient health and prepare for the demand for care in coming years, AHCs would benefit from a transparent discussion about benefits and barriers to service delivery for patients with OUD. Based on our experience creating system-wide change in one AHC, we articulate several barriers and strategies that other AHCs may consider when addressing the OUD crisis. In this article, we seek to address the cultural, structural, and procedural changes required to address the opioid epidemic within AHCs.

2. Context

OUD and associated overdose deaths have affected Pennsylvania at rates disproportionately higher than many other U.S. regions, with Pennsylvania now ranking 3rd highest for overdose deaths (Scholl et al., 2018). Penn State Health (PSH) includes the Penn State Milton S. Hershey Medical Center, community-based medical clinics, postacute care facilities, and alliances with the Pennsylvania Psychiatric Institute (PPI) and PSH Rehabilitation Center. Comprising a mixed demography of rural, semi-urban, and urban communities, PSH is located in south-central Pennsylvania and resides at the geographic nexus along a drug-trafficking corridor among several states and urban locations. By 2016, like many other AHCs, PSH’s leadership identified the need to more appropriately address the regional opioid epidemic. Providers’ concerns and struggles with addressing OUD had significantly risen amid a backdrop of an increasing number of patients diagnosed with OUD. This prompted several system-wide strategies to better align services with patient needs and to improve patient outcomes.

3. Elements for academic health centers to consider in addressing the opioid crisis

In pursuing these changes within our AHC, we used the McKinsey 7S model as a conceptual framework to organize our work, articulate the barriers that we encountered, and describe the strategies that we employed (Zincir & Tunc, 2017). A change management tool, the McKinsey 7S model allows for the analysis of an initiative within an organization, particularly when stakeholders agree on the need for change but are uncertain about the approach to take. The seven elements of the model include “hard” elements: strategy (devised plan); structure (organization structure/process); systems (daily staff activities to perform tasks); and “soft” elements: shared values (core organizational values); style (leadership approach); staff (employees and their capabilities); and skills (employees’ competencies). Table 1 shows barriers and strategies for each element that all AHCs could apply.

Table 1.

Barriers and strategies for academic health centers to consider in addressing opioid use disorder.

Categorya	Potential Barriers	Potential Strategies and Facilitators
Shared Values Core organizational values as evidenced in culture	Diverse departments/organizations may not agree on vision/values Lack of buy-in from higher levels of management Pervasive culture/stigma of OUD may prevent shared values	Explore shared values with diverse stakeholders and community organizations Build consensus amongst stakeholders with common interests “Make the case” using evidence from local region, health system, and nationally
Strategy Plan devised to build competitive advantage	Paucity of addiction expertise amongst providers and staff Apprehension for interdepartmental/community organization collaboration Limited funds available from health system, or state/federal mechanisms	Partner with a community organization (methadone clinic, FQHC) Appeal to leadership to help align interdepartmental goals Leverage state strategic imperatives and apply for external funds across departments
Structure The way the organization is structured and arranged	Lack of dedication of space and funds for creating space Disagreement on the types of services required to initiate programs	Consider how to make room in existing space Collaborate with county officials, development office, philanthropy for funding/space Develop a strategic plan and return-on-investment document for new structures/processes
Systems Activities/procedures staff engage in to do the work	Lack of delivery processes to ensure seamless transition to OTP Time consuming to provide addiction treatment in busy practice setting Lack of resources (e.g. financial, behavioral health, staff) to enact change	Develop pathways for screening/treating OUD in EDs, primary care/subspecialty clinics Apply for federal funds using cross-departmental collaboration Forge alliances with state government agencies
Style/Culture Style and approach adopted by leadership	Collaboration across groups (e.g. departments, services lines) not common Identification of providers with skills and passion to lead initiatives	Establish regular, ongoing discussions with system and departmental leadership Identify potential grants/initiatives to formalize collaborative working processes Search for champions in various departments and professions
Staff and Skills Employees and their competencies	OTP/new initiatives may not have staff with necessary skills Mixed provider engagement/enthusiasm for new learning/tasks (MOUD) Frontline staff may not be apprised of available resources for treating OUD	Recruit providers with needed skills (for OTP, research/education purposes) Develop procedures for referrals to assist frontline providers Initiate strategic educational activities across system with incentives (e.g. CME credit)

^aCategories derived from the McKinsey 7S Model for organizational change and assessment.

Abbreviations: CME=continuing medical education; ED=emergency department; FQHC=federally qualified health center; OUD=opioid use disorder; MOUD=medication for opioid use disorder

3.1. Element 1 - Shared values: Agreeing the opioid epidemic is a public health crisis that can be treated

All elements of the McKinsey 7S model originate from shared values among stakeholders. The historical context and stigma surrounding OUD has limited the actions that health systems have undertaken, including work in our local environment. For decades, medical professionals and individuals working in the drug treatment community, including those in leadership positions, viewed drug addiction as a “moral failing” of the individual (White, 2009). From a medical perspective, research has well established the benefits of medication for opioid use disorder (MOUD) (Veilleux et al., 2010). However, significant stigma around the use of MOUD remains within communities, peer-recovery groups, and health care (Olsen & Sharfstein, 2014).

Providers across all settings, from inpatient services to emergency rooms to primary care clinics, have exhibited assumptions and/or biases about services that facilitate opioid detoxification over MOUD. For our work, overcoming this stigma remained paramount to reaching mutually shared values. PSH’s academic mission includes research, education, patient care, and a commitment to improving community health. This mission coalesced into the realization of shared values among leadership, managers, and frontline providers. Alarming trends in overdose deaths, the need for a unified systems-level approach, and availability of federal and state funds coalesced shared values among PSH stakeholders.

Although we have not achieved full alignment, PSH now supports a general shared understanding of OUD as a manageable disease with evidence-based treatments. Additionally, shared values on the importance of patient-centered care and facilitation of MOUD have been enhanced because of the support from system leadership and department chairpersons. These values, starting with organizational leadership and ending with frontline providers, directly led to both the development of a comprehensive approach to OUD (described below), as well as a separate, multidisciplinary committee of inpatient and outpatient opioid administration and prescribing. Most importantly, we united to acknowledge that patients with OUD suffer from a disease that requires and deserves humane efforts to provide life-saving treatment.

3.2. Element 2 - Strategy: Breaking down silos to address a critical need and procure funding

With shared values as a guide, the next step involves the creation of a strategy to achieve objectives. As Olsen and Sharfstein have outlined, optimal strategies for addressing OUD involve a multi-pronged approach focusing on diagnosis, referral to treatment, and sustained recovery (Olsen & Sharfstein, 2014). However, the translational strategy in AHCs to employ this approach can be variable. Despite this variation, high-level leadership must endorse the developed plan, and consider financial and labor resource limitations.

In our experience, one component of the early strategy was mutual collaboration between our health system leadership and affiliated psychiatric treatment center. This collaboration allowed for clear articulation of the needs required to create the strategic plan. Stakeholders identified three main unmet needs: (1) specialty care; (2) availability of buprenorphine-waivered providers at multiple touchpoints for patients with OUD (e.g., emergency rooms, inpatient services, etc.); and` (3) follow-up care. Treatment for patients with OUD was often delayed, relegated to other facilities, and disconnected from necessary community resources and services (e.g., MOUD). These identified gaps directly informed our core strategy.

Next, we recruited a specialist and team to articulate the strategy and facilitate implementation. With a leader and team identified, we then identified three strategic areas that required a systems-level approach to address OUD (Figure 1). First, the development of a licensed opioid treatment program (OTP) by the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for the extension of a patient’s care beyond acute-care settings in a specialty addiction treatment center. Evidence has shown that availability of subspecialty care clinics improves continuity of care, referrals, and improved outcomes (Massachusetts General Hospital, 2020). Second, if we increased our buprenorphine waivered providers and facilitated their skill and comfort with buprenorphine initiation, we would be able to provide early identification of and treatment for OUD. Studies have found that patient engagement and adherence to care at 30 days are improved with early buprenorphine use (Hostetter & Klein, 2017). Third, if we implemented a formalized referral process, early and timely access for patients and easy communication between providers during transition to the OTP for follow-up care could be provided for patients. These strategies provided the basis for clearly articulated treatment pathways for OUD, thereby facilitating more seamless transitions from inpatient to outpatient/specialty care (Cook et al., 2009).

Figure 1. The Penn State Health modified hub and spoke model to address the opioid epidemic.

Figure 1 depicts the Opioid Treatment Program (OTP) – the hub of the model, and the multiple sites and programs that help facilitate treatment for opioid use disorder (OUD) – the spokes of the model. The OTP hub coordinates care with primary care clinics in addition to providing limited safety-net primary care services. A part-time psychiatrist provides ongoing psychiatric care on-site for individuals with co-occurring serious mental illnesses. We provide ongoing step-down care for inpatient drug and alcohol rehab centers that initiate medication for opioid use disorder (MOUD). We accept transfers from other local OTPs where insurance may be a barrier to ongoing treatment, or if patients lack stability at their level of care. These referrals are facilitated through our peer recovery specialist partnership. The lines connecting the spokes to the hub represent peer-recovery facilitated care transitions.

The final component of our strategy was procuring funding. We have found funding to address the opioid epidemic to be largely nonpartisan, as moral and economic imperatives drive desires to reduce overdose deaths. Local and state government officials facilitated public health alliances, goal setting, and advocacy at many levels. First, since federal funding grant opportunities (e.g., National Institute on Drug Abuse, SAMHSA) often require endorsements from state agencies, support from state leadership provided the credibility we needed. Working with PSH and departmental leadership, we secured $5.5 million in funds to set up a comprehensive treatment program. Our funding came from multiple sources, including federal and state agencies as well as a Highmark Health, a health insurance partner of PSH. We received funding from Pennsylvania’s State Targeted Response funds and the 21^st-Century CURES Act, which allowed us to enact the three strategic areas (OTP, referral process, and providers’ ability to prescribe buprenorphine). To ensure efficient clinical processes and accurate data collection, with the financial support of our insurance partner, we hired a data collection manager. The Pennsylvania state Medicaid services expanded behavioral health billing to include the use of peer recovery specialists, which the state previously did not permitted. Although these funds facilitated creation of the program, PSH committed to sustaining the program beyond initial startup. We obtained additional funds from various departments for certain aspects of the program. For example, the Department of Medicine obtained funding from SAMHSA to create Project ECHO (see below). Although funding must be considered in any AHC’s initiatives, given how dire the opioid epidemic is, funds are increasingly available from multiple sources.

3.3. Element 3 - Structure: Building the infrastructure

With values outlined and a strategy defined, we needed to develop the structure of the work, teams, departmental organization, and coordination of activities. Leveraging existing prototypes from other U.S. health systems, we developed a modified version of the “hub-and-spoke” model (Figure 1), with features from other nationally recognized and evidence-based models (Kawasaki et al., 2019). First introduced by the state of Vermont and funded by the state’s Medicaid Program, the hub-and-spoke model includes a hub opioid treatment program (OTP), staffed by addiction specialists and care managers, which is connected to several primary care spokes where outpatient addiction treatment is integrated with primary care services (Brooklyn & Sigmon, 2017). Figure 2 depicts the relationship between our implemented model, inclusive of patients’ access to care, formalized referral process, and the hub OTP. Unstable patients may be transferred to the OTP for stabilization, followed by continued treatment or referral back to the primary care site. Our patient-centered model also incorporated methods from two other existing treatment approaches: the Bridge clinic from Massachusetts General and ED provider waivers for buprenorphine initiation at Yale Health (D’Onofrio et al., 2015; Brooklyn & Sigmon, 2017; Martin, Bosse, et al., 2018; Martin, Mitchel, et al., 2018).

Figure 2. The Penn State Health model for initiating medication assisted therapy and referring patients to an opioid treatment program.

Figure 2 depicts the entry points for patients with opioid use disorder (OUD), including emergency and hospital-based acute care, outpatient primary and subspecialty care, and OUD Specialty Care (or opioid treatment program, OTP). Superscript numbers 1–3 indicate the three key components in the model, including (1) buprenorphine-waivered providers within emergency departments and inpatient OUD consult services who can treat and refer patients for intensive treatment with medication supply until OTP appointment. Often, these clinical locations are the first touchpoint for patients identified as high-risk for OUD; Outpatient primary and subspecialty care can diagnose and refer patients with substance use disorder for specialized treatment, or initiate treatment themselves if buprenorphine waivered. If patients are referred to specialty care (2, 3), they may be able to transition back to primary care for management if clinics have waiver-trained physicians. (2) formalized referral process to OUD specialty care, including 24/7 intake telephone line staffed by admissions team, which allows real-time communication for all referrals and scheduling of appointments with OTP within 24 hours; (3) OTP, which accepts timely referrals from outpatient and inpatient sources and works with peer support care managers who identify patients in the community, through probation and parole, and other non-medical spaces.

Abbreviations: MOUD=medication for opioid use disorder; OUD=opioid use disorder; OTP=opioid treatment program.

AHCs have the opportunity to create an OTP hub with specialty expertise. The OTP can be a dedicated structure, repurposed structure, or purposeful expansion within an existing structure. All structures should have dedicated staff to provide comprehensive specialty care (i.e., prior authorizations, urine drug screens, counseling, and psychiatric and medical care). Given improvements in mortality among patients with OUD, reduced imprisonment rates, and ongoing high-risk behaviors known to result in the acquisition of HIV and HCV, an OTP with methadone treatment is likely the ideal structure (Gowing et al., 2004). Unfortunately, not every AHC has the infrastructure, expertise, or administrative support necessary to create a fully operational OTP. Without full resources, the AHC should consider a stepwise approach starting with a buprenorphine hub with the potential to expand to methadone treatment.

The creation of our OTP required direct contributions from several AHC departments, centers, and community partners. A planning process that the Department of Psychiatry led sought to include several departments, including Emergency Medicine, Internal Medicine, Psychiatry, Pediatrics, Family and Community Medicine, Anesthesia/Pain Management, Obstetrics and Gynecology, Pharmacy, and medical school and health system leadership. These collaborations allowed for fine-tuning of OTP plans, and further creation of processes within each department to transfer patients more seamlessly into the OTP and engage frontline stakeholders. With time, these departments increasingly provided essential contributions. Emergency Medicine created a process to certify 30 providers to prescribe buprenorphine at the point of care. Obstetrics and Gynecology created toolkits on OUD and pregnancy. The Departments of Medicine and Family and Community Medicine advanced curricula in both the medical school and residency programs. Internal Medicine launched a video conferencing platform (Project ECHO) designed to educate physicians and improve access for patients with OUD (Arora et al., 2007). Finally, Pediatrics led the development of an addiction medicine fellowship, due to a new faculty member’s experience in adolescent addiction treatment and passion for graduate medical education.

As with any new health system change, data collection must identify treatment gaps, evaluate quality of care, and develop a repository for analysis to improve care processes; this work was no exception. We recorded all demographic and treatment outcomes in an online survey program (e.g., research electronic data capture, or REDCap) for patients seen at the hub and spokes. PSH collaborated with multiple community health centers using disparate electronic health records. We funded data collection managers through state and federal grants to keep track of all treated patients to prevent both privacy and legal hurdles. AHCs may opt to provide care for OUD entirely within their health system to avoid difficulties in data collection, but this approach may not address the needs of many patients. The tension between comprehensive data collection and providing care for those most in need influenced our decision to work with all community health centers and meet the needs of as many patients as we could.

3.4. Element 4 - Systems: Align goals across people, organizations, and system

The McKinsey 7S model describes systems in financial, human relations, and communications terms, and focuses on new structural and personnel infrastructure. The creation of a reliable transition of care for patients with OUD was essential for PSH’s inpatient and ED services, which now had a reliable OTP for patient referrals. With the establishment of our OTP, our ED medical director had the justification to require all physicians and advanced practitioners to become buprenorphine waivered. Additionally, several internal medicine hospitalists became waivered, allowing a consult service to initiate treatment for any hospitalized patient and guide the transition to outpatient services upon discharge.

Beyond collaborations within the AHC, we formed key alliances within the broader community. A key partner was the RASE project (Recovery, Advocacy, Support and Empowerment), which is a care management organization that facilitates OUD patients onto MOUD (The Rase Project, 2019). At PSH, our partnership with RASE was forged with a desire to help more patients with OUD stay in treatment. By aligning their goals with the expansion of their practice to allow for methadone treatment, we have been able to form a fruitful partnership that provides patients with much-needed services. Prior to working with our OTP, this program did not interface with methadone treatment programs, and with appropriate funding and collaborations, a new type of position within RASE guided patients with severe OUD into the OTP. These collaborations between the AHC and community organizations were critical to our success.

We connected with community providers who offer complementary services to expand the resources available for OUD patients. We established state and county contracts, and established relationships with government officials. We built coalitions and a learning collaborative for a coordinated approach to address the OUD crisis; this collaborative helped allay fears of competition from multiple providers treating OUD in the community. We collaborated with other hospital systems that lack methadone treatment services to help provide treatment for their patients. These partnerships have been mutually beneficial, as each group ultimately wanted patients to receive appropriate care.

3.5. Element 5 - Style: Finding the early adopters to initiate change

The next element of the McKinsey 7S model is leadership and the style of implementing change. With the establishment and expansion of a new OTP, ongoing system support is needed for the growth of the program and workforce. It is important to identify early adopters across inpatient, ED, and outpatient teams to foster a collaborative working environment. Early adopters led interdisciplinary and interdepartmental team meetings. Meetings aimed to provide direct, transparent answers to questions, ultimately leading to the development of new processes. The department chairs actively participated in developing the program, and most importantly, modeled and fostered a collaborative working environment. The mission and vision of the AHC facilitated a shared, collaborative working style among all stakeholders. The trust and relationships developed from these partnerships have resulted in several other collaborative ventures, including a new academic addiction medicine fellowship.

3.6. Elements 6&7 – Staff and skills: Integrating into workflow through current and new roles and competencies

The final two elements in the McKinsey 7S model address the staff and skills required to execute the plans. We identified three main categories that needed to be addressed to succeed: (1) hiring new staff with the skills necessary to lead the OTP; (2) developing new skills for existing providers who can treat and refer patients with OUD into the OTP; and (3) educating the larger community within the AHC about OUD. See Table 2 for representative competencies across various professions needed to address OUD.

Table 2.

New or enhanced competencies for healthcare roles needed to address opioid use disorder.

Categories		Representative Competencies to Address Opioid Use Disordera
Category 1	All providers (e.g. physician, nurse, nurse practitioner, physician’s assistant) and medical students	1.1 Recognize and address the stigma (including individual biases) about OUD 1.2 Recognize OUD as a chronic disease by effectively applying a chronic disease model 1.3 Understand core aspects of addiction and OUD 1.4 Assess, screen, identify OUD in patients presenting to clinical settings 1.5 Communicate with high-risk patients 1.6 Collaborate with interprofessional providers about patients with OUD 1.7 Identify system-level resources available to diagnose/treat OUD
Category 2	Frontline providers referring to OTP, including residents/fellows, APRNs, physicians Category 1 plus →	2.1 Educate patients about the benefits, risks, and appropriate use of opioids 2.2 Understand the role of and appropriately use opioids in the treatment of pain 2.3 Perform patient risk assessment related to opioids when treating pain 2.4 Appropriately initiate, monitor, discontinue opioid treatment 2.5 Recognize patients displaying signs of aberrant prescription use behaviors 2.6 Perform medication reconciliation with opioid medications 2.7 Employ motivational interviewing skills to guide patients to treatment 2.8 Evaluate patients for withdrawal signs and symptoms 2.9 Document medical care in the electronic health record regarding OUD 2.10 Refer and facilitate appointments to specialty care, including OTP, and mental health 2.11 Anticipate social needs for patients to receive OUD treatment (e.g. transportation) 2.12 Initiate buprenorphine treatment (in EDs, inpatient consult services, primary care)
Category 3	Frontline providers/staff within OTP and referral process	3.1 Identify/incorporate social determinants of health data into treatment planning 3.3 Describe OUD treatment options, including MOUD 3.4 Demonstrate evidence-based counseling and behavior change techniques 3.5 Demonstrate correct use of naloxone rescue
	Physicians and APRNs Category 1, 2, 3 plus →	Initiate buprenorphine treatment Initiate methadone maintenance, titrate according to individual patient Prepare evidence-based, patient-centered OUD treatment plans
	Nurses Category 1, 2.1–2.9, 3 plus →	Perform and interpret urine drug screens Facilitate/administer methadone maintenance Practice crisis de-escalation and trauma-informed care
	Care coordinators Category 1, 2.7, 2.10–11, 3 plus →	Facilitate access to transportation for patients to attend medical appointments Identify alternative funding opportunities for prescription access Refer/connect patients to peer recovery groups
	Social workers Category 1, 2.7, 2.10–11, 3 plus →	Facilitate gain of housing for patients without adequate housing Link patients with employment resources and opportunities Navigate insurance for patients in need (e.g. private insurance, medical assistance) Practice crisis de-escalation and trauma-informed care

^aSeveral competencies have been modified from published competencies related to opioid and substance use disorders (Antman et al., 2016; Ashburn & Levine, 2017)

Abbreviations: AHC=academic health center; APRNs = Advanced Practice Registered Nurses; EDs=emergency departments; MOUD=medication for opioid use disorder; OUD=opioid use disorder; OTP=opioid treatment program

3.6.1. New staff

The development of an OTP and related patient referral processes required the staff to accept and treat new patients every day of the work week. Our OTP employs two part-time physicians, a nurse practitioner, three nurses (who can dose methadone, room patients, etc.), and nine counselors who provide individual and group services.

3.6.2. New skills for existing providers

Providing comprehensive care for patients with OUD at multiple touchpoints within AHCs requires new skills for medical providers in multiple settings, and specifically, the availability of buprenorphine-waivered medical providers who are willing to and confident in treating patients with OUD. This resulted in reaching out to community partners and practitioners, leading buprenorphine-waiver trainings, and conducting case-based videoconferencing teaching sessions through project ECHO. A cultural change occurred in our ED, as all providers required data-waver training to prescribe buprenorphine. Understandably, they had questions about treatment effectiveness and medico-legal implications, which we addressed through education programs. EDs that providers with buprenorphine waivers staff help to ensure continuous patient care until they can schedule an urgent OTP appointment. For hospitalized patients with OUD, inpatient physicians had to learn to screen, diagnose, and initiate treatment to facilitate a patient’s access to the OTP, which research has shown to improve patients’ engagement in treatment (D’Onofrio et al., 2015). At PSH, we started strategically with educating early adopters on the inpatient consult service who could begin the process of early treatment. Although more work needs to be done, we found that identifying a small subset of providers, care managers, and social workers is a good place to start, with the ultimate goal of impacting other providers, including residents and fellows.

In addition to creating the new staff, the program would not succeed without a seamless referral process and staff to receive referrals. Our OTP is fortunate to be located within a psychiatric hospital with a 24-hour admissions phone line to schedule appointments, so that staff can communicate easily for an appointment. The RASE project guides patients to appointments and other community services for ongoing recovery. This staffing provides the comprehensive scaffolding needed to address patient care across the continuum.

3.6.3. Educating the AHC community

Implementation of the OTP and referral process required us to provide education and communication system wide. Patients with substance use disorders may be some of the most challenging patients as far as treatment adherence, attending appointments, and prolonged hospitalizations for a variety of medical conditions that could otherwise be controlled in the primary care setting (Hser et al, 2013; Lee et al., 2018; Leung et al., 2015). At PSH, the OTP medical director helped departments and divisions through the inevitable inefficiencies that arose with new processes and workflows. The OTP leadership team sought every opportunity to provide system-wide education through lectures at departmental grand rounds/division meetings and workshops. We set up weekly meetings with relevant faculty and support staff when we added new services, such as inpatient addiction consults or buprenorphine prescribing in the ED.

We forged strategic alliances with medical school and residency leadership to enhance the OUD education agenda, all with the goal of educating students, trainees, and fellows on the diagnosis and treatment of substance use disorders (Antman et al., 2016; Ashburn & Levine, 2017). We anticipate additional training for residents and fellows in specific programs will be needed as they are contributing significantly to treatment and care coordination for these patients. The learning occurring now for our trainees will carry over to their subsequent practice, and positively influence patient care in those settings as well. In sum, we believe the presence of system-wide education programs helps to facilitate the shift in culture regarding OUD.

4. Preliminary evaluation and next steps

Since the beginning of our initiatives in November 2017, we have worked with fifteen sites across seven counties, including EDs, drug courts, and probation and parole. We have treated 1,000+ individuals at the OTP (hub) and evaluated 900+ patients at our collaborative sites (spokes). Our model has facilitated more than 100 “hub-to-spoke” transitional visits, leading to the accelerated initiation of treatment. In the ED, in a one-year period, 112 patients have worked with the social work team to facilitate connection with community resources, and providers initiated 43 patients on buprenorphine prior to ongoing treatment at our hub. Within the first year of its launch, the tele-education platform (project ECHO) has resulted in the education of 40 providers in our region using a case-based approach that has led to improved confidence and competence (Komaromy, Bartlett, et al., 2017; Komaromy, Duhigg, et al., 2016). Our future work will examine additional process and outcomes measures. Although not significant, these data are a reflection of a new process, and we anticipate that over time the process will be used more by frontline physicians.

The feedback from the community, government, and board of trustees has been overwhelmingly positive. We have been able to meet the needs of individuals with OUD in a patient-centered way, and we have provided other specialists with the expertise necessary to address complex cases. We still experience stigma with the use of medication for OUD, specifically opioid agonist therapy, from several for-profit opioid detoxification inpatient programs and legislators who represent them. However, our proximity to the state capital allows for frequent lobbying and advocacy to ensure that evidence-based OUD treatment remains accessible.

Our work to date has allowed us to identify potential next steps to improve patient outcomes. We have started to shift the work within our AHC from silos to more collaborative processes that span departments and divisions. We believe a potential next step is the enrichment of an existing multi-disciplinary center that better aligns the structures, processes, and collaborations necessary to address the opioid epidemic. This center is situated at the nexus of clinical operations, education, and research, thereby allowing for the necessary collaboration to improve outcomes. This model is similar to other AHC Centers of Excellence models that exist for many diseases, and we believe OUD should be no different (D’Onofrio et al., 2015; Brooklyn & Sigmon, 2017).

5. Conclusion

The opioid epidemic is a complex public health crisis that requires collaboration and strategy, especially in academic health centers that are able to provide the services necessary for patients with OUD. Using the McKinsey 7S organizational development framework as a guide, we described an approach and strategies for other academic health centers to use in their work. The systems and processes that need to be implemented require broad-scale collaborations with clinical departments, community-based organizations, funding mechanisms, and patients. Institutional changes and collaborations are required to help care for patients with OUD and change the culture to appropriately address this public health crisis.

Highlights.

1. Academic health centers need guidance to improve outcomes in opioid use disorder.

2. The McKinsey 7S organizational framework provides a roadmap for change.

3. Redesign efforts are influenced by cultural, structural and process factors.

4. The transformation process must address strategies and barriers for other health systems to use in their efforts.