Relationship-Centered Addiction CareExperiences of the Inner City Health and Wellness Program

G I N E T T A S A L V A L A G G I O , M D , M S C , C C F PA S S O C I A T E P R O F E S S O R , U N I V E R S I T Y O F A L B E R T A D E P A R T M E N T O F F A M I L Y M E D I C I N E

A S S O C I A T E S C I E N T I F I C D I R E C T O R , I N N E R C I T Y H E A L T H A N D W E L L N E S S P R O G R A M

K A T H R Y N D O N G , M D , M S C , F R C P ( C )A S S O C I A T E C L I N I C A L P R O F E S S O R , U N I V E R S I T Y O F A L B E R T A D E P A R T M E N T O F E M E R G E N C Y M E D I C I N E

D I R E C T O R , I N N E R C I T Y H E A L T H A N D W E L L N E S S P R O G R A M

L E S U M P H E R V I L L EP A T I E N T A D V O C A T E , A A W E A R

F E B R U A R Y 1 2 , 2 0 1 8C O V E N A N T H E A LT H R E S E A R C H D AY

Faculty/Presenter DisclosureFaculty: Ginetta Salvalaggio

Relationships with commercial interests: Not Applicable

Faculty: Kathryn Dong

Relationships with commercial interests: Not Applicable

Faculty: Les Umpherville

Relationships with commercial interests: Not Applicable

Team MembersClinical Team

◦ Physicians (Kathryn Dong, Karine Meador, Devin Tucker, Tally Mogus, May Mrochuk, Patty Belda, Lovneet Hayer, Greg Gilmour, Arianna Watts, Valerie Giang)

◦ Janice Pyne (NP)

◦ Sasirekha Raja Rageswari (SW)

◦ Corinne Sawarin (Addiction Counselor)

◦ Robert Gurney (Peer Support Worker)

Education Team◦ VACANT (Clinical Nurse Specialist)

Administrative Team◦ Kathryn Dong (Director)

◦ Karine Meador (Asst. Director)

◦ Jennifer Brouwer (Unit Manager)

◦ Lois Miller (Admin Asst.)

◦ Terina Milavsky (Admin Asst.)

Key Liaisons◦ Shanell Twan, Chelsea Burnham (Community)

◦ Wayne Burnstick (Indigenous Cultural Helper Program)

◦ Community Advisory Group

Research Team◦ Elaine Hyshka (Scientific Director)

◦ Ginetta Salvalaggio (Associate Scientific Director)

◦ Klaudia Dmitrienko (Consultant)

◦ Arlanna Pugh (Research Coordinator)

◦ Kelsey Speed (Research Coordinator)

◦ Melanie Garrison (RA)

◦ Stacy Lockerbie (Site Coordinator, Calgary)

◦ Current research trainees: Hannah Brooks, Heather Morris, Daniel Dabbs, Daniel O’Brien

PRIHS Investigative Team◦ Cam Wild

◦ Chris McCabe

◦ Rhonda Rosychuk

◦ Lara Nixon

◦ Kelly Mrklas

◦ Shireen Surood

◦ Judith Krajnak

◦ Jen Nichol

◦ Meira Louis

ObjectivesDescribe the characteristics and needs of urban underserved patients accessing hospital care

Share key process learnings from the implementation of a hospital-based program for people who use alcohol and drugs

Provide a framework for involving people with lived experience in service co-design and evaluation

Explore relationship as an essential component of harm reduction and recovery

What is it like to go to the hospital?

Hospitals as Risk Environments

McNeil R et al. “Hospitals as a ‘risk environment’: An ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs” Social Science & Medicine 105: 59-66.

Abstinence only policies, inadequate pain & withdrawal management, negative stereotypes, limited access to evidence-based treatment for substance use disorders

Inability to practice harm reduction, involuntary discharge

Increased morbidity and mortality

Addiction Treatment in Hospital

• 24% had an addiction consultation

• 7.8% had a plan for opioid agonist treatment (one patient started on methadone, one given a phone number for a burprenorphine clinic, the rest were already on treatment)

• Naloxone was never prescribed

• 26% are deceased; median age of death 41 years

What if we designed hospital care differently?

Inner City Health and Wellness Program

MISSION:To provide patient centered, evidence based and holistic care for our patients with an active substance use disorder and/or those dealing with social inequity.

CLINICAL CARE RESEARCH EDUCATION

Addiction Recovery and Community

Health (ARCH) Team

Urban Health ServicesContinuity of Care

Harm Reduction in HospitalQI/Evaluation Support

Etc.

Front Line EducationGrand Rounds

SymposiaElectives

Community of Practice

Inner City Health and Wellness Program

How are Patients Involved?Community Liaisons◦ Information sharing◦ Coordination of CAG◦ Recruitment and retention◦ Data collection

Community Advisory Group◦ Staff hiring and training◦ Program design and

troubleshooting◦ Research methods◦ Research interpretation◦ Knowledge translation

Guiding Principles1. The team will take its direction from the

needs of the community that it serves.

2. All activities will be driven by the philosophies of reducing harm, respect and empowering people to make healthy choices.

3. The team and its activities will be culturally competent and will focus on relationship building and trust.

4. A broad definition of health (including physical, mental, emotional and spiritual) will be used to define outcomes.

5. Research and educational initiatives will be action-oriented and widely accessible.

Addiction Recovery and Community Health (ARCH) Team

Development of a standardized intake and assessment procedure

Comprehensive, evidence-based addiction management for all substances of use

Interventions to Maximize Social Determinants of Health◦ Housing, income support, ID

Health Promotion activities◦ STBBI screening, PAP smears, immunizations

Linkage to community and primary care

Addiction Recovery and Community Health (ARCH) Team

Comprehensive, evidence-based addiction management◦ Treatment of complicated intoxication and/or withdrawal◦ Initiation or maintenance of opioid agonist treatment◦ Harm reduction supplies and overdose prevention including

the distribution of naloxone kits◦ Managed alcohol program◦ Counseling, motivational interviewing, relapse prevention,

treatment referrals◦ Identification and referral for co-morbid mental health

conditions◦ Supervised consumption service (opening Spring 2018)

Transitional Clinic◦ Follow up of active addiction-related issues ◦ Ongoing withdrawal management◦ Bridging to opioid agonist treatment program◦ Follow up of tests performed in the hospital◦ Addiction counseling◦ Stabilization of social determinants of health

Urgent appointments are available for patients discharged from the emergency department

Addiction Recovery and Community Health (ARCH) Team

Presenter

Presentation Notes

Kathryn

Learning from our ExperiencePatient Outcomes Evaluation

Economic Evaluation

Process Evaluation

Principles, RevisitedAction orientation is critical◦ Patient-oriented outcomes!

Top down implementation of new services is unethical

Administrative data, without context, give a partial picture at best (and an inaccurate picture at worst)◦ Direct patient data necessary in order to correctly interpret administrative

data◦ Administrative data necessary to confirm patient responses and offset

attrition

Survey 1

BaselinePre-baseline(6 months)

Block 1 Block 2 Block 3

Survey 2

Survey 3

AdminData

Post-baseline(6 months)

Post-baseline(12 months)

Patient Outcomes Evaluation: Study Design

Data Sources

Patient

AHS Analytics

AHS AMH

Homeward Trust

Calgary Homeless

Foundation

Human Services –

Income Support

Police

Who are we seeing?

DemographicsEdmonton n=303 Calgary n=270

Age YearsRange

M = 44.48, SD = 13.32(18 to 82)

M= 44.01, SD= 12.92 (19 to 77)

Gender MaleFemale

Transgendered

186 (61.6%)116 (38.4)0 (0.0%)

185 (68.5%)83 (30.7%)

2 (0.7%) Ethnicity Indigenous

WhiteOther

126 (41.6%)154 (50.8%)

23 (7.6%)

65 (24.1%)177 (65.6%)28 (10.4%)

Education No High SchoolHigh school

Post-secondary

117 (38.6%)75 (24.8%)

111 (36.6%)

110 (40.7%)56 (20.7%)

104 (38.5%)Length of Residence

0-5 yr6+ yr

Entire lifeNot resident

50 (16.5%)169 (55.8%)57 (18.2%)27 (8.9%)

66 (24.5%)148 (55.0%)47 (17.5%)

8 (3.0%)

HousingEdmonton n=303 Calgary n=270

Had a home? YesNo

156 (61.9%)96 (38.1%)

113 (42.0%)156 (58.0%)

Transitory sleeping (having slept in >5 types of places in the past 6 months)

YesNo

88 (29.0%)215 (71.0%)

95 (35.2%)175 (64.8%)

Perceived housing stability

UnstableNeitherStable

152 (51.0 %)35 (6.2%)

130 (43.6%)

166 (61.7%)19 (7.1%)

84 (31.2%)

Housing satisfaction DissatisfiedNeitherSatisfied

154 (52.4%)20 (6.8%)

120 (40.8%)

153 (56.9%)21 (7.8%)

95 (35.3%)

Income, Employment & IDEdmonton n=303 Calgary n=270

Poverty (≤ $2000/month)

YesNo

218 (71.9%)85 (28.1%)

217 (80.4%)53 (19.6%)

Legal employment (past 30 days)

YesNo

54 (17.9%)247 (82.1%)

63 (23.5%)205 (76.5%)

Income assistance (past 30 days)

YesNo

181 (60.3%)119 (39.7%)

113 (42.2%)155 (57.8%)

Government-Issued ID YesNo

193 (66.1%)99 (33.9%)

177 (63.3%)90 (33.7%)

Substance UseEdmonton n=303 Calgary n=270

Tobacco use YesNo

231 (76.2%)72 (23.8%)

199 (74.8%)67 (25.2%)

Risky drinking behavioura No consumptionLow riskHigh risk

76 (26.6%)39 (13.6%)

171 (59.8%)

52 (19.9%)43 (16.5%)

166 (63.6%)

Non-IV drug use YesNo

166 (89.7%)19 (10.3%)

148 (99.3%)1 (0.7%)

IV drug use YesNo

82 (44.8%)101 (55.2%)

39 (26.2%)110 (73.8%)

Stimulant use (any) YesNo

136 (73.5%)49 (26.5%)

97 (65.1%)52 (34.9%)

Opioid use (any) YesNo

110 (59.5%)75 (40.5%)

66 (44.3%)83 (55.7%)

Health & HealthcareEdmonton n=303 Calgary n=270

HIV PositiveNegativeUnknown

28 (9.2%)193 (63.7%)82 (27.1%)

4 (1.5%)183 (67.8%)83 (30.7%)

Hepatitis C Virus PositiveNegativeUnknown

103 (34.0%)122 (40.3%)78 (25.7%)

40 (14.8%)126 (46.7%)104 (38.5%)

Depression symptoms YesNo

155 (52.7%)139 (47.3%)

163 (62.9%)96 (37.1%)

Primary care provider YesNo

194 (64.9%)105 (35.1%)

164 (61.4%)103 (38.6%)

Prescription Drug Coverage

YesNo

233 (78.7%)63 (21.3%)

175 (65.8%)91 (34.2%)

High ED or UC use (>2 visits)

YesNo

148 (50.2%)147 (49.8%)

146 (58.4%)104 (41.6%)

EMS activations (>1) YesNo

227 (76.9%)68 (23.1%)

148 (59.2%)102 (40.8%)

Hospital admissions (>1) YesNo

227 (76.9%)68 (23.1%)

148 (59.2%)102 (40.8%)

Perceived Need For Care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Edmonton (n=303)

Calgary (n=270)

Case #1•67 y.o. man, admitted from community inner city senior’s housing with hypoglycemia and malnutrition secondary to chronic alcohol use

•Long history of severe alcohol use disorder with minimal periods of abstinence, multiple hospital admissions and ED presentations for alcohol related issues

•Consequences of drinking included past homelessness, assaults, public intoxication, recurrent acute medical care needs, poor self care –evicted from housing on admission to hospital

•PMHx: L nephrectomy, BPH with urinary obstruction and chronic indwelling catheter, HTN, DMII, smoker, MoCA 28/30

Case #1•Prior to hospitalization patient reported drinking 8-10 beers/day + 13oz vodka/day, on admission he expressed a desire to keep drinking

•Sometime after admission, unit became concerned about ongoing drinking in hospital

•ARCH consulted• Patient adamantly declined any abstinence based approaches,

pharmacotherapy, withdrawal management, counseling• MAP initiated

•Discharged to community MAP/assisted living residence 5 months later

Case #245 M admitted with a septic left knee joint. Multiple previous infections in his left knee due to longstanding (>17 years) of IV heroin and prescription opioid use. Very high opioid tolerance (using >1000 MEQ / day).

Told by orthopedic surgeon that he needed a left above knee amputation. Overdosed on fentanyl that night in his hospital bed. Transferred to ICU for intubation and ventilation.

Eventually had surgery and then required rehabilitation.

Case #2PATIENT MANAGEMENT

Started on methadone

Harm reduction supplies provided until stabilized on methadone

CONSISTENT WITH CRISM OPIOID GUIDELINE

Buprenorphine/naloxone not the preferred option so methadone initiated

Harm reduction services provided as pare of routine care

Case #2PATIENT MANAGEMENT

Received counselling throughout hospitalizationIncome support, photo ID, Alberta Health Care Card and housing secured while patient was admitted

Naloxone kit and training provided

Received immunizations for Hepatitis B and PneumovaxCare transferred to addiction medicine specialist in the community

CONSISTENT WITH CRISM OPIOID GUIDELINE

Psychosocial supports routinely offered

Take home naloxone and other general healthcare services are integrated into treatment

What is the patient experience?

What is the patient experience?Improved emotional / social health

Substance use stabilization

Humanistic care

Autonomy support

“I was very impressed with the approach. I was very impressed how they listened to me. How they did things the way I wanted to do them in a certain way. But when they didn’t want to do it, they gave me options. It wasn’t like you’re wrong; you know what you could do instead? They let you decide for yourself. And that’s what I need.”

“I used to think of myself as a Bic lighter. When people are done with me, toss me away. You’re only useful a certain period of time. I don’t feel that way anymore. I feel like I have worth.”

What is the stakeholder experience?Coordination / communication / continuity

Longer admissions, but fewer readmissions / premature discharges

Improved social stability

Knowledge transfer and resources

Shift in awareness

“I’ve also found that, because initially I was worried it would be a burden, but not at all. If anything, when I have somebody with addictions come in we do ARCH referral, they come in, that patient hardly ever discusses addictions with me anymore. They know they have somebody they can talk to that’s knowledgeable, that can help them find the resources… and I did not expect that.”

“Our current inpatient services are not structured or designed to develop therapeutic relationships with patients. They’re very short-lived interactions, we have frequent handovers of care… So I think having a team that sort of provides some level of continuity… that kind of conversation can happen and actually provide some real therapeutic relationship And deal with those longer-term problems rather than just the acute problems at the same time.”

“H” is for…

Haggling?

Dixon-Woods M et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Medical Research Methodology 2006;6:35.

Hurting?

Dezelic M, Ghanoum G. The Trauma-Addiction Cycle: How life behaviors are used to avoid/receive physiological and psychology responses. 2015.Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study. Pediatrics 2003;111(3).

Helping?

Deci EL, Ryan RM. Self-Determination Theory: A Macrotheory of Human Motivation, Development, and Health. Canadian Psychology 2008;49(3):182-5.

Hope?“Don’t!” he says. “I’m not worth it.”

I look him in the eye. “Yes, you are.”

He glares at me, and holds out his arm. I tie the tourniquet wordlessly, and help him find a much safer vein. He injects himself, and then gruffly thanks me, tears welling up in eyes that refuse to meet mine.

This is grace, manifest in care of desperate persons, flesh and spirit. This is harm reduction.

Bai, M. Why I Help Addicts Shoot Up: A Christian Defense of Harm Reduction. Christian Week 2010 (October).

Relationship Reduces Harm

Pearls for PracticeUse person-centred language

Hospitalization is a period of opportunity

Meet patients where they are at

Naloxone = Epipen

Self-care

Thank you!ginetta@ualberta.ca

@ginettafammed

kathryni@ualberta.ca

@kathryndong

@TeamARCH

@AAWEARAlberta