Gene Gofman, MBA
Angela Burdick-Mcphee, LPC, CAADC
Rayek Nafiz, MD
Julie Dees, MA, LPC
Jeanmarie Perrone, MD, FACMT
Nicole O'Donnell, CRS
Bryant Rivera, CRS
Kelli Murray-Garant, CRS
Devin Yastro, MA, CAADC
Lauren Carbone, MA
Margaret Lowenstein, MD, MPhil, MSHP
Safety Award Winner, Health Care Improvement Foundation, 2019
UPHS Quality and Patient Safety Award, 2019
Innovation Accelerator Program
William Penn Foundation Special Gifts Program
Thousands of patients with opioid use disorder (OUD) visit Penn Medicine’s downtown emergency departments (EDs) each year. In 2018, more than 1,100 people died of accidental overdoses in Philadelphia, and the city's drug overdose death rate was among the highest in the nation - more than triple that of its homicide rate.
Treating OUD is not easy. Historically, rehab and detox were the standard treatment, but the success rate for these modalities alone is only 5 to 10 percent. ED visits for OUD present a critical opportunity to link patients to evidence-based interventions, such as medication-assisted treatment (MAT) and peer support from certified recovery specialists (CRSs).
When we started this work, MAT and CRS services were significantly underutilized. On average, 175 patients with OUD visited the ED at Penn Presbyterian Medical Center (PPMC) each month. Of those, only ten were started on MAT, and only four were referred to a CRS.
The Center for Opioid Recovery and Engagement (CORE) provides comprehensive support for ED patients struggling with OUD by focusing on three key touchpoints.
- Identification and engagement: CORE leverages an algorithmic patient identification system to identify OUD patients in the ED in real-time and alert care team members using secure text messaging. When a patient is identified, a CRS intervenes to discuss treatment goals and options.
- ED treatment: If the patient is amenable, a physician gets them started on Buprenorphine, or bupe, a medicine that can be administered in the ED. Bupe lowers the potential for opioid misuse, diminishes withdrawal symptoms, and increases safety in overdose cases. Research shows that ED-initiated bupe can double patient engagement in treatment 30 days after discharge.
- Support after discharge: Before patients leave the ED, follow-up appointments are scheduled and "bridge scripts" placed to cover medication needs in the short-term. After discharge, CRSs act as role models, mentors, advocates, and motivators to promote long-term recovery. CRSs check-in with patients via text or call and conduct rounds out in the community.
CORE ensures that ED patients struggling with OUD consistently receive evidence-based treatment to promote long-term recovery.
When CORE's new patient pathways were implemented at Penn Medicine's downtown hospitals, the number of ED patients started on bupe increased threefold, and CRS involvement increased twelvefold. We also saw more patients in treatment at 30 days - 68 percent compared to less than 5 percent pre-launch - and fewer returns to the ED within 30 days of discharge. It is estimated that CORE prevented more than 180 overdoses in Philadelphia in its first year.
And in 2022, in response to the challenges presented by COVID-19, members of the CORE team developed a virtual bridge clinic to enable providers to engage, monitor, and deliver care to OUD patients remotely as the pandemic persisted. CRSs provided support and connections to ongoing treatment as they would have in-person, and thanks to temporarily relaxed regulations surrounding the prescribing of bupe, CORE providers were able to issue prescriptions for MAT over the phone. This work was made possible thanks to a generous contribution from the William Penn Foundation Special Gifts Program.
CORE is the standard of care in the EDs at PPMC, Pennsylvania Hospital, and the Hospital of the University of Pennsylvania, as well as the Hall Mercer Crisis Response Center. In the future, the CORE team aims to increase its bandwidth and extend its reach to new clinical settings.
Fake back end
Fake back end
Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end
We hypothesized that an automated system could proactively identify OUD patients in the ED and notify CRSs promptly.
To test this hypothesis, we manually reviewed the EHR to find patients with OUD and notified CRSs upon identification. Not only were we able to identify more patients during the pilot, but we also validated that CRSs could take fast and meaningful action.
Insights from this pilot led to the development of an algorithm to identify OUD patients and alert CRSs via secure text message.
Human decisions and behaviors are heavily influenced by the environment in which they occur.
A nudge is an intervention that gently steers individuals toward a desired action. Nudges change the way choices are presented or information is framed without restricting choice – although some nudges do change available offerings to drive behavior change.
To learn more about this methodology, visit our Nudge Unit page.
When we started this work, few doctors at the pilot location had completed their x-waiver training, a requirement to allow bupe prescribing in the ED.
We launched a campaign that leveraged financial incentives to increase the proportion of x-waivered ED faculty from 5 percent to over 85 percent.
We also leveraged social norming to signal that bupe is a standard part of ED care. Public messages were displayed on screens in the ED, and physicians wore pins that said, "I have my x-waiver, and I use it!"