[dropcap]F[/dropcap]or several months in 2015, disgruntled patients in the emergency department at Ellenville Regional Hospital, a 25-bed facility in rural Ulster County, New York, were giving President and CEO Steven Kelley an earful about his staff. Kelley says a typical complaint went something like this: “They’re treating me like a drug addict. They won’t give me the medication that they’ve given me in the past. I need [intravenous] Dilaudid.” Dilaudid is a prescription opioid.
That July, the critical access hospital had launched an innovative program to change how it treated chronic pain patients who were high utilizers of its seven-bay emergency department. The department’s nurse practitioners and physician assistants were no longer routinely administering opioids and sending patients on their way with an opioid prescription. Instead, providers administered, when possible, non-opioid pain relievers and, when an opioid prescription was necessary, wrote one for only one day’s worth of medication or three days’ worth for a weekend.
They then referred patients to the local federally qualified health center a short walk away for primary care, behavioral health services and referrals to specialists.
From the start, the staff worried that some patients would rebel, and Kelley, whose office is steps from the emergency department, told them to send unhappy patients to him. It quickly became clear that for some patients, the new policy was an abrupt and unwelcome change. “We had patients who were used to coming here and, for lack of a better word, getting their fix and then leaving,” says Kelley. “And we took care of a lot of people that way.”
Nevertheless, many, but not all, patients adjusted, he says, and four years later, Ellenville’s program has become a model for other hospitals in the state and around the country that want to reduce the use of opioid medication and do a better job of addressing chronic pain patients’ needs.
But the program is not without its challenges. The hospital’s finances have taken a hit as emergency room visits declined and not all patients have been receptive.
Initially, the goal was to help New York cut its Medicaid costs. Attempting to break the cycle of opioid prescription and addiction grew out of that objective.
In 2014, the state received a waiver from the federal government to use $8 billion in federal funds to reform its Medicaid system. New York wanted to reduce patients’ avoidable hospital use, including in emergency departments, by 25 percent over five years, and it offered hospitals grants and incentive payments to participate in the effort. Ellenville Regional Hospital was one of the smallest facilities to apply.
After studying its emergency department visits, a team at the hospital comprised of executives and providers discovered that about 800 chronic pain patients accounted for roughly 2,000 out of 14,000 visits annually. Working with the Institute for Family Health, which operates federally qualified health centers in New York City and Ulster and Duchess counties, including the one in Ellenville, the team developed the new treatment protocol. It selected a cohort of 64 chronic pain patients to track over time. Some were Medicaid patients, some had commercial insurance and others were uninsured, and all had a history of frequent emergency department visits where they received opioids.
The new protocol was not only an adjustment for patients. Providers had to adapt, says Maria Gonzalez, the hospital’s director of nursing. “It had been easier to just give patients the [opioid] shot and let them go,” says Gonzalez. After all, patients were satisfied, wait times were manageable and providers were fulfilling government policy to treat pain as the “fifth vital sign” after blood pressure, heart rate, respiratory rate and temperature, she says.
The new protocol required the emergency department providers to spend more time with patients. “We had to reassure the patients, comfort them and educate them,” says Gonzalez. “We would say, ‘In reality, Dilaudid is a medication designed to treat cancer pain, and we are going to start to be more conservative and treat your pain with other medications like Toradol, and anti-inflammatory, or [intravenous] Tylenol,’ ” she says.
During these conversations, the staff discovered that many patients had unmet economic, social and psychological needs that were often affecting their health. In those cases, the staff would call the Institute for Family Health center and ask for a care navigator to come to the emergency department to meet with the patient.
“If they didn’t have a primary care provider, the navigator would set up an appointment at the health center. If they didn’t have food, if they didn’t have transportation, if they needed to be enrolled in insurance – all that was handled by the care navigator,” says Ashima Butler, the hospital’s vice president and chief operating officer.
A primary care provider at the Institute for Family Health center would then coordinate the patient’s care, including a pain assessment. “The pain assessment can’t be done in one visit,” says Neil Calman, a family physician and the institute’s president and CEO. “People might need to have new X-rays taken, they might need an orthopedic consultation or a neurologic consultation.” They might need pain management and physical therapy, says Calman, who sometimes had to “beg, borrow and steal” to get outside specialist care for uninsured patients.
For those patients who were truly drug seeking and addicted to opioids, the institute offered behavioral health services at its Ellenville center. “We have psychiatrists, psychiatric nurse practitioners, therapists, psychologists, addiction medicine specialists,” says Calman. Like all federally qualified health centers, the center turns away no one, including the uninsured.
The state funding for Ellenville Regional Hospital’s program ended last July, but the Institute for Family Health and the hospital continue to collaborate and the protocol remains in place.
There are many ways to try and measure the program’s success. Hospital Vice President Butler has analyzed the changes in emergency department practices among the 64 patient cohort that the hospital has been monitoring for four years.
Administration of opioids has dropped 94 percent for the cohort and emergency department visits have declined 77 percent, says Butler. Overall, emergency department annual visits fell from 14,000 to 12,000. In addition, less than 2 percent of patients left the emergency department in 2018 with an opioid prescription, far below the New York state average of nearly 38 percent, according to Butler.
Like all federally qualified health centers, the center turns away no one, including the uninsured.
Hospital President Kelley calls the drop in emergency room visits “dramatic” and the decline in opioid prescriptions an important step in breaking a deadly cycle. “Most people who die from opioids… die from heroin or fentanyl or heroine and fentanyl, and the vast majority of people on heroin started on prescription drugs,” says Kelley. “We realized that by reducing [prescription] opioids, we could be a lot less part of that long-term problem that is killing people.”
But there is a flip side.
“As we make it more restrictive for people to get opioids through the medical establishment, some people turn to heroin, which is cheaper,” says Calman. That could be one of the reasons why the hospital has lost track of 18 patients in the original cohort who never returned to the emergency department for any reason. It is also possible that some moved away, found care elsewhere or were not interested in the offered services. As a result, knowing whether chronic pain patients are better managing their pain and opioid use is more difficult than measuring emergency department statistics, says Calman.
Still, Calman considers the program a success. “We gave people options and an opportunity,” he says.
Yet as patients got better care and reduced their visits to the emergency department, the hospital paid a price. “Medicaid pays us the same amount per visit every time, so if we reduce the number of visits, we reduce our revenues,” says Kelley, while the hospital’s fixed costs, such as salaries, keep rising.
“But we’re doing the right thing,” he says.
Last April, Ellenville Regional Hospital launched a second phase of its opioid reduction program called Project Rescue.
In the past, many patients brought to the emergency department after an opioid overdose could only think of “getting out of here as fast as possible so that they could use again so that they would not be in withdrawal,” says Kelley. The hospital wanted to break that pattern and encourage patients to enter treatment.
The first step was to offer post-overdose patients buprenorphine, a medication that blunts withdrawal symptoms and treats addiction by blocking opioid receptors in the brain. The hospital’s emergency department providers took a course and received waivers from the Drug Enforcement Administration to prescribe buprenorphine.
Next, the hospital partnered with Catholic Charities of Orange, Sullivan and Ulster, New York to provide certified recovery peer advocates, who have lived experience with addiction, to help patients transition to addiction treatment and counseling at Catholic Charities or other providers.
But the hospital initially misjudged patient response, says Kelley. “It turned out that people were not that interested in jumping into treatment,” he says. Instead, some would come back later.
“We’d like to reach more of the population in need,” says Victoria Reid, executive director of the hospital’s rural health network. The hospital has been publicizing the program on radio, social media and with old-fashioned flyers.
“We have flyers all over Wawarsing, Ellenville, Pine Bush, Wurtsboro – all over the rural areas,” says Tonya Stokes, the hospital’s substance use disorder program coordinator, naming several small towns. “I found these mom and pop pharmacies, the little gas stations off the map,” says Stokes, who posted the flyers herself.
The advertising seems to be working. In the past several months, “there has been a huge pickup in the number of people asking about the program,” says Reid. Individuals want information for themselves, and family members are contacting the hospital requesting help to manage the “treatment labyrinth,” she says. They speak to Stokes, who talks to them about insurance, treatment providers, transportation and whether inpatient or outpatient care is the best approach.
Since April, the emergency department has seen 10 individuals who have overdosed and 24 walk-ins asking for information about opioid treatment.
Meanwhile, the hospital wants to reduce harm among individuals who are not ready for treatment or are struggling with recovery. It has begun to distribute in the community Narcan kits, which can be used to quickly reverse an opioid overdose; syringe vouchers to reduce the risk of developing hepatitis C and HIV from sharing needles; and medication disposal packets so patients can dissolve unused opioid prescriptions in an environmentally safe way and avoid the pills being used by others.
“We need to reduce harm so that people will be able to survive long enough until they reach the point where they are ready to make a change,” says Kelley.