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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
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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
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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
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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
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What is it like to go to the hospital?
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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
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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
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What if we designed hospital care differently?
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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.
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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
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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
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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.
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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
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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)
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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
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Learning from our ExperiencePatient Outcomes Evaluation
Economic Evaluation
Process Evaluation
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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
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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
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Data Sources
Patient
AHS Analytics
AHS AMH
Homeward Trust
Calgary Homeless
Foundation
Human Services –
Income Support
Police
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Who are we seeing?
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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%)
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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%)
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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%)
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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%)
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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%)
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Perceived Need For Care
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Edmonton (n=303)
Calgary (n=270)
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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
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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
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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.
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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
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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
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What is the patient experience?
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What is the patient experience?Improved emotional / social health
Substance use stabilization
Humanistic care
Autonomy support
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“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.”
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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
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“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.”
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“H” is for…
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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.
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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).
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Helping?
Deci EL, Ryan RM. Self-Determination Theory: A Macrotheory of Human Motivation, Development, and Health. Canadian Psychology 2008;49(3):182-5.
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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).
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Relationship Reduces Harm
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Pearls for PracticeUse person-centred language
Hospitalization is a period of opportunity
Meet patients where they are at
Naloxone = Epipen
Self-care