Addiction Medicine

Peer recovery coaches and emergency department utilization in patients with substance use disorders

a b s t r a c t

Background: Although Emergency Departments (ED) frequently provide care for patients with substance use dis- orders (SUD), there are many barriers to connecting them with appropriate long-term treatment. One approach to subside risk in this population is the Peer Recovery Coach (PRC). PRCs are individuals with a lived experience of the rehabilitation process and are a powerful resource to bridge this gap in care by engaging patients and their families and providing system navigation, self-empowerment for behavior change, and harm reduction strate- gies. The purpose of this project is to describe an ED-based PRC program, evaluating its feasibility and efficacy. Methods: This was a retrospective Quality improvement project conducted at 3 suburban hospitals. All patients arriving to the ED were screened with a brief questionnaire in triage and patients identified as a high-risk had referral placed to a PRC if the patient consented. The PRC met with the patient at the ED bedside if possible. The PRC program members collected prospective data on patient engagement with the PRC at 30, 60, and 90 days post ED encounter. Using the EMR we identified the number of subsequent ED visits at 30, 60, and 90 days (for both medical and substance use disorder-related visits) from the index PRC visit.

Results: There were 448 individuals identified and included in this analysis between January 1, 2019 and June 30, 2020, of which 292 (66%) were male and the mean age was 44 (range 18-80). Most patients identified alcohol as the primary substance they used (289, 65%), followed by heroin/opiates (20%). At 30, 60, and 90 days, there were 110 (25%), 79 (18%), and 71 (16%) patients who were still actively engaged in the program, respectively. Among all patients in the cohort, there was essentially no decrease in mean visits before versus after the PRC engagement visit. However, among patients who had at least one prior ED visit, there were significant differences in mean visits across all visit-types: for patients with 1 prior ED visit, 90 day mean decrease in visits = 1.0 visits (95% CI 0.7-1.2), for patients with 5+ prior ED visits, 90 day mean decrease in visits = 3.6 visits (95% CI 2.4-4.8).

Conclusion: We describe the implementation of an ED-based PRC program for patients with substance use disor- ders. While we demonstrated that it is feasible for the PRC to engage the patient while in the ED, there was poor follow-up with the program outpatient. For patients with at least one previous SUD visit to the ED, there was a statistically significant reduction in ED utilization after engaging with a PRC while in the ED, suggesting this may be a population that could be targeted to link patients to long term care and decrease repeated ED utilization.

Introduction

Patients with Substance use disorders (SUD) often present to the Emergency Department for treatment of acute overdose, intoxication, withdrawal, or related medical conditions. Emergency Department (ED) utilization is significantly higher for patients with SUDs compared to those without [1-3]. The chronic nature of addiction also contributes to these patients repeatedly presenting to the ED, representing critical opportunities to intervene [4].

* Corresponding author.

E-mail address: lauren.klein@chsli.org (L. Klein).

The current standard for discharge is to provide referrals to social services and behavioral counseling, but it is not clear if these passive in- terventions effectively address chronic addiction and encourage post- ED discharge engagement with treatment [5,6]. The interval between discharge from the ED and the initiation of outpatient care is a high- risk period for patients [7]. Systematic barriers and difficulty navigating through administrative requirements put patients at risk for both Acute withdrawal syndromes, relapse, and even death [8].

One strategy that has emerged in an attempt to address the gap in connection to long-term care is utilization of peer-based recovery services such as peer recovery coaches (PRC) [9,10]. These recovery coaches are individuals who are trained to provide informational, social,

and emotional support to those with SUDs using nonclinical, self- empowerment and strengths-based methods. Unlike other models of social-based interventions, PRCs have personal, lived experience with substance use disorders and substance use recovery. Strategies to achieve recovery goals can include assisting with system navigation, supporting behavior change, harm reduction, as well as supplying refer- rals for medications for Opioid use disorders (MOUD), and inpatient or outpatient treatment options.

In an effort to address gaps in care in our local community, in part- nership with a not-for-profit community advocacy group, the Family and Children’s Association [11], our hospital system piloted a PRC program to connect ED patients with appropriate longitudinal manage- ment for SUDs. Our program, named the “Sherpa” program after the Himalayan mountain guides, was implemented in three Emergency Departments, and its goal was to establish the connection during the ED visit itself. The purpose of this project was to describe the impact of PRC engagement during an ED visit on subsequent emergency department utilization. We also describe self-reported patient recovery outcomes as a result of an ED-based engagement visit.

Materials & methods
1. Study design & setting

This was a retrospective, quality improvement (QI) project designed to evaluate the implementation of a Peer Recovery Coach program based out of three Emergency Departments within a regional healthcare system located on XX. This occurred from September 1, 2018 (the onset of the program) to September 30, 2020. The institutional review board considered this QI project exempt from review.

All patients arriving to the ED were screened for high-risk substance use behaviors by a registered triage nurse. This was completed using a Screen- ing, brief intervention, and referral to treatment (SBIRT) [12] “pre-screen” questionnaire. The pre-screen asked the following questions: (1) in the past year how often do you have a drink containing alcohol, (2) when you are drinking in the past year, how many drinks containing alcohol do you have on a typical day, and (3) how often do you have six or more drinks on one occasion. Based on these questions, patients identified as a high-risk based on the pre-screen were then evaluated in the ED by a social worker who completed the full SBIRT tool and placed a referral to the PRC if the patient consented. The PRC met with the patient at the ED bedside or contacted them by phone if they were not able to physically get to the ED before the patient was discharged. If the PRC could not get to the ED be- fore discharge, the social worker helped establish the PRC process them- selves. social workers and PRCs were both available 7 days a week. If the patient declined the PRC referral, the social worker was still able to provide the patient with traditional SUD resources, namely in the form of lists of local treatment facilities, MOUD providers, and detoxification facilities.

Peer Recovery Coach training was performed by the Family and Chil- dren’s Association prior to working in the Emergency Department. PRCs were volunteers, all of whom had previous personal experience with SUDs and recovery. The content covered during the PRC engagement visit with the ED patient was at the discretion of the individual coach, and was tailored to the individual being assessed. In addition to offering active assistance with systems navigation and emotional/social support, PRCs provided a number of resources to the patient. PRCs were also often able to make personal connections to the resources being dis- cussed, providing an additional advantage. Potential referrals included: outpatient treatment, inpatient treatment, detoxification referrals, group therapy, community support groups, crisis respite, MOUD refer- rals, addiction provider referrals, and housing referrals.

1. Methods of measurement

Demographic and Encounter data was collected by the PRC during the patient encounter. This included age, gender, ethnicity, and types

of substances utilized by the patient. The PRC also recorded which com- munity or clinical resources they connected the patient with. PRCs con- ducted follow-up calls to each patient at 30, 60, and 90 days after initial engagement. During each phone call the PRC asked five questions:

(1) was the patient still engaged with a Sherpa, (2) was the patient

still engaged with clinical care, (3) was the patient still engaged with community resources, (4) was the patient presently abstaining from drugs or alcohol, and (5) did the Sherpa help meet your recovery goals. Additional data was collected by study investigators directly from the electronic medical record for each patient. Specifically, we identified the number of ED visits that occurred in the 90 days prior to the index PRC engagement visit and the number of ED visits that occurred in the 90 days after the engagement visit. Each ED encounter was classified as a substance use related visit or medical visit (non-substance use re-

lated) based on the discharge diagnoses and notes.

1. Outcomes

The primary outcome for this study was the difference in the mean number of ED visits for any purpose in the 90 days before versus 90 days after the engagement visit with the Peer Recovery Coach. Differences in visits were also examined in the 30-day and 60-day pre-and-post time frames, as well as stratified by visit type (substance use related visit, medical visit).

Additional secondary outcomes included differences in ED visits be- fore versus after the engagement visit for a subgroup of patients who had at least one prior ED visit during the 90 days before the engagement visit, reflecting a group of higher ED utilizers.

Finally, we performed subgroup analyses on patients based on their

primary substance used, focusing on three cohorts (alcohol, opioids, and polysubstance use). For purposes of that analysis, polysubstance use was defined as any individual who listed more than one primary sub- stance of abuse.

1. Data analysis

Data is presented descriptively including means (with ranges) and counts (with proportions), as appropriate. For all comparative analyses of ED visit numbers before versus after the PRC engagement visit (for the primary outcome and additional secondary outcomes), we calcu- lated the difference in mean visits with associated 95% confidence inter- vals. A 95% confidence interval that does not cross zero is considered statistically significant.

To compare individuals based on primary substance used (three co-

horts: alcohol, opiates, polysubstance users), categorical data were compared for the three groups with a Chi-squared test and continuous data were compared with a One-way ANOVA. An alpha of 0.05 was set for all analyses.

Results

All patient encounters between January 1, 2019 (the time point when the program starting tracking data) and June 30th, 2020 were reviewed. A total of 701 encounters were tracked by the PRC program. For the pur- pose of this study, patients were excluded if they were engaged in the community setting (i.e. not in the ED) (N = 31), or if there was no date of birth or medical record number recorded (N = 21), precluding the ability to obtain study related data. If a patient had multiple PRC re- ferral encounters, only the initial visit was included and used as the index visit for purposes of analysis. A total of 448 patients that completed an initial engagement encounter were included in the final analysis.

1. Patient demographics & follow up data

Baseline patient characteristics are shown in Table 1. The mean age was 44 (range 18-80) and 292 (68%) were male. Most patients

Table 1

Patient demographics & encounter data.

Variable

Age (mean, range) 44 (18-80)

Gender (male) 292 (66%)

Ethnicity

White – Non Hispanic	334 (75%)
Black	39 (9%)
White – Hispanic	34 (8%)
Other Race	26 6 (%)
Multi- Race	4 (1%)
Unknown	11 (3%)

Primary Substance of Abuse

Alcohol 289 (68%)

Opioids 87 (19%)

Stimulants (Cocaine, Amphetamines) 31 (7%)

Sedatives/Hypnotics 9 (2%)

Marijuana 8 (2%)

Hallucinogens 1 (0.2%)

No Answer 23 (5%)

Insurance type

Private Pay 102 (23%)

Medicaid/Medicare 311 (69%)

no insurance listed 35 (8%)

In-Person Method of First Contact 340 (76%)

Response Time Less than 30 Minutes 347 (78%)

identified by the program listed alcohol as their primary substance (289, 68%). The majority of patients experienced their first contact with the PRC in-person in the ED (340, 78%). The PRC response time to the ER was less then 30 min for 347 (78%).

The PRCs attempted to follow-up directly with all patients and phone calls were made by the PRC at 30, 60, and 90 days. At 90 days from the engagement visit, there was a high rate of patients unable to be reached (323, 72%). Among those that could be reached (N = 125), 81 (64%) reported that they were still engaged with the PRC, 40 (32%) reported that they were still engaged with the clinical care they were re- ferred to, 49 (39%) reported they were still engaged with the commu- nity resources they were referred to, 60 (48%) reported that they were presently abstinent from drugs and alcohol, and 54 (43%) reported that the PRC helped them meet their recovery goals.

1. ED utilization outcomes

In the 90 days after the engagement visit with the PRC, 202 (45%) had a subsequent ED visit for a medical or substance use related purpose (mean 0.9 visits per patient, range 0-13). In comparison, in the 90 days

before the engagement visit 213 (48%) patients had an ED visit (mean 1.1 visits per patient, range 0-12). The difference in mean ED visits before versus after the PRC engagement visit was 0.2 visits (95% confidence interval of the difference 0.01-0.3, p = 0.04), indicating a statistically significant decrease in mean visits per patient. Table 2 demonstrates additional data regarding changes in ED utilization, at the 30 and 60 day mark, as well as stratification by visit type (medical, substance use related). No other comparisons (at 30 or 60 days, or for specific visit types) were found to be significant.

1. ED visits and high-utilizers

We hypothesized a priori that the intervention would yield greater benefit among those who had demonstrated prior ED utilization. We compared ED visits in the 90 days before versus after the engagement visit for patients with at least 1 prior ED visit (for any reason) in the 90 days preceding the engagement visit. We made the same compari- sons for increasing numbers of prior ED visits (stepwise by one visit per person per 90 days). These results are displayed in Table 3. In con- trast to the previous analysis, there were significant differences in ED utilization for these subgroups of individuals. For those with at least one prior ED visit, the mean decrease in number of visits was 1.0 per person (95% CI 0.7-1.2). There was a proportional relationship noted for those with higher numbers of visits: those with more frequent ED visits prior to the engagement visit had increasingly greater mean de- creases in ED visits after the engagement visit.

1. Primary substance of abuse

When the PRC program was developed, its primary intent was to focus on those with opioid use disorders and the opioid epidemic. Subse- quently the majority of the population of patients identified in our three- hospital system listed alcohol as their primary substance of abuse. Table 4 depicts outcomes based on the primary substance used (alcohol, opioids, polysubstance), as stated by the patient themselves to the PRC during the engagement encounter. We describe the self-reported rates of engagement in resources offered by the PRC, rates of abstinence, as well as differences in ED visits before versus after the engagement visit. There were no differences among these groups for any variable.

Discussion

Peer-based support services for individuals with substance use dis- orders has become an increasingly popular option for assisting in

Table 2

Difference in mean visits per patient before versus after the engagement visit.

30 Days Pre v. Post (95% CI)

60 Days Pre v. Post (95% CI)

90 Days Pre v. Post (95% CI)

Any Visit Type 0.03 (-0.07 to 0.1) 0.1 (-0.02 to 0.2) 0.2 (0.01-0.3)*

SUD Visit 0.03 (-0.06 to 0.1) 0.08 (-0.04 to 0.2) 0.1 (-0.02 to 0.3)

Medical Visit 0.01 (-0.08 to 0.03) 0.02 (-0.1 to 0.05) 0.02 (-0.1 to 0.05)

Footnote: * Indicates significance if 95% confidence interval of the difference does not cross zero.

Table 3

ED visits for high-utilizers.

# of ED Visits in the 90 Days Prior	N	Mean ED visits 90 Days Prior	Mean ED visits 90 Days After	Difference in Mean ED Visits
1 Prior ED Visits	213	2.4	1.4	1.0 (95% CI 0.7-1.2)*
2 Prior ED Visits	121	3.4	1.9	1.4 (95% CI 1.1-1.9)*
3 Prior ED Visits	68	4.5	2.2	2.3 (95% CI 1.5-2.7)*
4 Prior ED Visits	41	5.5	2.7	2.8 (95% CI 2.0-3.6)*
5 Prior ED Visits	24	6.5	2.9	3.6 (95% CI 2.4-4.8)*

Footnote: * Indicates significance if 95% confidence interval of the difference does not cross zero.

Table 4

Outcomes for patients based on primary substance.

Substance Type	Alcohol	Opiates	Polysubstance
Engaged in Resources at 90 Days?	50/82 (61%)	18/25 (72%)	30/40 (75%)	p = 0.3
Reported Abstinence at 90 Days?	33/82 (40%)	16/25 (64%)	21/40 (53%)	p = 0.1
Difference in Mean ED Visits 90 Days Before vs. After PRC (95% CI)	0.2 (0.08-0.4)	0.2 (-0.04 to 0.5)	0.2 (-0.02 to 0.4)	p = 0.9

Footnote: Comparison for first two variables by Chi-squared, last variable by one-way ANOVA.

* Denominator is based on number of patients who were able to be reached at 90 day follow up.

patients’ recovery goals in response to growing substance use disorder trends. Also more novel is the implementation of such programs out of Emergency Departments, as these encounters have been shown to be a high-risk time for the patient with high rates of subsequent relapse, and even death. Reports have demonstrated the potential for various positive outcomes of ED based peer support services including high ac- ceptance of patient referrals [13], high rates of provider utilization [13,14], increased Naloxone distribution [14], and potential for decrease in hospital utilization [15].

In this study, we sought to describe outcomes from the first 18 months of a pilot PRC program implemented in our regional hospital system. Our results indicate a modest, yet statistically significant de- crease in mean ED visits for any reason in the 90 days after the engage- ment visit as compared to the 90 days prior. This could potentially represent a notable decrease in burden on ED utilization.

When reviewing the data of visit frequencies before and after the en- gagement visit, it was clear that many patients (36%) had only one total ED encounter during the study period (the engagement visit itself), with zero visits before and zero visits after, thus diluting some of the ef- fect size noted in the outcomes. For this reason, the subgroups of high ED utilizers may depict a better sense of the program’s utility. Among those with at least one visit to the ED for any reason, substance use re- lated or for medical purposes, mean decreases in ED visits were far more notable – visits decreased by as much as 55% for those with the highest pre-engagement visit utilization numbers. These findings sug- gest a greater utility for an ED-based PRC engagement in those more prone to utilizing the ED.

One aspect of this study’s cohort that is unique in comparison to other exploratory data regarding ED-based use of PRCs is the inclusion of individuals with any substance use disorder. The existing literature, including ongoing randomized clinical trials, focus primarily on those with opioid use disorders (OUDs). The initial guidance issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) on peer recovery support services appealed to a broad spectrum of substance use disorders, but in practicality, as peer recovery coaches became a more popular mainstay of treatment, opioid use disorders were highlighted. These programs focused on outcomes specific to OUDs such as opioid overdose and relapse, as well as naloxone admin- istration and referral to medication assisted treatment. Given the Rapid progression of the opioid epidemic over the last decade, it is not surpris- ing that these patients received much attention.

However, Alcohol use disorders (AUDs) compromise a substantial proportion of SUD related visits in the ED. [2,16] Those with alcohol use disorders are also highly likely to utilize ED resources frequently, due to related medical comorbidities, and social determinants such as homeless and concomitant Mental illness [16-19]. In this study, we did not focus on OUD-specific outcomes or target individuals solely with OUDs, thus intending to make these data and the findings from our pilot program more generalizable. We did not necessarily identify any significant differences in outcomes in those with OUDs versus AUDs, but this study was not powered to detect such differences. That being said, the high proportion of patients with AUDs identified by our PRCs suggest that a wider array of resources should be aggregated, particularly including those focused on alcohol-based treatment strategies.

There are numerous reasons as to why peer-based support services are ideal for use in Emergency Departments. Aside from the overall

benefit of connecting with an individual who has lived similar experi- ences with SUDs and recovery, peer recovery coaches are generally better able to make a personal connection with patients in the chaotic environment of the ED that often pulls physicians’ attention in multiple directions and interrupts in-depth interviews [20,21]. The PRC is also able to tailor their engagement visit to the needs of the individual pa- tient and their families, and will have access to resources that ED physi- cians may not be aware of or have comfort with. For example, while increasing numbers of ED physicians are initiating medication assisted treatment such as buprenorphine from the ED [22], the overall scope of this practice is still evolving, despite its demonstrated benefit to pa- tients with OUDs [6,23,24]. PRCs will help bridge this gap in care and knowledge with appropriate and timely referrals and more comprehen- sive education on MOUD, even if the ED providers are not equipped to do so.

Limitations

This study has several limitations. First, there was a very high rate of patients unable to be reached to obtain follow up information, which is unfortunately common in studies involving individuals with substance use disorders. Second, ED utilization data and follow up data was con- ducted over a relatively short time frame (90 days). Given the chronic nature of SUDs, data past the 90 day mark could provide a greater sense of a PRC program’s long-term utility. Along these lines, many pa- tients with SUDs have periods of sobriety alternating with periods of ex- cess use, so it is possible that this follow up interval identified patients during either of those periods, thus underestimating trends in overall ED utilization. Another limitation is that we did not exclude patients who may have died during the 90-day follow up interval, which could impact follow up Incidence rates. Next, ED utilization was only identi- fied for those visits that occurred within our health system. There are six regional EDs that are included in this health system, covering a rea- sonable amount of the local community, but other Hospital systems do exist, and these ED visits would be missed. And finally, our study popu- lation was predominantly suburban and white, thus these findings may not be generalizable to communities of different demographics.

Conclusion

Peer-based support services for individuals with substance use dis- orders is not a new notion but has become an increasingly important option for assisting in patients’ recovery goals. More novel is the devel- opment of ED-based programs. We describe the implementation of an ED-based PRC program for patients with substance use disorders. While we demonstrated that it is feasible for the PRC to engage the patient while in the ED, there was poor follow-up with the program out- patient. For patients with at least one previous SUD visit to the ED, there was a statistically significant reduction in ED utilization after engaging with a PRC while in the ED. Further data exploring the use of ED- based PRC programs is essential in order to help establish best- practices for the implementation of these services.

Funding

None.

CRediT authorship contribution statement

Teagan Lukacs: Writing – review & editing, Writing – original draft, Data curation. Lauren Klein: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Robert Bramante: Writing – review & editing, Conceptualization. Jennifer Logiudice: Writing – review & editing, Conceptualization. Christopher

C. Raio: Writing – review & editing, Formal analysis, Data curation, Conceptualization.

Declaration of Competing Interest

None.

References

AJEM

Peer recovery coaches and emergency department utilization in patients with substance use disorders

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