In a word, Nicole O’Donnell is personable. As a recovery specialist for Penn Medicine’s Center for Opioid Recovery and Engagement, she is, in many ways, the face of the program. When those with opioid use disorder enter a downtown Penn Medicine emergency room, she’s often the person who first touches base with them about potentially starting recovery. She’s also the one who keeps tabs on patients as they move forward. Sometimes, she’ll stay in contact with a patient for years.
That’s one of the reasons why the COVID-19 outbreak is so difficult for her.
“We don’t get to give hugs,” she explained with a weary laugh.
O’Donnell relishes the connections she makes with patients, but the virus has made in-person contact risky. Beyond that, it has made Penn Medicine’s new and integral CORE program difficult to continue implementing. Established through the Center for Health Care Innovation’s accelerator program last year, CORE uses algorithms to flag emergency department patients with opioid use disorder whose emergency symptoms that day may not outwardly present it. Once flagged, patients can be engaged with for potential further treatment. That often includes the use of a buprenorphine “bridge prescription,” which gets patients the medication that cuts into the toxic effect and cravings for opioids, decreasing the chance of an overdose and making patients more likely to continue with further appointments for recovery.
O’Donnell is the first link in the CORE chain, engaging with patients once flagged and helping guide them into the process. But that chain was built around a once (and future) unmet need: Opioid use patients coming into emergency departments but missing connections for lasting recovery care. COVID-19 threw a wrench into Penn Medicine’s solution.
“We did know patients would have less access to the emergency room because they might be exposed to the virus,” O’Donnell said. “We wanted to keep them safe and we knew there would be even more people out there because of job loss and because there were going to be releases from the prisons. Those were the big deciding factors for what we ended up doing.”
Like most of medicine, CORE shifted to a telehealth response. This was chiefly enabled by Pennsylvania’s response to COVID-19, which permitted buprenorphine to be prescribed over the phone or by a virtual visit. As such, CORE’s team began putting its phone number out into the community. The program has even (thanks to a grant from the William Penn Foundation Special Gifts Program) been able to provide phones to some patients who didn’t have them. The effort was dubbed the “Virtual Bridge Clinic.”
“Nicole called me and said, ‘We need to get this going,’” said Davis Hermann, the design strategist in the Center for Health Care Innovation who was a part of originally rolling out CORE. He was instrumental in retooling the program for its outbreak response.
The CORE team, which also includes Jeanmarie Perrone, MD, a professor of Emergency Medicine at the Perelman School of Medicine and the director of Medical Toxicology and Addiction Medicine Initiatives, and Utsha Khatri, MD, an emergency medicine attending and a National Clinician Scholar Fellow, worked with their partners to get the group’s phone number out there and spread the word about the recovery services they offered to those in need. That included giving the information to the prisons doing releases in response to the virus, as well as organizations hard-hit by cutbacks that had typically handed out the overdose reversal medication, naloxone, or NARCAN.
“We’re trying to be creative about this because we know that there are patients we’re missing,” Khatri said.
The line that patients call initially is staffed by volunteers, many of them students, from Penn Nursing and Penn Social Policy and Practice, under the leadership of Heather Klusaritz, PhD, a lecturer in Social Policy. The patients who call in are then directed to the help they need, whether that be engaging with the clinic to get their buprenorphine prescriptions, if they need them, or connecting with counselors or other professionals for further help, all via phone or video calls, without having to go anywhere.
Khatri was relatively new to providing substance use treatment when the outbreak began, having only worked in outpatient care for less than a year, so by now shehas been engaging with patients via telehealth as long as she had in-person. Doing these appointments via telehealth has resulted in far fewer no-shows, she said.
“It’s really interesting because I’m getting to meet people’s kids and parents and I see the home they live in,” Khatri said. “Medical care, and substance use care in particular, is traditionally so rigid and formal, there’s usually this pretty sizable professional wall that’s there. So it feels so different when we’re both sitting in our living rooms and having a visit.”
Since the program began, more than 20 patients received a buprenorphine prescription, and all have continued to engage with recovery since.
Something that Khatri believes is unique and worthy of reflection is the lack of urine testing. Although controversial, having patients provide a sample for screening before appointments is pretty standard. But amid the COVID-19 shutdowns, there’s no practical way to do it.
“I think the samples are supposed to confirm for a patient and the provider that the treatment plan is working,” Khatri said. “In lieu of that, I’m just asking whether they have used, and my patients are being pretty honest, so it’s making me question the practice.”
All of these measures hinge on the emergency provision allowing for telemedicine-based buprenorphine prescriptions. Once the public health emergency of the pandemic is declared over and preexisting regulations take effect, that is likely to go away. But everyone involved with Penn Medicine’s virtual bridge clinic is interested in continuing with it somehow. In fact, Perrone and Khatri have partnered with other providers, legal experts and advocates from across the country to organize and advocate for continued buprenorphine access through telehealth.
“This has been something we’ve thought about piloting for a long time because there are patients who have a need for this but don’t have a chance to come in to a medical facility,” Hermann said. “We hear that this emergency declaration will likely end, but we’ll definitely be looking for another way to continue it. We’re just not sure what it will look like.”