The BMC Brief Volume 6, Issue 7July 19, 2017
BMC providers were looking for ways to change a familiar story: a patient was hospitalized for a heart ailment, an infection or another acute condition. The patient was treated for their presenting condition and sent home, only to be readmitted time and again, with the same problem or another health issue. The reason for the revolving door was an underlying disease for which the patient was not yet seeking treatment – a substance use disorder.
Two years ago, the efforts of individual BMC providers to reach patients with addiction treatment – even though it wasn’t the immediate cause of their hospitalization – was formalized with the creation of a new addiction consult program. Patients receive medication-assisted or other appropriate treatment while they are still in the hospital, with an outpatient plan upon their discharge.
The need is great – a 2012 study found that 17 percent of patients hospitalized at BMC have a substance use disorder; statewide, the number is 15 percent. But BMC’s results have been striking. Patients who are treated through the addiction consult service have a 30 percent decrease in Emergency Department visits and a 40 percent reduction in readmissions.
As BMC continues to move towards operating within an accountable care organization model for MassHealth patients, programs such as the consult service will be a critical part of how we keep patients healthier while also addressing drivers of cost. BMC has a long history of treating not just acute medical needs, but also social determinants of health such as substance use disorder. In an ACO model, an even greater focus on these factors will be a key component of keeping patients healthy.
“Substance use issues can often underlie many reasons why people get admitted to the hospital,” says Zoe Weinstein, MD, an internal medicine physician and medical director of the inpatient addiction consult service at BMC’s Grayken Center for Addiction Medicine. “However, in many clinical settings, these issues are not routinely addressed once the more immediate health problem is solved. Our goal is to help physicians address substance use issues in patients, which helps keep patients out of the hospital.”
Despite medication being the preferred treatment for substance use disorders, only a minority of patients are on medications, according to Weinstein. Therefore, the goal of the addictions consult service is to assess a patient’s interest in addressing their disorder, start medication for patients who are willing to take that step, and get as close as possible to a therapeutic dose while the patient is still in the hospital.
The service also connects patients with outpatient providers, so that they can continue their treatment once they leave the hospital. All patients who are put on methadone must go outside BMC for outpatient care, but over 50 percent of patients continue to receive care at BMC. A nurse on the consult team coordinates with community partners and outpatient programs to help get patients accepted.
While similar consult services are available throughout the country, not all programs are able to get patients on medication-assisted treatment (MAT). The model at BMC has roots in several National Institutes of Health-funded studies done by Boston University and BMC researchers that found positive effects for patients when MAT was initiated during hospitalization.
“Continuing to receive appropriate treatment once they leave the hospital is a big roadblock for many patients, but we are able to help them overcome this through the partnerships that we have built in the community,” says Weinstein.”
The consult team works across the hospital and can be called by anyone on a patient care team. They primarily work with patients with an active substance use disorder who the care team thinks might be open to treatment. Occasionally, they are also called to consult when a patient previously had a substance use disorder or is being treated but has an issue that might complicate their treatment, such as having surgery that may require opioid painkillers. On average, the team sees 27 patients a week, most of whom are new to the team.
The inpatient addiction consult service consists of a half-time attending physician, a full-time nurse practitioner, a part-time nurse who coordinates care for patients, and residents and fellows. Although the service is a resident and medical student elective open to anyone, most residents are from internal medicine and family medicine. Working on the consult service is required for addiction medicine fellows, and addiction psychiatry fellows have also started to work with them. The service therefore has an educational component, to help residents, fellows, and medical students learn what options are available for patients to get treatment in a timely manner.
“We hear from many people who work with us that they thought we would have to convince patients to get on medication, but patients are often very motivated,” says Weinstein. “When we offer support and a path forward, they are enthusiastic and interested. People with substance use disorders don’t always know what options are available to them or think they don’t have any good choices. We are here to give them good choices for treatment.”
The inpatient addictions consult team can be reached at pager 6226. They round Monday-Friday but are available to page 24/7. For more on the inpatient addiction consult service, watch this video with Alexander Walley, MD, director of the addiction medicine fellowship.
BMC provides exceptional care to patients, but sometimes stressful patient events, such as unexpected complications, patient death, mistakes, or negative interactions with patients or family members, can happen despite best efforts. These events can have a negative impact not just on patients, but on employees as well. Peer Connection, which launched in early 2017, is a program aimed to help BMC employees provide exceptional care for each other by encouraging and facilitating caregivers to support one another and find new, healthy ways to cope with stressful patient experiences and events.
Research has shown that when a stressful or adverse patient event happens, medical caregivers can be deeply affected, even if the event was out of their control. A survey of BMC clinicians, for example, found that approximately two-thirds of respondents have experienced a stressful patient-related event causing significant depression, anxiety or concern about their ability to do their job. This is in line with research showing that anywhere from 30 to 67 percent of physicians have experienced negative impacts due to a stressful patient event.
These events can not only lead to depression or anxiety for the caregiver, but also negatively impact performance of both the caregiver and the team they work with. The problem is compounded, research shows, by a culture where stressful events are often not talked about due to shame, stigma, or fear. Only a third of caregivers at BMC report receiving support for stressful patient events at work, but Peer Connection aims to change that.
“Stressful patient experiences can happen to anyone and occur no matter how careful an employee is or how hard they try to avoid them,” says Carol Mostow, LICSW, associate director of psychosocial training in the Department of Family Medicine and one of the founders of Peer Connection. “However, people who experience these situations often suffer in silence, which is not healthy or productive. Giving providers a way to process and cope with these stressful situations helps them avoid becoming ‘second victims’ of the event.”
There are 61 peer supports in the program, all of whom were nominated by their peers. The supporters are a mix of residents, attending physicians, and nurses from 13 different departments. While the program started in departments where providers are most likely to see adverse events, it will soon be expanding across the hospital. Peer supporters are not limited to supporting colleagues in their own department; anyone at the hospital who has experienced a stressful patient experience can call, from physicians to nurses to pharmacists to Environmental Services employees. All peer supporters have been trained on how to effectively help their colleagues.
“Having a peer supporter is important because we relate to each other differently given our shared experiences,” says peer supporter Nkiruka Arinze, MD, a resident in the Department of Surgery. “Most importantly, it lets those that need support know that they are not alone. They are not alone in what they are feeling, they have support in their group, and they are not the first one to go through this.”
“During my intern year I experienced how taxing it is to take care of patients every day,” says peer supporter Erica Tsang, MD, MPH a resident in the Department of Family Medicine. “Hearing their stories, seeing them in a very vulnerable time in their life, all the while trying to take the very best care of them while I am still learning can be a lot. I needed, and still do need, a lot of support. In addition to my family, it is my co-residents who provide that support. They know where I'm coming from and can help me process difficult cases. Knowing how important it is to have peers who support me, I want to be the same resource for them.”
Any employee who experiences a stressful patient event can call a peer supporter. Once called, a peer supporter will follow up to talk about what happened and suggest healthy ways to cope with the situation to avoid depression, burnout, or other negative effects. If necessary, the peer supporter will recommend other resources or people to talk to, such as Beth Milaszewski, LICSW, the Working Well clinician, or BMC behavioral health services.
“Many of us get used to how challenging healthcare is, and don't recognize how often we also would benefit from sharing with a colleague and getting support for ourselves,” says Alysa Veidis, NP, associate medical director of Family Medicine. “It's great to see how many resources are available for employees who need support."
While the Peer Connection program is only about six months old, its impacts can already been seen around campus.
“After participating in the peer support training and learning the principles, I've started to recognize when peer support is being offered on the wards or in clinic,” says Tsang. “When I see my colleagues supporting each other as the need arises, using many of the techniques we've learned without even thinking about it, I am reminded that I work with remarkable compassionate people!”
Employees can contact a peer supporter directly or contact the program at [email protected] or 617-638-7910 to request support. Requests will be answered within 48 hours. A full list of BMC mental health resources, including urgent support, can be found on the intranet.
Q: What do you do at BMC?
A: I’m the manager of the new rooftop farm. I start most mornings at 7 a.m. by harvesting for the Preventive Food Pantry and the kitchens, then deliver the food to them by 9 or 10 a.m. I usually spend the rest of the day on maintenance for the farm, including planting, seeding, and weeding.
Q: How did you get into farming?
A: I worked at a farm in high school and really enjoyed it, but did nothing relating to farming for about five years and went to school for social work and nonprofit management. After college, I went to Panama and Costa Rica and interned on a few different farms and completely fell in love with it. From there, I’ve apprenticed at different farms, took a lot of courses and training, and have now been either an employee or manager of farms for the past eight years. I also teach agriculture and sustainable farming. I never ended up using my social work degree.
This is my first rooftop farming experience. It is very different from the last farm I was managing, which was a two acre dryland farm on a 450 acre property in California.
Q: What is the food from the farm being used for?
A: Food from the farm supplements the food that the Preventive Food Pantry gets from the Greater Boston Food Bank. We try to give them a lot of fresh, green produce, which is often lacking in food pantries.
The food is also used in the BMC kitchens. At the beginning of each week, I let the different managers know what will be ready to be harvested and they can choose what they want at the different stations in the cafeteria. We’ve been harvesting for about a month, so we’re still trying to figure out the best ways to integrate our food. For example, lot of people are now eating food from the farm, but they don’t know it, so we’re trying to work out labelling.
Some of the food goes to patient meals, but we’re still working on ways to work more farm produce into the meals.
Q: Why is having fresh, healthy food for our patients so important?
A: We are what we eat. People who come here are often very sick or in a vulnerable place, and we should be nourishing them. A holistic approach to health care includes our food and what we put in our bodies.
What BMC is doing with the rooftop farm is really important in terms of moving the conversation forward as to what hospitals can do with their resources and why it’s important to have local organic food for patients.
It’s one thing to be purchasing and supporting local farms – which BMC should be and is still doing – and another to actually have your own farm here on site. It’s also important as we move into the future, where we will have more and more people living in urban settings, to get more creative with the way that we’re growing food, utilizing available space and resources. We have a lot of food being produced in a small area here. And with our farm, we know exactly what we’re feeding our patients and visitors. Most food travels about 2,000 miles before it hits our plate and here we only need to move food 1,000 feet.
The other harvest that comes out of this farm is knowledge. Things like staff being able to volunteer and education programs through The Teaching Kitchen make it a much fuller package for the hospital beyond just the food. It’s great to support local farms, but this allows us to have those interactions and other touch points.
The most exciting thing to me is being at the forefront of this conversation around hospitals and local, organic food and how it ties into the larger sustainability project of BMC. I hope it will be a model for other hospitals.
Q: What’s next for the rooftop farm?
A: I would love to see BMC start prescribing vegetables from the farm to patients, kind of like a patient community-supported agriculture (CSA) membership through our farm.
I want to figure out how to get more staff and patients opportunities to engage with the farm. For example, our two beehives were painted by patients in the Pediatrics unit. They had a lot of fun and now we have two beautiful beehives, so we’re looking for more creative ways like that to get people involved.
We also want to do more education. We’re starting with a two-week summer camp through The Teaching Kitchen and we want to be able to expand that. One thing we’re looking at is working with The Teaching Kitchen on a “harvest to preparation” class where people can come to the farm and see how the food is harvested, then cook it in The Teaching Kitchen.
With the food, I would love to figure out ways where it can be more visual for people. They’ll be eating it either way, but there’s value in people knowing that they’re eating an organic, local salad from our farm. I’d also love to have an affordable farmer’s market for patients, since we’re producing a lot more food than we thought we would.
Q: What do you do for fun outside of work?
A: I cook and ferment a lot. I’m obviously very passionate about food! I’m into brewing beer and mead and making sauerkraut and kimchi. I’m also a big outdoor person, so I love to hike, run, bike, and camp. I try to get outside as much as possible.
I’m also getting my master’s degree in agroforestry, which looks at combining agriculture and growing trees to fight climate change through farming practices. And I work for the Anti-Racism Collaborative in Cambridge and teach a few permaculture design courses each year.
BMC frequently receives letters from patients sharing their experiences with the hospital. This letter was sent to Mia Amado, senior director of the Food and Nutrition Department.
I am currently a patient at BMC, writing to you in regards to the food and service I have received. I am a long-time vegetarian and manager of a restaurant. Working in the food industry, I know the good is often overlooked. I have been waited on by Najat and the gentleman Jaques on maternity. They are both an asset to your team.
Every morning I am met with smiles and a pleasant greeting from your servers. They have gotten to know my needs and have been very accommodating to my diet. I have been surprised that even when I have slept through the meal selection they remember that I love a side of vegetables with everything. I know it can be hard to please everyone, especially with special diets so common. They have made my hospital stay brighter and they should be recognized for their hard work.
BMC Named a Most Wired Hospital
Boston Medical Center was named a Most Wired Hospital by the American Hospital Association. This award recognizes hospitals that are using technology to create more ways for patients to access health care services and capture health information.
“The award is based on our overall IT program, including level of clinical functionality, administrative functionality, interoperability, infrastructure robustness, and security,” says Arthur Harvey, vice president and chief information officer. “The award recognizes ITS’s hard work across many projects and services - there is no single project that wins this award. I’m very proud of all the work we’ve done to make BMC a most wired hospital.”
Davidson Hamer Wins University of Vermont Medical Alumni Association Achievement Award
Davidson Hamer, MD, a physician in the Infectious Disease practice at BMC and a professor of global health and medicine at BU Schools of Public Health and Medicine, was honored with a Medical Alumni Association Achievement Award from the University of Vermont. Hamer was honored for his over 25 years of field research on malaria, pneumonia, neonatal and child survival, maternal health, micronutrient deficiencies, and HIV/AIDS in resource-limited countries in sub-Saharan Africa, South Asia, and South America. This work has yielded the World Health Organization, UNICEF, and Ministries of Health in Africa to change health policies, guidelines, and program implementation on maternal child health. Hamer is also an adjunct professor of nutrition at the Tufts University School of Nutrition Science and Policy and principal investigator for GeoSentinel, a global surveillance network of 66 sites in 30 countries that studies disease emergence and transmission patterns throughout the world.