Blog Archives
By aoguagha | Categories: | Comments Off on Paths to Recovery Clinic
In 2023, Parkland Health created a bridge clinic, Paths to Recovery, in response to the growing opioid epidemic impacting their patients. The program provides access to evidence-based treatment for opioid use disorder, with the goals of reducing hospital readmissions and improving overall patient health. The clinic connects patients to long-term care and community resources to support sustained recovery. The program also emphasizes improving treatment adherence and coordinating care across inpatient units, emergency medicine, outpatient services, and community partners. Patients are evaluated by an addiction medicine provider, supported by a multidisciplinary team that includes peer recovery navigators, social workers, psychotherapists, and pharmacists, then connected to community services to address social needs such as housing, employment, education, and nutrition assistance.
By decreasing preventable readmissions and reducing repeat emergency department visits, Paths to Recovery helps lower uncompensated care and generates cost-saving measures for the health system. Learn more here.
By Amanda Jepson | Categories: | Comments Off on Baystate Health Engages Employees in Sustainability Efforts
Baystate Health, in Springfield, Mass., developed a comprehensive sustainability strategy to reduce greenhouse gas emissions among staff in their facilities.
These efforts begin at onboarding. Baystate uses internal and external communications like newsletters, social media, and a sustainability webpage to ensure that programs are visible and accessible.
On the hospital’s medical intensive care unit, clinicians and nurses formed a sustainability committee and worked with management and the sustainability team to expand recycling on the unit. Climate and Coffee, an annual event that draws roughly 750 staff members across three hospitals, offers updates on sustainability efforts and invites staff to learn how they can participate, especially in reducing clinical waste. The health system also hosts a monthly onsite farmers market featuring local vendors to promote healthy eating while reinforcing sustainability values.
The Unusable Medical Supplies Collection initiative, in partnership with Partners for World Health, diverts supplies no longer suitable for patient care to health aid programs abroad, leveraging nurse and physician staff efforts. Additionally, the health system expanded its medical device reprocessing and buyback effort to include additional kinds of devices, which saves money and reduces landfill waste.
This model shows how embedding sustainability into culture and making it part of workplace norms, not just facility operations, can empower employees as change agents and help maintain momentum over time.
By aoguagha | Categories: | Comments Off on Prevention and Recovery in Opioid Use Disorder (PROUD) program
Through the Prevention and Recovery in Opioid Use Disorder (PROUD) program at the Chesapeake Regional Medical Center, patients work with physicians in the emergency department to create individualized treatment plans to support recovery from opioid use disorder and other substance use conditions. Additionally, patients are connected to an outpatient community partner to continue their treatment with guaranteed follow-up within 72 hours after release from the emergency department. The majority of PROUD program participants are uninsured and struggle with multiple social determinants of health; however, patients are not turned away due to financial limitations.
The program partners with the hospitalist and emergency medical services teams within the hospital to provide care through a mobile clinic for street outreach. Future enhancements aim to expand partnerships with outpatient clinics and increasing mobile outreach efforts.
By aoguagha | Categories: | Comments Off on Building Recovery Integration for Drug Users into Emergency Medicine (BRIDGE)
Tampa General Hospital’s Building Recovery Integration for Drug Users into Emergency Medicine (BRDIGE) program offers a range of services, including a mobile suboxone clinic, an office-based opioid therapy clinic, mental health and substance use counseling, and essential wrap-around services to improve post-discharge outcomes, decrease re-admissions and shorten the length of hospital stays all while providing world-class care to adults struggling with opioid use. The program, which opened Florida’s second legal syringe exchange that treats over 2,000 patients, is making a significant impact in the community.
The BRIDGE program collaborates with the Hillsborough Housing Authority to assist patients with housing instability, collaborates with local food banks to expand their ability to address food insecurity through mobile pantry days, and recently engaged a volunteer attorney to provide free consultations to patients facing legal challenges that can hinder their full engagement in their recovery program.
By Amanda Jepson | Categories: | Comments Off on The Digital Health Center: A Centralized Approach
Following a critical incident where delayed imaging led to advanced metastatic disease in a patient, Parkland Health conducted a subsequent analysis that revealed 17 percent of patients requiring follow-up imaging were overdue, leading to the development of the Digital Health Center (DHC). The DHC has three primary goals: provide eSupport to improve digital literacy and engagement for historically marginalized communities, implement safety net surveillance for high-risk conditions to prevent care gaps in vulnerable populations and conduct tactical outreach to engage patients with poorly controlled conditions and high socioeconomic risk.
The DHC transforms traditional passive follow-up into systematic intervention through digital health support, telehealth services, and remote patient monitoring. Following early successes, this integration of digital health support has been incorporated into the organizational strategic plan and applied to 11 other programs. Initially, funding for the DHC came from internal organizational investment. Since the pilot, the DHC has secured a $9.8 million grant to expand.
The DHC thrives through a multidisciplinary team of registered nurses, medical practice assistants, licensed vocational nurses, social workers, and virtual care physicians. This team maintains clinical workflows and processes, patient tracking systems, resource coordination with community organizations, and care progression pathways. An electronic health record consultant works closely with frontline staff to ensure digital health support is integrated functionally and that tools align with daily operational needs. Additionally, the DHC regularly engaged with the Patient Family Advisory Committee, which meets quarterly to discuss virtual care and digital health initiatives.
The program has had an impact in several key areas. Clinically, emergency room utilization has been reduced by 1.5 visits per patient in hypertension outreach, and blood pressure has improved in patients from historically marginalized communities. Social workers have connected patients to critical resources, including transportation, prescription drug coverage, and housing.
By Amanda Jepson | Categories: | Comments Off on Optimizing Access and Management for Opioid Use Disorder
JPS Health Network developed a bridge clinic to respond to pervasive under-treatment of opioid use disorder (OUD). It is a low-barrier model for enhancing linkage to long-term care and optimizing transitions to outpatient care for patients who screen positive or self-identify for OUD.
Key activities for the bridge clinic include treatment initiation, where patients identified with OUD receive immediate treatment; referral to the bridge clinic; and wraparound support services that address clinical, behavioral, and social needs. The clinic connects patients to appropriate follow-up care and provides harm reduction education. The bridge clinic is co-located within the emergency setting to reduce delays and increase efficiency. Screening, treatment, and referrals are all streamlined into the electronic health record system. The Substance Abuse and Mental Health Services Administration procured funding for the bridge clinic to support initial development, which became sustainable through program-generated revenue and cost savings.
The bridge clinic involves an interdisciplinary team of emergency medicine clinicians, behavioral health specialists, case managers, peer navigators, primary care providers, hospital administrators, researchers, and community partners. The team works outside of traditionally siloed departments, allowing them to identify and remove barriers to program development and implementation rapidly. The program involves multiple partners, internal to the health system and external community organizations.
Since initiation in January 2021, the bridge clinic has served more than 1,100 patients. Linkage to long-term care within 120 days increased 25 percentage points for patients referred to the bridge clinic compared with usual care. Inpatient admissions within 120 days decreased by 8 percent among patients without severe mental illness.
By Amanda Jepson | Categories: | Comments Off on Center for Comprehensive Addiction Treatment, “No Wrong Door”
Bergen New Bridge Medical Center in Paramus, N.J., established the Center for Comprehensive Addiction Treatment (CCAT) in response to an increase in patients returning to the hospital for addiction treatment post-discharge. The Center aims to expand availability and access to withdrawal management services and overall substance use disorder treatment.
The Medical Center offers numerous levels of care, including involuntary and voluntary crisis units, withdrawal management, and short-term residential care, allowing a “No Wrong Door” approach that supports immediate direct patient access. The multidisciplinary team consists of psychiatrists, physicians, nurse practitioners, nurses, social workers, and substance use disorder staff. CCAT offers peer recovery specialists who model what recovery could look like for patients. The program mitigates social determinants of health by tackling food security, housing, and transportation—barriers to successful treatment for many patients—and focuses on expanding accessibility to services for underserved, marginalized populations.
Partners for the program include Rutgers University, Integrity House, CarePlus NJ, and other substance use disorder treatment programs, strengthening the culture of change and continuous improvement. Bergen New Bridge hosts community partners including Alcoholics Anonymous and Narcotics Anonymous as well as medication-assisted treatment meetings to provide an all-encompassing approach to care for these patients.
Since starting the program, the Medical Center has expanded its licensures for additional outpatient programs, including adolescent services. Additionally, the team has introduced family nights to provide education about substance use disorders, treatment options, and recovery. In 2024, the program served 3,938 individuals with inpatient care and provided 17,613 units of intensive outpatient care to patients throughout New Jersey. On the office-based addiction treatment level of care, providers have supported and maintained 1,560 individuals in treatment for substance use disorder services. Rates of treatment refusal post-discharge have decreased from 21 percent in 2022 to 12 percent in 2024. The rate of leaving against medical advice also dropped, from 13.59 percent in 2022 to 8.6 percent in 2024.
By Amanda Jepson | Categories: | Comments Off on Hospital-Led Outreach to Reduce Anemia at Time of Delivery
Anemia in pregnancy increases the risk of needing a blood transfusion at the time of delivery threefold. It contributes to approximately 20 percent of severe maternal morbidity in historically marginalized groups. The transfusion rate at Natividad Medical Center, in Salinas, Calif., increased rapidly between 2021 and 2022, and anemia at the time of delivery had a prevalence of 18.8 percent of all births at Natividad. This problem was particularly evident in the Latina and Indigenous patient populations Natividad serves. Hospital leadership created this program to decrease the prevalence of anemia at the time of delivery and decrease Natividad’s transfusion rate.
Natividad’s systemwide leadership, including community clinic leadership, collaborated to create a multi-pronged approach to diagnose and treat antepartum anemia rates. This program includes educating staff on the negative effect of anemia and how to monitor and treat iron deficiency, as well as monitoring patients’ hemoglobin and iron stores throughout pregnancy.
Natividad created an infusion center to provide access to IV iron. Hospital leaders recognized that Medi-Cal only covered an iron infusion that required eight visits to infuse 1 gram of iron, which places a significant burden on patients that face transportation, financial, and time-related barriers to care. In response, Natividad collaborated with its Medicaid health maintenance organization to secure payment for single-dose IV treatments, increasing access to care.
The chief of obstetrics at Natividad worked with medical leadership at the community clinics to develop best practices for the program, which led to robust evaluative efforts and peer-to-peer learning. From January 2023 to August 2024, the overall rate of anemia at participating clinics fell from 18.4 to 11.7 percent, while the anemia rate at nonparticipating clinics increased from 22.3 to 26.5 percent. In 2022, the Indigenous patient population had higher rates of anemia—20.6 percent, compared with 18.4 percent for non-Indigenous patients. By 2024, both groups had decreased anemia rates—12.1 percent for Indigenous patients and 11.6 percent for non-Indigenous patients—and the gap between rates closed.
By Amanda Jepson | Categories: | Comments Off on The Clinical Patient Workflow Optimization
Average length of stay (ALOS) is a critical metric that measures the average time a patient spends in the hospital from admission to discharge. Regional One Health initiated the Clinical Patient Workflow Optimization (CPWO) program to reduce patients’ ALOS while maintaining high-quality care, improving operational workflows, minimizing hospital-acquired infections, and optimizing resource allocation.
CPWO activities include daily multidisciplinary huddles, virtual rounding, daily utilization reviews, monthly tactical reviews, and systematic data collection and analysis. These interventions create opportunities for better communication with patients and families and real-time identification of barriers. The program standardizes care protocols, identifies workflow gaps, and improves staff communication.
This enhanced collaboration among physicians, nurses, rehabilitation specialists, social workers, case managers, and ancillary teams ensures coordinated efforts in patient care planning and discharge execution. The program has fostered a continuous improvement culture, incorporating team members’ insights and tracking data metrics. To measure program success, Regional One Health tracked patient length of stay, patient discharge disposition, hospital readmission rates, case mix index, time from observation to expected discharge, bed turnover data, and harm events throughout the hospital. The health system collected patient data from electronic health records and a patient flow monitoring system, and digital dashboards streamlined data collection and analysis. Patient surveys provided integral qualitative feedback on patient experiences.
Between 2022 and 2024, Regional One Health reported a 42 percent reduction in harm events and an 80 percent decrease in the emergency department’s hours spent on diversion. In addition to that, noticed an improvement in patient experience scores by 15%. As a result of reducing ALOS by 0.85 days, the health system achieved an increased net revenue of more than $18 million. Since the health system integrated the program, hospital-acquired infections have decreased by 55 percent.
By Amanda Jepson | Categories: | Comments Off on Bringing the Justice System to Outpatient Addiction Care
Harris Health System’s Office-Based Addiction Treatment (OBAT) Program integrates physical, social, behavioral, and mental health to treat patients with substance use disorder (SUD) in a non-stigmatizing environment—the primary care setting. The program provides extensive support to patients with SUD and works to decrease drug misuse to less than 30 percent of the patient population. Additionally, it provides assessments and follow-up care for body mass index, depression, and tobacco use.
A team of nurses, community health workers, medical doctors, and executive leadership educates participants on establishing their place in the community, prioritizing their mental health, and practicing self-care to keep a healthy mindset. Eighty percent of OBAT participants are uninsured or underinsured. The program identifies social determinants of health on a case-by-case basis and takes measures to mitigate noncompliance risks with treatment plans. Since its 2017 inception, the OBAT program has been funded through federal Substance Abuse and Mental Health Services Administration grants, multiple state grants, and university research partnerships.
In 2022, Harris Health System’s OBAT partnered with the Harris County Success Through Addiction Recovery (STAR) Drug Court Program to better serve patient needs. The STAR program uses a unique judicial model of treatment and education to support recovery from substance use and mental health disorders and reduce the expense of criminal case processes and incarceration. This partnership allows the Harris Health OBAT team to visit the courts monthly to speak with clients about the program; discuss topics related to substance use, addiction, suicide, and overdose prevention; and provide connections to community resources. Additionally, the OBAT team partnered with Harris Health’s Health Care for the Homeless Program to provide mobile medical unit services outside of the courts for six months.
The program currently serves 287 opioid use disorder and 97 alcohol use disorder patients. OBAT participants have shown significant decreases in drug misuse, and 93 percent of program participants are opioid-free within six months. In collaboration with STAR, Harris Health System educated 730 clients on suicide and overdose prevention between November 2022 and September 2024, and distributed more than 300 boxes of naloxone to clients and courts.
