Exemplary Professional Practice: Care Delivery System(s) EP5 Nurses are involved in interprofessional collaborative practice within the care delivery system to ensure care coordination and continuity of care. EP5b: Provide a description, with supporting evidence, of nurses’ involvement in interprofessional collaborative practice that ensures care coordination and continuity of patient care. Introduction Addiction is defined as a primary, chronic brain disease characterized by compulsive use despite harm. It is a disease in and of itself. This can be the hardest part for family members, clinicians, and the public to come to terms with because addiction is completely irrational. It is a disease that hijacks the part of the brain that makes rational decisions and weighs risks and benefits. So just like a person with a stroke may be unable to use language or move a part of their body, a person with addiction is literally unable to use the part of the brain that can look at negative consequences and make a rational judgment about using. It is also for many people a chronic disease, meaning that people don’t get “cured” but rather treatment allows an individual to manage their illness and minimize relapses. The U.S. Department of Health & Human Services describes opioid abuse as a serious public health issue reaching epidemic proportions in the United States. Opioid-related deaths have been on the rise across the country, with Massachusetts surpassing the national average. At the Massachusetts General Hospital, the Emergency Department (Ellison 1/Lunder 1) feels the full impact of this patient population. The Emergency Department cares for over 9,000 substance use disorder (SUD) patients each year, seeing an average of 26 patients per day. Twenty-two percent of SUD patients are admitted to MGH as inpatients or for observation, while the other 78% are discharged by the Emergency Department. MGH Substance Use Disorder Initiative In 2014, Massachusetts General Hospital identified substance use disorder as a key clinical priority and designed a broad strategic initiative to improve the quality of care for these patients. MGH recognized the need for SUD care to shift from an acute, episodic approach to chronic care management and developed a new, integrated model with strong connections and linkages between inpatient, outpatient and community based services. This model leverages the clinical talents of the interprofessional team to ensure care is coordinated across the care delivery system and continuity of care is maintained, a key to therapeutic success in this population. Key components of the model include the Inpatient Addictions Consult Team, the Bridge Clinic and Recovery Coaches.
Transcript
Exemplary Professional Practice: Care Delivery System(s)
EP5 Nurses are involved in interprofessional collaborative practice within the care delivery system to ensure care coordination and continuity of care.
EP5b: Provide a description, with supporting evidence, of nurses’ involvement in interprofessional collaborative practice that ensures care coordination and continuity of patient care.
Introduction
Addiction is defined as a primary, chronic brain disease characterized by compulsive use despite harm. It is a disease in and of itself. This can be the hardest part for family members, clinicians, and the public to come to terms with because addiction is completely irrational. It is a disease that hijacks the part of the brain that makes rational decisions and weighs risks and benefits. So just like a person with a stroke may be unable to use language or move a part of their body, a person with addiction is literally unable to use the part of the brain that can look at negative consequences and make a rational judgment about using. It is also for many people a chronic disease, meaning that people don’t get “cured” but rather treatment allows an individual to manage their illness and minimize relapses.
The U.S. Department of Health & Human Services describes opioid abuse as a serious public health issue reaching epidemic proportions in the United States. Opioid-related deaths have been on the rise across the country, with Massachusetts surpassing the national average. At the Massachusetts General Hospital, the Emergency Department (Ellison 1/Lunder 1) feels the full impact of this patient population. The Emergency Department cares for over 9,000 substance use disorder (SUD) patients each year, seeing an average of 26 patients per day. Twenty-two percent of SUD patients are admitted to MGH as inpatients or for observation, while the other 78% are discharged by the Emergency Department.
MGH Substance Use Disorder Initiative
In 2014, Massachusetts General Hospital identified substance use disorder as a key clinical priority and designed a broad strategic initiative to improve the quality of care for these patients. MGH recognized the need for SUD care to shift from an acute, episodic approach to chronic care management and developed a new, integrated model with strong connections and linkages between inpatient, outpatient and community based services. This model leverages the clinical talents of the interprofessional team to ensure care is coordinated across the care delivery system and continuity of care is maintained, a key to therapeutic success in this population. Key components of the model include the Inpatient Addictions Consult Team, the Bridge Clinic and Recovery Coaches.
1
SUD Comprehensive Approach to Care
Inpatient(ACT)
Outpatient Community
Recovery Coaches
Bridge Clinic
Prevention, Education & Evaluation
Addictions Consult Team (ACT) The Addictions Consult Team (ACT) is an interprofessional inpatient consult team of addiction experts providing patient assessment and treatment recommendations including standardized withdrawal management and pharmacotherapy initiation. This inpatient team of internists, psychiatrists, advanced practice nurses, social workers, and recovery coach utilizes a specialized interdisciplinary approach that improves access to treatment, and facilitates transitions between inpatient, outpatient and community care. ACT collaborates with other departments, including Case Management and Pharmacy, to ensure inpatient care is comprehensive and individualized. A physician or nurse practitioner (NP) provides initial consultation and frequently a social worker consultation is indicated as well. A recovery coach is embedded with the ACT / Bridge Clinic to provide peer coaching and support to patients. The MGH Addictions Consult Team was launched in October of 2014 (attachment EP5b.a) and has been implemented hospital-wide since Dec 2016. ACT leadership includes co-medical directors from Medicine and Psychiatry, Sarah Wakeman, MD and Mladen Nisavic, MD and a Nurse Team Leader, Christopher Shaw, PMHNP-BC, Adult Psychiatric and Mental Health Nurse Practitioner. Other members of ACT include: Hasena Omanovic, MSN, PMHNP-BC (ACT/ Bridge Clinic) Marissa De Mirelle, Clinical Social Worker, LICSW Lorraine Salada, Clinical Social Worker, LICSW Jacqueline Bango, Clinical Social Worker, LICSW Nicole Bourgeois, Recovery Coach (ACT/Bridge Clinic)
In addition to the regular staff members listed, Psychiatry and Medical residents rotate on staff, spending 2-4 weeks with the team.
Bridge Clinic The MGH Bridge Clinic does just that, bridging the treatment gap by providing care to patients who need addiction care, but lack community based providers. This includes inpatients on discharge as well as patients from the ED and primary care clinics. The clinic provides medication management, peer support services, stabilization and linkages /referral to outpatient treatment services. Physicians and Nurse Practitioners provide pharmacotherapy and referrals to outside treatment services/providers, while Recovery Coaches provide peer support services. At a patient’s first Bridge Clinic meeting, the MD or NP, Clinical Social Worker, Recovery Coach and Resource Specialist develop a plan of care with the patient. Recovery Coaches provide peer support services to patients and the Resource Specialist helps with referrals to outpatient/residential programs and seeks out providers in the community able to provide ongoing support to patients once discharged from the Bridge Clinic. Typically patients are supported by the Bridge Clinic for 2-6 months. Bridge Clinic staff include: Dr. Laura Kehoe, MD, Medical Director Hasena Omanovic, MSN, PMHNP-BC Sophia Volcy, Resource Specialist Samantha Ciarocco, LICSW, Clinical Social Worker Nicole Bourgeois, Recovery Coach Jasmine Webb, Administrative Coordinator
Recovery Coaches Recovery Coaches provide peer support services to patients. They have all previously struggled with addiction themselves and have proven to be a valuable resource to patients and their families. These Recovery Coaches/community health workers receive formal training and supervision and like the ACT/Bridge Clinic Recovery Coach, are embedded in the Outpatient/Community setting. MGH Internal Medicine Associates (IMA): Erin White MGH Charlestown: Efran Lozada MGH Chelsea: Raina McMahon MGH Revere: Michael Phillips MGH Bulfinch Medical Group (BMG): Stephen Keizer Care Coordination and Continuity An example of the comprehensive approach to care of a SUD patient at the MGH is illustrated with the following example of patient MQ. On October 1, 2016 MQ, a 29-year old male, was admitted to the Medical Intensive Care Unit (Blake 7) with a severe drug overdose, requiring intubation and mechanical
ventilation. On October 3, 2016, he was transferred to the General Medicine Unit (Ellison 16) and a referral was placed for ACT. Hasena Omanovic, MSN, PMHNP-BC, conducted an initial consultation that same day. She noted that MQ was not interested in any addiction services, but he agreed to accept community resources that might help him on discharge. The following day, October 4, 2016, Marisa De Mirelle, Clinical Social Worker, LICSW, met with MQ and began aftercare planning support (attachment EP5b.b). MQ was identified as a suicide risk by Psychiatry and the decision was made to transfer MQ to an inpatient psychiatric unit. The MGH Psychiatry Unit (Blake 11) was full so Kristen Mohan, RN, BSN, Case Manager coordinated his transfer to McLean Hospital in Belmont, MA, on October 5, 2016. Her note informed the team that MQ would be transferred to McLean Hospital via ambulance at 5:30pm (attachment EP5b.c). On October 31, 2016, following his discharge from McLean, MQ met with Dr. Mary Zeng, M.D. Outpatient Psychiatry. MQ was no longer denying his problematic substance abuse and agreed to Dr. Zeng’s aftercare treatment plan, which included a referral to the Bridge Clinic. MQ had his initial Bridge Clinic visit on November 2, 2016 and continued with the clinic until the end of March 2017. The Bridge Clinic notes written by Omanovic detail that MQ received Suboxone medication, peer coaching and participated in group therapy. On March 8, 2017, Omanovic and MQ reviewed the plan for MQ to transition from the Bridge Clinic to a community based provider at the end of March, 2017 (attachment EP5b.d). Dr. Daniel M Horn, a PCP with Internal Medicine Associates (IMA) assumed primary care for MQ and they met on March 30, 2017. Horn’s note detailed the ongoing plan for suboxone treatment, and monthly visits (attachment EP5b.e).
MQ’s journey demonstrates how a committed interprofessional team collaborates to coordinate care and ensure continuity of care across the care delivery system. The continuity of care provided by Omanovic highlights the key role nurses play in collaborative practice and the ongoing support provided to patients struggling with addiction.
Progress Notes Date of Service: 10/5/2016 4: 13 PM
Kristen Marie Mohan, RN Case Management
Psychiatric Consultation Case Management
MRN:. · Description:
The patient has been clinically accepted for transfer to McLean Hospital Belmont with an available bed for 6:00p. The plan will be to transfer the patient via ambulance under Section 12, and current psychiatrist will provide Section 12 prior to transfer. Fallon Ambulance has been scheduled for 5:30p. Psych CL MD and current medical team are aware of, and in agreement with, this plan. Please provide the patient's AVS / DC Summary in preparation for the discharge.
Kristen Mohan, RN Beeper #:2387 4
ED to Hosp-Admission (Discharged) on 10/1/2016
Case Management Note
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Progress Notes Encounter Date: 10/31/2016
Mary C Zeng, MD y t1
MRN: Description:
Pt arrived on time for appt. He is s/p MICU > medicine admission for Klonopin OD, transfer to McLean STU, then transfer to LEADER program. For full details of hospitalization course, please see discharge summaries from those facilities.
reports having experienced a profound shift in mindset from the close call and subsequent treatment. "I was lying to myself and believed every lie." Since then says that he has embraced his problematic substance use and made significant steps to change it. Since discharge on Thurs denies using any substances whatsoever, has been going to up to 3 AA/NA meetings per day. Says that his family, including wife and father, are extremely supportive and know the full context of his use and what's involved in his recovery. Wife has been dispensing his Suboxone for him every morning from a lock box and gave him a congratulations card for 30 days sober, which he just recently achieved. His workplace knows everything about what he's been going through, since they were the ones who discovered him after the OD, and have given him paid leave "for as long as I need" to work through his SUD issues.
Was not agreeable to going to a higher LOC such as Brattleboro or Starlight due to feeling guilty about leaving his son for so long. Wanted to be at home with family. Therefore, aftercare plan consists of therapy/psych meds with me at HB, WEC IOP and bridge clinic for Suboxone both to start this Wed, AA/NA meetings, family therapy for wife and others at HB.
I went over in detail with him the team's encouragement, questions, and concerns, including that this may be a honeymoon period, that recovery is a long process with relapse always possible, and that he has an abundance of supports through his treaters, workplace, and family should he need it. Gave him all my contact info and directions for paging me and/or going to the ED in case of emergency, which for him I have defined as including relapse or desire to use again.
Reports no cravings whatsoever on Suboxone, says it's working great.
Current meds: Suboxone 16 daily Seroquel 200 qhs - not been taking since discharge, wants to try sleeping w/o meds
A/P: 29 yam, US Navy vet with no deployments/trauma/blast exposure, with lifelong anxiety and insomnia, BZD use d/o and OUD, 2 prior LEADER admissions who presents for f/up after most recent LEADER discharge following a near-fatal overdose on Klonopin requiring ICU admission and intubation.
Pt reports being much improved and indeed appears highly motivated to maintain sobriety. My concern is that he also presented in much of a similar fashion after his first LEADER discharge when he relapsed immediately thereafter. I, HB team, and WEC team will be providing as robust aftercare supports as we can in this transitional period to home, including recommended a longer-term residential treatment as indicated.
Diagnoses Primary: SUD (opioids, BZDs, gabapentin)
Bridge Clinic Notes
Secondary: anxiety NOS, insomnia
-c/w Seroquel 200 qhs if pt desires, otherwise can die
-wife dispenses pt's Suboxone; prescription deferred to bridge clinic/WEC-pt has bridge clinic and WEC IOP appts on Wed 11/2-f/up utox and VPAIN weekly-continue weekly therapy at HB-family also receiving therapy at HB-given my contact info and instructions in case of emergency, including danger of relapse-RTC in 1 week
HPI: is a 29 year old man with h/o anxiety d/o, SUD (opioids, BZDs, gabapentin) who comes here today as a referral from ACT. He was seen by this provider during his last hospital stay here for respiratory failure in the setting of opioid/ bzd overdose. At the time he was on suicide precautions and was also treated for aspiration pneumonia. After he was discharged from MGH he spent about a week or so at McLean (inpatient psych) then was transitioned to their 14 day LEADER program. has been home for about a week now, feels "great". Reports "33 days clean". He is engaged in daily meetings and is grateful for everyone involved in his care.
PMH:
Active Ambulatory Problems Diagnosis
• Moderate recurrent major depression• Elevated blood pressure• Lumbar herniated disc• Health care maintenance• Insomnia• Migraine• Pigmented nevus• Pain in joint, ankle and foot• Panic disorder• Overdose of drug/medicinal substance• Aspiration pneumonia• Benzodiazepine dependence• Opioid abuse with intoxication• Migraine• Diarrhea
• Migraine with aura• Benign melanoma• Airway trauma
• History of psychiatric careDate
07/29/2014 01/04/2014 10/02/2016
• Severe major depression, single episode, without psychotic features 4/7/2016
SUBSTANCE USE HISTORY: Marijuana: Smoked "once a month", helps with "anxiety and insomnia". Has not used any over the last month. Opioids: Used Vicodin pills since age 17. Up until recently "3-4 day" .He was able to obtain Vicodin from his father (who gets them prescribed) for medical reasons. Bzd: Previously prescribed bzd, then was misusing prescription. Frequently asked for early refills. This lead to last overdose. Has not used any over the last month. Alcohol: Denies Cocaine: Denies Other substances: Gabapentin misuse history, none since last hospitalization
Overdose x 1. Completed the LEADER (Law Enforcement, Active Duty, Emergency Responder) Program at McLean x 2. Go to AA and NA (daily) Now on Suboxone--- doing well on current dose
PSYCHIATRIC HISTORY: Depression (previosly on SSRI) Anxiety
Trauma: denies
Legal: denies Attended work und_er the influence of Klonopin in May 2016, placed on medical leave x 2 weeks. No active probation. No incarceration history.
Hospitalizations: denies
Receives behavioral health tx through Home Base on Merrimack Street. Has an intake at WEC today for psychopharm.
FAMILY HISTORY: Grandmother and 2 cousins with SUDs.
SOCIAL HISTORY: Patient lives in Malden with wife and two sons. Has a lot of support from family and friends. Patient works as a police officer for the city of Malden. He is taking time off work now to get better. Patient attend college at Umass Dartmouth. Patient is a veteran with no deployments/trauma/blast exposure.
ROS: As per HPI above, otherwise a 10 point ROS reviewed and unremarkable.
Current Meds: Current Outpatient Prescriptions: • buprenorphine-naloxone (SUBOXONE) 2-0.5 mg Subl, Place 2 tablets under the tongue 2(two) times a day., Disp: , Rfl: , Last Dispense: Unknown (outside pharmacy)• ibuprofen (ADVIL,MOTRIN) 800 MG tablet, Take 1 tablet (800 mg total) by mouth every 6 (six)hours as needed (headaches)., Disp: , Rfl: , Last Dispense: Unknown (outside pharmacy)• SUMAtriptan (IMITREX) 100 MG tablet, Take 100 mg by mouth as directed. q2h x2 PRNmigraine, Disp: , Rfl: , Last Dispense: Unknown (patient-reported)• [DISCONTINUED] zolpidem (AMBIEN) 10 mg tablet, Take 10 mg by mouth nightly. PRNinsomnia, Disp: , Rfl: , Last Dispense: Unknown (patient-reported)
ALLERGIES:
• No Known Allergies
PHYSICAL EXAM: BP 128/66 Pulse 70 Sleep improved. Previously on Ambien (d/c'd while at McLean). Was on seroquel- self d/c'd after hospitalization. Good appetite No recent illness Occasionally takes imitrex for HA No oversedation. Denies cravings.
Date 10/31/2016 10/31/2016 10/31/2016 10/31/2016 10/31/2016 10/31/2016 10/31/2016 10/31/2016
10/2/16 9:55 AM 10/2/16 3: 19 AM 3.8 3.4 0.4 0.4 <0.2 <0.2 73 72
30 32 39 40 6.4 6.0 2.6 2.6
Appearance: well groomed and appropriately dressed Behavior: cooperative and eye contact good Psychomotor Activity: normal Musculoskeletal: moves all extremities; no abnormal movements Station/Gait: normal Speech: regular rate, regular rhythm and regular volume Language: normal comprehension and fluent Mood: "great" Affect: smiles Thought Process: goal directed Associations: no loosening of associations Thought Content: no delusions and no obsessions Suicidal/Homicidal Ideation: no suicidal ideation and no homicidal ideation Perceptions/Experiences: no hallucinations Orientation/Sensorium: oriented x 3 and alert Memory: immediate recall intact. Attention/Concentration: intact to observation Abstract Reasoning: intact to observation Fund of Knowledge: average Insight: good Judgment: good
PMP: No unexpected findings.
RECOMMENDATIONS:
1. Continue Suboxone 8mg-2mg tab BID (7 day Rx given). Agreement signed.2. Narcan RX. Spouse has narcan as well.3. Follow up with MD/NP in 7 days4. Encouraged to join us for groups/coaching5. WEC intake today at 1 pm6. Oral tox x 2
I spent 30 minutes in this clinical encounter and >50% was spent in counseling and coordinating care.
HPI: Patient is a 30 y.o.male with h/o severe OUD who comes in today for suboxone follow up. has been doing well, reports no changes in health or medications since last visit. Has been
doing well on current dose of suboxone, has not had any cravings for opioids. No s/sx of active use, intoxication or withdrawal noted. Continues to meet with Malden chief of police, hopes to be able to go back to work soon. As of 2 weeks ago, he was told his deportment will need more time to make the decision of him going back to work, despite independent evaluation by MD who cleared him fit for work. has been sober for almost 6 months now, likely will be able to go back to work in the next 3 months or so. Patient continues to engage at Home Base for individual and couple's counseling as well as phychopharm. Goes to at least 2 meetings daily.
MEDS:
Current Outpatient Prescriptions: • buprenorphine-naloxone (SUBOXONE) 8-2 mg Subl, Place 2 tablets under the tongue dailyfor 14 days. OK to substitute film if tab not covered., Disp: 28 tablet, Rfl: 0, Last Dispense:Unknown (outside pharmacy)• ibuprofen (ADVIL,MOTRIN) 800 MG tablet, Take 1 tablet (800 mg total) by mouth every 6 (six)hours as needed (headaches)., Disp: , Rfl: , Last Dispense: Unknown (outside pharmacy)• SUMAtriptan (IMITREX) 100 MG tablet, Take 1 tablet (100 mg total) by mouth as directed.q2h x2 PRN migraine, Disp: 21 tablet, Rfl: 11, Last Dispense: Unknown (outside pharmacy)• [DISCONTINUED] zolpidem (AMBIEN) 10 mg tablet, Take 10 mg by mouth nightly. PRNinsomnia, Disp: , Rfl: , Last Dispense: Unknown (patient-reported)
PAIN MANi-\GEMENT PROFILE. URINE (Order #256275725) on 2/17/17 Other Results from 2/17/2017 Toxicology screen, urine Collected: 2/17/2017 1 :40 PM Status: Final result Visible to patient: No (Not Released) Next appt: 03/10/2017 at 11 :00 AM in Psychiatry (Mary C Zeng, MD) Ox: Screening
Ref Range & Units URINE PHENCYCLIDINE Negative URINE BARBITURATES Negative URINE CANNABINOIDS Negative URINE AMPHETAMINES Negative URINE Negative BENZODIAZEPINE
URINE OPIATES Negative Negative NegativeCM Comments: This assay is not sensitive for detection of oxycodone and oxymorphone. URINE COCAINE METABNegative Negative Negative URINE CREATININE mg/dL 107 120
Specimen Collected: Last Resulted: 02/17/17 1:40 PM 02/17/17 8:50 PM
Mental Status Exam: Appearance: well groomed and appropriately dressed Behavior: cooperative Psychomotor Activity: normal Musculoskeletal: moves all extremities; no abnormal movements Station/Gait: normal Speech: regular rate, regular rhythm and regular volume Language: normal comprehension Mood: "good" Affect: mood congruent Thought Process: goal-directed Associations: no loosening of associations Thought Content: no delusions and no obsessions Sicidal/Homicidal Ideation: no suicidal ideation and no homicidal ideation Perceptions/Experiences: no hallucinations Orientation/Sensorium: oriented x 3 and alert Memory: immediate recall intact. Attention/Concentration: intact to observation Abstract Reasoning: intact to observation Fund of Knowledge: average Insight: good Judgment: good
RESULT OF MassPAT: 02/22/2017 2 02/22/2017 BUPRENORPHIN-NALOXON 8-2 MG SL 28.0 14 JO JOY 00319296 CVS P (9357) 0 480.0 Comm Ins MA 02/08/2017 2 02/08/2017 BUPRENORPHIN-NALOXON 8-2 MG SL 28.0 14 LA KEH 00317823 CVS P (9357) O 480.0 Comm Ins MA 01/25/2017 2 01/25/2017 BUPRENORPHIN-NALOXON 8-2 MG SL 28.0 14 Ml BIE 00316214 CVS P (9357) O 480.0 Comm Ins MA 01/11/2017 2 01/11/2017 BUPRENORPHli\l-NALOXON 8-2 MG SL 28.0 14 ML NIS 00314644 CVS P (9357) 0 480.0 Comm Ins MA
01/07/2017 2 12/28/2016 BUPRENORPHIN-NALOXON 8-2 MG SL 7.0 4 ML NIS 00313024 CVS P (9357) 1 420.0 Comm Ins MA
PLAN:
1. Continue Suboxone at current dose x 28 days2. Urine tax screens done at Home Base--- reviewed- appropriate3. IMA PCP to take over Suboxone Rx at the end of March4. Bridge clinic phone call follow up on April 1st, verify transition to IMA
More than 50% of this 15 minute visit was spent on counseling and coordination of care.
Hasena Omanovic, MSN, PMHNP-BC P.28465
Office Visit on 3/8/2017
Progress Notes Encounter Date 3/30/2017
Daniel M Horn, MD Internal Medicine
Note Subject: Follow Up/Routine
HPI/ A&P:
Problem List Items Addressed This Visit Polydrug dependence including opioid type drug, episodic abuse
Current Assessment & Plan
MRN: Description:
This was an initial suboxone visit with me after -- who has been followed in the MGH bridge clinic since his overdose September 2016-- is now ready for transition back to primary management in the IMA. We reviewed his hx to date and his current goals.
Treatment team: -- Home base program weekly for therapy, family therapy, and groups -- NP Hasenovic at the bridge clinic -- His wife- who is doing regular pill counts and providing his suboxone I obtained a medical information release to share all medical information with his wife at any time. -- AA/NA; Attending 5 meeting weekly- does not yet have a sponsor
Substance abuse history: He was obtaining percocet previously from his father who continues to have a prescription, but has not found that being around his father to be a trigger.
He then began benzo abuse in the setting of panic symptoms around complications in his wife's pregnancy.
He has been stable at his current 16 mg dose since November. The bridge clinic had trasitioned him to monthly visits and prescriptions. He gets weekly utox at Homebase. Denies cravings, denies constipation. Has had no relapse since his overdose and is abstaining from EtOh.
Plan:
We reviewed the suboxone treatment agreement which was signed and scanned into the chart.
I provided a one month supply of suboxone at his standing dose of 16mg sublingual daily.
We agreed to continue monthly visits, with random utox. We also discussed the importance of ongoing transparency around relapse, cravings, side effects.
Primary Care Note
SUMATRIPTAN (IMITREX) 100 MG TABLET
Modified Medications
Modified Medication
BUPRENORPH INE-NALOXONE (SUBOXONE) 8-2 MG SUBL
Place 2 tablets under the tongue daily for 28 days. OK to substitute film if tab not covered.
Discontinued Medications
IBUPROFEN (ADVIL,MOTRIN) 800 MG TABLET
F/up: Monthly visits will be scheduled
Take 1 tablet ( 100 mg total) by mouth as directed. q2h x2 PRN migraine
Previous Medication
buprenorphine-naloxone (SUBOXONE) 8-2 mg Subl
Place 2 tablets under the tongue daily for 14 days. OK to substitute film if tab not covered.
Take 1 tablet (800 mg total) by mouth every 6 (six) hours as needed (headaches).
45 minutes spent with patient, over 50% counseling and coordinating care about management of his opiate abuse and our plan moving forward for suboxone therapy
Daniel M Horn, MD
Office Visit on 3/30/2017
From: Gallivan, Theresa M., R.N. Sent: Thursday, October 16, 2014 7:20 AM To: Good, Grace A.,N.P.; PCS Clinical Supervisors; Bethune Regan, Cristina M.; Donahue, Vivian E.; Fitzgerald, Patricia A., R.N.; Gonzalez, Colleen E, R.N.; Hall, Kathryn E.; Hughes, Maryfran, R.N.; Johnson, Stacy Hutton,R.N.; Joseph, Melissa,R.N.; Livelo, Jeanette N.,R.N.; Macchiano, Sara A.,R.N.; McKenna, Sharon; Mills, Jennifer C.,R.N.; Morash, Susan, R.N.; Moulaison, Walter J.,R.N.; Sargent, Jennifer L.,R.N.; Schnider, Maureen E.,R.N.; Silva, Judith H., R.N.; Sylvia-Reardon, Mary H.,R.N.; Tata, Lee Ann,R.N.; Tubridy, Aileen, R.N.; Winne, Maria D., R.N.; Ananian, Lillian, R.N.; Barba, Kate A., R.N.; Benacchio, Catherine, R.N.; Blanchard, Howard T.,R.N.; Casieri, Julianne A.,R.N.; Cierpial, Chelby L., R.N.; Collins, Jacqueline M.,R.N.; Culbert-Costley, Roberta,R.N.; Mahoney, Shannon A.,R.N.; Evans, Theresa E.,N.P.; Holmberg, Jacquelyn L.,R.N.; Gavaghan, Susan, R.N.; Haldeman, Sioban, R.N.; Harris, Catherine,R.N.; Larochelle, Nadine K.; Lasala, Cynthia A., R.N.; McDonald, Meghan L.,R.N.; McIntyre, Joyce A.,R.N.; Mian, Patricia, R.N.; Oertel, Lynn B., N.P.; Rudolph, Meaghan Morrison,R.N.; Staples, Monica G., R.N.; Stengrevics, Susan S., R.N.; Vallent, Heather J., R.N.; Wood, Susan L., R.N.; Banchiere, Jeremy; Gambon, Brian K.; Johansen, Kathleen A.; Kambegian, Jennifer L.; McCarthy, James C.; Powers, Lori A.; Roberts, Allen; Washington, Carolyn L. Cc: Annese, Christine Donahue, R.N.; Shaw, Christopher J.,N.P.; Omanovic, Hasena,CNP; Wakeman, Sarah, M.D.; Nejad, Shamim, M.D.; Nisavic, Mladen, M.D.; De Mirelle, Marisa E.; Salada, Lorraine; Bango, Jacqueline Mae; Bourgeois, Nicole Subject: FW:
Please see the attached for a progress update on the Addictions Care Team pilot.
A very dedicated, talented team of nurse leaders, physicians, social workers and administrators are collaborating every day to make this much needed resource a reality for our patients with substance use disorder ( SUD), and for all providing their care.
Please join me in thanking and supporting your colleagues, Sara Macchiano ND and Dawn Williamson Psych CNS/ED, both of whom have assumed substantial increased responsibility to help build a team structure and process that will ultimately support patients hospital wide.
Theresa
Theresa Gallivan, RN, MS Associate Chief Nurse Massachusetts General Hospital 55 Fruit Street, Founders 348 Boston, MA 02114 phone 617.724.1767 e-mail [email protected]
Promoting Excellence Every Day through knowledge and compassion www.mghpcs.org/EED
We thought it might be useful to update you regarding the new Addictions Consult Team (ACT), which was implemented on some medicine floors two weeks ago. Thank you to all who have utilized this new service. We received 36 consults in our first two weeks and look forward to continuing to collaborate with you in providing this service.
While we are excited to have this new service available for our patients, we’d like to take a moment to remind everyone of a few things:
1) This service is still in pilot phase and is strictly serving Bigelow Medicine(White 8, 9, 10, 11 and Bigelow 11), Ellison 16, Ellison 12 and Phillips 20.Teams on other floors seeking assistance on patients with substance usedisorders should continue to access the usual channels for support.
2) This is not a 24-hour service. All consults will be seen within 24 business hoursfrom the time of the request but if there is an urgent issue during non-businesshours, please contact the Acute Psychiatric Service (APS) or your usualchannels of support. Also, please note that currently there are no resources forweekend coverage and we will create an electronic resource for primary teams tohave available which may be utilized for patients who may be discharged duringthis or any other time that the ACT team may not be available.
3) At these early stages of the pilot, the team is still working its way to full-staffing,so we appreciate your patience as we aim to provide as many of our serviceofferings as possible to each patient.
To request an ACT consult, dial 4-SUDS between 8 AM and 4 PM Monday through Friday.
If you have any questions, concerns, or feedback on the service, please contact Naomi Kling ([email protected]) or e-mail the ACT group mailbox at [email protected].
Please join us in thanking the physicians, nurses, social workers, and front line administrative staff who helped bring this service to life! This is the first step in the broader MGH strategic plan around Substance Use Disorders and we look forward to sharing the news about the development of the suite of programs as we learn more about how best to impact this critically important problem.
Reason for Consultation: OUD s/p overdose, needs assessment, treatment recommendations
CC:" I don't remember what happened to me".
HPI: Patient is a 29 year old man with PMH of anxiety d/o, SUD (opioids, BZDs, gabapentin) who was transferred to MGH from OSH for respiratory failure in the setting of likely bzd overdose. On suicide precautions. Being treated for aspiration pneumonia. ACT consulted for management of SUDs. Psychiatry is following.
PMH:
Active Ambulatory Problems Diagnosis
• Moderate recurrent major depression• Elevated blood pressure• Lumbar herniated disc• Health care maintenance• Insomnia• Migraine• Pigmented nevus• Pain in joint, ankle and foot• Panic disorder
Resolved Ambulatory Problems Diagnosis
• Migraine with aura• Benign melanoma
Past Medical History Diagnosis
• Severe major depression, single episode, without psychoticfeatures
SUBSTANCE USE HISTORY: Patient provides limited substance use history also inconsistent to what he reported to psychiatry.
Marijuana: smokes "once a month", helps him relax and go to sleep. Opioids: uses Vicodin, once a day - 5 mg, since age 17. "helps get rid of any aches and pains". Denies history of w/d , OD or cravings which is different from what he/his spouse reported to psychiatry.He is able to obtain Vicodin from his father (who gets them prescribed) for medical reasons. Bzd: uses as prescribed, but "took an extra on Friday, day before admission" Alcohol: denies Cocaine: denies Other substances: denies
Patient recently completed the LEADER (Law Enforcement, Active Duty, Emergency Responder) Program at McLean for addiction to prescription medications. He was discharged September 1, 2016. No other addiction treatment history. Per psychiatry: pt's spouse reported ' he previosly misused prescription Xanax and had a presentation much like this time'. Spouse also reported, 'patient restarted opioid use almost immediately after discharge from the LEADER program'.
Patient reported to psychiatry that he uses 15 mg Vicodin daily. Also reported that he misused previously prescribed medications including percocet and gabapantin for back pain. He reported that he was able to obtain various bzd prescriptions from MGH psychiatrist and that he often asked for early refills.
PSYCHIATRIC HISTORY: Depression Anxiety
Trauma: denies
Legal: denies Attended work under the influence of Klonopin in may 2016, placed on medical leave x 2 weeks.
Hospitalizations: denies
Has a psychiatrist through Home Base on Merrimack Street. Has not been to counseling and is open to exploring this option.
FAMILY HISTORY: Grandmother and 2 cousins with SUDs.
SOCIAL HISTORY: Lives in Malden with wife and two sons. Has a lot of support from family and friends. Patient works as a police officer for the city of Malden for 3 years. Patient attend college at Umass Dartmouth. Patient is a veteran with no deployments/trauma/blast exposure.
ROS: As per HPI above, otherwise a 10 point ROS reviewed and unremarkable.
BP 137/78 mmHg I Pulse 100 I Temp(Src) 36.4 °C (97.6 °F) (Temporal) I Resp 18 I Ht 1.88 m (6' 2.02") I Wt 102.2 kg (225 lb 5 oz) I BMI 28.92 kg/m2 I SpO2 97% Pale skin Reports "a blastind headache" No other voiced complaints
Appearance: well groomed and appropriately dressed Behavior: cooperative and eye contact good Psychomotor Activity: normal Musculoskeletal: moves all extremities; no abnormal movements Station/Gait: normal Speech: regular rate, regular rhythm and regular volume Language: normal comprehension and fluent Mood: "fine" Affect: flat Thought Process: slowed Associations: no loosening of associations Thought Content: no delusions and no obsessions Suicidal/Homicidal Ideation: no suicidal ideation and no homicidal ideation Perceptions/Experiences: no hallucinations Orientation/Sensorium: oriented x 3 and alert Memory: immediate recall intact. Attention/Concentration: intact to observation Abstract Reasoning: intact to observation Fund of Knowledge: average Insight: limited Judgment: poor
PMP:
09/02/2016 2 09/02/2016 ESZOPICLONE 3 MG TABLET 30.0 30 RA TES 00801091 CVS P (6508) 0 Comm Ins MA 08/19/2016 2 08/19/2016 ESZOPICLONE 3 MG TABLET 14.0 14 RA TES 01790561 CVS P (9194) O Comm Ins MA 08/01/2016 1 05/24/2016 ALPRAZOLAM ER 3 MG TABLET 20.0 20 RO SCH 1728425 GENER (1926) 3 Other MA 07/22/2016 1 07/22/2016 ALPRAZOLAM ER 0.5 MG TABLET 7.0 7 MA LAH 1081853 WALGR (7988) 0 Comm Ins MA 07/15/2016 1 07/15/2016 ALPRAZOLAM ER 0.5 MG TABLET 7.0 7 RO SCH 1080484 WALGR (7988) 0 Comm Ins MA 07/08/2016 1 07/07/2016 ALPRAZOLAM ER 1 MG TABLET 7.0 7 RO SCH 3065420 WALGR (1794) 0 Comm Ins MA 06/30/2016 1 06/28/2016 ALPRAZOLAM ER 2 MG TABLET 7.0 7 RO SCH 1077760 WALGR (7988) 0 Comm Ins MA 06/23/2016 1 05/24/2016 ALPRAZOLAM ER 3 MG TABLET 5.0 5 RO SCH 1728425 GENER (1926) 2 Other MA 06/16/2016 1 05/24/2016 ALPRAZOLAM ER 3 MG TABLET 5.0 5 RO SCH 1728425 GENER (1926) 1 Other MA 05/24/2016 1 05/24/2016 ALPRAZOLAM ER 3 MG TABLET 30.00 30 Ro Sch 1728425 GENER (1926) 0 Other MA 05/16/2016 2 05/16/2016 CLONAZEPAM 2 MG TABLET 45.00 30 Ro Sch 00286729 CVS P (9357) 0 Other MA 04/30/2016 2 04/28/2016 CLONAZEPAM 2 MG TABLET 30 15 Jo Wor 00284678 CVS P (9357) 0 Other MA
04/26/2016 2 04/25/2016 CLONAZEPAM 1 MG TABLET 16 4 Jo Wor 00284183 CVS P (9357) 0 Other MA 04/22/2016 2 04/22/2016 CLONAZEPAM 1 MG TABLET 21 7 An Car 00283886 CVS P (9357) 0 Other MA 04/18/2016 2 04/18/2016 LORAZEPAM 2 MG TABLET 90 30 Jo Wor 00283329 CVS P (9357) 0 Other MA 04/15/2016 2 01/22/2016 ZOLPIDEM TARTRATE 10 MG TABLET 30 30 Da Hor 2942785 WALGR (7966) 2 Comm Ins MA 04/14/2016 2 04/14/2016 LORAZEPAM 2 MG TABLET 12 3 Da Hor 00283063 CVS P (9357) 0
IMPRESSION: Patient is a 29 year old man with PMH of anxiety d/o, SUD (opioids, BZDs, gabapentin) who was transferred to MGH from OSH for respiratory failure in the setting of likely bzd overdose. On suicide precautions. Being treated for aspiration pneumonia. ACT consulted for management of SUDs. Psychiatry is following. On assessment, patient provides very limited substance use history. He believes he does not have a problem with addiction as he "only takes one vicodin a day" and takes klonopin "as prescribed". He provided inconsistent data to this provider vs psychiatry. He recently attended the LEADER program. No previous addiction treatment history. Sees a psychiatrist through Home Base but has never been to counseling. He is focused on a headache "that just won't go away". Reports he has had "migranes since age 3". He is not interested in any addiction services but agreed to accept community resources that may be of help to him upon discharge. We have not discussed pharmacotherapy for treatment of OUD. I plan to discuss this with patient at follow up tomorrow.
Patient has an opioid use disorder, moderate/severe subtype based on meeting the following criteria:
Using larger amounts or over longer period y than intended
Persistent desire or unsuccessful efforts to y cut down/control use.
Great deal of time spent obtaining, using, recovering from use.
Craving y Recurrent use resulting in a failure to fulfill y major role obligations.
Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by substance.
Important activities given up because of use.
Recurrent use in situations in which it is physically hazardous.
Continued use despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by use.
Tolerance. y
Withdrawal. y
RECOMMENDATIONS: 1. Initiate seizure precautions2. Patient is not showing signs or symptoms of bzd or opioid withdrawal at this time3. Please provide with naloxone education/ prescription before discharge4. Will discuss Suboxone induction with patient tomorrow morning
5. Meet with ACT SW (Ml, community resources)6. Engage in 1: 1 counseling through Home Base7. Klonopin as written. ONLY for bzd withdrawal. If showing symptoms, nursing to contactpsychiatry for further management.
I spent 80 minutes in this clinical encounter and >50% was spent in counseling and coordinating care.
Thank you for consulting ACT.
Hasena Omanovic, MSN, PMHNP-BC p.28465
ED to Hosp-Admission (Discharged) on 10/1/2016
Consults Date of Service: 10/4/2016 12:03 PM
Marisa Elizabeth de Mirelle, LICSW Addiction
ACT SOCIAL WORK INITIAL CONSULT NOTE
MRN Description:
is a 29 y.o. English-speaking male who was admitted on 10/1/2016 with chief complaint of Overdose of drug/medicinal substance. Patient was referred to ACT social work for assessment, aftercare planning support .
Impressions
Patient was educated regarding the role of ACT SW and purpose of visit and agreed to interview. He was pleasant upon approach and throughout entire encounter. Patient was initially guarded but became increasingly open over the course of the encounter, endorsing recognition of his dependence upon both benzodiazepines and opioid pain medication and his need for help in order to achieve abstinence from both.
Patient discussed his career as a police officer, stating that he had always wanted to enter law enforcement and enjoys the work. He did not expect, he states, the camaraderie he has experienced with his peers. He discussed also the stress of his work, particularly entering complex situations in which a child is present. Recent stressors include he and his wife believing she was pregnant recently and not feeling ready for this life changing event. He states that on the day of his admission to this hospital, he was at a home at which a complex scene was unfolding, including a woman who was overdosing, a man who was angry with police and first responders, and a distressed toddler present. He minimizes the amount of medication he used, but states that after taking two of his prescribed Klonopin, "everything became foggy." He was found at his parents home by a friend who did not know about his substance use but was concerned because he had not returned to headquarters at the end of his shift and went looking for him.
Patient states that he has never had appropriate "respect" for prescription medications and has become dependent upon both opioids and benzodiazepines. He states that he was readily able to obtain prescribed opioid pain medication and frequently took more than prescribed. Similarly, he was started on benzodiazepines for anxiety and also used more than prescribed. Patient states that he learned to obtain prescription opioids through the internet and thought his problems were solved, until he experienced withdrawal for the first time. In addition to obtaining opioids through the internet, patient receives them from his father, who has had two knee surgeries and is prescribed pain medication regularly. Patient states that his father knows patient has a problem, but is unable to say no when patient requests medication from him.
Patient recently attended the McLean LEADER Program and found it helpful but did not follow up on recommendations for self help support because he did not think he needed help at the time. He states, "I thought I could do it on my own, but I was wrong." He is working with Home Base, a VA program which helps to connect veterans to needed care, but has become frustrated because he and his wife have attended multiple visits but he has not yet been able to obtain a Suboxone prescriber with their assistance and states his recognition that medication assisted treatment is a critical component of his recovery due to the constant presence of triggers and his
Consults Date of Service: 10/4/2016 3:58 PM
Marisa Elizabeth de Mirelle, LICSW Addiction
ACT SOCIAL WORK NOTE
MRN: Description:
ACT SW received a return call from Wendy, in admissions at the McLean LEADER program. Because of the serious nature of his overdose and his history of depression, he will need to go to an inpatient psych program or unit for at least 48 hours before he can return to McLean LEADER. He will not be able to discharge to home and enter the program from home, she states.
According to Wendy, patient will need to attend the McLean inpatient unit in order to step down to LEADER. The LEADER program can be reached at 617-855-3141 for additional information if needed. Psych is following patient and providing referral.
