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Health Care District of Palm Beach County’s Response to the Opioid Crisis in Palm Beach County

belma-andricOver the past several years, Palm Beach County has found itself in the epicenter of a growing nationwide opioid crisis. During this time, Palm Beach County was experiencing over 600 deaths annually from opioid overdoses. Something fundamentally needed to change in the way care is provided for this very complex, relapsing, lifelong and life-threatening illness – an illness for which treatment resources are scarce, fragmented and not very well defined by national medical associations.

The Health Care District of Palm Beach County’s response set out to create a different model of care that would go beyond the “traditional” models used to treat addiction disorders. Several criteria served as guiding principles: (1) provide evidence-based medical treatment; (2) ensure that life-saving treatment is readily available to the largest number of patients; and (3) make sure patients are treated with a warm handoff from the point of emergency overdose treatment through access to long-term treatment.

Medication Assisted Treatment Clinic
The Health Care District’s involvement and immediate response in early 2017 delivered positive results to combat the overdose crisis. What started as a pilot program with 30 patients through a partnership between Palm Beach County Fire Rescue, JFK Medical Center, and the Heath Care District has become a comprehensive outpatient-based Medication Assisted Treatment (MAT) clinic caring for more than 600 patients since inception. The pilot program tested and confirmed the success achieved in 2015 by Yale University researchers. The treatment approach recognized that addiction is both a medical condition and a psychiatric illness with many complex medical comorbidities that need to be treated under the “house of medicine,” like any other chronic medical condition, and addressed by an addiction-trained psychiatrist and a team of providers who follow evidence-based practices. These practices include treatment with the use of medication (MAT) when indicated. In addition to psychiatric assessment and MAT treatment, addiction-focused counseling services provided by licensed social workers in both individual and group settings, primary and dental care, along with infectious disease treatment, are all integral parts of the comprehensive care offered at the Health Care District’s clinics. The program is based on a one-stop-shop model where patients receive all of their care in one location.  

Addiction Stabilization Unit
Building upon the success of the outpatient treatment clinic, the Health Care District sought to develop a sustainable approach to addiction care and access to treatment. Borrowing elements from the nationally-recognized central receiving facility approach for overdose care and the evidence-based solution found in MAT models, the Health Care District sought to develop a response that would leverage the best elements of each model to create a unique Palm Beach County approach. Palm Beach County was fortunate to have the ideal partners in the community come together, including the Health Care District, Palm Beach County Fire Rescue, JFK Medical Center, and Palm Beach County government.
The Health Care District worked with JFK Medical Center (North Campus) to develop the idea of an Addiction Stabilization Unit (ASU) as the entry point of care, providing readily-available treatment for patients during the motivational moment after an overdose. Instead of a traditional central receiving facility, often developed as ER and jail diversion programs, this unit functions as a regular emergency room with clinical staff who have additional training in addiction. The team consists of addiction-trained ER physicians, nurses, EMTs, hospitalists, and psychiatrists on staff, along with other medical professionals trained in MAT treatment. The MAT treatment is introduced in the ER and continuously offered to patients throughout their stay at the hospital as well as during patient admissions for medical or mental health reasons. 

Similar to regional centers of excellence that address other complex conditions that require high levels of expertise, as found in trauma, heart, stroke and cancer care, Palm Beach County now has the first-of-its-kind specialized center for evidence-based addiction care. Here, medical professionals are ready 24/7 for patients to arrive to provide them with acute care for their addiction and all other medical problems. This specialized ED will also function similarly to trauma centers where EMS and ambulance services prioritize overdose patients to bring them directly to the Addiction Stabilization Unit. Fire Rescue municipalities have an option to adopt defined protocols whereby they bypass the closest emergency room and transport the overdose patient directly to the ASU as the facility specialized to treat this illness.  

For patients transferred to the ASU after an overdose, MAT is readily available and offered within the first few hours of arrival. This transformative practice has the potential to stabilize the cycle of withdrawal and patient drug use. Additionally, the treatment will postpone withdrawal symptoms for 12 hours, during which time compassionate care and appropriate assessment by a team of professionals at the ASU might increase the probability of compliance with the post-discharge, longer-term treatment plan. 
Once treated and stabilized in the Addiction Stabilization Unit, patients are discharged using a “warm handoff” where a personal referral is made with the patient directly with an individual at the most appropriate next level of treatment.

A majority of patients will qualify for outpatient treatment and they will be referred to a panel of community network providers. For patients who choose the Health Care District’s clinic, it is conveniently located adjacent to the JFK North Addiction Stabilization Unit, permitting an easy, warm handoff. At the Health Care District’s clinic, patients will receive comprehensive treatment and counseling for all of their medical needs as well as medication and lab services for as long as needed. The Health Care District’s clinics are Federally Qualified Health Centers that offer a sliding fee scale to patients and treat everyone regardless of their ability to pay. The clinic functions as a patient centered medical home and provides comprehensive chronic disease management, including addiction. Patients who need a higher level of care for their addiction treatment are referred to an available network of providers. 

Community Approach
The response to the opioid crisis in Palm Beach County brought together leaders in the community to develop something new and sustainable to address what had essentially become an abandoned field of medicine. The Health Care District recognized that a public health approach to the crisis was necessary to ensure that the largest number of patients would have access to addiction treatment through an outpatient model.  Providing care in a manner that works the best for the largest number of patients (outpatient care) also makes precious, publicly funded “beds” more available for those patients who need the highest level of addiction care. 

To fund the new Addiction Stabilization Unit, the Palm Beach County Board of County Commissioners, a critical leader in the county’s response to the opioid crisis, is providing important funding for other uninsured patients who arrive at the Addiction Stabilization Unit. JFK Medical Center North Campus has invested in the start-up and implementation of the new program. Additionally, the Health Care District is addressing the needs of Palm Beach County residents with substance abuse disorders by adding addiction care to the Health Care District’s specialty care benefit program, “District Cares,” that covers patients below 100% of the federal poverty level. The work of other community partners, including the Southeast Florida Behavioral Health Network, the Sober Home Task Force led by State Attorney Dave Aronberg and the Palm Beach County Board of County Commissioners led by Commissioner Melissa McKinlay, collectively contributed to improve care for everyone in Palm Beach County. What came together was a true public – private approach to a genuine public health crisis. 

Today, Palm Beach County is leading the way in the treatment of overdose and life-long care for addiction in Palm Beach County by “medicalizing” this field in an attempt to treat addiction the same as any other medical condition.