welcome to the second webinar of the University of Rochester Medical Center Recovery Center of for excellence I'm Kristen Quinlan I'm a researcher with the Education Development Center and I'll be facilitating the webinar today opioid treatment providers are committed to employing social distancing measures that will help protect patients and staff from contracting Kove at 19 at the same time this requires adaptation of traditional practices and these adaptations can be challenging in today's webinar we're going to be talking to treatment providers who can provide some sound advice on social
distancing practices that work in real-world treatment setup centers the University of Rochester Medical Center knows that substance use disorders have greatly impact rural areas and they're looking to reduce the harmful effects of substance use disorders in these areas through the University of Rochester Medical Center's recovery center of excellence a group that's committed to studying and disseminating best practices in substance misuse prevention for rural communities these are the on the screen are the faces of the University of Rochester Medical Center recovery centre of excellence team
the team offers a deep bench of experts in rural health substance misuse prevention and evaluation University of Rochester Medical Center recovery Center of Excellence is working to reduce the harmful effects of substance use disorders including opioid use disorders through three interconnected efforts first they're looking to partner with Appalachian communities in Kentucky New York Ohio in West Virginia to identify adapt and implement evidence-based practices also they're testing emerging best practices in New York's southern tier as communities in that region create an ecosystem of
recovery and third they're synthesizing wisdom by building a storehouse of resources and providing technical assistance to rural communities across the United States and I want to draw your attention to this third bullet that's the purpose of this webinar series we want to synthesize what we learn and we want to translate it for use in your communities our speakers for today are Patrick's age and Itza Morales Torres Patrick's age is the senior director of addiction services and a senior associate faculty member in the University of Rochester Medical Center's Department of Psychiatry and
currently oversees three clinics at strong recovery which is part of Strong Memorial Hospital on the steering committee for the University of Rochester's recovery center of excellence Patrick focuses on substance use disorder methadone treatment and community relations Itza Morales Torres is the director of opioid treatment programs at the University of Rochester Medical Center and the assistant director of strong recovery Itza has worked in addiction treatment since 2008 when she joined strong recovery as an addiction therapist in 2017 Itza became the program manager of the opioid treatment
program and in 2019 she assumed her current role as the program's director on the line today we also have Christine Lasher who is the director of the University of Rochester's recovery Center of Excellence who will be facilitating today's discussion I'm going to turn things over first to Christine Thank You Kristin and a special thank you to Patrick and Itza for joining us at what is a very busy time for them for the benefit of those listening today we have listed several key federal and state resources across our defined service areas in Kentucky Ohio New York and West Virginia which we will
leave up and available for your review while we discuss some of the challenges we have experienced around guidelines and rapidfire change in the past several weeks please become familiar with your state and local regulatory requirements as those should take precedence over what we may discuss for New York specifically today Patrick I'll start with you what is one of the things that surprised you most relative to pace and incoming guidance as you entered this period of preparation for kovat 19 thanks Christine the most thing was as things developed the volume of information that was coming in
that we needed to track from a myriad of sources local state and federal sources was what's surprising to me there were you know there was a drastic progression in the waivers that were coming out to help providers deal with Kovac 19 and make the modifications necessary in the clinic you know from you know being able to provide services off-site locations take home exception the delivery of medication telehealth and telephonic sessions they were just a number of waivers and guidance documents that were coming out from from multiple sources it sounds like they were coming at you pretty fast so
I guess so was there a moment in time that you thought there's no way that we're going to be able to do that and such quick succession if so what was that moment in time and how did you manage to get past that obstacle hi Christine I don't think we had enough time or I had enough time to even consider that question like Patrick mentioned before a lot of changes were thrown our way and we tackled them one at a time by just studying regulatory changes changes within our system and trying to adapt them as quickly as possible and also just being very transparent with our patients and with our
staff so that they knew that these changes were were coming down and as we learned things we shared and that's really the key and all of this is to maintain that open and honest communication with both your patients and your staff Patrick did you have anything to add to that one thing I will add Christine is that you know I did have some moments where I thought you know the number of page we have in our waiting room especially in the morning because you know we are clipping we have our ot peak Lincoln our outpatient clinic or two fairly large clinics that operate you know at the same site in
a very integrated way as a ccbhc and in the morning we have dispensing going on in a large number of groups so it's a very crowded and busy place and I thought you know how are we going to create social distancing in that kind of environment you know just just thinking about ways that we could do that and that was early on before you know we really had the kind of waivers that was necessary to make the modifications that we eventually ended up making but early on you know I was thinking how we're going to create social distancing in that space and so one other question then for you Patrick is
you know given all of this if you could give one piece of advice to our attendees who luckily may be a little bit behind the New York kovin 19 curve what would that advice be I think definitely is if you have the opportunity to is to start planning for your worst case scenarios now think of you know think of what what's the worst that could happen as it relates to Kovac 19 and the measures that you would need to take and work your way down to progression figuring out each phase of the process what are the changes that you would need to make to you know we related to your space and the number
of patients that you'll have to manage and the number of staff that you'll have to manage just you know take the time to figure that out now the advantage is that federal waivers already exist so you can go to the DA's website into SAMHSA's website and see what's provided for states that are in a state of emergency I think there may be some states that are still not in a declared state of emergency so those waivers wouldn't apply but if you have the opportunity to see okay if we ended up in a state of emergency in in our state what are the waivers that are in place that we would need to act
on of course that is working with your state opioid treatment authority and whatever state agency that certifies your clinic to do that but at least the federal entities have that information in place now that you can start doing some planning around great thank you and you'll see those resources again listed on this slide Samsa CSAT and DEA diversion control division and then before we move on to a recap its Oh is there anything else that you wanted to add on this topic I think if there was a piece of advice I could give clinics is to make sure that proactively you are updating patient
addresses telephone numbers getting emergency contact information for those patients in the event that we can't reach them via phone or we need to um kind of call their emergency contact for any reason and also identify start identifying your high-risk patients for colvett 19 so those patients that maybe have a compromised immune system that are over 50 years old that might have other hardships start pulling those patient lists so that you can best prepare for extending take-homes great thank you for that so just as a recap to the topics that we just reviewed you'll need real-time
communication with your staff and your patient patients excuse me and please remember health departments will be overburdened at this time so streamline the process in advance for maintaining contact be ready to screen and assess your patients over the phone because in-person visits should be limited to only what is absolutely required follow the process to seek those blanket exceptions or take homes as Patrick mentioned understand your obligations with respect to patient privacy track your expenses carefully related to coal at 19 and also be prepared to maintain rapport to submit to
regulatory authorities in your area strong recovery is a part of strong Memorial Hospital which as we mentioned has three clinics the opioid treatment programs outpatient chemical dependency and the newly opened adolescent and young adult clinic so we just spent a few minutes talking about the magnitude and pace of the changes that have been coming at you in the last several weeks basically the nuts and bolts of what has changed so the next logical question then is what did you need to do operationally to accommodate all of that and what did you learn through this process so let's start with
you and a topic of workflow changes what were the two or three biggest changes you needed to make and how did that transition go I think the first big change that we had to do is incorporating social distancing into our everyday practice because we are a fairly large clinic and we also have group therapy individual therapy provider appointments we had a very crowded waiting room so that was our big challenge that first challenge was how do we manage it so that we don't have as many people in our waiting room so we made the decision of not having groups because we could not keep social
distancing in a group room we also limited the amount of patients entering our clinic so we would have them ten patients at a time in each waiting room so a total of 20 patients and a fairly large waiting room and try as best as possible to expedite their dispensing and then they would leave after that the challenge was to start reaching patients via telephone telephonic session we had to address staff entirety as well as patient anxiety so making sure that everybody understood why we were do everything that we could do to incorporate you know the demands and we didn't know what needed to be
done sometimes we were changing workflows minutes a minute so being very patient being very clear and open with both our patients and our staff was very helpful and then came the trying to gather enough PPE for staff screening patients at the door that workflow changed a couple of times until it became what it is today which we will discuss hopefully a little bit later and again I think the biggest thing was just having that transparency with our patients with our staff reassuring them that we would keep them informed and that our we were acting in the best interest of everyone wanting to
keep everybody safe and I think also just changing the way we thought about risk versus benefit that's a big change in the way counselors and providers felt about it but it was necessary for us to redefine that so that we could give patients take home take on medication great thank you it's a and I guess Patrick for you then that's an awful lot of change for staff to get used to and you so just mentioned that it changed several times and there was lots of different kind of change happening so how did they manage all of this and was their anxiety involved and then did you have enough staff to
actually make these operational changes happen so the main thing for us is you know as as I mentioned earlier is there was a lot of information to digest so the strategy we use was is what I call you know step-down Huddle's so we had you know smaller and more frequent Huddle's to communicate information modifications and changes that needed to be made so I would first meet with the program directors and managers to communicate and dissect whatever new information we have they would then turn around and have Huddle's with all of the clinical supervisors and team leaders in the clinics and then
they have the responsibility to huddle with their team by keeping it smaller groups were able to do these Huddle's more often but it also presented a more comfortable environment for staff to ask questions supervisors could take their time explaining you know what's happening for when we had to make major workflow changes we incorporated walkthroughs and that's something I would recommend is walk through anything major that you're changing you know certainly as we were going through this there was the thought in my mind that what if we start losing a lot of staff to being sick or being
quarantined or having to be isolated so one of the one of the advantages for us is having multiple clinics and the ability to use all of the staff available to us to help with the OTP clinic and dispensing so that's one recommendation I would give other programs is that not only your OTP staff but if you have other programs at your site or if you're affiliated with any other programs within your organization that has staff available to you get them familiar with your OTP clinic dispensing process because you may be in a situation where you'll have to tap into other staff and Patrick you read
my mind for the next question actually that I had then and it was one I didn't even want to ask but you just adjusted a moment ago that did you have to do planning around the likelihood that your own staff might become ill you mentioned tapping into other resources that may not be normally a part of your OTP clinic but were there other changes that you need to make or anticipate around backfilling for that possibility yes absolutely you know it's to accomplish a couple of things one was to make sure each day we would have enough staff but we also needed to create social distancing among among
ourselves in the clinics because we have in our building a lot of people you know upwards of 70 people so we created a staggered schedule where some staff would work remotely and not come to the clinic building so that you know help create you know a little bit more social distancing with people in the clinic throughout the day but it also the staggered schedule allowed us to create a schedule with three to four backups built into it so that if we started to have you know fast getting sick we sort of had a backup system you know built in to be able to have people fill in we also have the
advantage of our larger organization you know having some healthcare staff that you know could be reassigned to us it's necessary so I think you know I think for for programs out there it's really assessing what all your resources are that could be available to you because it's you know in a worst-case scenario where that's something that you need but I think the the staggered schedule will really help so that we wouldn't we wouldn't be we would have the backup available for any given day great thank you for that and so I guess it so the question I have for you then is around communication so
with all this change and what could be chaotic you know how did you manage what is normally a very heavy load for documentation and communication with all of this added to that so um as far as communication I think the number one thing is transparency having open communication Patrick had mentioned before how we utilize our clinical supervisors to have smaller Huddle's and that works well because it allows for staff to be able to ask questions and in a more intimate setting and receive reassurance from their clinical supervisors we've also become quite savvy and the use of technology oh gee
so email zoom meetings and whenever possible we would meet in larger conference rooms making sure that we were taking into consideration social distancing I think the key thing about communication is just the ability of being able to listen to people's anxieties and fears both our staff and our patient and being able to give them reassurance and validation of their concerns and also to empower staff and patients to make suggestions because we are a team great thank you for that so just to recap the few things that we mentioned here be ready to modify your workflows prepare for staff shortages
should they arise maintain open lines of communication and find creative ways to do that communication and be prepared to address any staff or patient anxiety as it may occur maybe you can spend a few minutes talking about what it was like before and after covin 19 and OTP itza to start briefly walk me through a typical day in your clinic before this pandemic so I think I had mentioned earlier how we provide a lot of services so we would encounter very crowded waiting room patients waiting to be medicated as well as patients waiting for individual sessions or group sessions so our first
challenge was to kind of make incorporate social distancing so we started by actually removing a lot of our chairs in the waiting room and limiting the amount of patients that were coming in we have two fairly large waiting rooms so we were only allowing ten patients at a time to come in we also made the decision to stop doing the group so doing group and that helped also to slow down the traffic of patients in the clinic we then moved a lot of our medication to scheduled dosing so patients were giving given special times to come in for dosing and with that staggered so allowing patients for
increase in take-home medication which would also reduce the amount of times that they would come to strong recovery to get their medication so that gives me a good feeling for before and a little bit about after is there anything else that's really quite different now after the pandemic any new rules considerations aside from the few that you just mentioned I think the biggest changes have been to tell a home visit so being able to have sessions over the phone and we are currently working on group sessions as well as curbside dispensing so all of our medication dispensing is done now outside
and how have the patients adopted this new way of doing things have they been pretty open to it and receptive yes actually they have been very open and receptive and we've had very positive feedback and I think the key to that was explaining why we had to make these changes and answering any questions or concerns that they may have but for the most part patients are just very appreciative that we are taking their health into consideration and and our own great thank you just to recap a few of the things that we mentioned here is to practice social distancing and be sure to identify isolation
space on-site for any patients or staff who may become ill or that you suspect may be ill plan steps to take when a person is ill or test positive for the virus schedule your dosing times and prepare infrastructure for telehealth be sure in doing so that you've addressed privacy and any potential hacking that may occur and also look for alternatives to group therapy sessions so this last point the you are medicine Recovery Center of Excellence is doing some early planning on how to facilitate groups when you cannot be together extending this conversation then to therapy fitness support and
other related topics so you'll be hearing more on that very soon so delivering medication this is something Patrick that is vastly different from what was done before so could you talk me through how Dispensing is handled now and how your team managed to get there absolutely so we're you know as need to mention some of the measures we you know we took as far as you know reviewing patient schedules and reducing those as much as possible discontinuing you know group sessions and offering patients alternatives with telephonic sessions and and zoom telehealth sessions even with all those measures
we just could not maintain social distancing in our waiting room because we couldn't keep the patients from each other once they were in the waiting room even with some of the chairs we move and we kind of set up the chairs you know far apart from each other it still was impossible to keep the patients from each other so what we did is you know to further you know to take further precautions and make sure that our staff remain safe and our patients remain safe and and we you know we keep the possibility of infection as down as we possibly can we move to curbside dispensing protocols and this
had two sets of protocols to it where we're managing the entire process you know really you know outside of the clinic the the so one set of protocols for patients who get dropped off to the clinic you know get dropped off by public transportation of some sort we you know were able to check the patients in screen them for any kind of symptoms of cold they take their temperature manage whatever we may need to do you know for them when they show up in the clinic we have a tent set up outside as you can see in the slide with with spots marked in it the kind of you know point to patients exactly
where we need them to stand and wait until we're ready to medicate them and once their medication was ready and staff was you know delivering it to them we would call the patient to through the building and we have a secure vestibule in the building where we individually provide the patients with their medications so that there aren't multiple patient you know in that space then the second set of protocol for patients who drive to the clinic so we have a process that is you know everything is monitored by our Public Safety officers and our staff you know monitoring we have a dedicated parking
lot that is you know blocked off to anyone else other than patients in the clinic and we direct them to you know the exact spot where they need to wait and again the staff manage the process of checking them in I'm figuring out whether you know there's anything they need to do or if we need to assess them for some reason open it you know take a breathalyzer test of some sort and once everything is checked out staff deliver the medication to the patient and then we direct them to exit so we had to implement this process B you know because of the just a number of patients that we had to manage
even with scheduled dosing was basically still impossible inside the building so curbside dispensing you know I think really has provided us a way to safely continue to deliver services and provide medication to all of our patients and keep them in office taking off by a safe fantastic thank you for sharing that Patrick it's quite an operation to watch too and so different from what we did before I just wanted to recap a couple of the things here that Patrick mentioned moving to take home medications one possible considered dispensing curbside or in an alternative location if that makes sense
for your clinic you're going to need to plan for maintaining medication stock with these new procedures that may be different than what you're accustomed to in the plot in the past so please plan ahead for that think about how you would manage delivery of medications to quarantined or homebound patients and also be sure to provide medication safety education since in some cases they will have access to more medication than they have in the past and then lastly don't forget to distribute naloxone kits where appropriate so I wanted to recap a few things that both Patrick and itzá have mentioned
through the course of our discussion thus far first be ready to share changes to your clinic hours and days very clearly including advice about travel lockdown shelter in place and what that may mean in your specific community you're going to want to be ready to explain the different types of care that you may be offering such as telemedicine curbside other delivery in-person delivery and so forth be sure to teach your patients about protecting medication from theft plan for a supply of PPE needed for your staff again fully understanding the state and local requirements in your location as
that may differ from what we've shared here for New York update your patient files and confirm emergency contacts in advance so that you're ready to reach them as needed and then prepare any signs or posters or Flyers that you may have so eat son Patrick given this list and these few topics are there any real-life examples that you care to share about how important some of these items became as you are implementing these changes one of the things that actually happened to us apart you know as far as you really like real-life example is you know we you know before we had an actual positive in
our County you know things really were kind of going at a very very normal pace and once we had a positive it was a period
of time from like 5:00 p.m. on a Friday and then things changed drastically in our community from that Friday to early afternoon Saturday to where I had to call a meeting with our management team you know through Xoom Saturday evening then we had to come in to to our clinic on Sunday to contact patients and modify services including cancelling all of our group sessions because the the number of people that could be in a room or in the same room went down significantly to where we would not be able to have that number of patients in a group room impressed it just wouldn't be good social
distancing practice anyway so we had to contact all of our patients on a Sunday so that we could be ready to start delivering modified services to them on you know starting Monday morning so that you know that was one example where the the preparation we did with updating patients phone numbers email addresses you know as Lisa mentioned earlier it came in handy because we you know there's no way to have known that on Friday we would have had to make such changes over the weekend for Monday morning but that's how things change in our county and it's ah how about you I think one of the most
important things was the having to modify our clinic hours in the beginning like Patrick mentioned changes were occurring so quickly having patients telephone numbers was definitely updated list was definitely needed and appreciated and in the first I would say week to two weeks we were actually pretty much dispensing all day long so you know we had to prepare ourselves and our nursing staff for that so we would start dispensing at a you know at 6 o'clock in the morning which was a little bit earlier than usually and then we would dispense right
through to 2:30 and that was to allow for patients to be more staggered and also to give special dispensing times for those patients that we considered high risk for kovetz so more vulnerable populations after we modified our workflows we are now back to our normal dispensing set schedule and times but that in the beginning we had to do a couple of quick changes to then you know now we have a new normal thank you both for sharing those real-life examples so strong recovery through all this change is still accepting new patients administering medication utilizing phone and video calls for
visits and live-streaming group sessions where possible in fact a local news station recently featured Patrick in a segment and as he indicated and you'll see from his quote here it's all very essential because we don't want an increase in overdoses an increase of people going into withdrawal that require medical attention because that will add to the stress of the healthcare system so thanks Patrick for highlighting your work also here locally so before we get started with questions and answers I want to let you know that we will be sharing some basic tools we have created on our website
when we post the replay of today's session in the interest of getting you this information quickly we will be describing what we've done here at a large OTP but plan to modify those materials with recommendations for smaller rural clinics in the coming days as well so I wanted to go to some questions that have been submitted to us and have Patrick and itzá address each in turn so the first question we received was we have a small staff at our clinic do you think curbside dispensing could be implemented and what would that look like so I think you know I think this one I think you know
curbside dispensing is you know would be challenging with a smaller number of staff but a smaller number of staff also means it's a smaller clinic and I think you know some of the some of the earlier measures probably could be very effective you know scheduled dosing and maybe some modification to dispensing time to sort of space out the patients but I think scheduled dosing would be a real key to limit at any sort of time intervals whether you do it every half hour every hour as to how many patients are coming to the clinic and combining that with you know as Lisa mentioned earlier sort of
re a retooling of the evaluation of risk versus benefit for patient take home schedules so giving you know reducing patients scheduled to come to the clinic as much as you can safely do that and and really just so from a bare minimum medication safety standpoint you know give the patients as much take homes as possible so that you can limit the number of people that are scheduled to come on any given day and then any given time interval depending on how you do your scheduled dosing great thank you and the next question we had received was our patients and providers have concerns about
telemedicine because of technology and privacy issues how do you reassure staff and patients about its use and are there ways to make that transition easier as we try to meet in person less less often due to coronavirus you know one thing that was important with the transition of you know the alternative ways to provide services to patients is that you know telephonic sessions was you know fairly easy for from pretty much everyone so patients that maybe were less inclined or less familiarity with using technology it wasn't well you know it had to be it had to be telehealth and that it had to
be some kind of zoom session but that telephonic was an option that anything to our state agency we receive waiver to provide any kind of service to you know telephonic with our patients I think that helped help the transition being able to do that because just about everyone you know can handle talking on the phone but some people you know either don't have an email address or just don't want to zoom or have the ability to do that so we were able to sort of implement telephonic across the board while then we work with the patients that were either interested or have the capability to
transition to the zone session great thank you for that and I think this next one may be for Issa but either one of you can certainly answer what is your assessment process like when you're considering expanding take-homes for patients well like I said earlier I think it's important for us to redefine our risk versus benefit and now
the risk really is getting covitz 19:00 getting the coronavirus so we had to separate those patients that we consider to be at higher risk for coalbed and have very open conversations with the patients as well as the other history and we educate them on the importance of keeping their take home state taking them as prescribed and communicating to them that we will be checking in on you frequently so it's important that you answer your phone calls or that you return phone calls because we want to make sure that you're safe and so to those patients we give up to two weeks in some cases of
medication but with all of the patients we have evaluated and have given them some take homes unfortunately there are some patients that are using substances that can precipitate an overdose of fentanyl benzodiazepines alcohol so for those patients we are seeing them more frequently and having dialogue with them and saying you know how can we help you so that we can trust that you would keep your medication safe and also not die of an overdose and that an patient has been responsive to that and in some cases we've seen a reduction of substance use and they're accessing support systems and in
decades we're able to increase their take home so they don't have to leave their home great thank you and I think you mentioned earlier as well that in general patients have been responsive to the new procedures at the OTP very positively has there been any other feedback that you've been receiving from them or any particular feedback that you wanted to highlight today I think the most part of patients are just very appreciative that we have taken extra measures to provide them with the medication that they need and also with the with with touching bases with them I think one important thing
to always keep in mind is just because a patient maybe has been stable in treatment for a long period of time that doesn't necessarily mean that during this difficult time they might not be triggered for you so those patients also need a lot of our outreach so in a way we're treating all of our patients the same way and out reaching to them frequently and making sure that we're reviewing with them relapse prevention tools as well as easing their anxiety so again communication has been key throughout this whole process great thank you very much is there anything else Patrick or Itza that you
would also want to share today those are the questions that we've received so far but is there anything else that comes to mind before we move to wrap up today's session the thing I would say is I think of what's going to be key is for you to start preparing early and like Patrick said before just picture worst-case scenario and plan from there also familiarize yourself with some of the exceptions and regulations that the federal government has sent out so that when you need them you're familiar with them and outreach outreach to other OTPs that maybe have gone through this and ask for help
we're more than happy to provide you with our our guidance or our perspective on things and how troubleshoot is needed and Patrick anything from you yeah one last quick thing I would just add is to you know wherever you located start you know especially if you're not already in a state of emergency start communicating with your state opioid treatment authority to get a sense of how they're going to apply the federal waivers that are provided what kind of process that they're likely to put in place or they may be thinking about so that you aware what those things are so your your state of
pretreatment Authority becomes a key linkage to the federal waiver so I would if you're not already if you not already in communication I would be in communication with that person now great thank you and before we move to our wrap-up slide that shows our contact information I do just want to say the you are medicine Recovery Center of Excellence is very interested in hearing from you we would be happy to take any of your questions through any of the means that we're about to share so feel free to reach out if you have specific questions would be happy to talk about what we've done here and
what might potentially work for you and your community as well so we look forward to partnering with you and with that Kristen I'll hand it back over to you today thank you so much Christine so we encourage you to visit Recovery Center of Excellence work for details about our upcoming events and publications we have any suggestions or questions or things that you'd like to see covered in future sessions feel free to email us you our medicine underscore recovery at you are MC dot Rochester dot edu as Christine mentioned on our website you can also find a toolkit that will later be adapted for
rural communities exactly on this topic I want to take a moment to just thank Itza and Patrick for their time we know how busy clinics are in the COBIT crisis and we sincerely appreciate all your work and all your information found it very helpful so you want to thank you again for viewing our webinar and we look forward to connecting with you again in a future webinar thank you so much
