Table 2 Opportunity-Related Barriers and Facilitators

Opportunity (Physical) [Barrier]

MD/NP

Pharmacy pre-approval for IM NTX discourages providers from prescribing.

“No, I don’t know what the restrictions or authorizations are. If it was a prior auth situation, that will be a substantial hurdle” -Attending

Enablement: Eliminate or streamline pre-approval form for IM NTX.

Enablement: Remind providers the oral form of NTX is available if pre-approval for the IM form is unsuccessful.

Opportunity (Physical) [Barrier]

MD/NP/ RN/CSW

Lack of adequate discharge materials that are easily understood by patients.

“I would leave it as language is not the only barrier. Things like health literacy, world view and a lot of those things often go hand in hand, which makes it a triple whammy in terms of communicating with someone, particularly on a subject that I’m not truly an expert” -Attending

Enablement: Have patient educational materials appropriate for patients with low health literacy available in multiple languages (English, Spanish, Chinese, Tagalog).

“I get phone calls sometimes and they tell me, “I don’t understand this instruction.” Even if the primary language is English. And I have to explain to them in layman’s terms, how they can understand.” -RN

Opportunity (Physical) [Barrier]

MD/NP/ RN/CSW

Perception from staff that they are unable to effectively communicate with patients because of language barriers.

“The majority of my patients with alcohol use disorder speak Spanish, and I’m a certified bilingual but I’m not truly bilingual. Even with a translator, it’s a lot harder to have a subtle conversation either via a translator or in another language than it is with a native speaker. Querying somebody’s motivations by giving subtle instructions and consent is a lot harder. We keep things a bit simpler.” -Attending

Environmental Restructure: Hire more bilingual CSW and SUNs. Hire more in-person interpreters.

Environmental Restructure: Recruit and retain more residents and physicians who are bilingual.

Opportunity (Physical) [Barrier]

Pharmacy

Limited supply of NTX available to the ED.

“Oh, yeah. We keep like absolutely nothing of the intramuscular, or very, very few, so if we actually did roll out our true protocol for patients, then we would have to really get in touch with the line management to get them to know we’re going to be rolling out this protocol and we need to have this many on hand, we’re expecting this much usage of this medication.” -Pharmacist

Environmental Restructure: Work with pharmacy to increase supply of IM NTX.

Opportunity (Physical) [Barrier]

MD/NP/ CSW

Unable to follow-up with provider who can continue NTX treatment.

“I guess my concern would be, like anything you start, is having the back-end follow it up. It’s easy start things but if we prescribe naltrexone, you say, “Here’s your prescription,” if they’re coming back in a week for refills or two weeks because there is poor substance use disorder assistance in the community.” -Attending

Environmental Restructuring: Utilize Substance Use Bridge Clinic to bridge AUD patient to next prescriber.

Enablement: Compile list of inpatient and outpatient AUD treatment options.

Environmental Restructuring: Perform warm hand-offs with organization that provides AUD treatment.

Enablement: Increase number of Substance Use Navigators (SUNs) to help AUD patients access resources.

Enablement: Encourage use of existing adjunct programs, such as community health workers, to help AUD patients access more care.

Opportunity (Physical) [Barrier]

MD/NP/ CSW

Patients often have unreliable access to a phone.

“I’m wasting my time on doing something, if no one else help me to do something, because I can’t get a hold of the patient. Giving resources, it works probably 10% of the time, if that, because maybe 10% of patients have a phone” -CSW

Enablement: Establish connection to cell phone distribution program

Opportunity (Physical) [Barrier]

CSW

Social workers feel they don’t have enough time with the patients.

“The time constraint is also an issue. Let’s say, for example, patients being interested in being referred for detox. That is a lengthy process because right now, the only detox referral we use is Tarzana Treatment Center. We have to get the information they want, and they’ll have the patient sign a consent and then fax it over. Then you have to wait for them to review it and then call you back and then to let you know if they have a bed or not. Most of the times they don’t even have a bed.” -CSW

Enablement: Ensure enough time is given for social workers to work with AUD patients. Refer to CSW early in the process.

Enablement: Hire more SUNs.

Opportunity (Physical) [Barrier]

MD/NP

Cost of IM NTX is high.

“With the intramuscular injection, it’s ten times more expensive per month, so that’s one issue right there. And I’m not sure in terms of insurance how well that would work for some patients.” -Pharmacist

Enablement: Seek out cost-saving programs or subsidies offered by manufacturers.

Opportunity (Physical) [Barrier]

MD/NP/ RN/CSW

Sobering patients can remain in the ED for many hours, and the task of assessing for AUD can be missed prior to discharge.

“...you try to get them to the point where, clinically, they’re relatively sober in their clinical state and they’re safely able to discharge. Oftentimes I feel like the piece that’s missing is once you reassess them, [...] we would miss that opportunity to ask them, “Hey, now that I’m finally cognitively meeting you for the first time, are you interested in quitting?” -Attending

Environmental Restructure: Add screening for AUD to checklist of items to fulfill before discharge for patients who presented with intoxication.

Opportunity (Social) [Barrier]

MD/NP/ RN/CSW

Staff opposition to ED as source of long-term treatment.

“It’s easy to start things but if we prescribe naltrexone, you say, “Here’s your prescription,” and they’re coming back in a week for refills or two weeks because there is poor substance use disorder assistance in the community, then we’re becoming a continuity clinic, which-- no. It’s not how the ED is supposed to be” -Attending

Enablement: Strengthen communication between primary care and the emergency department.

Modeling: Demonstrate a culture of providing all needed care in the ED, including initiating treatment and connection to care, in addition to immediate medical emergencies.

Opportunity (Social) [Barrier]

MD/NP/ RN/CSW

Roles and responsibilities not clearly defined, specifically, which staff will assess AUD and stage of change.

“It’s mostly by consult. Essentially, the doctor or the nurse contact the social worker if the patient is interested in resources... So they know we’re stopping by. Because a lot of times they consult us without asking the patient and we show up and they’re like, ‘Why are you here?’” -CSW

Environmental Restructuring: Clearly define and assign roles in the management algorithm in advance of the implementation.

Opportunity (Physical) [Facilitator]

CSW

Clinical Social Workers and Substance Use Navigators (SUNs) in the ED are available for referral most days 24/7.

“About four years ago [...] there was no substance abuse counselor, no social workers, no medical case workers at the ED. Comparing that from four years to about to now, what we have is we have 24/7 social worker and case workers as well as occasional substance abuse counselors 8–12 h a day.” -Attending

Enablement: Encourage consultation with on-site CSWs and SUNs, who can help with assessment of patients’ stage of change, treatment center referrals, phone acquisition, and connect the patient to other assistance programs.

Opportunity (Physical) [Facilitator]

Pharmacy

Pharmacists in the ED 24/7 for assistance with medications.

“Before there had only been one pharmacist in afternoon and then one at night for graveyard. And there were some hours where there were no ED pharmacists. They were able to change that though. So now we have 24-h coverage.” -Pharmacist

Enablement: Encourage discussion with pharmacists, who can help with details of Naltrexone prescription.

Opportunity (Physical) [Facilitator]

MD/NP

SUD Treatment Centers like Tarzana exist in the area for referral.

“I think we’re doing better. For example, for opioids use disorder we do have a substance abuse counselor. We have, for example, something set up with Tarzana Treatment Center, which I think even more have played a big part.” -NP

Enablement: Encourage connection to outside treatment centers and strengthen referral relationship and data sharing.

Opportunity (Physical) [Facilitator]

MD

Weekly Grand Rounds for MDs offers an established opportunity for new education and initiatives.

“I think that conference might be the best avenue just because you’ve got everyone, or more people there at once, who are more likely to be paying attention...” -Resident

Enablement: Leverage existing dedicated education time, i.e. departmental conference

Opportunity (Physical) [Facilitator]

RN

RN daily huddles, with longer huddles on weekends to address more complicated in-service topics.

“We always have daily huddles. So we can educate our staff that way.” -RN

Enablement: Leverage existing dedicated education time, i.e. RN huddles

“During the weekends in the morning is when we have huddles that are lengthy. During the week the huddles are shorter, so we’ll do a lot of other stuff with short topics.” -RN