Evaluating the Integration & Utility of Collateral Contacts in Patient Recovery from Substance Use Disorder Madeline Lane, MS21; Linda DeMasi, MBA2 ; Karin Schlereth, ICPS, MPS2; Mary Silberstein, LCSW-R3; 1,2 2 Sandeep Kapoor, MD, MS-HPPL ; Laura Harrison, MPH 1Zucker School of Medicine at Hofstra/Northwell; 2Emergency Medicine, Northwell Health; 3Central Nassau Guidance & Counseling
Background
• Project CONNECT: Northwell Health, in collaboration with Central Nassau Guidance & Counseling, offers 120 days of nocost external care navigation to individuals who screen positive for a substance use disorder (SUD) at 10 Northwell Emergency Departments (EDs) in Nassau/Suffolk County → Communication structure: A care navigator reaches out to participant/collateral contact at baseline and 7/30/60/90/120 days to address needs, providing additional referrals/resources, and track progress of goals → Collateral contact: Participant-identified individual whom a care navigator may reach out to if the participant cannot be reached; collateral contacts may accept referrals on the participant’s behalf or for themselves
Objective Evaluate current integration of Project CONNECT participants’ family & personal support networks across the 120 days of external care navigation
Hypotheses 1. Participants whose collateral contacts interact with Project CONNECT will have higher rates of engagement and SUD treatment and lower rates of substance use and ED/hospital visits than those without collateral contact interaction 2. Participants whose collaterals accept referrals to family services will have higher rates of engagement and SUD treatment and lower rates of substance use and ED/hospital visits than those who do not accept family service referrals 3. Participants who face access-related issues (phone, internet, transportation) will have higher rates of Project CONNECT interaction with their collateral contacts
Treatment
Collateral Interaction Attempt to reach Successful connection Referral provided
p-value 0.003 0.060 0.506
Participant Engagement OR 95% CI 0.84 0.687 - 0.924 1.12 0.989 - 1.637 1.03 0.757 - 1.761
TABLE 2. Relationship between collateral and participant interaction
Total Collateral Contact Attempts (n=331) (+) Participant connection (-) Participant connection 16.0% (n=53) 84.0% (n=278) Total Collateral Contact Referrals (n=36) (+) Participant referral (-) Participant referral 52.8% (n=19) 47.2% (n=17) FIGURE 2. Rate of referral information sharing with collateral contact, per successful collateral connection, by Project CONNECT interval 43.3% n=13
50.0% 40.0%
26.1% n=12
30.0%
25.0% n=8
16.7% n=4
14.3% n=3
20.0%
15.4% n=2
0.0% 7-DAY
30-DAY Time-point
60-DAY
90-DAY
120-DAY
FIGURE 3. Rate of supportive service referrals provided to participant, per successful connection with participant, by interval. Supportive service referrals: disability, Medicaid, insurance, criminal justice, vocational, case management, transportation, housing, naloxone, and family services 12.0% 10.0%
10.3% n=53
All supportive services
Family services
8.0% 6.0% 4.0% 2.0%
1.7% 1.1% n=3 n=4
BASELINE
3.2% n=5
1.9% n=3
1.8% n=3 -
-
-
-
7-DAY
30-DAY Time-point
60-DAY
90-DAY
-
0.96
0.683 - 1.173
Phone Transportation Internet Phone Transportation Internet Phone Transportation Internet
Attempt to Reach <0.001 1.26 1.184 - 1.390 0.93 1.00 0.830 - 1.185 0.383 1.03 0.846 - 1.545 Successful Connection <0.001 1.19 1.070 - 1.183 0.763 1.01 0.910 - 1.137 0.282 1.04 0.919 - 1.335 Referral Provided 0.006 1.11 1.009 - 1.052 0.440 1.03 0.972 - 1.067 0.694 1.02 0.939 - 1.099
• Participants with lower engagement have significantly more frequent attempts to reach their collateral contact (Table 1)
10.0% BASELINE
0.424
• Only around half of participants offer collateral contact info; TABLE 4. Odds of collateral interaction for a given access-related concern additional description & encouragement surrounding Collateral Interaction Access-Related p-value OR 95% CI collateral contacts may be valuable for participants Concern
TABLE 1. Odds of participant engagement vs. collateral interaction
Rate of Collateral Referrals
• SBIRT: Northwell Health utilizes Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a foundation to humanize and to universally address substance use as part of usual care
Discussion
• Care navigators effectively integrate collateral contacts in cases • Retrospective cohort study of 667 ED patients with moderate- to high-risk substance use of unsuccessful participant engagement • Patients were identified by SBIRT at 10 EDs across Nassau & Suffolk County in NY, or through Remote SBIRT, and enrolled in Project CONNECT from 2021-2022 • Collateral contacts represent a valuable avenue for referral • Project CONNECT team entered data into REDCap5,6 at baseline and 7/30/60/90/120 days information delivery, as nearly half of referrals shared with • REDCap data was exported to IBM SPSS Statistics v27 for analysis collateral contacts occur in absence of participant referral • Descriptive statistics used to describe collateral contact interaction & service referrals • Collateral contact interaction represents a key strategy • Odds ratios calculated using logistic regression for collateral interaction vs. participant applied in circumstances of limited phone access recovery/engagement Results • Participant referrals to family services and other supportive FIGURE 1. Relationship of primary collateral contact to participant TABLE 3. Odds of referral information sharing with a collateral services are underutilized or under-reported. Referral sharing contact for a given self-reported substance use outcome 5.9% 7.8% CHILD with collateral contacts decreases after baseline n=21 Referral Provided to Collateral Contact n=28 Self-Reported FRIEND 7.3% Outcomes These findings present an opportunity to standardize referral p-value OR 95% CI 27.1% OTHER/UNKNOWN n=26 n=97 Alcohol use 0.028 1.11 1.018 - 1.380 PARENT offering practices at all intervals and supplement team training 33.2% 18.7% Drug use 0.847 0.99 0.919 - 1.071 SIBLING n=67 n=119 on available family programs, among other supportive services ED visits 0.854 0.99 0.962 - 1.033 SPOUSE/PARTNER
Rate of Participant Supportive Service Referrals
• Relevance: In 2021, 46.3 million Americans met criteria for a substance use disorder (SUD).1 Approximately 1 in 20 patients treated for a nonfatal opioid overdose die within 1 year,2 emphasizing a need for effective discharge planning & longitudinal support. Minimal data exists on the integration of family and personal support systems in longitudinal, postdischarge services for individuals with SUD3-4
Methods
-
120-DAY
• 53.7% (n=358) of participants provided at least one collateral contact • 47.2% (n=17) of collateral contact referrals occur without participant referral (Table 2)
• Higher participant-reported alcohol use correlates with more collateral contactaccepted referrals (p=0.028) (Table 3) • Significant increase in collateral contact interaction with participant phone issues (p<0.001) (Table 4) • Rates of participant-accepted supportive service referrals are low overall, with a sharp decline after the baseline rate of 10.3% and no referrals at 120-days (Fig. 3) à Only 4 documented family service (Fig. 3) à Despite modifications to data collection, preliminary 2023 data reveals similarly low supportive service referrals (n=17), with no referrals to family services
• Limitations: All data is self-reported and only available if successful contact is made with participant or collateral; relationship between collateral contact integration and substance use may require a longer period of data collection
Implications Current findings will inform referral practices and data collection strategies for quality improvement and planned Project CONNECT Plus (+) expansion of enrollment and services • Quality Improvement: Project CONNECT may now enroll patients who do not have a personal phone if a reliable collateral contact is available • Project CONNECT Plus (+): Enrollment will extend to family members of individuals with SUD, including from outside healthcare settings. Supportive services will expand to include resources and formalized referral process for domestic violence, social services, food insecurity
Future Directions • Evaluate collateral engagement vs. medical visits in EHR post 120 days of Project CONNECT care navigation • Conduct semi-structured interviews with care navigators to better contextualize current referral practices and identify opportunities for improvement
References 1. Substance Abuse and Mental Health Services Administration. Preliminary Findings from Drug-Related Emergency Department Visits, 2021. Rockville, MD; 2022. https://www.samhsa.gov/data/ 2. Weiner SG, Baker O, Bernson D, Schuur JD. One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020. 3. Ventura, Alicia S. MPH; Bagley, Sarah M. MD. To Improve Substance Use Disorder Prevention, Treatment and Recovery: Engage the Family. Journal of Addiction Medicine 11(5):p 339-341, September/October 2017. | DOI: 10.1097/ADM.0000000000000331. 4. Eddie D, Hoffman L, Vilsaint C, et al. Lived experience in new models of care for substance use disorder: A systematic review of Peer Recovery Support Services and recovery coaching. Frontiers. April 24, 2019. Accessed August 3, 2023. https://doi.org/10.3389/fpsyg.2019.01052. 5. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010 6. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi:10.1016/j.jbi.2019.103208
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