In rural Maryland, a telemedicine experiment solves pressing physician shortage in addiction treatment centers.
Since its founding more than four decades ago, Wells House has served the needs of addicted individuals in rural Hagerstown, Maryland. Operating at first as a halfway house for homeless alcoholic men, Wells House eventually provided more comprehensive behavioral health treatment, including counseling and rehab services for men and women addicted to drugs and alcohol. However, the Wells House bench was shallow, and when one local physician, Martin Gallagher, MD, announced his retirement, the future seemed uncertain.
Gallagher was invaluable to Wells House residents because he was specially wavered to prescribe buprenorphine, which suppresses withdrawal symptoms, relieves cravings and helps patients control behaviors that may prompt them to use opioids. When he announced he was going to retire, the Wells House was forced to scramble to meet the medical and psychological needs of their residents, many of whom were attempting to manage withdrawal symptoms and/or prevent relapse.
Without a trained clinician to prescribe and manage the essential medication component of treatment, the Wells House program was in a precarious position. At first, Charlie Mooneyhan, the director of Wells House, hoped to have a physician from the University of Maryland Department of Psychiatry travel to Hagerstown and replace Gallagher. But Hagerstown is nearly two hours away of Baltimore, so this wasn’t a practical solution.
Fortunately, Mooneyhan was able to link up with two physicians in Maryland’s Department of Psychiatry, and they began thinking outside the box. Eric Weintraub, MD, and Christopher Welsh, MD, both associate professors of psychiatry at the UM School of Medicine, thought that telemedicine might just be the solution that Wells House was looking for.
“We had been talking with the director about doing telemedicine with substance abuse and saw this as an opportunity to expand what we are doing,” says Welsh, who is medical director of the Substance Abuse Consultation Service.
Prescription opioid use is disproportionately impacting rural areas, according to Weintraub, also the School of Medicine’s Alcohol and Drug Abuse division head. “There is a huge increase in overdose deaths,” he notes. “There is a lack of access to medication-assisted treatment, very few methadone programs, and very few waivered buprenorphine physicians in rural areas,” Weintraub adds.
Planning the Program
Planning for the Wells House telemedicine program began in Spring 2015, but the first patient wasn’t seen until the end of August. Telehealth programs don’t happen overnight, note Welsh and Weintraub. “We had to appoint a coordinator in the Department of Psychiatry to work with a coordinator at Wells House. Wells House patients work with counselors and other staff there, while we provide the medication management component of their treatment,” explain Welsh and Weintraub.
The physicians set up two, two-hour blocks of time every week to see Wells House patients (via teleconferencing). Wells House provides the doctors with a list of patients they will be seeing ahead of time, and the coordinator brings each patient into a secure area there, one at a time.
“Before we see the patient, the Wells House coordinator sends us clinical information and urine toxicology screens,” Weintraub explains. “Then Chris and I put together progress notes and evaluation forms, consistent with what we do with our non-telemedicine patients. We maintain charts on both ends.”
Interoperable Records Prove Challenging
One aspect of the telemedicine approach that Welsh and Weintraub hope to improve upon is the record keeping. Currently, Wells House has an electronic medical record (EMR) system that is different from what the UM School of Medicine uses, and that’s an issue, says Welsh.
“We made attempts to create a template that would let us be able to log in to their EMR, but that didn’t go well,” says Welsh. “Now it’s a little primitive, but we actually write paper notes and fax them to Wells House. We are hoping that with future places we work with, we can streamline that a bit.”
Keeping It Simple
From a technology standpoint, the telemedicine connection between Wells House and UM School of Medicine is fairly simple. “I’d highlight that anyone can do it,” says Weintraub. “We are not the most tech savvy of our colleagues.” We use straightforward software, called Acano and we rely on our IT guy, Dave Flax, when needed.”
In the end, it’s simple – a little cumbersome in the charting – but highly effective. “We can do whatever we need to do to manage medication and facilitate professional treatment. We focus on a visual assessment, as opposed to anything that requires us to lay hands on the patient,” says Weintraub.
“When you are dealing with opioid addiction, you mostly want to see if somebody might be intoxicated or in withdrawal, so the cameras are sufficient for that,” he says. “We look at their pupils, see if they are sweaty, that kind of thing.”
Overall, Welsh and Weintraub say the program is successful. A chart review they conducted after one year showed that, by the primary outcome measures of treatment retention and opioid use, their success rate is equal to what they would see with in-person treatment (see Figure 1 below).
Indeed, the program proved so fruitful that at the end of last year, Welsh and Weintraub began to work with the Garrett County (MD) Health Department to provide the same service in a new county. Garrett County is even more rural than Washington County. Unlike Wells House, where many patients are residential, the Garrett County patients are all outpatient.
Get The Training
Medication-assisted addiction treatment may be the only solid path to recovery for many opioid abusers, according to addiction experts. And telemedicine may prove to be a boon to the delivery of that vital piece of the puzzle. Training to qualify for the waiver to prescribe buprenorphine requires an eight-hour commitment for physicians. In a recently enacted law, nurse practitioners and physician assistants now also can be trained and receive the waiver after completing 24 hours of training. That should help to ease some of the shortage of prescribers, which, though felt more keenly in rural areas, can also be a problem in major cities. “Opiate patients won’t stay in treatment if they are not on medication because they experience withdrawal symptoms and cravings,” Welsh explains. “Telemedicine allows them to stay in treatment and do the counseling piece and get further into recovery.”
Three tips for implementing a similar opioid addiction telemedicine program:
- Make sure you’re meeting an urgent and rising need for medication management and consultation
- Understand that, if done correctly, telemedicine consultations yield the same outcomes as in-person consultations and that care should not be compromised
- Keep the technology simple and have IT backup