Delivery of Care

In a time of pandemic, CODAC revamps its delivery model

Engagement and decision-making are changing on the front lines of health care delivery

Image courtesy of CODAC website

An image from the CODAC website, the largest nonprofit agency providing treatment and recovery services for substance use disorders in Rhode Island.

By Richard Asinof
Posted 3/23/20
CODAC, an agency on the front lines of delivering health care services for treatment and recovery from substance use disorders and behavioral health conditions, has had to improvise a new approach around engagement with clients and staff in a time of pandemic.
Will other agencies and health care providers consider changing their models of care, putting more emphasis on telemedicine and engagement with staff and clients? How will the necessity of changing the role of hierarchical decision-making in a time of disruption change the future of how business is conducted? Is the Brown School of Public Health conducting research to document the ways that health care delivery is changing? Will decision-making adopt the principles of arriving at a consensus, with staff having a major say in future directions, as an important tool for survival?
The Rhode Island Foundation, in partnership with United Way of Rhode Island, has launched a new fund to make investments in helping nonprofits change their methodology in a time of massive disruption from pandemic, an important and critical undertaking as agencies struggle to keep afloat in a time of enforced social distancing.
Another improvisation in the time of pandemic has been the effort by RICARES to ramp up distribution of naloxone and fentanyl test strips through the recovery community.
The broader question underlying these efforts, however, is how will the process of decision-making change, with a move away from hierarchical structures to a more consensus-driven methodology, where it is not so much about what the CEO says, but what the employees and clients need. Will the money be invested to support bottom-up innovation or to support the maintenance of the status quo?
As distance learning comes of age in Rhode Island’s public schools, a similar kind of challenge around curriculum exists: will the effort seek to reinforce the current kinds of top-down learning, or will it provide a ramp to change the nature of education and learning in the engagement of students and teachers? For instance, the last worldwide pandemic, the Spanish flu that began in 1917, killed millions of people around the world. How is that taught in the current history curriculum or even in the studies of literature and art of that time period?

CRANSTON – In a world disrupted by a pandemic, how do you maintain relationships with a vulnerable client population that struggles with anxiety and social isolation?

It is not the kind of question that has been asked – or answered – during the Governor’s daily news briefings.

Nor are there any easy answers to be found in clinical textbooks or leadership exercises. For CODAC, one of the state’s largest agencies delivering critical behavioral health, mental health and substance use disorder services, the last two weeks have been an ongoing improvisation on how to redefine its workflow and rethink its management approach.

For years, CODAC has been serving on the front lines of the substance use epidemic, the largest nonprofit outpatient provider for opioid treatment in Rhode Island, providing access to care within 24 hours, 7 days a week, at seven community-based locations.

CODAC is the only medication-assisted treatment provider in Rhode Island offering all three FDA-approved medications for opioid use order, including methadone, buprenorphine [Suboxone] and naltrexone [Vivitrol], conducted under strict federal and state guidelines.

The agency also manages an intensive outpatient program for its clients and their families focused on recovery, with a commitment to treating the whole person, including onsite psychiatric and mental health services and trauma-informed care.

CODAC has also offered specialized counseling groups for specific patient populations, such as pregnant and post-partum women, individuals involved with the criminal justice system, and patients coping with post-traumatic stress disorder. Its wellness programs include tobacco cessation, nutrition, yoga and expressive arts.

Translated, there are hundreds of employees and patients interacting on a daily basis across a large menu of services, where communications and face-to-face interactions are an integral part of the normal, everyday routine.

Now, the COVID-19 pandemic has changed all the ground rules about such interactions, forcing CODAC to adapt and to adopt to new approaches in the delivery of health care services, including a growing reliance on telephonic communications and take-home medications, in order to keep both patients and providers safe.

ConvergenceRI recently conducted a telephone interview with Linda Hurley, the president and CEO of CODAC, discussing how the agency was responding the demands of serving a most vulnerable population in a time of pandemic, talking about how the crisis had disrupted the way the agency had been doing business – and how it has prompted new, perhaps better methods of engagement.

The underlying messaging around the agency’s work has not changed for its staff or for its clients, according to Hurley. “It is always about clear, honest, and respectful communication that’s timely,” she said. “When people feel safe, and supported, and competent, they are providing better care.

Describing herself as a “glass-half-full” person, Hurley described how the challenges of responding to the threat of pandemic had opened new doors about becoming more competent around engagement with staff and clients.

The biggest frustrations, Hurley said, were not about the new challenges of operating in a disrupted world of pandemic. Rather, it was the difficulty of securing adequate resources and insurance reimbursements for the work.

“It’s like proving gravity at this point; there is nothing left to prove,” Hurley said, when talking about her work as a member of the Senate study commission on insurance rate reimbursements chaired by Sen. Joshua Miller, regarding her presentation that detailed the ongoing disparities in insurance rates and the detrimental impacts on clients and being able to recruit and maintain staff.

And, Hurley emphasized, the biggest challenges of the work still had to do with the difficulties overcoming the stigma, fear, prejudice and bias around substance use – and the failure to recognize that such disorders are “chronic, relapsing diseases of the brain.”

“I don’t think we can ever say it enough, over and over, that the diseases we treat here at CODAC, including substance use and opioid use disorders, are chronic, relapsing diseases of the brain, and need to be respected as that,” Hurley said.

The first “use” of a substance may be “volitional,” Hurely explained, but once addictive changes in the brain have occurred, it is no longer a matter of personal choice.

“This is a disease of the brain, and treatment works; sometimes it needs medicine, sometimes it doesn’t,” Hurley continued. “The more we can help individuals, the more we can rid of judgment and self-judgment as barriers to treatment, the closer we are to healing more people from the disease. We all deserve to walk this planet with some peace,” saying she was speaking from the heart.

Here is the ConvergenceRI interview with Linda Hurley, president and CEO of CODAC, the state’s largest provider of health care services for the treatment of substance use disorders, during a time when the COVID-19 pandemic has disrupted our lives, our economy and our relationships with each other, forcing the agency to rethink how it does business.

ConvergenceRI: How has the COVID-19 pandemic changed all the ground rules for your agency? What is happening with treatment for your clients? How have you had to improvise and innovate as a result?
HURLEY:
It’s true. That’s what the balance has been over the last few weeks, of really doing an assessment of how we can best serve, how we can safely serve, those who come to us for care.

With federal [and state] approval, we’re giving take-home medicine to people so that they’re so they are not coming in and being exposed every day [to the virus].

The take-home medicine has to be assessed for number of take-homes, and for an individual’s resources in protecting that medicine. Because we know that having too much opioid medicine on the street, whether you call it OxyContin or you call it methadone, is what got us into this mess in the first place.

Everything is a balance. Our guidance from the federal government and from the state government have been to err on the side of mitigating exposure [to COVID-19] versus mitigating diversion, although both are of equal importance, because exposure impacts more people than diversion.

I think, at the end of the day, all the conversations have gotten down to that. We’re looking at how we can have more telephonic support for people.

Do you want to hear what we’re doing with this?

ConvergenceRI: Yes, that’s why I’m calling. I have stopped going in person to the news conferences that the Governor and the director of the R.I. Department of Health are having daily. It’s not that I don’t trust the news media, but I don’t trust the news media. It was too risky. I don’t know what their habits are or with whom they have been in contact. I felt as if I was putting my own health at risk.
HURLEY:
I think that’s where we need to be coming from right now. That’s how we are making the decisions.

We’re going to have a lot of telephonic contact for support, for the anxiety, to be able to talk to your counselor by telephone, any time.

We’re setting things up so that there is a lot of availability when our patients and their families are calling in for questions.

We started that yesterday [Monday, March 16]. Some of our therapists are working from home today.

We made sure last week that we had everybody’s updated telephone numbers. Updated emergency contacts, all that kind of thing, so that we could start to cut back both on the number of patients that come through the buildings, and the number of staff.

By the end of the week, we will be down to just essential staff for both behavioral health and medical services.

We’re working together with BHDDH [the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals], they are working with us, “forcing” other entities if they can, so to speak, if they can force them, to come up with waivers and other things that we need to have in place in order to keep everybody safe.

We are over-regulated anyway, and at this point, we simply can’t be frivolous about enforcing non-essential contact.

ConvergenceRI: One of the questions I have is: Is there stigma attached to testing for COVID-19 and being found positive, on top of the stigma associated with being in recovery from substance use disorders – if you are a person of color, if you are a single parent, if you have a job that could be in jeopardy by testing positive?
HURLEY:
I think you’re right on target. That makes good sense to me. I have not seen it yet. But it certainly makes sense as we understand that fear, bias and prejudice, with the fear and anxiety that is being attached to this state of emergency.

What we are doing, and I am sure that other [health care providers] are doing as well, we now do the preliminary screening every single day when anyone comes into the building,

You know, a comparison to baseline, asking about new coughs, new sneezing, new fevers. There is a certain set of questions that the Centers for Disease Control and Prevention have released for screening that at least gives us some insight into somebody being vulnerable.

What we do in that case is that they get medicine to take home so that they are not coming back in and that the virus has a chance to run its course, whatever it may be. It might be the flu; it might be a common cold.

But we do not have enough testing out there. We’re so far behind the eight ball in terms of testing capability that we just have to err on the side of caution against exposure.

ConvergenceRI: You were meeting with Director Kathryn Power yesterday at R.I. BHDDH. Was she supportive of your efforts? Was there any opportunity to talk about the need to increase insurance rate reimbursements?
HURLEY:
Absolutely. Richard, you know me well enough by now.

I actually provided her – I had sent it by email, but I provided her with a hard copy of the presentation that I gave to Sen. Miller’s commission, with simple graphics [illustrating the problems], using undeniable red lines and blue lines. It’s like proving gravity at this point. There is nothing left to prove.

Director Power was very open, very receptive, and in no way minimized the gravity of the situation. After our conversation, I felt very supported and hopeful.

The staff at BHDDH, in terms of [responding] to this epidemic, their availability and their constant connection to federal oversight, has just been amazing.

All weekend long, I mean we worked like 14 hours on Saturday and Sunday, trying to create systems that are going to keep people as safe as possible, and they’ve been right there with us, no obstacles whatsoever.

BHDDH has been very strong.

ConvergenceRI: In last week’s edition, I published a story about how the Childhood Lead Action Project had engaged with its staff to develop a new virtual workplace in a time of pandemic, to keep staff and their families safe while continuing to do outreach with clients with an online presence. [See link below to ConvergenceRI story, “Acting locally.”]
Has the COVID-19 pandemic created an opportunity to force you to think more out of the box about your mission and staffing in developing a better treatment methodology than you had deployed before?
HURLEY:
You are absolutely right. As an example, we absolutely need to decrease exposure for medical staff. We have to.

So, when we get down to essential staff and the numbers that are needed, if we are doing the work and it ends up being effective, then we’ve learned a new a method on how to deliver whatever that medical service is competent and comprehensive, at the same time it is more cost-effective and safer.

We don’t know that yet. We’ve also adopted new methods of communication between departments and layers of management.

I was talking with Rebecca Boss last night [Boss joined CODAC after retiring from her position as director at R.I. BHDDH], we were discussing about how some 50 percent to 70 percent of what we were developing around communications between departments and layers of management, we’re going to adopt, because it’s working.

People who know me well may get tired of my “glass half full” attitude. But, you have to take what is positive form this [crisis], and honestly, that’s a very positive finding. When your staff feels less anxious, more competent and supported, they are providing better care.

ConvergenceRI: How has this created a new level of engagement with staff and clients, one where the staff feels heard and the nature of the top-down hierarchy has changed?
HURLEY:
This is exactly right on. Rebecca and I had this exact conversation with our doctors on Saturday. We can’t look around and say, this is what we are going to do at our nine sites, to tell our program directors, this is what needs to happen.

Because how that happens is going to be different at each of the nine sites. Rather, we asked: Tell us about how you think you can make it happen. Because you know your sites, you know your staff, and your patients.

We are relying heavily on the program managers to make decisions. We are having daily de-briefings, there are calls in the morning and in the afternoon with each of our local program directors. They are going back to their staff every day and checking in, and figuring out what they need to do differently tomorrow.

I teach leadership. And, for me, I actually feel guilty or laugh at myself sometimes, because I know what I teach, and I know what I do, is not always congruent.

ConvergenceRI: On a broader scale, from the 30,000-foot perspective, do you feel as if you have access to all the data you need as you conduct your health care delivery?
HURLEY:
We don’t have enough data, and one of my concerns, when we recognize that we don’t have enough, solid data, is that we then take data that we do have that has not had enough to be mature or show a longitudinal [trend].

The data hasn’t had enough time to tell us what we need to know. We can’t just take a snapshot and say, “Check this out!”

The snapshot may give us some direction, but it’s not the answer. If we use that underdeveloped data, and give it more weight than it has earned, because it’s been too short a time frame, that’s where my concern lies.

ConvergenceRI: Is there also a problem about ignoring the results of the data that is more long-term?
HURLEY:
I get so tired of being asked to prove what has already been proven, just because you don’t like the answer. If you don’t like gravity, you want me to prove it again. I can’t help you there.

Even the study commission’s need to create political will by showing state leaders, elected leaders, if we put money here, we’ll save money there.

I think it should be the mission of the leadership to access that data and look at it over a five-year span of time.

If we look at expenditures, we give people treatment, we put money into the treatment site, they’re finally able to access primary care, maybe they are discovering some chronic conditions, and [as a result], there is usually is a bump in expenditures, but then it comes down and evens out because you’re not having the ED visits.

It’s common sense. It’s all been demonstrated, in small demonstration pilots, all over the place. But nobody has really taken [those outcomes] and flown with that.

A lot of times our leaders [appear to be] not all that interested in long-term outcomes, whether its CEOs of various institutions that are held accountable by annual budgets, or whether it is elected officials that are held accountable by their elections.

You know, we as consumers and voters don’t often hold people accountable for long-term outcomes; we want to see short-term outcomes, too.

It’s a societal thing. And, it makes our positions harder in proving that making expenditures now is going to be creating savings five years from now.

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