Levels of Care

On April 30, Mayor Catherine E. Pugh and Health Commissioner Dr. Leana Wen joined the leadership of Baltimore City’s 11 acute-care hospitals to launch the Levels of Care for Baltimore City Hospitals Responding to the Opioid Epidemic.

We are in the midst of the deadliest drug epidemic in American history, and Baltimore City—with the highest age-adjusted overdose fatality rate of any metropolitan county in the United States—is one of its epicenters. Between 2011 and 2017, the number of overdose deaths in Baltimore more than quadrupled. Fentanyl-related deaths in particular are rising at an astonishing rate. There were 12 fentanyl-related deaths in 2013. Through September of last year, there were 427.

Baltimore City has responded to the opioid crisis aggressively. We issued a standing order that provides a blanket prescription for naloxone, the medication that reverses an opioid overdose, to all city residents; opened the state’s first Stabilization Center; launched a Law Enforcement Assisted Diversion program that allows those arrested for low-level drug offenses to choose treatment over prosecution; and created a rapid response system that sends outreach teams with naloxone to any neighborhood experiencing a spike in overdoses.

Baltimore City’s hospitals, for their part, are national leaders in the fight against addiction and overdose death. With the help of strong partnerships—convenings at the Health Department, the expertise of the Mosaic Group, coordination from Behavioral Health System Baltimore, and funding from the state and federal governments—almost all of the city’s emergency departments now screen all patients for addiction, offer treatment on-demand for patients who screen positive, and employ peer recovery specialists to connect these patients with ongoing care in the community. This is true of almost no other city in the United States.

The Central Role of Hospitals

Hospitals play a central role in responding to the opioid epidemic. Many people with opioid use disorder move through America’s hospitals every year, and the services that hospitals do or do not provide to these patients have a significant effect on their morbidity and mortality. Hospitals can, in addition, affect the number of Americans who develop opioid use disorder in the first place.

In recent years, the rate of opioid-related emergency department visits and inpatient stays has increased dramatically, rising by 99 and 64 percent, respectively, from 2005 to 2014. Between 2015 and 2016, overdose-related emergency department visits rose by more than 5 percent per quarter across the country. Approximately 15 percent of all hospital patients have a substance use disorder. And, according to a study published in Health Affairs last year, the in-hospital mortality rate for patients admitted with an opioid-related diagnosis—in other words, the likelihood that an opioid-related hospital admission ends in death—has more than quadrupled over the last two decades, from less than .5 percent in 1999 to more than 2 percent in 2014. 

In light of these trends, hospitals’ opioid-related policies and protocols have become increasingly important. There is evidence for the efficacy of a slate of different hospital interventions. Most immediately, hospitals can help patients at high risk for overdose by prescribing or dispensing naloxone, the medication that reverses an opioid overdose. In one study, nearly one third of emergency department patients who received naloxone and later witnessed an overdose used their naloxone to save the person’s life.

Hospitals can also effectively treat the disease—opioid use disorder—of which opioid overdose is a symptom. A 2015 study in the Journal of the American Medical Association, for example, found that initiating addiction treatment for patients in the emergency department, rather than simply referring them to treatment at a community-based provider, led to a dramatic increase in the likelihood that patients were still engaged in treatment 30 days later—78 percent compared to 45 percent. Another study, also from the Journal of the American Medical Association, found similar results for initiating addiction treatment for inpatients; 6 months after the intervention, median opioid use (measured by days of use within the last 30 days) was nearly 75 percent lower among patients who received treatment. Addiction consult services—often the vehicle for addiction treatment in a hospital setting—are broadly effective: in diagnosing addiction, initiating treatment for it, and linking patients to ongoing care. Recently, both hospitals and community-based providers have begun to employ peer recovery specialists—people themselves in recovery from addiction—to support patients diagnosed with substance use disorder on their journeys to recovery. While a new practice, peers appear to improve the efficacy of treatment along multiple dimensions. 

Treating those who already have opioid use disorder is paramount—especially in Baltimore, where the number of residents with opioid use disorder is very high. It is also true, however, that hospitals have a role to play in preventing new cases of opioid use disorder. For many people with opioid use disorder, their first opioid was a prescription painkiller. Different mechanisms for reducing opioid prescribing are being tested across the country; there’s even evidence that guidelines alone can reduce the prescribing rate.

Building on Progress through Levels of Care

Baltimore’s hospitals are national leaders in the fight against addiction and overdose death. The Levels of Care build upon this progress. They will recognize what the city’s hospitals have already achieved and provide a shared framework for ongoing improvement. They involve identifying evidence-based best practices for responding to the opioid epidemic and publicly recognizing those hospitals that successfully implement them.

Developed with active input from hospitals, the levels will be scored on numerous evidence-based criteria, such as hospitals’ ability to provide treatment to any patient who screens positive for addiction, distribute naloxone to patients, connect patients with peers or other support services, and ensure physicians are prescribing opioids judiciously.  A hospital can be level 3, 2, or 1—with a level 1 hospital offering the most comprehensive response.

The initiative is based on a similar program in Rhode Island, one of the only places in the country where overdose deaths went down last year, rather than up. All Rhode Island hospitals will soon qualify for at least one of the Rhode Island Department of Health’s three levels of care.

Proposed Levels of Care

Below is an example of what the Levels of Care could look like. The details will be finalized in collaboration with the city’s hospitals and with the community.

Whether you’re a front line hospital provider, a community leader, an advocate, a community-based treatment provider, or someone who has experienced one of these interventions as a patient, we want to get your feedback.

Please email us at [email protected] or respond using the form below. We will be accepting responses through May 31, 2018. Every piece of feedback will be reviewed.

A Level 3 hospital:
1) Screens emergency department (ED) patients for substance use disorder
2) Has an ED discharge protocol (as required by state law) that includes a referral to community-based treatment for patients with SUD
3) Prescribes naloxone to ED patients at high risk for opioid overdose
4) Maintains capacity for medication-assisted treatment initiation in the ED
5) Promulgates guidelines for judicious prescribing of opioid analgesics and provides information about safe storage and disposal to patients who are prescribed opioids
A Level 2 hospital meets the criteria of Level 3 and:
6) Offers peer recovery specialist services or similar support services to eligible ED patients
7) Screens admitted patients for SUD
8) Maintains capacity for medication-assisted treatment initation for admitted patients
9) Monitors fidelity to prescribing guidelines and addresses cases of overprescribing
A Level 1 hospital meets the criteria of Levels 3 and 2 and:
10) Maintains capacity for medication-assisted treatment initiation with all clinically appropriate opioid use disorder medications
11) Offers ongoing medication-assisted treatment in all hospital campus primary care and behavioral health clinics
12) Offers peer recovery support services or similar support services to admitted patients
13) Dispenses naloxone to ED patients and admitted patients at high risk for opioid overdose prior to discharge

Once the Levels of Care are finalized in the summer of 2018, the City will work with participating hospitals to implement the various components of the Levels of Care. Any hospital that meets a given Level will be formally recognized for their achievement.