Complex Coordination: Emergency Planning for Those on Medication-Assisted Treatment

State: CA Type: Promising Practice Year: 2019

The San Francisco Department of Public Health (SFDPH) serves the people of the City & County of San Francisco. The 2018 population is 885,000, which represents residential population, and does not fully encompass San Francisco's daytime community. Emergency planning is based upon a figure closer to a population of 1.2 million, accounting for those commuting in as well as daily tourists.

Located in the Northern California, the City & County of San Francisco is approximately 47 square miles, representing a dense, highly-populated area.

The San Francisco Health Network is housed under SFDPH, representing the network of clinical services available to the community. This includes two hospitals, behavioral health, a system of primary care clinics, many of which provide care to underserved members of the community, such as low-income and homeless individuals. A critical population considered in emergency planning, the number of homeless individuals in San Francisco totals 7,499 (January 2017).

San Francisco previously had no plan in place to manage the needs of those requiring methadone in an emergency. The provision of methadone has been deemed an essential service that must continue in the face of disaster. Because of its addictive nature, methadone dosing and distribution is highly regulated. This presents a challenge, particularly to patients who dose on-site daily, if their clinic becomes non-operational following a disaster. The public health issue: how can this essential service be maintained? How can plans be centered upon a resource so highly regulated and secure?

Persons on a steady dose of methadone may be able to manage 1-2 days of no dosing without experiencing intense withdrawal. Severe and relentless, withdrawal symptoms include diarrhea and stomach cramps, nausea and vomiting, muscle and joint achiness. In addition to the discomfort and pain one experiences, a lapse in methadone dosing can increase the likelihood that a patient will seek illicit drugs. This in turn, increases the risk of overdose due to reintroduction of the illicit drug, paralleled with an increased risk of disease transmission. Missed doses of methadone for 3 days or more may result in reduced opioid tolerance. Consequently, this may increase a patient's risk of overdose once methadone is reintroduced into their system.

In 2017, the Methadone Emergency Preparedness Workgroup” was established to initiate planning efforts focused on a population that has previously been largely overlooked in emergency planning. The overarching goal: outline strategies to continue methadone dispensing operations during an emergency. The intended outcome is twofold: provide continuity of care resulting in improved patient outcomes, as well as reduction of unnecessary emergency room hospital surge. If patients know where to go to receive treatment, this may preclude them from presenting to (an already overwhelmed) hospital during a disaster.

The core workgroup represents opioid treatment providers, however additional partners play crucial roles, including Substance Abuse Services, SFDPH Pharmacy, EMS, Human Services Agency. Partners that are consulted with include: DEA, Methasoft, CA Department of Healthcare Services. Activities are implemented through monthly meetings to facilitate decision-making and to seek solutions.

Intended outcomes to support disaster planning/response for patients on opioid treatment:

  • SFDPH Methadone Planning Operational Guide
  • Clinic Emergency Response & COOP Plans
  • Memorandum of Agreement, to include process standardization grid
  • Emergency Communications Spreadsheet
  • Patient Disaster Preparedness Brochure
  • San Francisco Map of Methadone Clinics
  • Reference documents incorporating this into SFDPH's Emergency Operations Plan

The objectives are in progress, with pivotal decision points and useful lessons learned already. Preliminary activities are taking place to ensure the successful development of these tools.

Targeted outreach has contributed to an engaged and active workgroup. When participation was low, direct phone calls were made to clinics, conveying an important message, demonstrating that their expertise is not only valued, but crucial to the success of the workgroup. As key stakeholders, they understand that their concerns are listened to, their voices heard.

The public health impact focuses on building a culture of preparedness. Process steps, identified barriers, and draft tools may be utilized and adopted by other jurisdictions. Opioid treatment patients will receive educational brochures outlining personal preparedness and recommended actions following a disaster. Counselors will initiate discussions with patients, providing education and triggering conversation previously not included during counseling sessions. The intent: pre-disaster awareness will reduce patient anxiety surrounding uncertainty of obtaining one's next methadone dose. This is coupled with the goal of prevention of patient suffering due to lapse in treatment.

SFDPH also aims to build a culture of preparedness among clinic staff, as demonstrated by the provision of COOP training, encouragement of staff call-down drills and recommendations to update plans.

San Francisco had no plans in place to address opioid treatment within the context of disaster response. A population often overlooked, there was no process outlining how to continue the provision of methadone to patients following a disaster. 

In the initial planning stages, the target population was methadone patients. The focus later expanded more broadly to opioid treatment, thus inclusive of patients on buprenorphine. A decidedly vulnerable population, many of these individuals experience homelessness, suffer from psychiatric illnesses, and/or have been diagnosed with chronic diseases such as HIV, Tuberculosis, Hepatitis C.

Based on the information received from opioid treatment partners, SFDPH has calculated approximately 2,700 methadone and buprenorphine patients in San Francisco. The frequency of patients presenting to their clinic varies; some patients dose twice a day, some are eligible for take-home dosing, with the majority of patients dosing daily.

The goal of this planning process is to reach all patients that dose at San Francisco opioid treatment clinics. Pre-incident planning involves educating patients through distribution of the SF Disaster Preparedness Brochure and including preparedness discussions during patient counseling sessions. It involves increasing the level of preparedness among clinics through training and review of clinic disaster plans. Similarly, the aim is to reach all SF patients during and post-incident, through continuity of methadone/buprenorphine dosing.

The City & County of San Francisco has deemed methadone management an essential service, as referenced in SFDPH COOP (Continuity of Operations) Behavioral Health Services Annex. The proposed practice, and the purpose of the workgroup, is to establish processes to continue dosing medication assisted treatment for populations in need. The current practice of methadone management provides opioid treatment to patients on a daily basis. SFDPH has proposed to improve the existing practice by developing plans and tools outlining how this critical service will continue during a large-scale, citywide disaster.

Disaster planning for patients requiring methadone management is not new to the field of public health. However, while this planning gap has remained a persisting concern, in the past little has been done to address this population's critical need. SFDPH conducted preliminary research to obtain guidance from other health jurisdictions. With minimal results, SFDPH chose to forge its own path in establishing a project plan, thus undertaking an innovative initiative. This is demonstrated through the development of new tools, an attempt to standardize processes among multiple clinics, and creative solutions to significant challenges.

Numerous disasters have demonstrated the many problems associated with patients' inability to receive their opioid treatment. These include: inability to access medical records, interruption in treatment, patient distress due to uncertainty in obtaining next dose, surge in hospital emergency departments. As indicated in a case study highlighting Hurricane Sandy findings, patients received suboptimal dosing by Emergency Department physicians. Some refused to treat methadone patients, while others provided patients with a higher level of dosage than necessary.

Evidence validates the critical need to develop plans, and an abundance of guidance tools have been released specifically focused on establishing crisis standards of care. In the Institute of Medicine's Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response”, crisis standards of care is explained. Medical care delivered during disasters shifts beyond focusing on individuals to promoting the thoughtful stewardship of limited resources intended to result in the best possible health outcomes for the population as a whole.” Tasked by the Department of Health and Human Services (HHS), the Institute of Medicine convened a committee of experts to create guidance for health officials. As referenced in the report, the committee strongly urges embedding crisis standards of care into the broader scope of disaster planning. Based on the committee's recommendations, a systems approach incorporating crisis standards of care, must be implemented to provide the best possible care to the greatest number of patients. Recognized as an essential and effective planning measure, crisis standards of care is now included in both the Public Health Emergency Preparedness (PHEP) & the Hospital Preparedness Program (HPP) funding opportunities.

The goal of this practice is to create strategies to continue the provision of opioid treatment during an emergency. Ensuring methadone clinics are prepared will result in improved patient outcomes and reduce overwhelming surge to San Francisco's hospital system. Deliverables for this practice include: SFDPH Operational Guide, Clinic Emergency Response and COOP Plans, Crisis Standardization of Care Processes, Memorandum of Agreement (MOA), Disaster Preparedness Brochure, and a communications list. SFDPH aims to strengthen the level of disaster preparedness on a citywide level; the success of this is also contingent on clinic-level of preparedness.

SFDPH's role involves coordination, facilitation and fostering collaboration among key partners in order to achieve project objectives. After identifying community partners, the following steps have been implemented:

  • Methadone clinic information gathering – needs assessment (emergency plans) & learn about current clinic processes
  • Early identification of challenging considerations, such as: dosage verification when patient records are not available, provision of services in non-traditional setting (ex: medical needs shelter, alternate dispensing location), standardization of processes during crisis, securing and movement of highly regulated medication
  • Information gathering surrounding electronic patient records system, via discussion with Methasoft
  • Review of exemplary tools from other jurisdictions and feasibility for use in San Francisco (Seattle/King County Continuity of Care Memorandum of Agreement, New Zealand Client Information Sheet)
  • Review of case studies from previous disasters: lessons learned, anticipated challenges
  • Expansion of workgroup to include additional, federal partners:  Drug Enforcement Agency (DEA), Assistant Secretary for Preparedness & Response (HHS ASPR), Substance Abuse and Mental Health Services Administration (SAMHSA), San Francisco VA Medical Center Substance Abuse Program
  • Facilitation of MOA workshop to discuss content for agreement and to begin initial draft
  • Development of patient questionnaire – the workgroup created questions to elicit information from patients, to incorporate into SFDPH's planning process. Questionnaire asked about preferred mode of notification, length of time before experiencing withdrawal symptoms, where a patient would go to receive treatment if primary clinic was closed.
  • Establish trigger criteria to activate MOA, determining when to shift strategies (ie: when to direct patients to another existing methadone clinic in SF vs. when to establish an alternate location to dose methadone). Discussion focused on circumstances that guide these decisions and sharing of key resources. The workgroup also addressed responsibilities associated with each role, particularly primary provider (clinic patient is enrolled) and receiving provider (clinic that doses methadone in an emergency on behalf of primary provider)
  • Create a disaster preparedness brochure for San Franciscans on medication assisted treatment, using New Zealand tool as a guide
  • Incorporate Human Services Agency into workgroup – facilitate discussion on how to address methadone needs among displaced populations temporarily residing in a disaster shelter
  • Attempt to standardize protocols among San Francisco clinics, based on specific functions, resulting in Crisis Standards of Care” grid. This tool outlines service adjustments that will be activated in a disaster, and the goal is to align the modified processes among clinics. In the event that patients and/or staff are directed to clinics other than their own, operations will be more effective if protocols are streamlined, and processes consistent. The grid highlights current processes, proposed modifications, and whether all clinics come to a consensus, focusing on these functions:
    • Urine test
    • Breathalyzer
    • Methadone dosing – how to proceed with dosing when patient dosage is unknown and collective, citywide methadone supply is low
    • Take-home dosing
    • Counseling session
    • Direct observed therapy                                                                                                                   Some decisions were made among workgroup members present at the meetings, while other decisions must gain approval from clinic medical directors. SFDPH is currently finalizing a questionnaire designed for medical directors to make clinical decisions related to dosing protocol in a disaster setting.
  • Develop Clinic Profile Forms, which were sent out to opioid treatment providers to collect data and obtain an overall citywide picture of patient needs and medication supply/stockpile
  • Create a Conference Call Template for opioid treatment clinics. SFDPH encourages clinics to communicate with one another, collaborate and share resources. One mechanism to accomplish this is to establish a communications protocol, coordinating a clinic-led conference call as a platform to discuss resource needs, facility status, and staffing. Clinics identify a spokesperson to brief SFDPH
  • Provide COOP (Continuity of Operations) training for opioid treatment clinics to strengthen clinic's internal plans
  • Consult with the DHCS (Department of Healthcare Services) State Opioid Treatment Authority to understand what mandated requirements would be lifted in the event of a large-scale citywide disaster

Stakeholders have been involved in the practice since the beginning of the planning process, initiated January 2017. The workgroup remains active and will continue to until objectives are met.

Stakeholders, particularly opioid treatment clinics, serve as the subject matter experts. While SFDPH is driving this process, treatment providers have the expertise to make decisions. If disaster strikes and clinics are impacted, the providers will be implementing the response to ensure continuity of care.

SFDPH values the knowledge of community stakeholders, as well as their commitment to their daily mission. Collaboration is fostered by ensuring all partners have a voice. Feedback is encouraged, and innovative ideas applauded.

No costs other than provision of COOP training by a contracting agency, at approximately $300.

The practice goal is to collaboratively develop plans to continue the provision of opioid treatment during an emergency. Intended results focus on improving patient health outcomes and reducing avoidable surge on the San Francisco hospital system. Various tools have been created to accomplish these goals.

Some discoveries identified during the planning process involve lack of process uniformity amongst methadone clinics. For instance, each provider uses a different scale to determine dosing for patients under the influence of alcohol. Further, some clinics provide direct observed therapy medication, such as HIV, TB, psychiatric medication, while others do not. These variations require additional planning if, due to a disaster, staff must transfer to another clinic, or patients receive care at a location other than their primary clinic.

Given the practice is still in progress, limited evaluation has occurred. There are many indicators SFDPH is interested in assessing, such as: the number of clinics who have elected to purchase an emergency medication cache, increase in staff knowledge of clinic emergency plans, increased knowledge of city disaster response processes among stakeholders. Following the COOP training, (scheduled for January 2019), SFDPH will evaluate how many clinics have used the template provided to create their own clinics' COOP Plan. Additional evaluation opportunities include: the number of clinics who agree to standardize disaster protocols, as well the number of patients that counselors reach when including disaster preparedness guidance during patient counseling sessions. Aside from experiencing a real incident, the most effective method to test response processes, is to conduct exercises. SFDPH looks forward to this evaluation opportunity to partner with, and support clinics testing their plans and analyzing results.

SFDPH recognizes the importance of program sustainability as well as continuous improvement given that disaster may strike unexpectedly, impacting our community without any notice.

Additional work needs to be carried out in order to fulfill the practice objectives. The workgroup is dedicated to these activities, such as improving communication processes between clinics, and assessing the feasibility of establishing pre-designated, pre-DEA approved alternate dispensing sites, should multiple clinics be rendered non-operational. Moving forward, stakeholders will strategize how to manage the persisting challenge of medication transfer of a Schedule II drug to comply with strict federal regulations. SFDPH will determine how to best incorporate this plan into the larger, broader public health plans such the Disaster Shelter for People with Medical Needs (DSPMN) Annex to the Emergency Operations Plan.

Lessons learned involve ensuring the right partners are included, that a complicated practice requires the expertise and input of a diverse group. Collaboration is key, as is a shift in strategies when a process is not achieving the desired outcome. Stakeholders are committed to sustaining this practice, which will be encouraged by SFDPH through continual targeted outreach.

SFDPH foresees sustainability plans based on exercise conduct. These may be carried out through clinics conducting staff call-down drills to assess staff availability during a notional disaster. SFDPH can assist in coordinating a clinic conference call, allowing for the template to be tested; this will provide clinics a platform to discuss operational capacity, resource needs, activation of the Memorandum of Agreement. A newly developed activity, this will signify the first time the San Francisco opioid treatment community will practice this capability.

With each exercise, gaps will be identified, lessons will be learned, and corrective actions performed. SFDPH does not anticipate significant funding will be required to ensure this practice is sustained following initial development. This, coupled with SFDPH's unwavering commitment to disaster preparedness, particularly focused on vulnerable populations, supports a strong outlook on future progress and practice sustainability.

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