Heart, Vascular and Thoracic Institute Opioid Use Disorder Patient Tracking

Executive Summary   

In 2020, during the COVID epidemic, drug overdose deaths rose to almost 92,000, a new high according to data released by the CDC. The misuse of and addiction to opioids—including prescription pain relievers, heroin and synthetic opioids such as fentanyl—remains a serious national crisis that affects public health as well as social and economic welfare. The CDC estimates that the total economic burden of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. 

Injection drug use associated endocarditis cases have increased significantly in the past years, paralleling the rise in opioid use occurrence. Endocarditis is a life-threatening infection of the heart. “Without valve surgery, patients can suffer a variety of symptoms related to damaged heart tissue, including fatigue, shortness of breath and an increased risk of other cardiovascular problems such as heart failure, stroke and death” (Kadri et al., 2019). 

In addition, drug abuse relapse is a leading cause of death and reoperation in those who have undergone prior heart valve surgery.   

As a leading referral center, Cleveland Clinic has seen these same trends:  

• Surgery for injection drug use infective endocarditis has increased dramatically over the past 10 years 
• Relapse of drug use leads to reoperation and/or death 

This highlights the need to address substance use disorder during valve surgery hospitalization, to include clinical interventions, education, support, transition of care and patient follow-up to improve short- and long-term outcomes. 

As Dr. Gosta Pettersson states, “We would not operate without antimicrobials, so why would we operate if the addiction is not treated and associated with such high risk of relapse and death?” 

Based on the Endocarditis Center team’s review of outcomes data and team discussions, it was determined the Management of Substance Use Disorder and Heart Infections in Cardiovascular Patients (MOSAIC) program should be implemented. 

A real-time list in Cleveland Clinic’s electronic medical record (EMR) was created to look at patients’ inpatient (IP) problem list. This real-time logic uses a predefined list of ICD-10 codes for the purpose of scanning the problem list for those patients admitted to the hospital. Consult teams use the real-time list for the purpose of identifying patients with substance use disorder (SUD). Once the clinical determination has been made that the patient has infective endocarditis (IE), the patient is evaluated by a multidisciplinary team for appropriate treatment (including cardiac surgery, intervention or medical management).   

The EMR tools allow for: 

• A real-time list for consult teams to follow inpatients. 
• A link from the 72-hour snapshot within the EMR to the list of protocols for care of patients with IE and SUD. 
• Reminder cues to know what discharged patients need to be called each week, as well as program summaries to highlight patients enrolled, completed, and those with specific factors for outcomes tracking. 

Definition of terms  

• DC = Discharge 
• IE = Infective endocarditis 
• IOP = Intensive outpatient program  
• LTAC = Long term acute care (hospital or facility) 
• MOSAIC - Management of substance use disorder heart infections in cardiovascular patients 
• MAT = Medication assisted therapy 
• OUD = Opioid use disorder 
• PAC = Post-acute care  
• SNF = Skilled nursing facility 
• SOAR = Supporting opioid addiction recovery (peer support)* 
• SUD = Substance use disorder  
• EMR = Electronic medical record 

*Project SOAR is a peer support group that offers OUD patients support throughout their hospital stay.    

Peer support specialists: 

• Are Specially trained and peer support certified individuals 
• Have an average of four years of recovery experience 
• Undergo 30 hours of CE credits every year 
• Are funded by Ohio’s State Opioid Response Fund, which is managed by the Ohio Mental Health and Addiction Services as part of the Substance Abuse and Mental Health Services Administration  

Patients may enter this process via several methods, including: 

• ICU transfer 
• Hospital transfer 
• Direct admit 
• Emergency  
• TCI (planned) surgery 

Cleveland Clinic’s MOSAIC program is designed to address the needs of patients who are admitted with infective endocarditis and have a SUD, such as opioid use or intravenous drug use. The main goals of the program (during patient admission) are to initiate addiction management measures, optimize pain control post-surgery, and provide early discharge planning. This can be done using methods that include MAT, social work assessment and interventions and the introduction to the peer support program SOAR, which are important steps prior to the patient having cardiac surgery.   

As most patients with IE require post-discharge intravenous (IV) antibiotics after cardiac surgery, social workers and case managers provide choices for post-acute care, which must include LTACs, acute rehabilitation or SNFs offering MAT and IV antibiotics; facilities that also include IOP are recommended. They also collaborate with teams to offer MOSIAC services, including physical therapy, cardiac rehabilitation, art and music therapy, and SOAR during their hospital stay. In addition, the patient is regularly contacted after discharge by the patient outreach team to confirm the patient is following their medical plan and to determine if they need additional support.  

Cleveland Clinic case managers, social workers and the patients may ask for SOAR to follow the patient at the post-acute care facility. This is a significant benefit for patients as a bridge to the community and necessary resources and support the patient requires. Case managers will follow up with discharged patients on request from MOSIAC team members.  

Cleveland Clinic attempts to contact all MOSAIC patients at one week,  one month, three months, six months and one year post-discharge. If a patient requires contact at other times for a follow-up appointment or other needs, the team will reach out to the patient. A challenge to this patient population is accurate and reliable contact information. The nurse attempts to call each patient at least twice. If the patient is unable to be reached at the phone numbers listed, there will be an attempt to contact their alternate contact listed in the EMR. In addition, if the patient is residing at a SNF or LTAC, the registered nurse, case manager or nursing director is asked the scripted questions. During the call, reminders of the patient’s upcoming appointments are shared with the patient and/or caregiver. 

If a patient has not made follow-up appointments and plans to return to Cleveland Clinic, the specific department schedulers (i.e. cardiology, infectious disease and/or behavioral health) are notified. If a patient requests psychiatry or SOAR, these services will be coordinated as well.   

Several measurements are tracked within the program, including initiation of MAT, MOSAIC program completion, readmissions and deceased patients—the goal is improvement in these quality metrics.