BY CHRISTOPHER WELLINS, MD, MS, FACP, RENEE FAY-LEBLANC, MD, FACP, AND COURTNEY PLADSEN, DNP
Maine Medical Center (MMC) is a 700-bed tertiary care facility located in Portland, Maine, and is the anchor hospital of the nine-hospital MaineHealth System. In 2012 we developed the Long Stay Intervention Workgroup (LSIW) as a way of getting all the right stakeholders together who were empowered to make decisions regarding achieving discharges for our most challenging patients. The group was convened by the senior vice president of service lines. The current makeup includes: senior medical director of utilization management (co-chair), senior director for care management, manager of social work (co-chair), MaineHealth legal counsel, representatives from our central billing office, medical director of several local skilled nursing facilities, manager of rehab services, P6 (inpatient geropsychiatric unit at MMC) social worker. The group meets once weekly for one hour. Cases are identified for presentation to the group by the co-chairs who round the day prior and identify patients with substantial barriers to discharge. Commonly identified barriers include but are not limited to patients lacking capacity, particularly if state guardianship will be required and or they will require long-term Medicaid coverage; patients experiencing homelessness who require longer medical therapies; patients who require post-acute rehabilitation with barriers such as bariatric patients; patients requiring hemodialysis; and patients requiring skilled to long-term care. Current hospital length of stay is less of a consideration than anticipated length of stay and whether there are discharge barriers that will significantly prolong discharge.
In 2015 the LSIW noted a persistent uptick in people who use injection drugs and required 4-6 week stays for IV antibiotics for infections such as endocarditis and epidural abscess. Many of these patients were also experiencing homelessness, so discharge home with a peripherally inserted central catheter (PICC) line for intravenous (IV) antibiotics was not a reasonable expectation. In April of 2015, representatives of the LSIW visited the Barbara McInnis House in Boston, which is a recuperative care facility (RCF), and we knew right away that Maine needed this type of resource. We began to socialize this idea at MMC. It became clear that in the constrained fiscal environment of a large hospital, doing the right thing for a relatively small segment of the hospital population was not going to be enough to convince leaders to back such a plan. The LSIW committee developed a database to track numbers of patients with a projected length of stay reduction if an RCF was available. One of the most useful data points was a determination of the date at which a patient would have been stable for discharge to an RCF if one were available. That date was compared to the actual discharge date, which allowed us to estimate the potential for bed days saved.
In March 2016, a varied group of MMC leaders representing medical affairs, neurosurgery service line, linen services, associate vice president for nursing and information technology took part in an Advisory Board Fellowship and chose the development of a medical respite facility (term is interchangeable with RCF) as their capstone project. This group sought and was granted budget for the program in 2018. The neurosurgery service line lead continued to be a driving force behind moving the proposal forward. In the summer of 2017, MMC began discussions with Courtney Pladsen, DNP, to help to develop the program and formally engaged her as a consultant in April 2018. Dr. Pladsen was well-positioned as a consultant as she had experience starting a recuperative care program for women in Washington, D.C. She worked locally as a nurse practitioner with those experiencing homelessness and also served as the director of clinical and quality improvement at the National HealthCare for the Homeless council. As the plan emerged, meetings began with our local Federally Qualified Health Center, Greater Portland Health (GPH) and Preble Street (a Community Social Services Organization) to form a cooperative effort to open the recuperative care facility. Based on the data, the target population was identified as adult individuals with needs for long-term IV antibiotics, wound care needs and treatment for substance use disorder (SUD). Many RCFs do not provide Medication Assisted Therapy for the treatment of SUD, but we felt this would be crucial to the long-term success of our patients. The physicians and APPs from Greater Portland Health all had their X-waivers for prescribing Suboxone, which was important at the time, less so now that the prescribing regulations have changed. We developed a relationship with a local methadone clinic so that patients could have take-home doses securely stored at the facility, thus minimizing the need for daily transport to the methadone clinic.
On September 19, 2022, the RCF opened its doors. Our facility is a 15-bed secured, coeducational Federally Qualified Health Center. GPH provides the medical care, Preble Street provides social services and MMC provides facility support and financial backing. Patients are required to be fully independent in the management of their activities of daily living. Typically, acute rehabilitation facilities are reluctant to accept patients who will be discharged to homelessness, but MMC has been able to discharge several of its patients into acute rehab from the hospital with the understanding that they would be accepted to RCF to complete their IV antibiotics once they have rehabbed to an independent level. The initial plan was for a slow ramp up to full capacity so that workflows could be fine-tuned, and this ramp up was somewhat lengthier than initially planned due to challenges in hiring staff for the 24-hour facility.
As of May 15, 2023, 72 patients have been treated in the RCF, the average length of stay is 27 days and 1563 bed days have been saved for the hospital. MMC’s hospital average length of stay is 7 days; that means that you can provide care for 223 more patients at the hospital. Projections at full capacity will save MMC over 2,000 bed days per year. Although some patients have to return to homelessness, the LSIW committee is excited about the following discharge dispositions, which Preble Street has helped patients to achieve:
Shelter (23),
Sober house (9),
Single room occupancy at the YMCA (10),
Readmitted to hospital (63),
Family/doubling-up (11),
Camping/tent (12),
Hotel room (3)
In the first year of operation, there have been many lessons for community benefit as well as challenges such as maintaining adequate 24/7 staffing and cross-organizational communication due to each organization having different electronic health records. This challenge has been addressed in part by having the GPH providers privileged at MMC, so they are able to review information in MMC’s EHR. After GPH staff evaluate a potential candidate for admission to RCF they can document in MMC’s EHR as well as use the EMR’s secure chat communication tool to help to coordinate the transfer. LSIW continues to work on organizational culture including the balance between harm reduction and risk aversion. There have been some instances of substance use in the space, and this is continuously monitored. The RCF team must also maintain awareness for the patient culture of scarcity in people who experience homelessness and how that impacts a communal living situation.
We are so gratified by the successes that our patients have experienced, which are summarized below in their own words:
“Accomplished sobriety for six weeks, accepted at a sober living house, infection gone and walking without walker.”
“Was able to finish my antibiotic treatment all the way for the first time.”
“I’ve accomplished a lot since being here. I’ve been going to AA and am now going to a sober house.”
“Set up food stamps, SSI review, found a room and recovering from a stroke”
“YMCA bed. Dialysis starting. Learning how to be independent. ID, SS card, Birth certificate, EBT cars all ordered and received.”
Moving forward, the team is working to find the means to extend access to RCF for eligible patients at other MaineHealth facilities and hopes to inspire other communities in Maine to develop similar facilities.
Christopher Wellins, MD, MS, FACP, received his BS in biology from Duke University in 1997. He went on to complete a medical degree at the University of Vermont College of Medicine. He completed his residency in internal medicine at Maine Medical Center in Portland, Maine, and during that residency also completed a Masters of Evaluative Clinical Sciences at Dartmouth College in 1996. After completing residency, Dr. Wellins joined an internal medicine practice in Cape Elizabeth, Maine, where he also resides. Dr. Wellins started the physician advisor program at Maine Medical Center in 2010, and that program now provides services to the nine hospitals of the MaineHealth System. In his free time, Dr. Wellins enjoys playing squash and doing whatever he can in, around or on the ocean. He has served as the chief medical officer for Sailing Ships Maine since the summer 2021.
Dr. Courtney Pladsen, DNP, FNP-BC, RN, is director of clinical and quality improvement at the National Health Care for the Homeless Council. Dr. Pladsen leads initiatives to improve the delivery of primary care, substance use treatment and mental health care nationally. She directs training and quality improvement initiatives and contributes to research and policy recommendations on emerging clinical issues affecting people experiencing homelessness. She is a family medicine provider and works locally at the FQHC Greater Portland Health in the Health Care for the Homeless Clinic and Recuperative Care Program.
Renée Fay-LeBlanc, MD, FACP, is board certified in internal medicine, a Fellow in the American College of Physicians and a McAfee Fellow through the Hanley Center for Health Leadership. Dr. Fay-LeBlanc attended the University of Vermont College of Medicine and completed her residency in internal medicine at New York University. Dr. Fay-LeBlanc now serves as the chief medical officer at Greater Portland Health, a Federal Qualified Health Center serving greater Portland.
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