Pennsylvania Mobile Team Addresses Substance Use Disorders

by Allee Mead

Learn more about the Addiction Recovery Mobile Outreach Team (ARMOT) program in RHIhub's Rural Health Models & Innovations.

Mike Krafick's struggles with substance use disorder began in seventh grade. It started with alcohol and marijuana, with a promise to himself that he'd never touch hard drugs or be impaired when he went to work or school. But by the time he graduated high school, he'd crossed off every item on his "I'll never" list except for heroin.

"At 20 years old, I tried heroin for the first time, and I can remember every detail about that day. I can tell you everything about who I was with, what the weather was like, even what I was wearing, but most importantly how I felt," Krafick says. "I remember saying out loud that I'm going to do this again tomorrow."

Krafick checked himself into rehab at the age of 22. His family's health insurance covered 10 days of inpatient rehabilitation including four days of detox. "So after using heroin every day for two years," Krafick explains, "I was supposed to get better in 10 days."

In the eight years of his heroin addiction, Krafick was hospitalized five times for overdoses. He entered rehab for the final time in 2008. Three months into treatment, he learned that he was going to be a father; this news motivated him to continue with the recovery process. "Growing up raised by a single mother," Krafick says, "it was very important to me to make sure I was around to be involved in my child's life."

I've gotten to work with people who have gotten custody of their children back, found employment and housing, and seen people get trained to become Certified Recovery Specialists themselves.

Two years after entering rehab, Krafick began helping others with substance use disorders navigate the recovery process. His work as a Certified Recovery Specialist (CRS) has helped clients take back control of their lives: "I've gotten to work with people who have gotten custody of their children back, found employment and housing, and seen people get trained to become Certified Recovery Specialists themselves."

A Crisis in Pennsylvania

In Pennsylvania, more people are dying from drug overdose than from car accidents. The state, 7^th in the nation in drug overdose mortality rates, had over 3,000 people die from heroin overdoses from 2009 to 2013.

The rural counties of Armstrong, Indiana, and Clarion have been hit especially hard by the opioid crisis. Many residents of these counties work in the coal mines, steel mills, and logging industries. Since these are active, physical jobs, many residents were prescribed opioids for their injuries or chronic pain.

Many people lost their jobs when the mills began to close, while others were out of work because of their substance use disorders. Even those who seek treatment often struggle to find work due to the tight job market in the area. Because they don't feel like they're moving forward in recovery, they can grow discouraged and relapse.

Pennsylvanians aren't alone, as communities across the country are facing the opioid crisis. Rural opioid users are more likely than urban users to have less income and formal education, no insurance, and poorer health, factors which put them at a higher risk of adverse outcomes. In addition, rural counties tend to have fewer behavioral health workers than urban counties.

"So many things are compounding the issue of addiction," explains Nicole Salvo, Program Director of the Armstrong-Indiana-Clarion Drug and Alcohol Commission (AICDAC). "The number that we serve just grows and grows and grows."

A Mobile Team to Address Addiction

AICDAC has been serving the Armstrong and Indiana counties since 1973 and Clarion County since 2010. AICDAC focuses on prevention, intervention, treatment, case management, and recovery support.

Thanks to a 2015-2018 Federal Office of Rural Health Policy (FORHP) Rural Health Care Services Outreach Grant, AICDAC was able to launch a mobile team to travel among the counties' hospitals and provide support and education to adults and adolescents showing signs of substance use disorders. The Addiction Recovery Mobile Outreach Team (ARMOT) program is a collaboration of three hospitals, two substance abuse providers, and AICDAC.

The ARMOT Program's goals include screening patients for substance use disorders, referring patients to drug and alcohol assessment and subsequent necessary treatment, educating medical staff on addiction and recovery issues, and assisting patients with substance use disorders to bridge the gap between behavioral and physical health services.

"Our agency was approached to find a way to streamline and better serve the numbers coming in the hospital doors so that we didn't have a wrong door, so that patients could get that addiction help they needed, even though they were seeking it in a medical entity like a hospital," explains Salvo.

In addition to this difficulty of finding the "right door" for treatment and other services, some residents with substance use disorders didn't want to go to a hospital because of the stigma they experienced there. The first step for AICDAC was to address this stigma by training line staff on the best ways to help patients toward and through recovery.

The program's Mobile Case Managers and a CRS educate each hospital's new employees. This education goes both ways: ARMOT staff attend new employee orientation at the hospitals to learn about the hospitals' regulations, and they even receive hospital employee badges to increase their access to needed information.

ARMOT's Path to Treatment

When a patient struggling with addiction is admitted to a hospital, the staff determine whether the patient has a drug, alcohol, or other substance use disorder and ask if the patient would like to be referred to the ARMOT program. If the patient gives written permission, an ARMOT staff member meets with the patient by his or her bedside.

If the family's in the waiting room, ARMOT staff are available to answer questions and explain the recovery process. ARMOT also provides education and referrals to support groups for family members.

The Mobile Case Managers screen and assess patients to determine what type of treatment they need. Patients who are unable or unwilling to go to inpatient rehab have the option of attending a partial or outpatient program. The Mobile Case Managers also connect patients to community resources. This access can remove barriers that hinder a patient's recovery process.

Krafick and other CRS staff are people in long-term recovery, so they know firsthand what their clients are going through. CRS staff also attend support group meetings with clients. "If someone were given a meeting list and told, 'Hey, there's a meeting Monday night at 8:00, go to this church,' they may not feel comfortable about walking in there," explains Krafick. "But if our staff could meet them there and walk into the meeting with them, it's increasing their odds of even showing up and getting more out of that experience."

Since ARMOT serves adults and adolescents, it approaches each age group a little differently. In Pennsylvania, an adolescent does not by law need a parent's permission to go to drug and alcohol treatment. That said, ARMOT staff prefer family involvement, with the patient's permission, since ARMOT can then educate family members on the types of support adolescents will need when they return home.

Fewer treatment facilities exist for adolescents, so it can be a challenge to find an open bed. As soon as the adolescent and the case manager meet, other staff members are working to find an available bed.

Timing and scheduling are challenges as well. An ARMOT employee is stationed at the hospitals from 8:00 a.m. to 4:00 p.m., but patients experiencing an overdose tend to enter the hospital outside these hours. A patient coming in at 11:00 p.m. might not want to wait until 8:00 the next morning to meet with an ARMOT staff member, so ARMOT staff have trained hospital staff on after-hours treatment referrals and engagement techniques to encourage patients to stay and meet with a Case Manager.

Difficulties also come with having one CRS covering three hospitals in three different counties. Being creative with scheduling, Krafick says, helps to provide adequate coverage for each hospital.

Successes Now and Hope for the Future

In the program's first year, 88 patients were referred to ARMOT. Of those, 48 participated in a level of care assessment with a case manager, following which 37 (or 77%) were admitted into drug and alcohol treatment. Of the total referrals, 22 patients met with a peer CRS; 24 patients involved family members in their care.

Year two, which began May 1, 2016, has already seen over 200 referrals. "Year one really laid the groundwork for people to know that the program exists," Salvo explains. "Now that they know, the floodgates are open, which is great, because that's why we're here."

And I think that is how we help reduce some of that stigma that we get…addiction is treated like a disease rather than a choice or a moral failing.

Healthcare staff benefit as well. Once, a physician at Indiana County Medical Society thanked Krafick for his presentation "The Science of Addiction and Recovery." The physician had attended medical school 55 years ago when much of this information was not available, but now he better understood substance use disorders. "And I think that is how we help reduce some of that stigma that we get," Krafick says. Thanks to ARMOT's training, "addiction is treated like a disease rather than a choice or a moral failing."

Salvo hopes that communities across the country can also incorporate detox beds or units into their hospitals. That way, "anyone can walk into a hospital and receive the care right there that they need, similar to the circumstance if you were having a heart attack."

Krafick echoes this no-wrong-door approach: "When somebody has that moment where they say, 'I want to do something about my problem,' we want to try to remove as many barriers for them to getting into treatment as soon as possible."