Avera Health’s Successful Reintegration Program with Carin Yale, CPhT Controlled Substance Coordinator at Avera Health, and Thomas Johnson, Pharm D, MBA, BCCCP, BCPS, FACHE VP Hospital Pharmacy and Laboratory Services at Avera Health
Avera Health has worked hard to dial in their reintegration program. You will hear them say it is not a one size fits all and patient safety is never compromised. Their mission of helping people extends to their staff and they do a great job of putting that into action when it comes to staff with a substance use disorder. They have developed a culture throughout their organization that incorporates accountability and compassion and is immensely rewarding. This is a must-listen for anyone currently without a reintegration program.
Transcript:
Terri
Welcome back, everybody. My guests are Carin Yale, the controlled substance coordinator, and Tom Johnson, the VP of pharmacy and lab at Avera Health. They have a reentry program and that will be our focus for today’s interview. Welcome, Carin and Tom. Both of you. The first question I have for you is, was the program in place when you got there, or did one or both of you have the opportunity to be involved in getting it started?
Carin
Hi, Terry. I’m going to let Tom answer that one.
Tom
Well, I’ve been at Avera for 25 years.
Terri
Wow, okay.
Tom
But I am going to answer that it really was in place prior to me being in an administrative role. It has been our approach for a long time of allowing people to have a second chance to prove what they can do, but they do have to follow what is prescribed for them in terms of an overall recovery plan to be eligible to be considered. And I think that’s a great place to start. That of this isn’t for everybody. It is a controlled process and there are set criteria that people need to meet in order to work through this.
Terri
Yeah, absolutely. That’s a really good point. It’s just because you have a program doesn’t mean when I’m having that initial conversation with you, it’s, don’t worry, you’ll keep your job and you’ll come back. I mean, it’s a long road for them.
Carin
Right.
Terri
And then to get to that position. Okay, great. So now, Carin, I think if I saw your LinkedIn profile correctly, you are the first controlled substance coordinator for the health system, correct?
Carin
I am.
Terri
Okay.
Carin
We’ve had a program for diversity prevention and investigation, but they’ve never had one person in a central location doing it. We’ve had analysts and pharmacists, nurse leaders and executives, each doing a different portion of the job. And so when they hired me just under four years ago, they said, hey, we would like for you to homogenize this. Please put us all together so that we have one person looking at all the data in real time rather than having four different people looking at it. Right. One of the things that I was tasked with doing is kind of writing what it is that we down, even though were doing the things we needed to be writing it all down. So writing policies and procedures, especially around stuff like this is a large portion of what I do here.
Terri
Okay. All right. Fantastic. So when you came into this position, was the program already up and running, the reintegration program? Or was it in some form and improved?
Carin
I would say that it’s evolved over time, especially in the last four years since we’ve discovered how robust our partnership could be with them. But I will say that the process has always been there. Like I said before, it’s just never really been written down into policy. It isn’t really written down into policy now either. It’s such a case by case type scenario that it’s difficult to have one set of instructions for each person reentering the field. However, we are kind of like using a certain central philosophy for it, which is that one of compassion that we talked about in the past.
Terri
Right. So can you run us through kind of in general? You’ve got the philosophy, you believe in second chances. That’s why the hospital system is doing that. In general, how does this work? Somebody comes to your attention, you’ve confronted them. Is it different if they admit versus don’t admit? In general, how does this work?
Carin
I like to call them members of our home team. So when we discovered that there’s diversion taking place and it’s a member of our home team, we see them as someone who’s suffering from substance abuse disorder, and that is a medical condition that leads them to make poor decisions. So this is what our human resources team and our pharmacy group and our Diversion Investigative Response team sees it as an opportunity to get them the help that they need. So that doesn’t mean that we’re going to always be a part of their recovery. They won’t always come back to us. In fact, a lot of them don’t even seek reentry into the field after they’ve been caught diverting. But I know not every health system does it this way, but we have found it to be cohesive with our mission to give people the second chance that Tom had discussed.
So if someone is in a Diversion Investigative Response interview and they’ve been asked about diverting narcotics or controlled substances and they’ve admitted to it, then what’s most likely is that we’ll refer them to an employee assistance program. And there are a handful of them that work really well in this. We have a partnership with one that’s state sponsored, and we also have a homegrown employee assistance program that’s really effective. So we’ll refer them to one or both of those programs, and then we’ll let them know that this may not be the end for them, or it might be. It depends on the severity of what decisions they made. Like if there’s patient harm that came, then that’s almost never going to be okay. But I will say that every situation is different and every person responds differently. So for the most part, we will encourage them to get help and get better. But I would say that it’s rare that we see them come back to the field.
Terri
Interesting. Okay. Yeah. And you touched on the patient harm, and that could be maybe a discussion for another day, unless one of you has something else to say. But if they have a disease and they’re not thinking clearly and it results in patient harm, do we treat that differently than if there is no harm? Right. It’s kind of the medication error. If it wasn’t reckless, but they committed made an error that resulted in patient harm, do we treat that differently than if it didn’t? That’s a whole nother can of worms, I think, to open up. It’s like, should we treat it differently? We want to. That’s going to be our first gut reaction, right? Because somebody has to pay for this, so why would we take them back? But that’s an interesting thing to consider. That doesn’t mean there’s no accountability, obviously, but what happens later?
Terri
Okay, so tell me about the re-entry piece of it. Say they want to come back. Do they typically go into a different area, like, I don’t know, telemedicine clinic, like maybe where there’s not access to controlled substances? Or do they actually potentially go back to the bedside?
Tom
Well, I’ll take a run at it. Potentially, right? They can be in different spots. So we’ve had people come back into a variety of different areas, sometimes back to where they were, but that really depends on their plan for recovery. So if they were diverting for their own use and part of that was a product that was easily attainable for them and that’s not a good part of their recovery plan, then that’s not the right place to put them, right? There might be other controlled substances in that place where they go back to work, but perhaps they’re different than what they were diverting in the first place. So it really Carin’s point of this is very specific to the person and their recovery plan and the needs of the organization and how this all fits to her point of view. It’s pretty hard to write this down as to exactly how you’re going to do it. You just have to walk people through this and walk with them as you go through this whole process.
Terri
Yeah, that makes perfect sense. And so is it safe to assume then that your whole organization, they know that this is part of the culture, it’s built into that. Okay, so if somebody comes back and obviously if they go into their same unit, then people are going to remember from whatever, two years ago, or this person, if they go to a different unit, is it just at their discretion if they want to tell people? Or how do you handle that so that you can continue to monitor? Do you continue to monitor? How long do you continue to monitor? Who knows when they come back that they’ve gone through a program. These are all questions like, oh, how long do we have to monitor to help hold them accountable? Right?
Carin
Well, like Tom said, it’s different for every person. But what we’ve seen in the past is situations where people will come back. And if they choose to go back into patient care and we feel like our patients are safe, then they do have a responsibility to work with liaison on their nursing unit, for example, so they will have someone who is monitoring their utilization every step of the way during their probationary period. So let’s put it this way. A provider comes back to work under specific customized restrictions. We can easily put a hard stop on their medication dispensing cabinet so that they can’t access, like Tom said, their drug of choice, for lack of a better word. Or we’ll put them in a place where they won’t have access to that because their patients don’t need that drug of choice. So they’ll be taking care of patients in a different facet and a different care level. What we have learned is that our Liaisons between the provider and their treatment program, they have to communicate frequently.
So like what you said earlier about how often do we look into that and how do they approach this. Yes, they’re going to have coworkers if they worked with us before, they’ll have coworkers that recognize that they’ve been gone for a while or whatever, and it’s really up to them what they want to divulge. But they will have a Liaison and a group of supervisors that know exactly what happened and they know exactly what to watch for. And they’ve been briefed before that person came back into the nursing unit or back to their clinic. So they know exactly what to watch for. Now, that being said, we also know that having a Liaison looking at someone’s utilization every 30 days doesn’t cut it. So we’ve tightened up some this is part of the evolution of this program. We’ve tightened up the amount of time that we spend between day of reentry and the first review.
So we know we need to look at it more often. We know we need to have a tighter grip and a closer monitoring system in place for some of them that come back. Now, like what Tom said, we use conservative work locations for some of them as well. So a lot of times they’ll come back. They’ve been working in hospice, they struggled in hospice, started to divert drugs. If we find that they’re eligible for the program, then they’ll come back to a different location. So we won’t put them back in hospice. We’ll put them somewhere that’s safer, like on AFC Nurse or something that’s like Medical Record Review, something like that. That doesn’t put them in a position where they are tempted or they have a difficulty making the right decisions. Does that make sense?
Terri
Yes, makes complete sense. Three questions came to my head, but I didn’t write them down, so let me see if I can remember them. The first one, you had said that with the automated dispensing machine, you can kind of lock it down so they can’t get to certain meds. So I’m certainly familiar with the class of people, right. You got your pharmacists, your pharmacy technicians, your respiratory therapists. You kind of put things where they need to be so they can only get what they need and do what they need. How do you lock down drug of choice?
Carin
It’s done by schedule. So, like, we can remove a schedule of drugs, and for most of us that are listening to your podcast, we’re all aware that there are different schedules of drugs based on DEA and FDA recommendations. So we can remove only C two S from them. I misspoke. We can’t do that by drug and remove only C two S from their access of care. We can remove only that particular schedule. The point that I’d like to make, though, is that if that person, like Tom suggested, has an addiction to pain pills and they had a problem with Oxycodone, then we won’t put them in a place where they have patients that are suffering from pain remediation problems. Does that make sense?
Terri
Yeah, makes sense.
Carin
We’ll lock it down as in, like, they won’t have access to those patients, they won’t be caring for them, so they won’t have patient profiles with those drugs.
Terri
Sure. Yeah. So even if they’re back at the bedside, it is quite possible that they’re back with a different kind of patient that doesn’t need that, certainly not regularly, and then wouldn’t be assigned those patients probably, if somebody were to slip through. Okay. Now, for your liaisons, do you have any kind of training program, or is there a requirement?
Carin
Okay, absolutely. They all undergo a training program once a year that’s put forward in our mandatory annual education for nurse leaders. And we’ve just started a more robust nurse leaders program. Well, it’s for nurses right now, but it will be for clinic leaders as well. But it’s how to determine whether or not there are red flags on your unit. So there’s the one that’s mandatory for all of the employees in our health system. And then now there’s another one that’s just for nurse leaders and clinic leaders so that they can identify what they need to be watching for someone that’s come back and reentered into the program or for folks that are working under their nose and need additional review so they know what to watch for. They do undergo rigorous training every year, if not once, then twice.
Terri
Okay. All right, great. And then in terms of monitoring, I’m assuming the hospital itself doesn’t do the drug screening and stuff. The recovery program is doing that and reporting back to the hospital to make sure that the employee is passing all of their tests, or is that the wrong assumption?
Carin
So our policies on drug screening are system wide, so we will drug screen upon reentry. We will drug screen prior to employment, and then we also drug screen based on reasonable suspicion. So our policies suggest that we do that upon those three different scenarios. But then as far as, like, the probationary drug screenings, those take place at the facility that monitors their contract.
Terri
Okay. And then they’re reporting to you. So you’re getting that report in all the time. Is that something that is and I don’t know if you’re intimately involved with that piece of it, but is that something that is a no news is good news and you know that they’re passing? Or do they literally give you a weekly report or a monthly report saying they took a test and it was negative?
Carin
I’m not exactly sure.
Terri
Yeah, you’re probably not the right person. Too much detail for your position. Yeah, I was just curious. Yeah, I mean, if you trust the recovery center, then I probably know news is good news, right? Because you know they’re doing it regularly. Yeah. So you’ve mentioned a few things that you’ve learned along the way. Some lessons learned. The liaison needs to report more frequently, I think probably where you place them. And just the whole process, I’m sure, has been refined over time. Are there any other things that you have seen over the four years that you’ve been working with the program or tom even longer that you’ve been there that are lessons learned? Like if somebody else is thinking about doing this at their facility, something you would really recommend because you kind of learned the hard way or it took you a while to figure it out and it’s made things much smoother and more successful.
Tom
Go ahead, Carin, you’ve got any initial thoughts? I know I’ve got at least a couple of thoughts, but you’ll probably cover them.
Carin
Well, the way that we see it is not all of them go back to patient care, like I said before, but ultimately it is going to be their goal. So nurses don’t go into the business so that they can answer phones and fill out paperwork. They’re here because they want to care for people. Providers are the same way, pharmacists are the same way. So as far as things that we’ve learned the hard way, it’s just that it’s not one size fits all, like we have said a couple of times. We do take cues from the ASHP. The American Society of Health System, Pharmacists, joint Commission, national Institute of Health and the DEA. These things change, so we change based on what they say is new. So, yeah, we’ve learned quite a few lessons. The one thing I think that has been kicked into me number of times is that not everyone diverts the same way and they certainly don’t all recover the same way.
So whatever makes sense, as far as patient care is concerned, has to come first. The level of risk, as much as we do, believe in second chances. And substance use disorder is a disease and it has been named by multiple organizations. Our patients have to be cared for first, so we do put those hard stops in place, whereas sometimes we couldn’t before or we didn’t know or the systems have changed, the level of technologies changed. So much of it has, and there really isn’t much of a manual for us to go by. And Tom, being kind of someone who’s been around the block a few times, can understand this too, but healthcare is an ever changing animal. As soon as you learn something new happens.
Terri
Yeah. You have to keep up. And Tom, I think she just called you old.
Tom
That’s what I was going to try to be nice about it, but it really that’s okay, I get it. We were talking with a group of pharmacy technicians, and one of them, somebody asked her in the room today, well, how old are you? And she said she’s 22. And I said, I have shoes older than you are, my child. Yeah, I get it. I’ve been around for a little bit. I would say that the things that I’ve learned is, one, it can be very successful. I know in particular, we have a few folks that have had struggles with this and have come back and had very successful careers. So that’s the first thing. The second thing, though, is that there’s a lot of people that need to know, and then there’s a lot of people that don’t necessarily need to know other than if they tell them.
Making sure that the people that need to know are aware of this so they can help and are understanding of what kind of program you’re working on is really important. You can’t miss on that. And I think that’s a really important part. So the nurse supervisor, the unit supervisor, whoever that person’s boss is that’s coming back in needs to understand what’s going on. They need to be clear with that. Human resources needs to understand what this is and they need to be connected with their recovery program. The pharmacy folks that are helping lock any of this down or track any of this have to know what they’re looking for because there’s a lot of data out there. And if Carin doesn’t know that she’s supposed to be looking extra close at this particular person in this particular area, you can let that go. And then they’re going to be out and have an issue again. And that’s not what we want. So you have to make sure that you coordinate across all of those different areas and that’s what’s super important to them.
Terri
Yeah, all very good points, and I do like too, Carin, what you also said about patient care comes first. And I think some facilities that’s where leadership, maybe struggles if they’re not as educated on the whole thing, and they’re focused on the patient safety, which absolutely needs to be a big focus, and they can’t get past that, and they can’t see how to reconcile the two together. And so it’s just like that’s. It it’s not worth the risk. Do you have a general plan for how long you continue to have them with a liaison? Again, it’s probably different and depending on the setting, if they have no meds that they have access to, then maybe that doesn’t really I don’t even know if it even needs to start at all, the liaison part of it, because what are they monitoring? But is there a general for how long you monitor?
Carin
I’ve seen folks come back and they’re under strenuous review for nine months.
Terri
Okay.
Carin
Seen some come back, and they’re under review for over a year. So what we do is we speak with not just the assistance program, but then we also talk to the Board of Nursing. One of the things that we do is we communicate really well with them. The Board of Nursing will have their own set of guidelines, so we may say, okay, we think nine months is enough to be under rigorous review here. But the Professional Licensure Board, whether it be the Department of Health or the Board of Nursing, they have their own rigorous regulations. So once someone has had their license, had action upon their license, or if it’s been revoked or suspended, they have their own set of review. Folks that sit in a room and talk about what this person needs, and then we try to go with whatever it is that they do.
I wanted touch on something else that you had said, is that, yes, we give them a series of period of time where they undergo rigorous review as far as their utilization and their care for patients and pain scores, and whatnot if they do find themselves at bedside? But as far as how long does that period last, it does not end here. We do have artificial intelligence. We have drug diversion prevention software. They go back into the general population of our home team members, and we continue to look at them. So if Terry comes back to work and she completes her nine months, then Terry goes into the rest of the pool of our team members, and we watch all of them. So I want to say that it just doesn’t ever end.
Terri
Right.
Carin
The more we work towards complete and total transparency, especially regarding controlled substances, the more we work towards that, the more we’re going to include every single person that crosses the threshold.
Terri
Right? Yeah. And tom’s point of making sure that all the right people know, then they’re back into the general workforce. But there are people that know and are keeping an eye on things. So you may spot some behavioral changes or what have you sooner because they know what they’re looking for. Yeah, that’s really important. I mean, I’ve seen it where you find out something happens, and then you find out they’ve been through a program and they’ve relapsed, and it’s like, Are you kidding me? Why didn’t you we could have helped watch for this, but you didn’t tell us. And I think that’s the case, especially with physicians. Do you do the same thing with your physicians, or do they fall in a separate bucket being med staff program?
Carin
But we do monitor physician use as well. And you hit the nail on the head, Terry, when you said, we found them diverting again. That’s the point. Right, right. That’s why I feel like the program is 100% successful, is because those people that divert again are found. If you look at it this way, so many of them will recover, but the program is 100% successful because those that do recover and go on to have robust careers with us, and they’re successful. Like Tom said, they move up through the ranks, and they’re really great caretakers. And then there are those that don’t those that struggle again, and they find themselves in that same position. We’re going to find them immediately now because they’re under this rigorous review process. Now, if our hospital system decided we didn’t want to participate in something like that, then what are the chances that someone would come in and work for us for a significant amount of time?
They’ve already had action on their license somewhere else, and we never knew. We’d much rather have people under the understanding from day one that they can come back into the workforce if they choose to, but we’re going to monitor them very closely. They happen to do it again, we’re going to find them immediately before they have the chance to hurt another patient or overdose or ruin their lives worse than they were before.
Terri
Right. Yeah. Keep them close, work with them, keep them close, and then instead of sending them out someplace else. Yeah, that really does make sense. So I’m guessing this must be I don’t know, you’re probably doing a lot of things over there, but would you say that this is one of the things that you’re most proud of with your health system, that you guys do this?
Carin
Tom is proud of everything I do.
Tom
That’s exactly right, Carin! Well, I think what we’re proud of is that we have an opportunity to help people and to help them continue their careers and provide care to people. And it’s not like we’ve got an excess of health care providers. And when you have people that have struggled but still can come back effectively into the workforce in some capacity, we want to make sure that can happen. But again, it has to be according to that person’s recovery plan, and it’s not for everybody. This is absolutely not 100% that oh, yeah, you can just come back, and it’s got to be something that you, as that individual, are willing to commit to and that particular area and that particular care area can commit to in terms of that extra monitoring. But we’re absolutely proud of that, along with a lot of other things that we’re doing to just try to help take care of our patients and provide our mission.
Terri
Yeah. Now Avera health is in South Dakota. So do you have quite a few hospitals that are considered more of a small rural type hospitals throughout your system? Do you find that this program works equally as well in those more rural settings, or are there different challenges just because of size and of the community?
Carin
We actually hit more than just South Dakota, but our footprint spans across much of the Midwest, so we have facilities tom, correct me if I’m wrong. We’ve got Iowa, Nebraska, Minnesota, North Dakota.
Terri
Oh, wow. Okay.
Tom
Yeah, there’s a couple of clinics in North Dakota.
Terri
Okay.
Tom
You’re right about critical access in rural parts of the state. In this area, the program can work anywhere. But you’re right, there can be some unique challenges based on just work areas. In some spots, it may not be the best idea when you’re the only provider in a given space. Pretty hard to provide oversight when you’re it right. So it may not be for every site in every spot, but if we can figure it out, I don’t know that there’s really any specific limitations, but depending on that particular caregiver’s recovery, what they’re needing to do, we might have to think about that. It might not work everywhere.
Terri
Sure. Okay.
Carin
That makes sense. That I think that it’s something to be proud of, especially with our rural facilities and our critical access hospitals, is that just having a culture that surrounds the recovery and substance abuse disorder, having a culture that’s a little more compassionate towards, that really encourages people to self report, especially in our smaller facilities. Like Tom had said, yeah, it doesn’t work for everybody. Does encourage people to self report? I think that in the past, what we’ve seen is that folks in smaller communities, they will take the initiative, especially in the Midwest, to go and get better if we encourage them to do that.
Terri
Interesting. Yeah. I don’t know if you have numbers or if you could even share them, but I’d love to know what percentage are self reported, what percentage admit when you confront them, like, okay, that’s it. You got me, versus the ones that just double down and say when you’re pretty sure they got something going on, but they still are not giving into it because of your culture right. That you have more people that are maybe willing to admit it.
Carin
I did a little research. We talked, and what I found from the National Institute of Health is that recovery periods or recovery for healthcare workers is about half, which is. Four times the national average. So it’s another reason why I think that the math kind of adds up for us. I know too, how often, I guess, in our situation here at our health system, every interview has an outcome, and for us, the outcome is like 78%. They confess, okay, I think that’s pretty good. By the time we get there, I quote it to an exact state, but by the time we get someone sitting down, we know. And they know.
Terri
Right. But they still double down often and say “nuh-uh”, come on, I mean, it’s right here in front. So I have to think that your culture makes it your percentage higher that 78%. Because then they know, okay, this maybe isn’t the end for me. They’ll still love me, they’ll still take me back, they’ll still work with me. Maybe this isn’t the end of my career and my license. Yeah.
Carin
If that’s what the facts add up to for different, but right.
Terri
Yeah.
Carin
I mean, self reporting is the way to move toward, like we’re that self reporting scenario.
Terri
Right. Great. Well, this is great information. And for those of you out there that are listening, that have maybe been thinking about it or have been resistant to it because you just think it’s I don’t know. I think some places feel like it’s. I don’t know. Maybe they’re turning their back on the patient where that should be their priority and they just can’t bring themselves to do it. But Avera has a very healthy, successful program, and we do have to remember, it’s not for every case. Each case is individualized. We’re not sacrificing patient safety, but we’re also bringing in the safety of our healthcare professionals and giving them an opportunity to work through whatever issues they have that have put them there in the first place. Really. So I think that’s great. Okay. Any final thoughts?
Carin
I think that, like you said, a lot of other facilities just don’t work that way. I know that our mission is rooted in teachings of the gospel, so I work for a religious organization. And if you call any one of our clinics, what you’ll hear is that hold music that says mind, body, and spirit. Avera yeah. Tom’s laughing, but he knows it’s true.
Terri
Forgiveness, mercy, and grace. Right.
Carin
It is. It’s a culture thing, and it’s not for hospital system. And I would hate to bat somebody over the head with it, but I would say that for our system, it really does mesh well with our mission. So it works for us really well.
Terri
Great.
Tom
Yeah. And I’ll just say thank you for the time, Terry, and thanks to Carin for all she does to help keep everything organized within our controlled substance program. She’s done a wonderful job for the last several years of keeping us going the right path.
Terri
Yes. Seems like you got a winner there.
Carin
Thanks.
Tom
Recorded for later.
Terri
All right, well, thank you, Carin and Tom. And thank you, everyone, for listening. Hit that subscribe button. And I also want to thank our sponsor, IMI. And a reminder to take advantage of their free trial box of prep lock tamper evident caps for IV syringes by going to imiweb.com getprep. Thanks, guys.
Carin
Thanks, Terry.
Tom
Thank you.
