Adding/expanding MOUD treatment:

A quick guide to establishing a bridge clinic in general medical settings

Innovative Strategy: Bridge Clinics in General Medical Settings

  • Bridge clinics provide low-threshold, on-demand substance use care, including medication for substance use disorders (SUDs), harm reduction services, and linkage to community-based, longitudinal substance use care1.
    • Patients seeking medication for treatment of opioid use disorder (OUD) and other SUDs through a clinic that offers same-day and next-day appointments for treatment are more likely to attend addiction appointments compared to patients who are scheduled further out.
    • Patients report positive experiences in a transitional, low-threshold bridge clinic for SUD due to the flexibility of the model, harm reduction approach, non-judgmental interactions with caring providers, and support from peers.

Potential Benefits to Community

  • Reduce wait time for treatment.
  • Engage patients earlier on in the care cascade in overdose prevention and MOUD.
  • Provide high touch care and stabilization before referral to long-term addiction treatment.
  • Especially when combined with an inpatient Addiction Consult Service, fill the treatment gap between inpatient and ongoing care in the community.
  • Especially when combined with the implementation of ED buprenorphine take-home kits, fill the treatment gap between emergency care and ongoing care in the community.
  • Avert unnecessary ED presentations and follow-ups for substance use care.

Estimated Time from Planning to Implementation

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3-4 months

Cost Considerations

  • $132,000—$400,000 total cost
  • Consider using existing ED and urgent care infrastructure, if possible
  • Cost of medication storage (e.g., machine)
  • Cost of IT analyst time, if required to set up a new clinical area in electronic medical record or infrastructure for documentation of medication administration
  • Pharmacy support for medication inventory
  • Any additional provider, RN, case management time needed to support increase in clinic visits and referral volume
  • Patient supplies, including safer injection kits (NB: federal funds cannot be used for syringes)
  • Patient transportation costs
  • Some staff will be able to bill for services

Operational Considerations

  • Bridge clinics are most effective when they can administer medications, including comfort medications, buprenorphine, and methadone for emergency withdrawal management under the 72-hour rule, on demand.
    • Co-locating bridge clinics with inpatient and outpatient pharmacy resources greatly facilitates medication access.
  • Need a clinical space that is ideally easy to access on a walk-in basis and includes at least 1 provider exam room.
  • Need to have strong connections to community partners and expertise in linking patients to long-term OUD care.
    • Formal affiliation agreements can be helpful in some cases
    • Leverage existing navigation infrastructure: recovery coaches, nurses, social work staff
    • Ensure 42CFR compliant 2-way consent forms available
  • To store controlled substance medications in clinic, you need secure medication dispensing cabinet in DEA-compliant space with protocols for inventory, waste and administration documentation in the electronic medical record (EMR).
  • There are a range of staffing models. Roles to consider (not all required):
    • Physician, nurse practitioner, or physician’s assistant
    • Nurse care manager for clinical assessment and care management
    • Dedicated nurse care manager or case manager with relationships with community MOUD providers
    • Resource specialist or other role to help with psychosocial support and community transition
    • Medical assistant or administrator to support scheduling and patient check in
    • Pharmacist to support medication administration protocols
    • Social worker or psychologist for behavioral health
    • Program manager

Other Considerations

  • Low-threshold addiction treatment models emphasize engagement and harm reduction rather than abstinence. It is important to develop staff skills in eliciting patients’ individual treatment goals and discussing ongoing substance use openly and with non-judgment.
  • Some bridge clinics provide access to same-day methadone initiation for up to 72 hours while linking patients to local Opioid Treatment Programs (OTPs). Learn about 72-hour methadone.

Evaluation Metrics

  • Number of patients initiated on medication for substance use disorders
  • Number of patients successfully linked to community provider (referred, appointment scheduled, appointment attended)
  • Number of patients engaged in substance use care at 6 months

Acknowledgments

We wish to express our thanks to all community partners who have implemented these programs during the HEALing Communities Study. Key insights from these partners were crucial in the development of these resources that will be important tools for programs looking to build on the successes of these strategies to reduce fatal overdoses.

Reference

  • Taylor JL, Wakeman SE, Walley AY, Kehoe LG. Substance use disorder bridge clinics: models, evidence, and future directions. Addict Sci Clin Pract. 2023;18(1):23. doi:10.1186/s13722-023-00365-2

Additional Resources