Addiction in the Emergency Room

In this episode Zach is joined by Cathy Cooke and Mary Jo Jennison-Stelzer. Cathy is a CDCA and Certified Interventionalist Professional who works for Sober Escorts. Mary Jo is a CDCA and is finishing her last few classes to become a Certified Intervention Specialist who works for The Ridge Ohio Treatment Center. The three discuss misconceptions of interventions and how to know when it is time to stage an intervention for a loved one. Following Cathy and Mary Jo, Zach is joined by Dr. Charles Miramonti, an emergency medicine physician and senior medical director of community health. Zach and Dr. Miramonti discuss how hospital doctors and nurses handle addiction, and what to expect when coming into an emergency room struggling with addiction.

 

Welcome to Recovery Radio by Landmark Recovery with your host Zach Crouch. In this program we’ll discuss the root causes and treatments of alcohol and substance addiction, speak with experts in related fields and help navigate the road to recovery. Now here’s the host of Recovery Radio Zack Crouch.

 

Zach: Hi, I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. Listen, guys you can find us online wherever you get your podcasts. Subscribe, tune in. Each week we’re going to have new episodes. We have a great one today we have guests Cathy Cooke and Mary Jo Jennison-Stelzer joining us on the show today.

 

Cathy is a CDCA, that’s a Chemical Dependency Counselor Assistant and Certified Interventionist Professional or CIP. She has worked with Sober Escorts for the last nine years. Sober Escorts provides services designed to help those suffering with addiction get into treatment. These services include sober transport, sober coaching and companions, case management and interventions. Cathy is a graduate from the Ohio State University. In 2011 after getting sober herself she changed her career path to helping other families and individuals suffering from the disease of alcoholism and addiction through the process of interventions. In addition to her work as an interventionist she is also a sober and codependency coach.

 

Mary Jo is a CDCA and is finishing her last few classes to become a CIP or Certified Intervention Specialist. She works for the Ridge Ohio Treatment Center as the discharge coordinator where she also facilitates interventions. Mary Jo is also in recovery herself and takes great pride in being a part of the recovery community. Ladies, it’s a pleasure to have you on the show. Welcome to show Mary Jo and Cathy.

 

Cathy: Thanks for having us Zach.

 

Mary Jo: Thanks Zach.

 

Zach: I appreciate that. Tell us a bit about your backgrounds and how did you come to kind of get interested in this field of recovery. Cathy, why don’t you start and we’ll hear from Mary Jo.

 

Cathy: Sure Zach. I think like so many people who have ended up devoting their careers and their lives to helping people in the treatment and recovery field. For me it really started in my childhood. I was born into a family with alcoholism where addiction and alcoholism was sort of is a genetic force on both sides. Therefore a lot of childhood trauma. As a kid I learned anxiety, fear, shame. I didn’t like my parents drinking. I had sort of a hatred of alcohol and didn’t drink as a teenager. Even I did develop an eating disorder in college which was very debilitating. Somehow I graduated. Got my first professional job and from that first day of work that fear, anxiety and shame really took hold and I started drinking for the next three decades, daily drinker.

 

I refer to myself when I was in my 20s as sort of a baby alcoholic. I drink every day and often it was a problem but not always. In my 30s it got worse. In my 40s I was a later stage alcoholic. The last several years my drinking was very destructive for me and my kids, my family. A couple things happened in that last year that really took me out of my denial but I decided that I needed an intervention. I really didn’t know what one was but what I envisioned was people gathering around me telling me what I needed to do and they love me and I would go off someplace and get better. I called a treatment center. I said I really don’t know what an intervention is but I think I need one. I don’t know why I invite to invite the people.

 

I still remember his words which was Cathy, this is unusual. It was also the first time I had experienced the magic of one alcoholic talking to another and essentially he helped me in the intervention and probably no one was going to show. I couldn’t get myself organized to, I went to treatment in California. He came out and flew me to treatment. Interestingly even though I was very intoxicated on the flight to California I asked him a lot about his work. The best way I can describe it is I had a knowing that I was going to help other people get to treatment which is interesting to me because at that time I didn’t even want to be sober but I did get out to him in Sober Escorts and I said I want to help other people get to help because I know the image I had and the environment that I was raised in and I wanted to help other families. From there I got a lot of training, a lot of experience taking people to and from treatment. I do sober coaching, co-dependency coaching with families and I do intervention.

 

Zach: Great. Wow. Well, that’s a whole lot. You have a rich history it sounds like and I think the people who come from alcoholic families, families where the dynamic is dysfunctional and substances are present there’s a vocabulary that people have that unless you’ve lived through that you wouldn’t have. I appreciate all that. What about you Mary Jo, how did you become interested in this field?

 

Mary Jo: I got sober in 1997. I was 34. On the outside I had everything that I always thought that if I got all those things that I’d be there, I’d be happy and I wasn’t. I lived in southern California. I worked in the insurance field. I would work for an insurance brokerage. I had a great job. I had a good husband, a nice home, two golden retrievers, three beautiful kids.

 

We’ve had that like peace that felt like that was missing. I was a daily drinker. I was not if you want to call it like maybe I was like a stage two or stage three alcoholic but really I was like dead inside. My intervention as it were was waking up after a company event after having felt like I was a total idiot and wanting just to die. Kind of one of those like oh my gosh, what’s wrong with me. I’m so bad. I didn’t want to get sober.

 

I wanted relief. I wanted some hope and I didn’t think that I was worthy of anything. After a couple days and I’m reaching out to a couple people they recommended maybe I try Alcohol Synonyms. I wasn’t an alcoholic like I thought an alcoholic would look. I showed up there and I felt home. I felt like again I didn’t want to not drink because drinking felt like my solution but right away the service piece and the people in the rooms of Alcoholics Anonymous felt like I was home like they understood me in a way that nobody ever had.

 

I jumped into service and I loved it. It’s like alcohol anonymous became my family. My kids were little. I had twins and then a younger one. My husband was supportive. When I came here in 2000, when I moved to Cincinnati in 2000 kind of got back. Obviously I’d always been in AA. I went to AA every single day and jumped into it here and always wanted to work in the field of recovery but didn’t really know how to go about it. I was kind of busy raising my family. I felt like okay that’s my primary thing. I would learn more and do a bunch of service.

 

When I met Cathy Cooke, she’s like one of the most tenacious people I’ve ever met in my life. When I had the opportunity to meet her and to get to know her as a friend and a fellow recovering person I would kind of be her cheerleader. When she said she wanted to do this I’m like you could do it. You’ll be great all the while saying I want to do that too but I’m not as smart as you. I didn’t graduate college. She kind of blazed the trail and I love the fact that I get to like kind of hold on to her coattails and get to be on the ride with her.

 

Zach: I’m curious Mary Jo, I think you bring up a really great point about, you said this when you when you first started telling your story a little bit about how these things that you had that from the outside it sounded like you had the dog, you had the family, the house and all these nice things. This is all common to hear this from people who have what we have. Talk to me though a little bit into our audience about I don’t know what the word would be. Maybe the unsettledness of all that and how it can bring about from my perspective at least a false belief that those things will bring about a sense of peace, belonging, love, purpose but it doesn’t last. I’m curious in your time with recovery when did that shift happen for you from going from like these things are nice but they’re really just things to this is really what I needed?

 

Mary Jo: For me it was like that peace of like I never felt okay in my own skin from as long I remember. I’m seventh of nine kids and kind of wanting, just wanting to be my own person but not knowing how. Alcoholism is I believe is a disease. When you break that word down it’s that element of dis-ease that I had. Then I drank and I felt like Cathy, I started out with I didn’t feel like I fit. Then in high school I had depression, anxiety, whatever you want to call it disorder. Then I discovered alcohol and cigarettes and that gave me the relief I needed without the weight.

 

Then it wasn’t working anymore because I used that I thought to get the things and the relationships and the family. I thought then the solution would be in those things the material as well as the children and husband and yet then the alcohol was actually standing in the way of the relationship with my husband and my children and the higher power. When I walked in honestly to my first meeting it was a Sunday. It was 5:30 in the afternoon on a Sunday. I remember thinking I don’t look like these people and I don’t want to belong here.

 

As soon as someone started talking and they started talking about their feelings I was in. I heard in that first meeting I heard we’ll love you till you can love yourself. I heard to not listen for the outcome but listen to the feeling. Like because what happens to people or what they did is different but the feeling will tend to be kind of in line and that was true. Then I went to a 6 AM meeting the next morning and I went to that meeting for the next two and a half years until I moved to Cincinnati.

 

Zach: I think that you bring up a really excellent point. The words that I’d use to sort of follow up what you said is to look for the similarities and not the differences between yourself and other people. One of the things you mentioned is the feelings. Cathy, you talked about you grew up in a family where alcoholism was pretty present. I’m wondering how because it’s not normal. It becomes normalized this whole process of alcoholism in the family but by normalize I mean so that not too many questions get asked about the craziness or the contradictions that take place within the family but I’m curious that that experience for you growing up Cathy in your home. How did your family normalize things?

 

Cathy: The bottom line is again addiction on both sides of the family for generations. The best way I can describe it is we had this silent code which is we will support each other through divorces, through legal issues, to kids being taken away but we will never talk about alcohol being the root cause of anyone’s problems. Mary Jo and I are friends with Jerry Moe and respect his work a lot, who’s been the national director of the children’s program for many years at the Betty Ford Center and worked with so many kids.

 

What he says is that kids silently and eloquently obey the cardinal rule of the addicted family don’t talk. They’re trapped in the silence by a family that usually denies the existence of the illness which grips it and that is definitely what happened in my family which is why it took me 30 years to be able to say out loud I have a drinking problem. I’m an alcoholic. I need help.

 

Zach: I want to move in to a different direction because this is all I’m sure something that we could talk about for a while because it’s such a rich subject. I want to talk about how you guys do interventions and why don’t you explain a bit about what an intervention looks like and how to tell it’s actually time to stage one for a loved one.

 

Cathy: I think it’s a good question Zach around when is the right time because going back to what we were just talking about which is alcoholism and addiction is a disease that invokes shame. We don’t like to talk about shame. No one wants to talk about it. The less we talk about shame the more we have it and the more control it has over us. Often we’ll get calls from family members saying they need an intervention.

 

My first question is tell me about the conversations that you’ve already had or one of the first questions, around your loved one and their drinking or using and getting help. So often the response is we haven’t. There’s too much fear around even broaching the topic. Often we’re coaching families on some of the basics of having some initial conversations because it’s not just the addict and alcoholic that feels shame. It’s the family member too. When there’s a loved one in a family who has an addiction or an alcoholic the whole house is on fire. It might be the addiction that got the flames on them but everyone else in the house is burning to some degree.

 

Before someone thinks about doing an intervention I’m usually coaching them on let’s have some initial conversations and talk about what can make those initial conversations more successful. Part of that is just getting the elephant out of the room and having some loving frank conversations. Also a key component of that is talking about treatment. If they’re having conversations usually the conversations are along the lines that you need to get help. You need to stop drinking. With someone who’s actively using that doesn’t translate into very much. They don’t know how to do that with their own health. Helping a family get organized on what treatment is affordable and what makes the most sense for their loved ones and then having some conversations around that.

 

Often family members can be successful on their own but with again some coaching and encouragement and insight around addiction and really what’s going on with their loved ones. Those conversations can be much more successful than what they’ve previously done. If families have already had or there’s just so much fear around the topic that they don’t feel empowered to do that then an intervention is appropriate.

 

Mary Jo: The other thing that I think is really important Zach is Cathy’s really good and we try to be really good at reminding the person that’s calling or asking them if they’ve done any work themselves. Like do they go to Al-Anon, do they go to Nar-Anon. Have they done any work themselves to understand the disease and to therefore to kind of know what their power is in it. Also to get some insight around co-dependency enabling enmeshment because as we know a lot of those behaviors need to be looked at if we want someone to get better.

 

Zach: Those are those are two interesting terms because they get I think misunderstood a lot. Can you explain Cathy what enmeshment and codependency actually means?

 

Cathy: I mean there’s so many good definitions. I think the definition for me because I’m a very good co-dependent and have done a lot of work in that area is when my own is dependent upon how somebody else in my family was doing. Enabling and enmeshment, I mean to me the best definition of enabling which seems to make sense to a lot of people, a lot of family members that we talk to is when we’re doing something for another adult that they should or could be doing on their own but we’re getting because we’re trying to control the outcome either force it to happen or avoid something bad from happening.

 

I mean the most classic example is I’m going to have my adult addicted child live in my house because I’m too afraid if they leave something bad will happen to them. The problem behavior is they actually support somebody’s addiction not recovery.

 

Zach: Often it’s all in the name of loving them.

 

Cathy: Sure and sometimes you know it makes us feel good. We’re doing something here even though it’s not getting the result that we want. We’re helping in some way when in fact those behaviors…

 

Zach: I was just going to ask a quick question just as we’re on this topic. When we’re talking about enabling and we’re talking about enmeshment and we’re talking about co-dependency I think what we’re really also talking about is attachment, talking about attachment and the connection that we have with people within our family. To augment that connection, to make it different takes a lot of work on the behalf of the person who’s perhaps not the alcoholic. Often it’s not. It’s the as you said the codependent. What have you found to be the most helpful for that to change the relationship?

 

Mary Jo: It starts with its most helpful if their loved one gets sober but even if they don’t one of the things that I’ve learned is families can’t change on a dime. You can’t educate a family on their enabling behaviors and the next day they’re going to change. It’s just like recovery and sobriety takes time for an alcoholic or an addict. Being patient with them and not making them feel ashamed because they can’t change quickly. We’ve worked with a lot of families who know that having an adult child in their house is contributing to the problem but they’re not ready to change yet until they’re in enough pain and they’re so tired and exhausted that they’re willing to have a different boundary. They’re still showing up though. I think that’s the key too. If they’re like being willing to look at it differently.

 

It’s why we need to advocate and I am a member and have been for eight years of Al-Anon because it’s that ongoing support of hearing other people talk about these topics and sharing their experience, strength and hope which gives other people hope. In Al-Anon we get the enormous comfort of knowing that we’re not alone which breaks through that family shame.

 

Zach: Talk to us briefly if you can just a little bit about what some of the myths and misconceptions are of interventions. Is it all similar to like the TV and the movies that we see or is it is it perhaps a lot different?

 

Mary Jo: I hate when people say it’s like you’re confronting them because we’re not confronting anyone. I think that’s what and it’s just such a loving fact. Intervention I think gets such a bad rep. People hear that and they get scared.

 

Funny thing that happened, Cathy and I a few years back we were doing an intervention up in Dayton. We’ve done the family meeting day before and there are about 10 people. We met at the end of the street and we all walked up to the house and knocked on the door. The guy came to the door and he opens the door and he sees all these people and Cathy and I standing there. He goes oh, expletive. It’s intervention. It is exactly what it was but that word scares the heck out of people. If you’ve ever been in one or had the opportunity to be a part of one it’s one of the most loving…

 

Cathy: Compassionate.

 

Mary Jo: Yes. Beautiful experiences and for family and friends to allow us to get to be kind of a facilitator or an instrument in that is it’s just beautiful. It’s kind of hard to explain.

 

Zach: Sounds like a great honor.

 

Mary Jo: Absolutely.

 

Cathy: It is an honor. One of the things that I try to get families comfortable word with is like take out the word intervention. This is simply a conversation where people who love the identified patient or the person being intervened on, love them enough to come and have what is sometimes a risky, awkward yet really brave conversation around this disease.

 

Mary Jo and I, this isn’t our term. We brought it from Jeff Jay, who is one of the leading interventionists in the country. He describes an intervention and it’s so accurate as a spiritual negotiation between somebody’s higher power, the family and the individual.

 

Zach: Wow, I love that. Can you say that again?

 

Cathy: It’s a spiritual negotiation between somebody’s higher power, the family and the addicts.  As we fail is telling an addict or alcoholic that they need treatment. We all know that. Yet the reason we do believe that the spiritual negotiation is because we’ve been in so many situations where I mean the success rate of interventions is about 80% to 90%. It’s a high success rate and it’s because there is a spiritual aspect to it that just takes over.

 

Mary Jo: It’s also it’s also kind of like have you ever trained for a marathon?

 

Zach: No.

 

Mary Jo: You may someday. You never know.

 

Zach: I trained for golf tournaments and that’s about it.

 

Mary Jo: Okay but running the marathon is not that hard. The heart is in the preparation. The struggle and the pain is in is in the months beforehand when you stress your body. With that intervention as it were or that family meeting that’s the accumulation of all of the work and pain and pouring out families and letters and in coaching and in doing their own preparation and education and finding the treatment centers and all that so that when that day comes.

 

Jeff Jay tells a story about doing an intervention in Pasadena where I grew up near Pasadena, California, where he walked up to the house of this woman with the family. This woman said to him I don’t know who you are. You get out of here. He walked away but that family was so prepared they didn’t really need him. The day of it’s like they’ve done their work and we’ve gotten to be part of that. Then it’s a matter of letting that bigger, that group the power of the group again because one-on-one they know. Go to hell you’re crazy but you get that group and the love of that group. You can’t explain it.

 

Zach: Like you said I think it’s the higher power piece. There’s a spiritual drive behind all this that really kind of takes this takes the driver’s seat. You guys are, it sounds like kind of conduits of that power to this family that you’re seeing and being a part of that you’re in front of. I had a question for you guys. I was wondering too because you named I think two of the sort of stalwarts of intervention trainings Jeff and Debra Jay with their Love First methodology of teaching interventions. Would you suggest you know for people who are considering you know becoming interventionists that they go through any particular kind of training or things that they should avoid etc., things like that?

 

Cathy: Good question. I would say that in general there are two trains of thought and therefore two different kinds of techniques for interventions. There’s separate trainings for those techniques. Very simply put one is an invitational style where someone is invited into the process. The other one is where someone is not aware that the intervention is going to happen or the conversation until the morning of or the day of.

 

There’s training for both of those. I did my training with Mary Jo with a gentleman named Ken Seeley who’s the regular on the intervention bringing us through intervention 9-1-1 but Jeff and Debra Jay have training. The Love First website has a lot of good training there as well.

 

Zach: Fantastic and it sounds like you, how many interventions are you doing in 2020?

 

Cathy: I mean we do a lot of what I would say coaching around intervention, a lot of those, many, many, many actual interventions because again when families are coached properly so many times they can successfully have a conversation. I’d have to go and count but we’re working with a couple families this week. Sometimes on a weekly basis there aren’t any and then other times they’re doubled up like this week.

 

Mary Jo: There have been so many where coaching it all the way through and then it’s a simple question of like we think you need help and they say okay. It is pretty interesting. People are so afraid to bring it out but I think for the people that have kind of over and over tried or don’t. We’ve heard many times they’re not going to do it. It’s not going to work. It just won’t happen. One in particular where they were sure it wasn’t going to work. A lot of you know angry friends but what’s going to be different this time.

 

Cathy and I going oh man this is going to be the one that’s it’s not great. I try to put on the happy face. We both say God’s got it. Cathy likes to say I’m just like okay. This is the last I’m doing. I’m like oh you’re full of baloney. It’s not the last one. It’s just amazing. We’ve never worked with a family who didn’t try to convince us that would be the one experience.

 

Zach: This has been great. Cathy and Mary Jo, it’s been an absolute pleasure to have you on the show today and thank you. Thank you both for the work that you’re doing that you’re going to continue to do to help change people’s lives but also I think is important or maybe even more so the family’s lives that you come in contact with. Thank you for your service.

 

Mary Jo: Thanks for doing this podcast. You’re doing some really great work too. It’s really cool to get to be a part of it. We appreciate it.

 

Cathy: We’re all in this together.

 

Zach: Absolutely. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts. Please subscribe, get the most up-to-date information from leading experts.

 

We have guest Dr. Miramonti joining us on the show today. Dr. Charles Miramonti is an emergency medicine physician and senior medical director of Community Health. He also teaches at the Indiana University School of Medicine. Dr. Miramonti, it’s a pleasure to have you on the show sir. Thank you for joining us.

 

Charles: Well, thank you. I appreciate the opportunity to come and talk.

 

Zach: Tell us about your background. What got you interested in medicine?

 

Charles: That’s a long story. To make to make a very long story very short I essentially failed out of mechanical engineering in school because I was spending so much time on ambulances and doing EMT work I really love. I found a love for biology and for health sciences later in college and then sort of pursued that afterwards. After I failed out of engineering I was like I got to figure out something I really like to do and medicine just seemed like an obvious choice. I sort of went from there and I’ve loved it ever since.

 

Zach: Is there any family background, history of people in medicine?

 

Charles: No, I’m the first. I got into it by starting with EMS and starting as an EMT in college and then I volunteered a ton doing the campus EMT service and then into fire departments and whatnot from there. After med school I did additional fellowship in EMS and medical direction and flew with Lifeline for a number of years and stayed on as a medical director with the Old Bush and Ambulance service here and helped rebuild Indianapolis EMS back in 2010. Stayed on as chief with them for another nine years or so. It’s been a great ride on that side.

 

Then about a year and a half or so ago, two years ago I got really interested in value-based care and how systems can do more for underserved communities and whatnot. I’ve sort of been following that passion for years now with Oak Street Health.

 

Zach: The audience because that’s a very interesting term I think it’s probably misunderstood too. What is value-based care? What is that exactly?

 

Charles: Actually it’s a different model of healthcare that really helps to align the incentives on the providers with the same incentives the patient has and really about creating value for the patients. Most value-based programs in some way, shape or form drive providers to keep you well rather than take care of you when you’re sick. It’s a lot of investment on the front side.

 

It’s additional, providers are incentivized and even funded to create additional programs and wrap around services to really help patients become skilled, engaged, educated patients who have strong advocates and can navigate a system to their end. That’s really what it’s all about is creating access and equity. Like I said earlier real value for the patients. It’s a different way to look at healthcare.

 

Zach: Is this similar in some respects to like I’m thinking from the insurance side of things where Humana as an example, large. Humana is a gigantic insurance company and they provide incentives like gift cards, even things like that to people that do their regular checkups that are participating in exercise programs. Is that is that along those lines?

 

Charles: It is along those lines. Humana is one of our bigger partners in this front. Oak Street’s real sort of niche is what they call Medicare Advantage which is a kind of value-based care program in which the providers or the physicians and nurse practitioners are sort of paid on the front side. Instead of us charging you for every single visit, lab work, x-ray, medication intervention, all that stuff is sort of bundled up front. Based upon how sick somebody is you get a certain amount of payment per member per month. If you can take care of that patient for less than that the organization keeps the change. If it costs you more than that to take care of a patient then the organization is at risk for covering that.

 

That puts the organization in a or the providers in a space that says hey, my practice and my well-being is tied to the patient’s well-being. We are really, really incentivized to do all the things we possibly can do to keep you very well and diagnosed correctly on the right medications and out of the hospital.

 

Zach: It sounds like there’s skin in the game then.

 

Charles: Skin in the game is exactly right.

 

Zach: What have you guys found to be helpful with implementing this value-based care? When I ask that what I mean is in terms of motivating people to stay better, to not wait. What have you all found to be useful?

 

Charles: I think the biggest things is sort of taking almost a retail approach to medicine and trying to meet the patient on their terms, trying to deliver care and access in a way that makes it easy for them. You reduce barriers, you tackle social issues in the home, you provide additional resources and really help them to navigate. I can tell you as a physician myself trying to get my kids scheduled or do get testing for myself on particular things. Trying to be your own advocate in the healthcare system is very, very difficult.

 

We provide that kind of additional elbow support to make it easy and get the obstacles out of the way. Those are the things that create engagement having smaller panels for the physicians that allow them time to spend with their patients to really get to know those patients, having visits that have enough time books to work through things and creating easy access to their providers either electronically or getting them in back in center or into visits when they need to.

 

We have outreach programs that I oversee where we use paramedics and community health workers in the home to really help redirect folks away from the hospitals and emergency departments when they don’t need it. Again, tackle social determinants, tackle housing, tackle food issues, all these sorts of things that really affect how folks exercise and or access their care. Really tackling those things from a team-based approach has been a win for us.

 

Zach: There’s a, you might be familiar with them Dr. Miramonti but there’s a large conglomerate in town called Norton Healthcare in Louisville, Kentucky. What they’ve begun to do is place psychologists and therapists in these PCP offices. I’m wondering if you’re seeing more of that in your area because to your point the mental and the physical have so much interplay with each other and then you just don’t address one.

 

Charles: I’ll say we see lots of depression, lots of personality adjustment disorders, things that get in the way and again making it easy for them to access behavioral health specialists either through televideo visits or through licensed clinical social workers in these particular centers. We really try to provide resources and services to them to one, get things addressed relatively quickly and two, make sure that they have the right resources and specialty referrals and again be that advocate, be that navigator for them so that they can tie it all together relatively easy.

 

Zach: You’ve been an emergency physician for quite some time. As an emergency physician what were you taught or what are you taught to do when a patient comes in and they are presenting with symptoms of substance use disorder?

 

Charles: That’s a great question. It’s changed dramatically I would say in the last 10, 15 years on how sophisticated we’ve got especially in the last five years probably due in some parts of the opiate crisis that we’ve been facing and how we’ve gotten more savvy with more resources and support there in the emergency department. Just from a medical standpoint our job one is addressing any sort of medical issues that are at hand. If they’ve had respiratory arrest or cardiac arrest, they have certain toxic drones, do they have metabolic abnormalities, kidney damage, heart damage, those sorts of things. Best job one is to look for that and treat those things appropriately.

 

Then obviously are there other underlying behavioral health issues that need addressed, mental health issues that need addressed. Is this a suicide attempt? Is this something more? If this is an addiction issue where’s this person at on their road to recovery or in their journey at all? From there once we’ve got the medical and the mental health issues at hand and we’re looking now at okay, what’s the long-haul plan here. Are we discharging to home or how are we going to handle the next step for them, really trying to assess okay what resources do they have? What resources do they need and how are we going to provide those appropriately?

 

What you’ve seen in the last, I’m going to say the last 10 years or so the role of the social worker in the emergency department has just, I mean blown up tremendously. We use them everything from helping folks get placed in nursing facilities, helping folks get placed in rehab facilities, to helping folks put those resources together, put the referrals together, what kind of acute intervention versus what can we do at home. Those sorts.

 

Once you get through all the medical and mental health stuff and there’s not the acute issue to go wrangle, understanding where that person’s at on their journey and then understanding where or what resources we’re going to be able to offer. Like I said from the ER side the amount of psychiatric and social work support that you’ll see most emergency departments have invested in the last five, ten years is tremendous. We didn’t have that kind of stuff when I got started. If there’s nothing wrong with you medically see you. Here’s a card with the number to call and here’s our best. That was it. Now we’ve gotten way, way more sophisticated, more savvy about how to address these issues.

 

Zach: Walk me through that because I’m curious to know just, I mean when I think of an ER I think of okay, we got we got this person. We need to get them in. Get them out as soon as we can because we got other people that are coming in. Maybe they’re being Lifelined in, life flighted in, the ER, ambulance is here, etc. Has the timeframe shrunk or expanded on these implementations of a plan or resources as you’re talking about with these different professionals in there?

 

Charles: I would say the timeframe has expanded dramatically. They’ve created new observation statuses. They’ve created new like I said additional in ER support services that we didn’t have years ago. Even from the medical legal liabilities standpoint the hospitals are much more reticent to release folks back to the street unless they are 100% percent sober and upright. We just didn’t have that years ago. It was much more especially in the ER setting I came up in downtown Indianapolis at Wishard, it was such a zoo in there in terms of volume.

 

We just didn’t have time or resources to offer all of this. Today, ERs are built around these kind of expectations. When the new Eskenazi was built years ago these kinds of things were taken into account in terms of bed volume and resource support down in the emergency department. The way that we were layering in outpatient psychiatric services into the emergency department experience changed dramatically.

 

Now at the VA, VA is very sophisticated and progressive about the kinds of services they layer into the ER experience for patients and our ability to connect them quickly with psychiatric services, mental health and whatnot and then outpatient rehab and whatnot. It’s wonderful to have those kinds of resources today but on our side the expectation is a much longer ER stay than we had in years past.

 

Zach: I’m curious to know too I’m sure, I’ve got to believe in some level that you’ve been in this a while. As you’ve said already that it wasn’t the same as it is today. It’s been a lot of change that’s happened since the days of just kind of getting people in and out. What do you think enacted this change? Was it the opioid epidemic that made this change a big piece that kind of got your colleagues and you thinking that there’s some kind of change that has to be enacted but I’m sure that as doctors you guys can’t like move mountains either. If you had to say what sort of got this change going what was it?

 

Charles: I think there was an evolving initiative across the country to do a better job to solve these kinds of issues in the emergency department because it was such a significant volume of our patient population everywhere. You see more in terms, from the ER side you see more projects and more focused research social initiatives, grant projects and whatnot around these sort of social programs along homelessness and drug addiction and mental health services and whatnot.

 

It was an area that we found not only was there a tremendous paucity of knowledge and resource support but tremendous opportunity to have real impact which made it appealing. I think those things were going in the early 2000s um before the epidemic hit. Then for us in Indianapolis the epidemic really took off in 2011 when we saw it. Then I think that catalyzed a lot of hospital dollars and healthcare dollars towards these kinds of programs when folks are saying it’s oh, it’s not just a drug addiction. It’s not just these typical sort of cliché people or in communities that we’ve always thought of.

 

Now it’s in upper middle class white suburban neighborhoods. It’s in all of our high schools. It’s everywhere and the awareness that half of these very high class neighborhoods and whatnot where the parents are on Valium and Norco. It’s right throughout the community. Everybody had easy access to it and really the a-ha moment probably around I’m going to say 2012, 2013 of connecting that with the just horribly downplayed and under-treated mental health issues that were pervasive throughout our country. I think really all of that came to light at catalyzing a lot of these programs.

 

Zach: That makes a ton of sense.

 

Charles: I’ll tell you the other thing that really I think catalyzed it is in healthcare you can always just follow the money. Billing changed dramatically and hospitals were able to actually get reimbursement on these things in the last 10 years. There was financial incentive to take care of these, financial resources to create new wings and new bed space, financial opportunity for psychiatrists to take on this kind of work and whatnot. I think the refocus of Medicaid and Medicare to open up these kinds of funding opportunities in the last, I’m going to say last seven years also had a huge impact on changing the game.

 

Zach: I bet. A lot to digest here Dr. Miramonti. It’s been a pleasure talking about it.

 

Charles: I can still talk.

 

Zach: This is probably a three-part episode right here. There’s so much to pack in. I appreciate your time. Tell us briefly if you can about your work at Oak Street. What does that look like?

 

Charles: Today at Oak Street, I was originally started there to help with emergency department utilization. In many health systems and healthcare populations generally the top five, top 10% of the healthcare utilizers are roughly responsible for 60% to 70% of your healthcare costs in any given healthcare business. The organization was interested in targeting those real high ER utilizers. What were we missing? What are the different things that we could do?

 

We evolved some programs that we had done in years past in my prior role as an EMS chief using paramedics and community health workers and social workers to go into the home and be front frontline elbow support for folks that we had identified as high ER utilizers. Most of that was really just addressing social determinant issues, creating resources for them, doing a little bit of in-home sort of urgent care if you will. We trained up the paramedics to do lots of disease management and then really serving as an extension of the primary care team and bringing in everything that we were learning about the home to really sort of change the game on how care planning was done and how resource utilization was done.

 

Since then my job has evolved to take on in-home primary care services for the company across the organization. We have teams in Detroit, in Chicago and Indianapolis taking care of some of our sickest patients, most complicated patients. We do that through a very team-based approach and we’re very lucky to have lots of social work support, lots of mental health support, pharmacy support.

 

We have these expansive teams that really provide wrap-around services and navigation for these patients. Even though it’s a relatively small number of patients to the organization maybe the top 1% or 2% percent of the total we’re able to have a huge impact on their lives and obviously huge impact on some bottom line issues for the organization but it’s been great to really sort of take what we’ve learned in EMS and on the ER side over the last 20 years and then be able to apply that in novel ways in the home that the patients will actually engage with. Patients who have been ostracized from the healthcare system in the brick and mortar model for so many years, it works great for them. It’s a real win.

 

Zach: That’s awesome. Listen, I really appreciate all your time today. I always end by saying if you know someone struggling with an addiction and you’re searching for answers you can visit us at LandmarkRecovery.com and you can learn more about substance abuse programs that are both saving lives and empowering families. Dr. Miramonti again, pleasure to have you on the show. Thank you so much.

 

Charles: Thank you. This has been a real privilege. Thank you.

 

Zach: Until next week, I’m Zach Crouch with Landmark Recovery Radio wishing you well.

 

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