Bon Secours Baltimore leverages BH-Works to address social determinants and behavioral health issues

Working for Recovery: Utilizing Peer Recovery Specialists in Vulnerable Populations

Peer recovery specialists, health workers that have a shared understanding or experience with the populations they are serving, are becoming an integral part of the new healthcare landscape. These workers are utilized in many clinical and non-clinal settings across the country, and they are trained to provide emotional, informational, and social support to patients with mental health problems and substance use disorders. They take a disease management approach to improve outcomes for these patients, helping them overcome common barriers to care before and after they leave the acute care setting.

Ollie Dorsey, a peer recovery specialist hired to work on a proof of concept project at Bon Secours Baltimore, has never used drugs and she doesn’t drink alcohol, but she spent years taking care of a brother who struggled with addiction. After watching him face countless obstacles – particularly the way people treated him after he was diagnosed with AIDS – she found her place in the world of recovery. “God told me this was what I needed to do,” she assertively states, “that I was going to have to be the one to take care of people in my family that do these things.”

She’s since shouldered the responsibility of extending this care throughout a West Baltimore neighborhood that has some of the sickest, most vulnerable patients in the state. Ms. Dorsey is currently the peer recovery specialist for an ED (Emergency Department) Diversion project where she continuously engages with patients flagged as “high utilizers”. Most high utilizers suffer from substance use disorders, mental health problems, and/or chronic physical illnesses, and many of these patients don’t have adequate access to basic needs like food, clothing, and shelter. Ms. Dorsey screens these patients for behavioral health issues once they’re admitted to the hospital, referring them to outpatient care and social support within the community. The project, which has been funded by Open Society Institute – Baltimore, will track these high utilizers for 18 months, hopefully resulting in a reduction in ED visits and expensive hospitalizations within the population.

Ms. Dorsey is notified each time a high-utilizer has been admitted to the hospital, and she must determine when she can engage with the patient to assess them for behavioral health issues and social determinants of health. She has access to BH-Works, a web-based platform developed by Baltimore-based firm mdlogix, which includes tools that screen patients for mental health conditions as well as common social risk factors. The Comprehensive Universal Behavioral Screen (CUBS) takes about 20 minutes to complete and can be administered for the patient to self-report on a laptop or mobile device, or through an interview conducted by staff.

Once a patient completes an assessment, the screening results are immediately summarized, and Ms. Dorsey can determine if the patient should be referred to behavioral health services inside or outside of the Bon Secours system, something she can do directly in the BH-Works platform. The analytics function in BH-Works displays graphic representations of just how sick these patients are – many of them showing risk for severe mental health problems like psychosis, substance use, suicide ideation, depression, anxiety, and trauma. About 40% of them are homeless, and many of them are older patients.

By the time Ms. Dorsey engages with a patient, they have seen multiple clinicians, nurses, social workers, and sometimes other peer workers. Dorsey has now screened several patients who were identified as a suicide risk through the BH-Works system, and she was able to refer these patients to mental health services within the hospital. Ms. Dorsey admits that a lot of times the patients don’t want help, or they’re only willing to accept help in stages. She explains, “Sometimes they’re ready for recovery, but sometimes all they want to do is get out of here, and they’ll say and do anything to get that.”

The patients often reach out to Ms. Dorsey for help with other issues, and she does her best to help them overcome each barrier, understanding the impact these things can have on their overall health. She secures transportation, prepaid phones, and food for them. She helps them address dental and vision issues. She finds shelters for patients with immediate housing needs, and helps them locate resources that could provide a track to permanent housing. She notes, “They see someone cares enough to help them, so maybe they should do something to keep themselves healthy.”

Sometimes she worries about what the future holds for her patients, but she plans to keep fighting for them as long as she can. Her experience with people in recovery, and those that desperately need to be in recovery, has shaped her life in ways she never expected. “You learn so much about people doing this kind of work,” she states. “We’re all going through recovery of something.”