Patients with Substance use Disorders Receiving Continued Care in Skilled Nursing Facilities following Hospitalization

Abstract

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Information sharing to support care transitions for patients with complex mental health and social needs

“…In fact, we find some evidence that facilities that accept complex patients are in fact more likely to receive critical and often missing information related to patients' behavioral, social, mental, and functional status. This is reassuring from a quality of care perspective, given that hospitals are known to act cautiously with respect to sharing information that could make patients difficult to place 4,26 . As health system leaders and policymakers continue to grapple with how best to strengthen systems of care and improve value across PAC providers (home health, long‐term care hospitals, and intermediate care facilities), further investment in improving transitional care practices for all facilities—with a focus on these social and behavioral information elements—will be increasingly critical.…”

“…If the SNF reported accepting patients at least sometimes in two or more of the three focus conditions, we defined them as willing to accept more complex patients after hospital discharge. These conditions—SMI, MAT, and SUD—were identified as challenging to care for in our formative case studies, and in prior literature because they require additional capacity for psychosocial support 23–26 . We opted to compare the acceptance of two to three complex conditions to zero to one because the theoretical and empirical literature on organizational specialization suggests that organizations are more likely to change structures and processes of care only when they can be applied to a broader segment of their patient population 27–29 …”

The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study

“…Prior studies have shown that healthcare providers' stereotypes of patients with OUD such as their perceived dangerousness can lead to avoidance. 7,[22][23][24] Second, SNFs might not have the resources to invest in programs that patients with OUD require such as recovery-focused programming or social workers who can address negative social determinants. 23,24 Finally, SNFs face challenges in continuing medications for OUD, particularly methadone.…”

“…7,[22][23][24] Second, SNFs might not have the resources to invest in programs that patients with OUD require such as recovery-focused programming or social workers who can address negative social determinants. 23,24 Finally, SNFs face challenges in continuing medications for OUD, particularly methadone. Unlike acute care hospitals, SNFs cannot dispense methadone for OUD and must coordinate with opioid treatment programs for delivery.…”

Perspectives on Admissions and Care for Residents With Opioid Use Disorder in Skilled Nursing Facilities

“…Despite federal antidiscrimination laws that protect individuals with OUD (unless they are engaged in active substance use) and those who are in treatment or recovery, an emerging literature suggests that individuals with OUD and those who receive medications for OUD (MOUD) are less likely to be placed in SNFs. Staff unpreparedness to care for residents with OUD; negative perceptions about risk to facility, staff, and other residents; lack of resources; and discriminatory admissions practices appear to limit access to SNFs . The existing literature is based on a few states, and, in some instances, emerged from expert opinion, pointing to the need for further empirical investigation in diverse states and more contemporary periods considering the evolving landscape of OUD treatment policies in the US.…”