1
|
Franz B, Cronin CE, Lindenfeld Z, Pagan JA, Lai AY, Krawczyk N, Rivera BD, Chang JE. Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 160:209280. [PMID: 38142042 PMCID: PMC11060933 DOI: 10.1016/j.josat.2023.209280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/07/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Hospitals are an ideal setting to stage opioid-related interventions with patients who are hospitalized due to overdose or other substance use-related complications. Transitional opioid programs-which initiate care and provide linkages upon discharge, such as screening, initiation of medications for opioid use disorder, and addiction consult services-have become the gold standard, but implementation has been uneven. The purpose of this study was to assess disparities in the availability of hospital-based transitional opioid programs, across rural and urban hospital settings in the United States. METHODS Using hospital administrative data paired with county-level demographic data, we conducted bivariate and regression analyses to assess rural-urban differences in the availability of transitional opioid services including screening, addiction consult services, and MOUD in U.S general medical centers, controlling for hospital- and community-level factors. Our sample included 2846 general medical hospitals that completed the 2021 American Hospital Association (AHA) Annual Survey of Hospitals. Our primary outcomes were five self-reported measures: whether the hospital provided screening in the ED; provided screening in the inpatient setting; whether the hospital provided addiction consult services in the ED; provided addiction consult services in the inpatient setting; and whether the hospital provided medications for opioid use disorder. RESULTS Rural hospitals did not have lower odds of screening for OUD or other SUDs than urban hospitals, but both micropolitan rural counties and noncore rural counties had significantly lower odds of having addiction consult services in either the ED (OR: 0.74, 95 % CI: 0.58, 0.95; OR: 0.68, 95 % CI: 0.50, 0.91) or inpatient setting (OR: 0.76, 95 % CI: 0.59, 0.97; OR: 0.68, 95 % CI: 0.50, 0.93), respectively, or of offering MOUD (OR: 0.69, 95 % CI: 0.52, 0.90; OR: 0.52, 95 % CI: 0.37, 0.74). CONCLUSIONS Our study suggests that evidence-based interventions, such as medications for opioid use disorder and addiction consult services, are less often available in rural hospitals, which may contribute to rural-urban disparities in health outcomes secondary to OUD. A priority for population health improvement should be developing implementation strategies to support rural hospital adoption of transitional opioid programs.
Collapse
Affiliation(s)
- Berkeley Franz
- Ohio University Heritage College of Osteopathic Medicine, Appalachian Institute to Advance Health Equity Science (ADVANCE), United States of America.
| | - Cory E Cronin
- Ohio University College of Social and Public Health, Appalachian Institute to Advance Health Equity Science (ADVANCE), United States of America
| | - Zoe Lindenfeld
- New York University College of Global Public Health, United States of America
| | - Jose A Pagan
- New York University College of Global Public Health, United States of America
| | - Alden Yuanhong Lai
- New York University College of Global Public Health, United States of America
| | - Noa Krawczyk
- New York University Grossman School of Medicine, United States of America
| | - Bianca D Rivera
- New York University Grossman School of Medicine, United States of America
| | - Ji E Chang
- New York University College of Global Public Health, United States of America
| |
Collapse
|
2
|
Koester M, Motz R, Porto A, Reyes Nieves N, Ashley K. Using Project Extension for Community Healthcare Outcomes to Enhance Substance Use Disorder Care in Primary Care: Mixed Methods Study. JMIR MEDICAL EDUCATION 2024; 10:e48135. [PMID: 38557477 PMCID: PMC11019412 DOI: 10.2196/48135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 11/06/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Substance use and overdose deaths make up a substantial portion of injury-related deaths in the United States, with the state of Ohio leading the nation in rates of diagnosed substance use disorder (SUD). Ohio's growing epidemic has indicated a need to improve SUD care in a primary care setting through the engagement of multidisciplinary providers and the use of a comprehensive approach to care. OBJECTIVE The purpose of this study was to assess the ability of the Weitzman Extension for Community Healthcare Outcomes (ECHO): Comprehensive Substance Use Disorder Care program to both address and meet 7 series learning objectives and address substances by analyzing (1) the frequency of exposure to the learning objective topics and substance types during case discussions and (2) participants' change in knowledge, self-efficacy, attitudes, and skills related to the treatment of SUDs pre- to postseries. The 7 series learning objective themes included harm reduction, team-based care, behavioral techniques, medication-assisted treatment, trauma-informed care, co-occurring conditions, and social determinants of health. METHODS We used a mixed methods approach using a conceptual content analysis based on series learning objectives and substances and a 2-tailed paired-samples t test of participants' self-reported learner outcomes. The content analysis gauged the frequency and dose of learning objective themes and illicit and nonillicit substances mentioned in participant case presentations and discussions, and the paired-samples t test compared participants' knowledge, self-efficacy, attitudes, and skills associated with learning objectives and medication management of substances from pre- to postseries. RESULTS The results of the content analysis indicated that 3 learning objective themes-team-based care, harm reduction, and social determinants of health-resulted in the highest frequencies and dose, appearing in 100% (n=22) of case presentations and discussions. Alcohol had the highest frequency and dose among the illicit and nonillicit substances, appearing in 81% (n=18) of case presentations and discussions. The results of the paired-samples t test indicated statistically significant increases in knowledge domain statements related to polysubstance use (P=.02), understanding the approach other disciplines use in SUD care (P=.02), and medication management strategies for nicotine (P=.03) and opioid use disorder (P=.003). Statistically significant increases were observed for 2 self-efficacy domain statements regarding medication management for nicotine (P=.002) and alcohol use disorder (P=.02). Further, 1 statistically significant increase in the skill domain was observed regarding using the stages of change theory in interventions (P=.03). CONCLUSIONS These findings indicate that the ECHO program's content aligned with its stated learning objectives; met its learning objectives for the 3 themes where significant improvements were measured; and met its intent to address multiple substances in case presentations and discussions. These results demonstrate that Project ECHO is a potential tool to educate multidisciplinary providers in a comprehensive approach to SUD care.
Collapse
Affiliation(s)
- MacKenzie Koester
- Weitzman Institute, Moses Weitzman Health System, Washington, DC, United States
| | - Rosemary Motz
- Weitzman Institute, Moses Weitzman Health System, Washington, DC, United States
| | - Ariel Porto
- Weitzman Institute, Moses Weitzman Health System, Washington, DC, United States
| | - Nikita Reyes Nieves
- Weitzman Institute, Moses Weitzman Health System, Washington, DC, United States
| | - Karen Ashley
- Weitzman Institute, Moses Weitzman Health System, Washington, DC, United States
| |
Collapse
|
3
|
Sokolski E, Buchheit BM, Desai S, Englander H. It's Time to Train Residents in Addiction Medicine. J Grad Med Educ 2023; 15:632-637. [PMID: 38045952 PMCID: PMC10686659 DOI: 10.4300/jgme-d-23-00317.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Eleasa Sokolski
- Eleasa Sokolski, MD, is Assistant Professor of Medicine and Psychiatry, Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Bradley M. Buchheit
- Bradley M. Buchheit, MD, MS, is Assistant Professor of Medicine and Family Medicine, Program Director, Oregon Health & Science University Addiction Medicine Fellowship Program, and Medical Director, Harm Reduction and BRidges to Care (HRBR) Clinic, Oregon Health & Science University, Portland, Oregon, USA
| | - Sima Desai
- Sima Desai, MD, MACP, FRCP, is Professor of Medicine Division of Hospital Medicine, Department of Medicine, Program Director, Oregon Health & Science University Internal Medicine Residency Program, and Vice Chair of Education, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA; and
| | - Honora Englander
- Honora Englander, MD, is Professor of Medicine, Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, and Director/PI Improving Addiction Care Team (IMPACT), Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
4
|
Heerema MR, Ventura AS, Blakemore SC, Montoya ID, Gobel DE, Kiang MV, LaBelle CT, Bazzi AR. Evaluation of the New England Office Based Addiction Treatment ECHO: A Tool for Strengthening the Addiction Workforce. Subst Abus 2023; 44:164-176. [PMID: 37287240 PMCID: PMC10688578 DOI: 10.1177/08897077231179601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Reducing substance-related morbidity requires an educated and well-supported workforce. The New England Office Based Addiction Treatment Extension for Community Healthcare Outcomes (NE OBAT ECHO) began in 2019 to support community-based addiction care teams through virtual mentoring and case-based learning. We sought to characterize the program's impact on the knowledge and attitudes of NE OBAT ECHO participants. METHODS We conducted an 18-month prospective evaluation of the NE OBAT ECHO. Participants registered for 1 of 2 successive ECHO clinics. Each 5-month clinic included ten 1.5-hour sessions involving brief didactic lectures and de-identified patient case presentations. Participants completed surveys at Month-0, -6, -12, and -18 to assess attitudes about working with patients who use drugs and evidence based practices (EBPs), stigma toward people who use drugs, and addiction treatment knowledge. We compared outcomes using 2 approaches: (i) between-groups, which involved comparing the first intervention group to the delayed intervention (comparison) group, and (ii) within-groups, which involved comparing outcomes at different time points for all participants. In the within-group approach, each participant acted as their own control. RESULTS Seventy-six health professionals participated in the NE OBAT ECHO, representing various roles in addiction care teams. Approximately half (47% [36/76]) practiced primary care, internal, or family medicine. The first intervention group reported improved job satisfaction and openness toward EBPs compared to the delayed intervention group. Within-group analyses revealed that ECHO participation was associated with increased positive perceptions of role adequacy, support, legitimacy, and satisfaction 6 months following program completion. No changes were identified in willingness to adopt EBPs or treatment knowledge. Stigma toward people who use drugs was persistent in both groups across time points. CONCLUSIONS NE OBAT ECHO may have improved participants' confidence and satisfaction providing addiction care. ECHO is likely an effective educational tool for expanding the capacity of the addiction workforce.
Collapse
Affiliation(s)
- Matthew R. Heerema
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Alicia S. Ventura
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Samantha C. Blakemore
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Ivan D. Montoya
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Danna E. Gobel
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Mathew V. Kiang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Colleen T. LaBelle
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
- Boston University School of Medicine, Boston, MA, United States of America
| | - Angela R. Bazzi
- Boston University School of Public Health, Boston, MA, United States of America
- Herbert Wertheim School of Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, United States of America
| |
Collapse
|
5
|
Adeniran E, Quinn M, Wallace R, Walden RR, Labisi T, Olaniyan A, Brooks B, Pack R. A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100152. [PMID: 37069961 PMCID: PMC10105485 DOI: 10.1016/j.dadr.2023.100152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/19/2023]
Abstract
Background Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC. Methods A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems. Results Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access). Conclusions This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.
Collapse
Affiliation(s)
- Esther Adeniran
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
- Corresponding author at: Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States.
| | - Megan Quinn
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Richard Wallace
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Rachel R. Walden
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Titilola Labisi
- Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Afolakemi Olaniyan
- Department of Health Promotion and Education, School of Human Sciences, University of Cincinnati, Cincinnati, OH 45221, United States
| | - Billy Brooks
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Robert Pack
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| |
Collapse
|
6
|
Chicoine G, Côté J, Pepin J, Dyachenko A, Fontaine G, Jutras-Aswad D. Improving the self-efficacy, knowledge, and attitude of nurses regarding concurrent disorder care: Results from a prospective cohort study of an interprofessional, videoconference-based programme using the ECHO model. Int J Ment Health Nurs 2023; 32:290-313. [PMID: 36300644 DOI: 10.1111/inm.13082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2022] [Indexed: 01/14/2023]
Abstract
Several challenges have been identified for patients with concurrent disorders to access adequate services and for nurses to care for them. These challenges contribute to a pressing need for continuing educational interventions, particularly within the mental health nursing workforce. To address this issue, an innovative interprofessional videoconferencing programme based on the ECHO® model (Extension for Community Healthcare Outcomes) was implemented in Quebec, Canada to support and build capacity among healthcare professionals for CD management. The aim of this prospective cohort study was to examine nurses' self-efficacy, knowledge, and attitude scores over a 12-month period. All nurses who registered in the programme between 2018 and 2020 were invited to participate in the study (N = 65). The data were collected online using a self-administered survey at baseline, after 6 months, and then 12 months following entry-to-programme. Twenty-eight nurses participated in the study (96.4% women), with a mean age of 39.1 (SD = 6.2). Compared to other professions (n = 146/174), the group of nurses also showed significant improvements in their knowledge and attitude scores, with respective effect sizes of 0.72 and -0.44 at 6 months, and 0.94 and -0.59 at 12 months. However, significant changes in self-efficacy were only found at the 12-month follow-up (P = 0.0213), among the nurses who attended more than 25% of the 20-session curriculum. ECHO is a promising intervention to improve the accessibility of evidence-based practice and to support nurses in suitably managing concurrent disorders. Further research is needed to establish the effectiveness of this educational intervention on clinical nursing practice and patient outcomes.
Collapse
Affiliation(s)
- Gabrielle Chicoine
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada.,Université de Montréal Hospital Research Centre, Montreal, Quebec, Canada.,Research Chair in Innovative Nursing Practices, Université de Montréal, Montreal, Quebec, Canada
| | - José Côté
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada.,Université de Montréal Hospital Research Centre, Montreal, Quebec, Canada.,Research Chair in Innovative Nursing Practices, Université de Montréal, Montreal, Quebec, Canada
| | - Jacinthe Pepin
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
| | - Alina Dyachenko
- Université de Montréal Hospital Research Centre, Montreal, Quebec, Canada
| | - Guillaume Fontaine
- Center for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Centre for Nursing Research, Jewish General Hospital, CIUSSS West-Central Montreal, Montreal, Quebec, Canada
| | - Didier Jutras-Aswad
- Université de Montréal Hospital Research Centre, Montreal, Quebec, Canada.,Faculty of Medicine, Department of Psychiatry and Addiction, Université de Montréal, Montreal, Quebec, Canada
| |
Collapse
|
7
|
Inpatient care provider perspectives on the development and implementation of an addiction medicine consultation service in a small urban setting. Subst Abuse Treat Prev Policy 2022; 17:70. [PMID: 36303182 PMCID: PMC9612624 DOI: 10.1186/s13011-022-00497-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To evaluate provider perspectives on the development and implementation of an inpatient Addiction Medicine Consult Service, including their awareness of the service, its perceived role in the continuum of care, and changes over time in their perceptions of care quality for inpatients with substance use disorders. METHODS Repeated cross-sectional survey of hospital-based physicians, nurses and social workers performed at service launch (April-June, 2017) and 4 years later (March-June, 2021). RESULTS Providers had generally positive perceptions of the service and its impact on care quality, but encountered significant barriers at both time points in meeting patient needs (related to high patient complexity and difficulty connecting patients with community services post-discharge). Relative to physicians and social workers, nurses were less likely to be familiar with the service or see it as beneficial. CONCLUSIONS Findings indicate that the service fills a gap that existed previously in the local system of care; however, numerous opportunities exist to further strengthen the system beyond the hospital setting to promote longer-term health among people who use substances. For nurses in particular, outreach, education, and other resources (e.g., dedicated nursing role support, nurse liaison) are warranted to ensure that nurses feel supported and confident caring for this patient population.
Collapse
|
8
|
King CA, Cook R, Korthuis PT, McCarty D, Morris CD, Englander H. Expanding Inpatient Addiction Consult Services Through Accountable Care Organizations for Medicaid Enrollees: A Modeling Study. J Addict Med 2022; 16:570-576. [PMID: 35135988 PMCID: PMC9357852 DOI: 10.1097/adm.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Addiction consult services (ACS) care for hospitalized patients with substance use disorder, including opioid use disorder (OUD). Medicaid Accountable Care Organizations (ACOs) could enhance access to ACS. This study extends data from Oregon's only ACS to Oregon's 15 regional Medicaid Coordinated Care Organizations (CCOs) to illustrate the potential value of enhanced in- and out-patient care for hospitalized patients with OUD. The study objectives were to estimate the effects of (1) expanding ACS care through CCOs in Oregon, and (2) increasing community treatment access within CCOs, on post-discharge OUD treatment engagement. METHODS We used a validated Markov model, populated with Oregon Medicaid data from April 2015 to December 2017, to estimate study objectives. RESULTS Oregon Medicaid patients hospitalized with OUD with care billed to a CCO (n = 5878) included 1298 (22.1%) patients engaged in post-discharge OUD treatment. Simulation of referral to an ACS increased post-discharge OUD treatment engagement to 47.0% (95% confidence interval [CI] 45.7%, 48.3%), or 2684 patients (95% CI 2610, 2758). Ten of fifteen (66.7%) CCOs had fewer than 20% of patients engage in post-discharge OUD care. Without ACS, increasing outpatient treatment such that 20% of patients engage increased the patients engaging in post-discharge OUD care from 12.9% or 296 patients in care at baseline to 20% (95% CI 18.1%, 21.4%) or 453 (95% CI 416, 491). DISCUSSION ACOs can improve care for patients hospitalized with OUD. Implementing ACS in ACO networks can potentially improve post-discharge OUD treatment engagement, but community treatment systems must be prepared to accept more patients as inpatient addiction care improves.
Collapse
Affiliation(s)
- Caroline A King
- From the Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR (CAK); Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR (RC, PTK, HE); School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR (DM); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (CDM); Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland, OR (HE)
| | | | | | | | | | | |
Collapse
|
9
|
Englander H, Jones A, Krawczyk N, Patten A, Roberts T, Korthuis PT, McNeely J. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. J Gen Intern Med 2022; 37:2821-2833. [PMID: 35534663 PMCID: PMC9411356 DOI: 10.1007/s11606-022-07618-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews. METHODS Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types. RESULTS Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components. DISCUSSION A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.
Collapse
Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Amy Jones
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Noa Krawczyk
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Alisa Patten
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Roberts
- NYU Health Sciences Library, New York University Grossman School of Medicine, New York, NY, USA
| | - P Todd Korthuis
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
10
|
Experiences and perceptions of nurses participating in an interprofessional, videoconference-based educational programme on concurrent mental health and substance use disorders: a qualitative study. BMC Nurs 2022; 21:177. [PMID: 35787275 PMCID: PMC9251915 DOI: 10.1186/s12912-022-00943-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Individuals with co-occurring mental health and substance use disorders (i.e., concurrent disorders) have complex healthcare needs, which can be challenging for nurses to manage. Providing optimal care for this subpopulation requires nurses to develop high-level competencies despite limited resources at their disposal and the isolated settings in which many of them work. The Extension for Healthcare Community Outcomes (ECHO®) is a promising collaborative learning and capacity building model that uses videoconference technology to support and train healthcare professionals in the management of complex and chronic health conditions. The aim of this study was to explore the experiences and perceptions of nurses participating in a Canadian ECHO programme on concurrent disorders about the competencies they developed and used in their clinical practice, and which factors have influenced this process. Methods The study was qualitative, guided by an interpretive description approach. Individual semi-structured interviews were held with ten nurses who had participated in the programme between 2018 and 2020. A thematic analysis was conducted iteratively using an inductive approach to progressive data coding and organization. Results Four themes and eighteen sub-themes were identified. During their participation in ECHO, the nurses perceived as having further developed eight clinical nursing competencies. Nurses viewed ECHO as a unique opportunity to open themselves to their peers’ experiences and reflect on their own knowledge. Learning from experts in the field of concurrent disorders helped them to build their confidence in managing complex clinical situations. The nurses’ sense of belonging to a community further enhanced their engagement in the programme, and learning was facilitated through the programme’s interprofessional environment. Nevertheless, the lack of contextualized educative content linked to local realities, the limited resources in concurrent disorders, and time constraints were experienced as factors limiting competency development. Conclusions ECHO is a promising alternative to conventional, in-person continuing education programmes to improve the development of advanced competencies among nurses providing care to individuals with chronic and complex health conditions. These findings can inform clinicians, educators, researchers, and decision makers who are developing, implementing, evaluating, and escalating future educational interventions in the field of CDs. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-022-00943-w.
Collapse
|
11
|
The Development and Implementation of a Hospitalist-Directed Addiction Medicine Consultation Service to Address a Treatment Gap. J Gen Intern Med 2022; 37:1065-1072. [PMID: 34013473 PMCID: PMC8971245 DOI: 10.1007/s11606-021-06849-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Hospitalizations related to the consequences of substance use are rising yet most hospitalized patients with substance use disorder do not receive evidence-based addiction treatment. Opportunities to leverage the hospitalist workforce could close this treatment gap. AIM To describe the development, implementation, and evaluation of a hospitalist-directed addiction consultation service (ACS) to provide in-hospital addiction treatment. SETTING Six hundred fifty-bed university hospital in Aurora, Colorado. PROGRAM DESCRIPTION Hospitalists completed buprenorphine waiver training, participated in a 13-part addiction lecture series, and completed a minimum of 40 hours of online addiction training. Hospitalists participated in shadow shifts with an addiction-trained physician. Dedicated addiction social workers developed relationships with local addiction treatment services. PROGRAM EVALUATION METRICS Physician-related metrics included education, training, and clinical time spent in addiction practice. Patient and encounter-related metrics included a description of ACS care provision. RESULTS Eleven hospitalists completed an average of 95 hours of addiction-related didactics. Once addiction training was complete, hospitalists spent an average of 30 days over 12 months staffing a weekday ACS. Between October 2019 and November 2020, the ACS completed 1620 consultations on 1350 unique patients. Alcohol was the most common substance (n = 1279; 79%), followed by tobacco (979; 60.4%), methamphetamines/amphetamines (n = 494; 30.5%), and opioids (n = 400; 24.7%). Naltrexone was the most frequently prescribed medication (n = 350; 21.6%), followed by acamprosate (n = 93; 5.7%), and buprenorphine (n = 77, 4.8%). Trauma was a frequent discharge diagnoses (n = 1564; 96.5%). Leaving prior to treatment completion was commonly noted (n = 120, 7.4%). The ACS completed 47 in-hospital methadone enrollments. DISCUSSION The hospitalist-directed ACS is a promising clinical initiative that could be implemented to expand hospital-based addiction treatment. Future research is needed to understand challenges to disseminating this model into other hospital settings, and to evaluate intended and unintended effects of broad implementation.
Collapse
|
12
|
Pals H, Bratberg J. Improving Access to Care via Psychiatric Clinical Pharmacist Practitioner Collaborative Management of Buprenorphine for Opioid Use Disorder. J Am Pharm Assoc (2003) 2022; 62:1422-1429. [DOI: 10.1016/j.japh.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/12/2022] [Accepted: 03/04/2022] [Indexed: 11/26/2022]
|
13
|
O’Donnell M, Englander H, Strnad L, Bhamidipati CM, Shalen E, Riquelme PA. Expanding the Team: Optimizing the Multidisciplinary Management of Drug Use-Associated Infective Endocarditis. J Gen Intern Med 2022; 37:935-939. [PMID: 35018563 PMCID: PMC8904655 DOI: 10.1007/s11606-021-07313-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022]
Abstract
Amidst a substance use epidemic, hospitalizations and valve surgeries related to drug use-associated infective endocarditis (DU-IE) rose substantially in the last decade. Rates of reoperation and mortality remain high, yet in many hospitals patients are not offered valve surgery or evidence-based addiction treatment. A multidisciplinary team approach can improve outcomes in patients with infective endocarditis; however, the breadth of expertise that should be incorporated into this team is inadequately conceptualized. It is our opinion that incorporating addiction medicine services into the team may improve outcomes in DU-IE. Here, we describe our experience incorporating addiction medicine services into the multidisciplinary management of DU-IE and share implications for other hospitals and health systems looking to improve care for people with DU-IE.
Collapse
Affiliation(s)
- Matthew O’Donnell
- Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Honora Englander
- Division of Hospital Medicine, Department of Medicine, Section of Addiction Medicine in General Internal Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Luke Strnad
- School of Public Health, Epidemiology Programs, Portland State University, Division of Infectious Disease, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Castigliano M. Bhamidipati
- Division of Cardiothoracic Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Evan Shalen
- Division of Cardiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Patricio A Riquelme
- Division of Hospital Medicine, Department of Internal Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| |
Collapse
|
14
|
Englander H, Patten A, Gregg J. Collaboration in a time of crisis: Adapting a telementoring ECHO for addiction leaders during COVID-19. Subst Abus 2022; 43:547-550. [PMID: 34520678 PMCID: PMC8792166 DOI: 10.1080/08897077.2021.1975865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Substance use disorder (SUD) organizations are often siloed, with little integration across specialty addictions treatment, primary care and hospitals, harm reduction, policy, and advocacy. COVID-19 introduced a pressing need for collaboration and leadership, given a fast-changing, high-stakes environment; widespread anxiety; and lack of guidance. This research letter describes our approach to convening and supporting leaders across the US state of Oregon's SUD continuum during the pandemic. We rapidly developed and implemented a SUD COVID Response ECHO, adapting ECHO - a telementoring model - to convene leaders across 32 statewide agencies. Our experience allowed participants to lead their agencies to respond to real-time COVID-related needs, address existing barriers within SUD systems, and build relationships and community across statewide SUD leaders. This kind of collaboration - which helped bridge gaps among the diverse agencies, disciplines, and regions addressing SUDs in the state - was long overdue, and sows seeds for long-term advances in care for people with SUD.
Collapse
Affiliation(s)
- Honora Englander
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States,Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States,Corresponding author, Twitter: @honoraenglander, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: BTE 119, Portland, OR 97239
| | - Alisa Patten
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Jessica Gregg
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States,Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| |
Collapse
|
15
|
King C, Collins D, Patten A, Nicolaidis C, Englander H. Trust in Hospital Physicians Among Patients With Substance Use Disorder Referred to an Addiction Consult Service: A Mixed-methods Study. J Addict Med 2022; 16:41-48. [PMID: 33577229 PMCID: PMC8349928 DOI: 10.1097/adm.0000000000000819] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Trust is essential in patient-physician relationships. Hospitalized patients with substance use disorders (SUDs) often experience stigma and trauma in the hospital, which can impede trust. Little research has explored the role of hospital-based addictions care in creating trusting relationships with patients with SUDs. This study describes how trust in physicians changed among hospitalized people with SUDs who were seen by an interprofessional addiction medicine service. METHODS We analyzed data from hospitalized patients with SUD seen by an addiction consult service from 2015 to 2018. Participants completed surveys at baseline and 30 to 90 days after hospital discharge. Follow-up assessments included open-ended questions exploring participant experiences with hospitalization and the addiction consult service. We measured provider trust using the Wake Forest Trust scale. We modeled trust trajectories using discrete mixture modeling, and sampled qualitative interviews from those trust trajectories. RESULTS Of 328 participants with SUD who had prior hospitalizations but had not previously been seen by an addiction consult service, 196 (59.8%) had both baseline and follow-up trust scores. We identified 3 groups of patients: Persistent-Low Trust, Increasing Trust, and Persistent-High Trust and 4 qualitative themes around in-hospital trust: humanizing care, demonstrating addiction expertise, reliability, and granting agency. CONCLUSIONS Most participants retained or increased to high trust levels after hospitalization with an addiction consult service. Addiction consult services can create environments where healthcare providers build trust with, and humanize care for, hospitalized patients with SUD, and can also mitigate power struggles that hospitalized patients with SUD frequently experience.
Collapse
Affiliation(s)
- Caroline King
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- MD/PhD Program, School of Medicine, Oregon Health & Science University, Portland, OR
| | | | - Alisa Patten
- Department of Medicine, Oregon Health & Science University
| | - Christina Nicolaidis
- Department of Medicine, Oregon Health & Science University
- School of Social Work, Portland State University
| | | |
Collapse
|
16
|
Trends in Substance Use Disorder-related Admissions at a Safety-net Hospital, 2008 - 2020. J Addict Med 2022; 16:360-363. [PMID: 34380984 PMCID: PMC8828803 DOI: 10.1097/adm.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Safety-net hospitals disproportionately care for people with substance use disorders (SUDs), yet little is known about trends in hospital admissions related to specific substances. This study uses electronic health record data to describe trends in substance-specific admissions at a Midwest urban safety-net hospital. METHODS We included all admissions from 2008 through 2020 and defined them as non-SUD (N = 154,477) or SUD-related (N = 63,667). We described patient characteristics and trends in substance-specific admissions. We estimated the association of SUD diagnoses with discharge against medical advice and length of stay using logistic regression and generalized linear models. RESULTS Between 2008 and 2020, SUD-related admissions increased from 23.1% to 32.9% of total admissions. Admissions related to SUD had significantly more comorbidities than non-SUD-related admissions (4.7 vs 3.5, P < 0.001). Among illicit substances, cocaine-related admissions were the most common in 2008 (3.9% of total admissions, 17.2% of SUD admissions) whereas psychostimulants (eg, methamphetamines) were the most common in 2020 (7.8% of total admissions, 23.8% of SUD admissions). SUD-related hospitalizations had higher rates of against medical advice discharge (3.8%; 95% CI 3.6-3.9 vs 1.4%; 95% CI 1.3-1.4) and longer length of stay (6.3 days; 95% CI: 6.2-6.3 vs 5.3 days; 95% CI: 5.3-5.4) than non-SUD-related admissions. CONCLUSIONS Over the study period, the proportion of admissions related to substance use rose to approximately one third of all admissions, driven by a rapidly increasing share of psychostimulant-related admissions. Identifying substance use patterns quickly using electronic health record data can help safety-net hospitals meet the needs of their patients and improve outcomes.
Collapse
|
17
|
Understanding the impact of the SARS-COV-2 pandemic on hospitalized patients with substance use disorder. PLoS One 2021; 16:e0247951. [PMID: 33635926 PMCID: PMC7909702 DOI: 10.1371/journal.pone.0247951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/16/2021] [Indexed: 11/19/2022] Open
Abstract
Background The SARS-COV-2 pandemic rapidly shifted dynamics around hospitalization for many communities. This study aimed to evaluate how the pandemic altered the experience of healthcare, acute illness, and care transitions among hospitalized patients with substance use disorder (SUD). Methods We performed a qualitative study at an academic medical center in Portland, Oregon, in Spring 2020. We conducted semi-structured interviews, and conducted a thematic analysis, using an inductive approach, at a semantic level. Results We enrolled 27 participants, and identified four main themes: 1) shuttered community resources threatened patients’ basic survival adaptations; 2) changes in outpatient care increased reliance on hospitals as safety nets; 3) hospital policy changes made staying in the hospital harder than usual; and, 4) care transitions out of the hospital were highly uncertain. Discussion Hospitalized adults with SUD were further marginalized during the SARS-COV-2 pandemic. Systems must address the needs of marginalized patients in future disruptive events.
Collapse
|
18
|
Priest KC, Englander H, McCarty D. Hospital policies for opioid use disorder treatment: A policy content analysis and environmental scan checklist. Gen Hosp Psychiatry 2021; 70:18-24. [PMID: 33667810 PMCID: PMC8127397 DOI: 10.1016/j.genhosppsych.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Hospital-based delivery of opioid agonist therapy ([OAT]; buprenorphine, methadone) is an often-overlooked component of the opioid use disorder (OUD) care continuum. Hospitals are complex clinical environments and organizational policies may inform access to care. This study aimed to identify and describe OUD-related hospital policies. METHODS We obtained policies through a purposive sampling of addiction physicians affiliated with 10 U.S. hospitals. Experts provided 25 documents that we analyzed using a framework analysis. We then assessed policy concordance with national recommendations and conducted a post-hoc synthesis to create an environmental scan checklist. RESULTS We observed two hospital policy domains, with four sub-domains, each: 1) OAT management (a. acute pain and perioperative; b. OAT continuation; c. OAT initiation; d. opioid withdrawal) and 2) security and behavioral management (a. aberrant drug use; b. patient-directed discharge; c. safety protocols; d. peripherally inserted central catheters). OAT policy concordance with national guidance varied by sub-domain. Our post-hoc synthesis resulted in a hospital policy environmental scan checklist. CONCLUSIONS Hospital policies are not a singular solution to increasing OAT access, however, in the midst of a worsening drug-related overdose crisis, we observed the divergence of policies from federal recommendations. Policies should enhance, rather than deter OAT access.
Collapse
Affiliation(s)
- Kelsey C Priest
- School of Medicine, Oregon Health & Science University, Portland, Oregon, United States; School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon, United States.
| | - Honora Englander
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States; Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Dennis McCarty
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon, United States
| |
Collapse
|