Substance Use Disorder as a Predictor of Skilled Nursing Facility Referral Failure

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

BACKGROUND

Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs).

OBJECTIVE

To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD.

EXPOSURE

OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD.

KEY RESULTS

The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD.

CONCLUSIONS

This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

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

Importance

Skilled nursing facilities (SNFs) are being referred more individuals with opioid use disorder (OUD), even when their medical needs are not directly associated with OUD.

Objective

To characterize factors that influence SNF admission for individuals with OUD and identify strategies for providing medications for OUD (MOUD) in SNFs.

Design, Setting, and Participants

In this semistructured qualitative study, interviews were conducted with SNF administrators from 27 SNFs in Rhode Island from November 5, 2021, to April 27, 2022. Data analysis occurred from August 22, 2022, to May 31, 2023.

Main Outcomes and Measures

Themes and subthemes on administrator perspectives on admissions and care for people with OUD in SNFs. Audio interviews were transcribed, coded, and analyzed using codebook thematic analysis and guided by community-engaged and participatory research principles.

Results

The study included 29 participants representing 27 SNFs in Rhode Island. Participant roles were administrators (17 participants [59%]), directors of nursing (6 participants [21%]), directors of admissions (5 participants [17%]), and unit managers (1 participant [3%]). Participants described active substance use, Medicaid insurance, housing instability, and younger age as potential barriers to SNF admission for individuals with OUD. The lack of formal guidelines for OUD management, staff shortages, facility liability, state regulations, and skills and training deficits among staff were cited among challenges of effectively meeting the needs of residents with OUD. Many participants reported inadequate institutional capacity as a source of negative outcomes for people with OUD yet expressed their concerns by characterizing individuals with OUD as potentially violent, nonadherent, or likely to bring undesirable elements into facilities. Participants also shared strategies they used to better serve residents with OUD, including providing transportation to support group meetings in the community, delivery in advance of resident arrival of predosed methadone, and telemedicine through the state's hotline to prescribe buprenorphine.

Conclusions and Relevance

In this qualitative study of administrator perspectives about admissions and care for individuals with OUD in SNFs, gaps in institutional capacity overlapped with stigmatizing beliefs about OUD; such beliefs perpetuate discrimination of individuals with OUD. Adequate SNF funding and staffing combined with OUD-specific interventions (eg, antistigma training, community partnerships for MOUD and recovery support) could incentivize SNFs to serve individuals with OUD and facilitate OUD care consistent with practice guidelines.

Impact of an opioid use disorder consult service on hospitalized trauma patients with opioid use disorder

BACKGROUND

Opioid use disorder (OUD) is common in the hospitalized trauma population, being a comorbid diagnosis in approximately 1% of operative trauma cases. The impact of an addiction consult service in this population has been less well studied but may lead to increased provision of evidence-based OUD treatment and improved postdischarge outcomes.

METHODS

One hundred thirteen patients with an International Classification of Diseases diagnosis of OUD who were admitted to the trauma service at a single academic hospital between January 2020 to December 2021 were included in a retrospective chart review. Wilcoxon rank-sum tests were used to evaluate differences between patients who received an OUD consult and those who did not. Regression analysis was used to assess differences in postdischarge acute care utilization, attendance of follow-up appointments, initiation of and discharge on medication for opioid use disorder (MOUD), naloxone prescribing at discharge, and length of stay (LOS) between the consult and no-consult groups.

RESULTS

Eighty-one patients in the study population received a consult and 32 did not. Patients in the consult group were more likely to have started MOUD during their admission (odds ratio [OR], 2.09; p < 0.001), be discharged with naloxone (OR, 1.89; p < 0.001), have a plan in place for continued OUD treatment at discharge (OR, 1.43; p < 0.001), and attend scheduled follow-up appointments with the trauma team (OR, 1.76; p = 0.02). Differences in acute care utilization and LOS between the two groups were not statistically significant.

CONCLUSION

An OUD consult service can provide benefit to hospitalized trauma patients by increasing likelihood of starting MOUD, of discharging with MOUD and naloxone, and of attending trauma follow-up appointments without increasing LOS or acute care utilization. Thus, addiction consult service interventions during hospital admissions for trauma may serve to facilitate both evidence-based OUD care and posthospitalization trauma care.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.